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Chapter 63. OR Fires

Jean Charchaflieh, MD, DrPH, FCCM, FCCP

  • Most recent (2010) estimates: 550–650 occurrences per year in the United States
  • Oxygen-enriched atmosphere (OEA) involved in 72–74% of fires; alcohol prep solutions and drapes are most common fuels
  • Most fire-related burn claims involved plastic surgery performed on the face under MAC with supplemental O2 where electrosurgical unit (ESU) comes in contact with drapes/gauze wet with alcohol prep solution

Three elements must exist for fire to occur: ignition source, fuel and oxidizer. The APSF Fire Prevention Algorithm recommends securing the airway with ET tube or LMA if >30% oxygen is required to maintain oxygen saturation.

Table 63-1 Examples of Elements of Fire Triad in an OR Setting
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Table 63-1 Examples of Elements of Fire Triad in an OR Setting
Ignition source (heat)FuelOxidizer
  • Electrosurgical units (ESU)
  • Fiber-optic light source
  • Laser beams
  • Drills
  • External defibrillation
  • Prep solutions: alcohol, chlorhexidine, benzoin, Mastisol, acetone, petrolatum products
  • Surgical drapes, gowns, sponges, packs, sutures, mesh
  • Plastic/PVC/latex products (ETT, masks, nasal cannulas, tubings)
  • Intestinal gases (CH4, H2)
  • Hair, other bodily tissues
  • O2
  • N2O
  • Air
Table 63-2 Elements of Fire in the OR: Mechanisms and Prevention
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Table 63-2 Elements of Fire in the OR: Mechanisms and Prevention
MechanismPrevention
Oxygen:
  • FiO2 ≥21% → ⇑ ignition, temperature, combustion
  • O2 heavier than air → collects under drapes
  • O2 at 3 L/min via NC → FiO2 70–80% under drapes
  • D/C NC O2 → FiO2 ⇓ to 30% in 30 s
Oxygen:
  • Provide lowest FiO2 consistent with adequate SaO2
  • Use O2 “for rescue only”
  • Tape NC in place to avoid blowing O2 into surgical field
  • Discontinue O2 60 s before use of ESU
N2O:
  • FiO2 25% + N2O 75% ≈ FiO2 100% in ability to support combustion
  • N2O ⇑ risk of fire when combined with intestinal gases (CH4 + H2), which act as fuels
N2O:
  • Avoid N2O during cases where ESU is used on gas-filled intestines (GI obstruction)
Volatile anesthetics:
  • Sevoflurane + desiccated Baralyme may → fire
Volatile anesthetics:
  • Replace Baralyme regularly, especially on Monday morning
Hair:
  • Retains prep solutions longer, ignites easily
Hair:
  • Clip hair in operative site or render it nonflammable by heavy coating with water-soluble lubricant jelly
  • Instruct patients not to use petroleum-based facial creams and hair products
Drapes and towels:
  • Absorb O2 and alcohol → facilitate ignition
  • Fire-resistant cotton towels → “surface fiber flame propagation,” that is, fire underneath drapes without drapes being on fire → ignition of materials at some distance from operative site with no intermediate fire (“mysterious spark”)
Drapes and towels:
  • Thoroughly moistened gauze in operative field
  • Minimize drape tenting to prevent entrapment of O2 and alcohol vapors
Skin prep solutions:
  • Alcohol-based solutions extremely flammable (ChloraPrep: 2% ...

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