• Surgical fires can occur either on the patient or in the patient's airway (1). They are most commonly observed during procedures that involve the open delivery of oxygen near an ignition source, like electrocautery or laser.
• Airway fires are defined as either within the airway or within the breathing circuit. Many fires occur during relatively minor procedures of the head and neck which involve the use of a cautery device and a simple facemask or nasal cannula.
• As with operating room (OR) fires, airway fire prevention depends on:
  • An understanding of how triad elements (ignition, fuel, oxidizers) interact to create a fire
  • Recognizing how standard OR equipment, materials, and supplemental oxygen can become one of those elements
  • Vigilance for circumstances that bring fire triad elements into close proximity (2)

• High-risk procedure: Use of an ignition source in close proximity to an oxidizer (oxygen and nitrous oxide) (1). Fires have been reported during head and neck procedures including tracheostomies, adenotonsillectomies, endoscopic airway surgeries, and cutaneous surgeries of the head and neck.
• Monitored anesthesia care (MAC)/sedation cases, especially when there is/are:
  • Open delivery of oxygen at a FiO₂ >30%
  • Drapes and towels configured in a manner to "trap" oxygen underneath drapes and allow for significant accumulation.
  • Patients with obstructive sleep apnea or other diseases (decreased functional residual capacity) that cannot tolerate sedation without oxygen supplementation
  • Surgeries that involve the head and neck or are above the xiphoid process
• Laser use in or near the airway
• Prep solution and drapes:
  • Adequate drying time is not observed when using alcohol-based preps or if pooling of prep has occurred.
  • Flammable prep solutions are used in hairy locations or crevasses of the body or if large-sized sponge containers (26 mL) are used for head and neck cases.

• Fire occurs when elements of the fire triangle are combined (3):
  • Ignition source
    • Electrosurgical units (ESU), cautery, lasers, and light sources
    • Usually controlled by the surgeon
  • Fuel
    • Alcohol-based preps, towels, and drapes
    • Usually controlled by the OR nurse
  • Oxidizers
    • Oxygen and nitrous oxide
    • Usually controlled by the anesthesia provider
• Fires which occur in oxygen-enriched environments may result in a sudden flash fire where the burn injuries occur in a matter of seconds (too quickly for extinguishment).

• Often, fires are the result of a lack of communication among surgical team members.
• Injury and damages commonly occur when the response to the fire is uncoordinated and haphazard.
• Assess the fire risk prior to every surgical procedure; this is especially important for cases involving the head and neck or cases performed under MAC.
  • Perform fire risk assessment during surgical "time out"
  • Assign specific tasks for each OR team member to perform in case of a fire
• MAC/sedation cases with increased fire risk
  • Do not use supplemental oxygen unless clinically necessary
  • Allow sufficient time for oxidizer levels to drop before using an ignition source. This may take several minutes.
  • If an FiO₂ >30% is required:
    • Communicate with the surgical team.
    • Titration of the FiO₂ can be accomplished with the use of an oxygen blender or by using the common gas outlet found on some anesthesia machines.
    • Consider using an ETT or supraglottic device such as the laryngeal mask airway (LMA) to eliminate the open flow of oxygen, especially in cases above the xiphoid
    • Configure drapes to prevent accumulation of oxygen and to facilitate open ventilation.
• Prep solution and drapes
  • Allow flammable surgical preps such as alcohol-based solutions to dry fully before the application of surgical drapes or barriers
  • Assess for pooling as a routine part of the time-out process
  • Avoid 26 mL applicators in head and neck cases
• General anesthetics, particularly for procedures above the xiphoid
  • Use cuffed tracheal tubes when possible
  • FIO₂ <30% may reduce the risk of fire, particularly for intraoral cautery.
  • Decreasing the electrocautery wattage may reduce the incidence of airway fires (5).
• Laser procedures
  • Use an appropriate laser tube for the type and frequency of the laser
  • Use an indicator dye such as methylene blue in the distal cuff of laser tubes to detect inadvertent rupture
  • Moisten gauze or sponges if used to pack the airway
  • Participate in OR-specific fire drills which include the practice of patient evacuation methods and involvement of all team members, including surgeons and anaesthetists
• Know the location of fire extinguishers and gas cut-off valves before the case begins
• Consider assembling a cart for high-risk procedures which includes saline or water bottles, fire extinguishers, and placards to guide response

• Claims approaching $1.5 million per case have been paid for MAC cases resulting in fatal or disfiguring burn injuries.
• Most cases involve head and neck surgeries.
• 74% of burn cases involve oxygen supplementation.

• Smoke Inhalation Injury
• Burns
• Operating Room Fires

Charles E. Cowles, Jr. , MD