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Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 1-5

Surgical fires: An ongoing intra-operative challenge

Department of Surgery, Division of Plastic Surgery, PMB 06 ABUTH Shika Zaria, Kaduna State, Nigeria

Date of Web Publication28-Aug-2013

Correspondence Address:
Ibrahim Abdulrasheed
Department of Surgery, Division of Plastic Surgery, PMB 06 ABUTH Shika Zaria, Kaduna State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-9596.117117

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Background: A surgical fire is a rare but life-threatening event. They are always unexpected and commonly occur in head and neck surgeries resulting in severe burns, disfigurement, and in some cases death. Injuries are not limited to patients alone as they may also involve health-care personnel in the operating theater. There is a resurgence in the awareness of this intra-operative challenge as well as an understanding of the need for a team approach to prevention.
Materials and Methods: The surgical fire triangle is a useful paradigm that describes the three elements necessary for initiation of a surgical fire i.e., ignition source, fuel, and an oxidizer. This review will identify operating theatre contents capable of acting as ignition/oxidizer/fuel sources and highlight the management and prevention of surgical fires.
Results: Surgical fires can be prevented by education across all professional boundaries in the operating theater. This will entail information on how the elements of the fire triangle interact, recognizing how standard operating room equipment can initiate a fire, and vigilance for the circumstances that increase the likelihood of a surgical fire.
Conclusion: Promoting a culture of fire safety in the theater is not optional. Education on the prevention of surgical fires should be included in the curriculum of undergraduate medical students. There is an urgent need to stimulate debate within National burn associations in this context, leading to the formation of proposals to be incorporated into existing National burn prevention plans.

Keywords: Fire triangle, fuel, ignition, oxidizer, prevention, surgical fire

How to cite this article:
Abdulrasheed I, Lawal AM, Eneye AM. Surgical fires: An ongoing intra-operative challenge. Arch Int Surg 2013;3:1-5

How to cite this URL:
Abdulrasheed I, Lawal AM, Eneye AM. Surgical fires: An ongoing intra-operative challenge. Arch Int Surg [serial online] 2013 [cited 2017 Sep 20];3:1-5. Available from:

  Introduction Top

A surgical fire is perhaps one of the most unique complications of surgery and anesthesia with potentially catastrophic threat to the patient. [1],[2] Patients entrust themselves to surgical intervention and are actually set alight when at their most vulnerable, sustaining burns to surgically unrelated body areas. [2],[3],[4],[5],[6] In seconds, a life-threatening situation can arise with little or no time to react. Adverse patient outcomes that can occur include severely disfiguring burns that are both physically and psychologically disabling necessitating extended hospitalization. [2],[7],[8],[9],[10],[11]

Most surgical fires are not reported in the literature because of liability issues. [4],[7],[10],[12] Exact numbers are also difficult to ascertain due to the absence of a standard reporting system. [2] Indeed, only a minority of hospitals require any reporting of operating-room fires and in the majority of those that are reported, this occurs only when significant patient morbidity or mortality results. [13] Published data put the incidence at approximately 20-200 surgical fires each year. [1],[5],[10],[12] This makes the problem of a similar order of magnitude with other low incidence but potentially serious or fatal surgical misadventures such as wrong site surgery or retained instruments. [2],[14]

Education has been advocated as the key to reducing the risk of surgical fires. [5],[8],[15],[16],[17],[18] The findings that both medical doctors and nurses are unaware that commonly used solutions are highly flammable, that nearly two in three newly qualified doctors had never heard of surgical fires and that even amongst experienced surgeons awareness was far from universal would support this. [2],[19],[20] This patient safety issue, the hazard of igniting a fire on or within a surgical patient remains a clear and present danger. [14] This review will identify operating theatre contents capable of acting as ignition/oxidizer/fuel sources and highlight the management and prevention of surgical fires.

  How Does It Start? Top

The surgical fire triangle is a useful paradigm that describes the three elements necessary for initiation of a surgical fire i.e., ignition source, fuel, and an oxidizer [Figure 1]. [8],[10],[21],[22] Well-established principles of chemistry require these three must be present for the rapid exothermic reaction known as "fire" resulting in the generation of intense heat and light. [4],[7] All three are in ample supply in the operating theater with a different member of the team supplying each. [Table 1] the nursing staff supply fuel in the form of skin preparation agents, swabs, and drapes. The anesthetist provides oxygen (O 2 ) and nitrous oxide (N 2 O) as the oxidizer. Ignition is triggered by the surgeon, with the use of diathermy, and more recently lasers. [2],[7],[10] The initiation and propagation of any fire requires a spark, O 2 , and something to burn. [23] With the advances in surgical practice and an abundance of high-energy surgical ignition source (spark), open oxygen sources (O 2 ) and flammable surgical materials (something to burn) in most operating theaters, approximately 65% of surgical fires involve surgeries on the head and neck. (plastic surgery, neurosurgery and otolaryngology). [15],[10],[19] There are two key reasons for this increased risk in head and neck surgery. First, is the routine administration of O 2 during anesthesia and sedation, meaning that head and neck surgery is performed in an O 2 enriched environment. Secondly, head and neck surgeons also make frequent use of ignition tools, including, diathermy and lasers. [2]
Table 1: Sources of surgical fire in the operating theater

