FIRE RISK Many fires start when the surgeon activates the electrosurgical device in the presence of an oxygen-enriched environment or in the presence of an alcohol-based prepping solution that has not been allowed to dry.

In the 40 years I've been studying surgical fires, I've investigated hundreds of them on behalf of hospitals and surgery centers trying to piece together the chain of events that led to the fire. It usually takes me about 20 seconds to retrace the lines of the fire triangle: the oxidizer, the fuel and the ignition source. But one case took me about 20 minutes to reconstruct. A patient's face caught fire during a gynecologic laparoscopic surgery. Yes, I know what you're thinking: How in the world did that happen?

I took a cross-country red eye from Philadelphia and arrived at the hospital at 2 a.m. As soon as I got there, one thing was obvious: the ignition source was the disconnected fiber optic light cable that the surgeon had rested on the drapes (fuel) near the patient's left clavicle. Those light cables can cause charring, but they don't usually cause a flaming fire unless there's excess oxygen (oxidizer) present.

So where'd the oxygen come from? The cuff on the patient's anesthesia endotracheal tube was inflated. The heat from the disconnected light cable melted the inflation tube. Once the tube melted, the cuff deflated, which caused oxygen to leak past the cuff and build up under the drapes around the patient's head. Right then I knew that somewhere on the floor, there had to be a Luer connector that had come loose from the inflation tube when it melted. I started looking around for the luer like a contact lens, and sure enough, found it. Case closed.

Could this fire have been prevented? Yes, had the OR team placed the light source in standby when the surgeon disconnected the light cable. For most outpatient surgeries, these 3 preventative measures will help minimize the risk of a surgical fire.

DANGEROUS TRIO Before each surgery, OR staff should conduct a fire risk assessment, taking into account the "fire triangle" of heat, fuel and oxidizing agent.tion

1. Question the need for 100% oxygen delivered on the face. A surprisingly high number of OR staff members think alcohol-based skin preps are the biggest cause of surgical fires, but that's not the case. Skin preps make up only 4% of all surgical fires in ECRI Institute's experience. You'd also be wrong if you guessed draping technique or ignition source power were the leading causes. No, the most significant factor leading to most surgical fires is using 100% supplemental oxygen delivered openly on the face by mask or nasal cannula. Historically that has been common during surgery performed under monitored anesthesia care (MAC). Fortunately, that mindset is changing.

More than 70% of fires involve oxygen enrichment. Most patients undergoing MAC procedures don't need 100% oxygen on the face, so always question how much the patient requires before you enter the OR and during initial patient prepping. You can safely sedate most patients without any open oxygen supplementation, using air instead via the face mask or nasal cannula. However, the use of air versus supplemental oxygen is a clinical decision that must be assessed individually for each patient.

The current clinical recommendations are to eliminate open O2 delivery on the face and to secure the patient airway if oxygen supplementation is needed. For patients that are clinically judged to need open oxygen delivery, such as for those who need to verbally respond during surgery, set the concentration at the lowest amount necessary — no more than 30% oxygen enrichment. You're monitoring the patient's oxygenation status with a pulse oximeter, so you'll know if a patient is desaturating and may need a temporary increase in the delivered O2 concentration.

2. Let the prep dry. Flammable alcohol skin preps commonly fuel fires. The solution must completely dry before you drape the patient. Otherwise, the drape may get wet and become a fuel source. Most preps need 3 minutes to dry. It's a good idea to set a timer in the OR to be certain you've waited long enough. To be certain that the prep has dried, use sterile gloves to feel the site of the alcohol prep for any tackiness. If it's tacky, or sticks to your gloves, that means it's still wet and alcohol vapors are still present. An important note: If the surgeon wants to start the case before the prep dries, let your nurses know that they have the authority to tell him that the alcohol prepping solution is not dry, and that you must wait until there is no tackiness.

3. Respect electrosurgery's dangers. Don't assume that your OR team knows the risks of surgical fires. Take electrosurgery, for example, which is used in 85% of all surgical procedures and has many associated fire hazards. Many fires start when the surgeon activates the electrosurgical device in the presence of an oxygen-enriched environment or in the presence of an alcohol-based prepping solution that has not been allowed to dry. Another common fire risk: failing to use a holster. If electrocautery and surgery electrodes will be present, they should be placed in a holster when not in use and not laid on a patient when not in active use (i.e., going to be used in the next few seconds). Encourage your surgeons and staff to read the fire hazard warnings in the user manual for your electrosurgical equipment. I've talked to many surgeons and tactfully observed to them: "You're an expert user of electrosurgery, but you're not an expert in understanding all of the hazards." Unless you understand the equipment, you won't understand your risk of fire.

Education key to fire prevention
The more you educate OR team members on fire safety, the more you'll lower the risks. Free educational posters on fire prevention and extinguishment, along with other resources, are available at ecri.org/surgical_fires. OSM