Circulation 94,429 • Volume 26, No. 3 • Winter 2012   Issue PDF

Surgical Fire Injuries Continue to Occur: Prevention May Require More Cautious Use of Oxygen

Robert K. Stoelting, MD; Jeffrey M. Feldman, MD; Charles E. Cowles, MD; Mark E. Bruley, BS, CCE

A shocking and dramatic picture from the Fire Safety Video. Watch the whole video online at the APSF website home page—

The conditions placing patients at risk for surgical fires on the body surface are well-defined:1-7

  • Procedures involving the head, neck, and upper chest (above T5)
  • Use of an ignition source (electrosurgical or electocautery devices, laser) in proximity to an oxidizer-enriched (oxygen, nitrous oxide) atmosphere

Steps to decrease the likelihood of surgical fires on the body surface are well defined:1-7

  • Determine if the patient is at risk for surgical fire • Surgical team discusses the strategy for preventing and managing a surgical fire in a high risk patient
  • Minimize the concentration of oxidizer (oxygen, nitrous oxide) near the surgical site
  • Safely manage ignition sources
  • Safely manage fuels (alcohol-based skin preps, drapes, oxygen masks, nasal cannulae, patient’s hair).

Despite the fact that we know which patients are at risk for fire and understand how to prevent a fire, SURGICAL FIRES CONTINUE TO OCCUR.

no fire 

In many of these fires, a common characteristic is the use of supplemental oxygen via an open delivery system, thus creating an oxidizer-enriched atmosphere in proximity to an ignition source. Anesthesia professionals have direct control over the delivered concentration of oxygen and the method of its administration.

The authors of this report propose that anesthesia professionals can contribute to the protection of patients at risk for surgical fires by reassessing the administration of supplemental oxygen using the algorithm shown below.

Preventing surgical fires is ultimately a team responsibility and depends on the surgeons, operating room nurses, and anesthesia professionals working together (communication) to identify patients at risk and then following safety practices that have been clearly defined.6

Robert K. Stoelting, MD, President, APSF (on behalf of the APSF Executive Committee)

Jeffrey M. Feldman, MD, Chair, APSF Task Force on Prevention and Management of Operating Room Fires

Charles E. Cowles, MD, Member, APSF Task Force on Prevention and Management of Operating Room Fires

Mark E. Bruley, BS, CCE, Vice President for Accident and Forensic Investigation. ECRI Institute


  1. Preventing surgical fires. Sentinel Event Alert. The Joint Commission. 2003 (
  2. Association of periOperative Registered Nurses (AORN). AORN guidance statement: Fire prevention in the operating room. AORN J 2005;81:1067-75.
  3. Fighting fire with fire safety. Graling PR. AORN J 2006;84:561-3.
  4. Caplan RA, Barker SJ, Connis RT et al. Practice advisory for the prevention and management of operating room fires; A Report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2008;108:786-801
  5. New clinical guide to surgical fire prevention. Health Devices. ECRI Institute. October 2009:314-332 (
  6. Prevention and management of surgical fires (video). Anesthesia Patient Safety Foundation. 2010 (
  7. Preventing surgical fires: collaborating to reduce preventable harm. Food and Drug Administration. October 2011 (
*The following organizations have indicated their support for APSF’s efforts to increase awareness of the potential for surgical fires in at-risk patients.

  • American Society of Anesthesiologists
  • American Association of Nurse Anesthetists
  • American Academy of Anesthesiologist Assistants
  • American College of Surgeons
  • American Society of Anesthesia Technologists and Technicians
  • American Society of PeriAnesthesia Nurses
  • Association of periOperative Registered Nurses
  • ECRI Institute
  • Food and Drug Administration Safe Use Initiative
  • National Patient Safety Foundation
  • The Joint Commission