Prevention and Management of Operating Room Fires

All anesthesiologists should have fire safety education, specifically for operating room (OR) fires, with emphasis on the risk created by an oxidizer-enriched atmosphere.

Anesthesiologists should periodically participate in OR fire drills, with the entire OR team. This formal rehearsal should take place during dedicated educational time, not during patient care.

For every case, the anesthesiologist should participate with the entire OR team (e.g., during the surgical pause) in assessing and determining whether a high-risk situation exists. If a high-risk situation exists, all team members—including the anesthesiologist—should take a joint and active role in agreeing on how a fire will be prevented and managed. Each team member should be assigned a specific fire management task to perform in the event of a fire (e.g., removing the tracheal tube, turning off the airway gases). Each team member should understand that his or her preassigned task should be performed immediately if a fire occurs, without waiting for another team to take action. When a team member has completed a preassigned task, he or she should help other team members to perform tasks that are not yet complete. In every operating room and procedure area where a fire triad can coexist (i.e., an oxidizer-enriched atmosphere, an ignition source, and fuel), an easily visible protocol for the prevention and management of fires should be displayed. Equipment for managing a fire should be readily available in every procedural location where a fire triad may exist.

The anesthesiologist should collaborate with all members of the procedure team throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source. For all procedures:

• Surgical drapes should be configured to minimize the accumulation of oxidizers (oxygen and nitrous oxide) under the drapes and from flowing into the surgical site.

• Flammable skin-prepping solutions should be dry before draping.

• Gauze and sponges should be moistened before use in proximity to an ignition source.

For high-risk procedures:

• The anesthesiologist should notify the surgeon whenever there is a potential for an ignition source to be in proximity to an oxidizer-enriched atmosphere or when there is an increase in oxidizer concentration at the surgical site.

• Any reduction in supplied oxygen to the patient should be assessed by monitoring (1) pulse oximetry and, if feasible, (2) inspired, exhaled, and/or delivered oxygen concentration.

For laser procedures:

• A laser-resistant tracheal tube should be used.

The laser-resistant tracheal tube used should be chosen to be resistant to the laser used for the procedure (e.g., carbon dioxide, Nd:YAG, Ar, Er:YAG, KTP).

• The tracheal cuff of the laser tube should be filled with saline and colored with an indicator dye such as methylene blue.

• Before activating a laser:

The surgeon should give the anesthesiologist adequate notice that the laser is about to be activated.

The anesthesiologist should:

• Reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.

• Stop the use of nitrous oxide.

• Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving activation of the laser.

For cases involving an ignition source and surgery inside the airway:

• Cuffed tracheal tubes should be used when clinically appropriate.

• The anesthesiologist should advise the surgeon against entering the trachea with an ignition source (e.g., electrosurgery unit).

• Before activating an ignition source inside the airway:

The surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated.

The anesthesiologist should:

• Reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.

• Stop the use of nitrous oxide.

• Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source.

• In some cases (e.g., surgery in the oropharynx), scavenging with suction may be used to reduce oxidizer enrichment in the operative field

For cases involving moderate or deep sedation, an ignition source, and surgery around the face, head, or neck:

• The anesthesiologist and surgeon should develop a plan that accounts for the level of sedation and the patient’s need for supplemental oxygen.

If moderate or deep sedation is required or used, or if the patient exhibits oxygen dependence, the anesthesiologist and surgeon should consider a sealed gas delivery device (e.g., cuffed tracheal tube or laryngeal mask).

If moderate or deep sedation is not required, and the patient does not exhibit oxygen dependence, an open gas delivery device (e.g., face mask or nasal cannula) may be considered.

• Before activating an ignition source around the face, head, or neck:

The surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated.

The anesthesiologist should:

• Stop the delivery of supplemental oxygen or reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.

• Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source.

When an early warning sign is noted, halt the procedure and call for an evaluation of fire. When a fire is definitely present, immediately announce the fire, halt the procedure, and initiate fire management tasks. Team members should perform their preassigned fire management tasks as quickly as possible:

• Before the procedure, the team may identify a predetermined order for performing the tasks.

• If a team member cannot rapidly perform his or her task in the predetermined order, other team members should perform their tasks without waiting.

• When a team member has completed a preassigned task, he or she should help other members to perform tasks that are not yet complete.

For a fire in the airway or breathing circuit, as fast as possible:

• Remove the tracheal tube.

• Stop the flow of all airway gases.

• Remove all flammable and burning materials from the airway.

• Pour saline or water into the patient’s airway.

For a fire elsewhere on or in the patient, as fast as possible:

• Stop the flow of all airway gases.

• Remove all drapes, flammable, and burning materials from the patient.

• Extinguish all burning materials in, on, and around the patient (e.g., with saline, water, or smothering).

If the airway or breathing circuit fire is extinguished:

• Reestablish ventilation by mask, avoiding supplemental oxygen and nitrous oxide, if possible.

• Extinguish and examine the tracheal tube to assess whether fragments were left in the airway.

Consider bronchoscopy (preferably rigid) to look for tracheal tube fragments, assess injury, and remove residual debris.

• Assess the patient’s status and devise a plan for ongoing care.

If the fire elsewhere on or in the patient is extinguished:

• Assess the patient’s status and devise a plan for ongoing care of the patient.

• Assess for smoke inhalation injury if the patient was not intubated.

If the fire is not extinguished after the first attempt (e.g., after performing the preassigned tasks):

• Use a carbon dioxide fire extinguisher in, on, or around the patient.

• If the fire persists after use of the carbon dioxide fire extinguisher:

• Activate the fire alarm.

• Evacuate the patient if feasible, following institutional protocols.

• Close the door to the room to contain the fire and do not reopen it or attempt to reenter the room.

• Turn off the medical gas supply to the room.

• Follow local regulatory reporting requirements (e.g., report fires to your local fire department and state department of health).

• Treat every fire as an adverse event, following your institutional protocol.