ONLINE COMMENTARY TO ACCOMPANY OR FIRE PREVENTION VIDEO
The most notable finding when cases of operating room fires are reviewed is that most if not all are preventable! This video is intended to promote the best practices known to prevent the potentially devastating complication of a fire in the operating room. Each member of the operating room care team has a role to play in preventing operating room fires. The following commentary is intended to put the recommendations in the video into the context of current practice.
FOR THE OTOLARYNGOLOGIST - HEAD AND NECK SURGEON (Prepared by Otolaryngologists Drs. Lee P. Smith and Soham Roy)
What operations represent the highest risk of OR fire for Otolaryngologists?
Of all the surgical specialties, Otolaryngology procedures are associated with the greatest risk of fire. Most procedures by otolaryngologists are associated with a fire risk due to the close proximity to the airway where oxygen enriched gases and/or nitrous oxide are often present, and the use of surgical devices which can ignite a fire. Endoscopic airway surgery, oropharyngeal surgery, cutaneous surgery of the head and neck and tracheostomy all present a risk of operating room fire for the Otolaryngologist.
What are the best strategies for protecting my patients from fire?
In addition to surgical techniques (described below), developing a team approach to fire prevention in the OR is essential. The time out is an ideal opportunity to discuss the risk of fire for the individual patient with the rest of the OR team. Discussing the details of the surgical plan, especially the need for electrocautery, is important to help the other team members plan for the patient's care. The patient's oxygen requirements should be discussed with the anesthesia professional. Ideally, less than 30% oxygen should be delivered to the patient without nitrous oxide. There are few if any indications for nitrous oxide during head and neck procedures, and if it is to be used, the benefit for the patient should be questioned. If the patient will require greater than 30% oxygen, the risk of fire increases and the details of how the surgical technique will be approached to minimize fire risk should be described. This is especially true if the patient's trachea is not intubated and oxygen is delivered in "open" fashion using a nasal cannula or face mask. If oxygen is delivered in "open" fashion to the patient there is an especially high risk of enriched oxygen accumulating in the surgical field. It is imperative in that case that the team discuss draping techniques and methods to insure that a high concentration of oxygen does not accumulate at the surgical site and/or under the drapes.
What can I do to reduce the risk of causing an operating room fire during endoscopic airway surgery?
The risk of fire during endoscopic airway surgery is most frequently associated with laser surgery when an endotracheal tube is in place. The endotracheal tube becomes a ready source of fuel if ignited by a laser, especially in the presence of an increased oxygen concentration. Airway fires from burning endotracheal tubes have been well documented with devastating consequences for the patient. To reduce the risk of fire, surgeons should perform endoscopic laser airway surgery without an endotracheal tube or with a laser resistant endotracheal tube. Laser resistant endotracheal tubes can offer some protection, but only under conditions defined in the product literature. The oxygen concentration should be kept as low as clinically possible, ideally less than 30%, and nitrous oxide should be avoided. Flexible laser fibers and laser waveguides represent a significant risk of ignition. Surgeons can decrease that risk by keeping the fiber tip more than 1 centimeter from the tip of the bronchoscope, the laser tip clean and free of debris, and sponges or wet pledgets. Should a fire occur, rapidly remove all the burning material from the airway while simultaneously disconnecting the breathing gas supply from the patient.
What can I do to reduce the risk of fire during oropharyngeal surgery?
The risk of fire during oropharyngeal surgery is increased when oxygen and/or nitrous oxide fills the oropharynx by leaking around the endotracheal tube. To reduce the risk of fire during oropharyngeal surgery (e.g. tonsillectomy), a cuffed endotracheal tube is absolutely preferred. Uncuffed endotracheal tubes can be used, but it is difficult to be certain that gases will not leak around the tube into the oropharynx. If clinically possible, oxygen concentrations delivered to the patient should be less than 30% and nitrous oxide should not be used. If greater concentrations of oxygen are used, the risk of fire increases, but the risk can be minimized by using a metal tip suction in the oropharynx to evacuate any gases that leak around the endotracheal tube. In addition, do not place make-shift insulation (e.g. red rubber cather tubing) over the tip of an otherwise unguarded electrosurgical unit as this only adds another source of potential fuel.
What can I do to reduce the risk of fire during tracheostomy?
Whether performing tracheostomy on an intubated patient, or a patient under local anesthesia who is spontaneously ventilating, discuss the patient's oxygen requirement with the Anesthesia professional. If clinically possible, oxygen should be delivered in a concentration less than 30% and nitrous oxide should be avoided. Patients requiring tracheostomy often have some degree of respiratory failure which makes increased oxygen concentrations necessary, and also increases the risk of fire. To avoid igniting a fire, never enter the airway with an electrosurgical unit. "Cold instruments" like a scalpel or scissors should be used to enter the airway. Obtain hemostasis prior to entering the airway, because once the airway has been opened, electrocautery should be avoided. Bleeding from the edges of the tracheostomy will usually stop spontaneously and do not require cauterization.
Lee P. Smith, MD
Chief, Division Pediatric Otolaryngology
North Shore Long Island Jewish Health System
Soham Roy, MD, FACS, FAAP
Director of Pediatric Otolaryngology
Children's Memorial Hermann Hospital