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Figure 1: Surgical fire triangle

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  Ignition Source Top

The most common ignition source in operating-room fires are electro cautery units (monopolar and bipolar diathermy), which are used in approximately 85% of surgeries, and was responsible for initiating 100% of the fires reported in a recent literature review. [5],[8],[13] The temperature at the tip of a diathermy can reach several hundred degrees. [5] Similarly, prior to endoscopic connection, the terminal end of a fiber optic cable can achieve temperatures of 190.6°C. [24] Lasers are another common ignition source and have been reported to ignite endotracheal tubes during airway surgery, creating a potentially lethal airway fire extending down the trachea. [5],[24] They can all ignite an operating-room fire, particularly in the presence of either O 2 or direct contact with a fuel source. Thus, these sources pose a high-risk for direct burns as well as additional ignition and explosion reactions from the intense heat they generate. [13],[24] Other ignition sources include sparks from high-speed surgical drills and surgical burrs, glowing embers of charred tissue, flexible endoscopes, tourniquet cuffs and faulty electrical equipment. [Table 1]. [8],[11]

  Fuel Source Top

Fuel sources are ubiquitous in the operating room [Table 1]. Some fuel sources are so flammable that they require only the slightest of contributions from the other two components of the surgical fire triangle. For example, a surface wiped down with 100% alcohol requires only a single spark at room air O 2 concentrations to ignite, making this a very dangerous skin preparation solution. [13] Most skin preparation solutions are alcohol-based and their flammability is in direct proportion to their alcohol concentration.These solutions include 10%povidone-iodine (Betadine ® ), 0.5% chlorhexidine (Hibisol ® ),

5% chlorhexidine (Hibitane ® concentrate), methanol and ethanol (surgical spirit). Moreover, all skin preparation solutions will support combustion if not given adequate drying time for the alcohol content to evaporate. [3],[6],[12] Only water-based skin preparation solutions such as betadine, soloprep, and pharmaseal contain no alcohol and therefore, considered truly nonflammable. [13] Experimental studies have shown that diathermy generates enough heat to ignite all alcohol based antiseptics even if these contain as little as 20% alcohol. The ignition temperatures for these antiseptics are within the range of 800-900°C and these temperatures are easily achieved with the use of typical electro surgery units. [21] It has also been suggested that fires may be initiated by ignition of the vapor generated from the antiseptic solution. The heat of the skin ensures that this is in high concentration near the operating site. The potential for fire is increased when the alcohol based skin antiseptic is applied in a way that allows the solution to spill and pool on the skin, or wick into the patient's hair or surrounding drape. [25] Furthermore, formation of air pockets during draping allows flammable vapors to accumulate near the surgical site. Thus, if the patient is draped before the solution is completely dry, alcohol vapors can be trapped and channeled to the surgical site, where a heat source can ignite the vapors. [21]

  Oxidizer Top

O 2 is the principal oxidizer in the operating theater although N 2 O is also dangerous when present. [11],[24] The operating room can present a relatively high-risk environment for fire especially, with the use of 100%O 2 leading to an oxygen-enriched atmosphere (OEA), [12] An OEA is defined simply as an O 2 concentration greater than the normal atmospheric concentration of 21%. [2],[7],[8] An inverse relationship between time necessary for fire ignition and O 2 concentration has been described. [11] As the O 2 concentration rises above 21% (normal atmospheric concentration), the propensity to generate an aggressive and vigorous fire also increases. Most patients receive supplemental O 2 during head and neck surgeries through an endotracheal tube or nasal cannula. Gravitational forces promote the accumulation of supplemental O 2 in dependent regions (ears and angle of the mandible) because of its higher density compared to room air. The use of drapes around the patient sequesters O 2 underneath and prevents its rapid clearance. [4] The area below drapes can develop an O 2 concentration of 50% with administration of 6 L/min of O 2 . [11],[24] Drape fabric will also absorb O 2 , thus, greatly enhancing its potential to ignite and enhancing its heat intensity after ignition. [2],[7],[8] Furthermore, when fires occur with some of these products, the hazard is not only the burn injury, but the inhalation of products of combustion; carbon monoxide, ammonia, hydrogen chloride, and cyanide. These products of combustion pose a hazard, not only to the patients but also to exposed operating-room personnel as well. [13]

