CONSTANT THREAT Fires can spark when elements of the fire triad combine, even during seemingly minor procedures.

Consider this true-life case: An 18-year-old underwent minor surgery to have a mole removed from his cheek. Although he was in good health and had no comorbidities, the anesthesia provider opted to give supplemental oxygen with a nasal cannula. As soon as the surgeon activated an electrocautery device to stop bleeding at the operative site, a fire ignited that severely burned the patient. The young man arrived for a minor procedure and exited disfigured, requiring extensive reconstructive surgery. The tragedy of it all: This OR fire could have been prevented if the surgical team had adhered to these basic protocols.

Communicate clearly
A review of OR fire claims shows most are caused by a lack of communication among the OR team. Surgeons are unaware of how oxidizers are being administered by anesthesia providers, while anesthesia providers don't anticipate when surgeons are going to use ignition sources. All members of the surgical team must remain in constant communication when surgical energies are employed. Clear communication is also especially important during seemingly minor procedures performed around the face or above the xiphoid process.

Learn the risks
Teach your staff about the dangers of OR fires. Lessons should cover what to do during high-risk surgeries, including explaining open methods for surgical draping: Positioning drapes over the patient and securing them to a pole prevents oxygen from accumulating to dangerous levels underneath the covers. A fire can occur if oxygen is trapped under drapes and an ignition source such as an electrocautery pen is used. Materials that usually do not easily burn in room air can ignite in this oxygen-enriched environment.

MNEMONIC AIDS
When Every Second Counts

R Remove everyone from fire area

A Alert others and use pull station

C Confine fire by closing doors

E Extinguish or evacuate

P Pull pin on extinguisher

A Aim at base of fire

S Squeeze handle

S Sweep from side to side

— Charles Cowles, MD

There is a greater risk of fire with open-oxygen delivery systems such as nasal cannula or masks than there is with closed delivery systems such as laryngeal masks or endotracheal tubes. If electrocautery or other devices will be used with an open-oxygen delivery system, ensure oxygen concentration is below 30%. (Sixty-five percent of surgical fires reported occur in cases of surgeries above the level of the xiphoid. Most occur when the concentration of oxygen eclipses the 30% threshold).

TRIPLE THREAT
Elements of the Fire Triad

1. Oxidizer

• oxygen
• nitrous oxide

2. Ignition source (heat)

• electrocautery or electrosurgical devices
• lasers
• heated probes
• drills
• burrs
• argon beam coagulation
• fiber-optic light cables
• defibrillator paddles or pads

3. Fuels

• alcohol-based prepping solutions
• tracheal tubes
• sponges
• drapes and gowns
• gauze, dressings and ointments
• solutions containing volatile compounds
• oxygen masks
• nasal cannula
• patient's hair
• GI tract gases

— Charles Cowles, MD

Remove just one element of the fire triad and you remove all risk of fire. So do all patients require oxygen? Don't automatically assume they do. A relatively healthy patient with no comorbidities may not need supplemental oxygen. If a patient does need oxygen, how will it be delivered? Best practice is the use of an air-oxygen blender to deliver O2 at a concentration of less than 30%.

Prepare and practice
Staff should know the locations of the nearest fire extinguishers, fire alarm pull stations and gas cut-offs, and 2 ways out of every OR. Each team member should be given an assigned task to complete in the event of a fire. If they complete their assigned tasks, they should assist whoever needs additional help. Ensure your team recognizes the early signs of fire: flashes, unusual sounds such as pops or snaps, odor, smoke or excessive heat.

Hold regular fire drills, which should include stopping procedures and alerting the surgical team that a fire has started. Practice taking appropriate action to put out the fire, and remove tracheal tubes and all flammable materials such as drapes, even if the fire is not on the patient. Immediately stop airway gases and pour saline into the patient's airway to extinguish residual embers and cool tissues. Treat the patient and evacuate the OR if necessary.

Add fire risk assessments to your surgical safety checklist. Before each case ask: What's the fire risk for this procedure? The checklist should verify that alcohol-based solutions are thoroughly dry. Also use the checklist as a reminder to identify the location of the oxygen cut-off valve.

Surgeons set the tone in the OR. If they treat fire prevention with the respect it deserves, the rest of the surgical team will do the same. But if they're cavalier about the risks, the rest of the team won't see the value of drills, preparation and constant vigilance.