  Management Top

When a surgical fire occurs, a swift and appropriate response can reduce the severity of the burn injury. [2] The first step is to recognize that a surgical fire has occurred. This is usually obvious with the presence of flames or smoke but a fire can also be first noticed by an unusual noise or smell. It is imperative to quickly announce the fire to everyone and stop the procedure. [2],[5],[24] The next step is to remove the fire from the patient. This is done by simultaneously removing all burning material from the patient and the fire should be extinguished immediately with a gloved hand or a towel. Larger fires require terminating the flow of the O 2 immediately (i.e., disconnecting the breathing circuit), removing burning materials and dousing the patient with water to limit thermal injury. [1],[5],[9] Burning materials may include swabs, drapes, and other items in the surgical field. These should be removed, even if doing so compromises the sterility of the surgical field. In an airway fire with a burning endotracheal or tracheostomy tube, the recommendation is to remove the tube. [24] This is to prevent damage to the trachea, distal airways and to reduce the risk of inhalation of toxic material from the fire. [2],[9] These steps will almost always be enough to put out the fire. If the surgical fire is large then a fire extinguisher should be used, a carbon dioxide type being preferred. [24] Dry powder extinguishers are not recommended because the powder released is not water-soluble, is difficult to remove from the wounds, and irritates respiratory mucus membranes. [1] The carbon dioxide extinguisher leaves no residue as it smothers the fire and minimizes thermal injury through its cooling effect. [1] A fire blanket should never be used as this will contain the fire on the patient, including potentially hot material, and fires may continue unnoticed beneath the blanket. [1],[24] All scorched material should be removed, as it may be hot even after the fire is out. Once the fire is out then attention should be rapidly turned to caring for the patient who may be bleeding and without an airway. A secure airway should be re-established and the patient ventilated with room air. When it is absolutely certain that the fire is out O 2 may be reintroduced to the breathing circuit. In the case of an airway fire, bronchoscopy, [9] preferably rigid, should be performed to assess the extent of injury to the airway and perform a lavage as appropriate. [2],[5] A meticulous examination for fire-related injuries both at and distant to the operative site should be undertaken. [26] Further evaluation and management will require the multidisciplinary care of a burn treatment center. This will include respiratory care, pain control, wound management, and psychological support for emotional distress. [26],[27] A recent literature review of a burn center management of patients following surgical fires revealed that most of the burns sustained involved the periorbital areas, nose, and ears because of proximity of the fire to the face. [25] The wounds typically ranged from superficial to intermediate depth. Although, the average percentage of burns was relatively small (3.95%), the mean length of stay was 12 days with a median of 9 days. These patients were followed for at least a year and most had permanent scarring with post-traumatic stress disorder as a result of their injuries. All cases led to litigation however, the out-of-court settlements allowed the hospital and staff involved in the incidents to bear minimal financial loss. [1]

  Prevention Top

Surgical fires have justifiably received increased attention and are now classified as "never events." [27] Vigilance is required to prevent the hazardous combination of the three arms of the fire triangle. [1],[2],[5],[8],[11],[14],[16],[18],[28],[29] Being prepared for a fire is inexpensive insurance that will minimize cost and prevent injury or death.For this reason, maintaining awareness with surgical fire prevention posters in the operating room is highly encouraged. [2],[11] Posters can provide specific fire safety precautions and are a constant reminder on how to prevent and control fires in the operating room. It is important to change posters at regular periods to reinforce the safety message. Educational videos can also be used to provide the fire safety training that surgical staff require. [5] Excellent communication amongst team members is essential to improving operating theater safety generally and is also relevant to reducing the risk of a surgical fire. [2] Communication can be structured by the use of a checklist at the beginning of surgery. The check-list will build the culture of team work, promote awareness and will bring the entire operating team to be together at different critical time points during the surgery. [30] This consistency of care will ensure that perioperative team members are responsible for maintaining a separation of the elements of the fire triangle. Silverstein has suggested the use of a scoring system as a guide in the assessment of the risk of surgical fire [31] [Table 2]. This scoring system sets out a simple three point score for the risk of fire. A surgical site above the xiphoid, an open O 2 source and presence of a source of ignition each score one point. If the score is 2 or 3, then specific protocols are followed to reduce the risk of fire [Table 3]. The fire risk assessment is performed by the entire surgical team before the incision is made and is documented by the circulating nurse.
Table 2: Surgical fire risk scoring system

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Table 3: Fire risk protocols

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All personnel working in the operating room, including consultant surgeons and anesthetists, residents, nurses, technicians, and medical students should have an annual fire education complemented with fire drills so that everyone has the opportunity to practice proper fire prevention procedures. [15],[32] This will provide information about the prevention of surgical fires, the role and responsibility of each team member, as well as the type,use and location of fire extinguishers. [14],[15],[17] All theater staff should also be able to locate and switch off the gas pipeline shut off valves, sound a fire alarm, have an evacuation plan and be able to rapidly call for help. [11],[16],[17],[18] One never knows who will be present when a surgical fire occurs. Thus, the role of each member may change in any given scenario. Flexibility on the part of team members will be successfully executed only with regular practice and timely preparation. [19]

  Conclusion Top

Promoting a culture of fire safety in the theater is not optional. [11] The prevention of surgical fires with established institutional protocols must be a priority across the professional boundaries in the operating theater. Education on the prevention of surgical fires should be included in the curriculum of undergraduate medical students. There is an urgent need to stimulate debate within National burn associations in this context, leading to the formation of proposals to be incorporated into existing National burn prevention plans. As long as we understand the causes of surgical fires and continue to raise the prevention bar, we can have some sense of comfort that as the demand for surgical intervention increases it will remain safe.

  References Top

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2.Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon 2010;8:87-92.  Back to cited text no. 2
3.Spigelman AD, Swan JR. Skin antiseptics and the risk of operating theatre fires. ANZ J Surg 2005;75:556-8.  Back to cited text no. 3
4.Barker SJ, Polson JS. Fire in the operating room: A case report and laboratory study. Anesth Analg 2001;93:960-5.  Back to cited text no. 4
5.Daane SP, Toth BA. Fire in the operating room: Principles and prevention. Plast Reconstr Surg 2005;115:73e-5.  Back to cited text no. 5
6.Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl 2012;94:87-9.  Back to cited text no. 6
7.McHenry CR, Berguer R, Ortega RA, Yowler CJ. Recognition, management, and prevention of specific operating room catastrophes. J Am Coll Surg 2004;198:810-21.  Back to cited text no. 7
8.Lowry RK, Noone RB. Fires and burns during plastic surgery. Ann Plast Surg 2001;46:72-6.  Back to cited text no. 8
9.Macdonald AG. A brief historical review of non-anaesthetic causes of fires and explosions in the operating room. Br J Anaesth 1994;73:847-56.  Back to cited text no. 9
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12.Tooher R, Maddern GJ, Simpson J. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004;74:382-5.  Back to cited text no. 12
13.Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol 2008;21:790-5.  Back to cited text no. 13
14.Bruley ME. Surgical fires: Perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care 2004;13:467-71.  Back to cited text no. 14
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16.Ehrenwerth J, Seifert HA. Fire safety in the operating room. ASA Refresher Courses in Anesthesiology 2003;31:23.  Back to cited text no. 16
17.Corvetto MA, Hobbs GW, Taekman JM. Fire in the operating room. Simul Health Care 2011;6:356-9.  Back to cited text no. 17
18.American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA, Barker SJ, Connis RT, Cowles C, de Richemond AL, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008;108:786-801.  Back to cited text no. 18
19.Hart SR, Yajnik A, Ashford J, Springer R, Harvey S. Operating room fire safety. Ochsner J 2011;11:37-42.  Back to cited text no. 19
20.Lypson ML, Stephens S, Colletti L. Preventing surgical fires: Who needs to be educated? JtComm J Qual Patient Saf 2005;31:522-7.  Back to cited text no. 20
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22.Greco RJ. Beware of fire! Plast Reconstr Surg 2001;107:1828-9.  Back to cited text no. 22
23.Smith LP, Roy S. Fire/burn risk with electrosurgical devices and endoscopy fiberoptic cables. Am J Otolaryngol 2008;29:171-6.  Back to cited text no. 23
24.Zahiri HR, Stromberg J, Skupsky H, Knepp EK, Folstein M, Silverman R, et al. Prevention of 3"never events" in the operating room: Fires, gossypiboma, and wrong-site surgery. Surg Innov 2011;18:55-60.  Back to cited text no. 24
25.Prasad R, Quezado Z, St Andre A, O'Grady NP. Fires in the operating room and intensive care unit: Awareness is the key to prevention. Anesth Analg 2006;102:172-4.  Back to cited text no. 25
26.Meltzer HS, Granville R, Aryan HE, Billman G, Bennett R, Levy ML. Gel-based surgical preparation resulting in an operating room fire during a neurosurgical procedure: Case report. J Neurosurg 2005;102:347-9.  Back to cited text no. 26
27.Engel SJ, Patel NK, Morrison CM, Rotemberg SC, Fritz J, Nutter B, et al. Operating room fires: Part II. optimizing safety. Plast Reconstr Surg 2012;130:681-9.  Back to cited text no. 27
28.Halstead MA. Fire drill in the operating room. Role playing as a learning tool. AORN J 1993;58:697-706.  Back to cited text no. 28
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30.Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 30
31.Mathias JM. Scoring fire risk for surgical patients. OR Manager 2006;22:19-20.  Back to cited text no. 31
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  [Table 1], [Table 2], [Table 3]


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