Electrocautery-ignited endotracheal tube fire: case report

Electrosurgical unit: Iatrogenic injuries and medico-legal aspect. Italian legal rules, experience and article review

BACKGROUND

The use of the electrosurgical unit (ESU) is well-established in the surgical practice. The Authors, to better understand the genesis of injuries connected to the use of electrosurgical instruments, conducted an in-depth literature review pertaining to this topic.

MATERIALS AND METHOD

Using the most important medical databases, a research of experimental studies in the last 20 years was conducted.

RESULTS

The analysis of the mechanisms responsible for the lesions showed that high energy devices remain as the most common cause of injury. Adverse events are mainly given by thermal injuries; cases of electromagnetic interference are also described in patients with pacemakers or sacral nerve stimulator and spinal stimulators as well as cases of fire of the endotracheal tube in the course of tracheostomy for the use of the electrosurgical unit in an environment with a high concentration of oxygen or anesthetic gases. Also reported in the literature are individual cases of fires caused by sparks from the electrosurgical handpiece also for the use of disinfectants and/or in relation to surgical drapes.

CONCLUSION

In order to clearly define the medical-legal aspects, focusing on the professional responsibility of the surgical and nursing staff, the authors' attention was brought to the need for an effective prevention plan that highlights not only the importance of an accurate procedural knowledge in order to safety use the electrosurgical instruments, but also the need for a system that monitors any complications or adverse events resulting from the use of such instruments.

The prevention of fire during oropharyngeal electrosurgery

We report the results of our study of 25 children who underwent tonsillectomy and/or adenoidectomy under endotracheal general anesthesia with respect to their risk of fire in the oropharynx. We also attempt to explain the reasons for the difference between the relatively high incidence of airway explosions and fires that have occurred during tracheostomy with electrosurgery and electrocautery and the low incidence of these events during electrosurgical dissection of the tonsils. Finally, we review the precautions that physicians can take to lower the risk of operating-room fires and explosions.

Surgical Fires in Otolaryngology: A Systematic and Narrative Review

Objective

To bring attention to the epidemiology, prevention, management, and consequences of surgical fires in otolaryngology by reviewing the literature.

Data Sources

PubMed, EMBASE, Web of Science, and Scopus.

Review Methods

Comprehensive search terms were developed, and searches were performed from data source inception through August 2016. A total of 4506 articles were identified; 2351 duplicates were removed; and 2155 titles and abstracts were independently reviewed. Reference review was also performed. Eligible manuscripts described surgical fires involving patients undergoing otolaryngologic procedures.

Results

Seventy-two articles describing 87 otolaryngologic surgical fire cases were identified. These occurred during oral cavity or oropharyngeal procedures (11%), endoscopic laryngotracheal procedures (25%), tracheostomies (36%), “other” general anesthesia procedures (3%), and monitored anesthesia care or local procedures (24%). Oxidizing agents consisted of oxygen alone (n = 63 of 81, 78%), oxygen and nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81, 1%). The fractional inspired oxygen delivered was >30% in 97% of surgical fires in non–nitrous oxide general anesthesia cases (n = 35 of 36). Laser-safe tubes were used in only 12% of endoscopic laryngotracheal cases with endotracheal tube descriptions (n = 2 of 17). Eighty-six percent of patients experienced acute complications (n = 76 of 87), including 1 intraoperative death, and 22% of patients (n = 17 of 77) experienced long-term complications.

Conclusion

Surgical fires in otolaryngology persist despite aggressive multi-institutional efforts to curb their incidence. Guideline recommendations to minimize the concentration of delivered oxygen and use laser-safe tubes when indicated were not observed in many cases. Improved institutional fire safety practices are needed nationally and internationally.

Successful Treatment of Carcinomatous Central Airway Obstruction with Bronchoscopic Electrocautery Using Hot Biopsy Forceps during Mechanical Ventilation

We report the case of a 72-year-old man with occlusion of the left main bronchus due to squamous cell carcinoma of the lung. He required tracheal intubation and mechanical ventilation because of the aggravation of atelectasis and obstructive pneumonia. Electrocautery using hot biopsy forceps was performed during mechanical ventilation with a 40% fraction of inspired oxygen. He was extubated following improvement in the atelectasis and obstructive pneumonia and discharged with shrinkage of the tumor after chemotherapy. We describe a safe electrocautery procedure using hot biopsy forceps during mechanical ventilation with reference to previous reports.

Electrocautery-Ignited Surgical Field Fire Caused by a High Oxygen Level during Tracheostomy

Tracheostomy is a relatively common surgical procedure that is performed easily in an operating room or intensive care unit. Open tracheostomy is needed in patients requiring prolonged ventilation when percutaneous tracheostomy is inappropriate. Sometimes, it is difficult to achieve bleeding control in the peritracheal soft tissue, and in such cases, we usually use diathermy. However, the possibility of an electrocautery-ignited surgical field fire can be overlooked during the procedure. This case report serves as a reminder that the risk of a surgical field fire during tracheostomy is real, particularly in patients requiring high-oxygen therapy.

Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires

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Laryngeal surgery using a CO2 laser: is a polyvinylchloride endotracheal tube safe?

OBJECTIVE

We performed retrospective clinical analysis and in vitro testing to analyze the risks involved in laryngeal surgery using a CO(2) laser.

MATERIALS AND METHODS

The occurrence of adverse events during laryngeal surgeries using a CO(2) laser, the reasons for these adverse events, and the risks of laryngeal laser surgery were analyzed in 704 patients. In vitro experiments were performed to observe the tolerance of the cuffs of polyvinylchloride (PVC) endotracheal tubes to the CO(2) laser under conditions of filling water or air, different laser power levels, and different cutting patterns. The flammability of the PVC endotracheal tube under different oxygen concentrations, laser power levels, and laser cutting patterns were also studied.

RESULTS

In the 704 patients who underwent laryngeal laser surgery, the tracheal cuff broke in 92 cases; sparks were observed in 8 cases; and dense smoke, in 27 cases during surgery. No fires or explosions occurred. The in vitro results were as follows: (1) Under the intermittent stimulation mode, the water cuff did not break, but the air cuff broke during the first stimulation. (2) Under the continuous stimulation mode, the water and air cuffs broke easily, and the water and air cuffs broke immediately when the stimulation power was greater than 8 W. (3) Under the intermittent stimulation mode, the PVC endotracheal tube burned only under conditions of pure oxygen supply and 10 W of laser power. Under the continuous stimulation mode, the tube did not burn with 5 W of laser power, regardless of the oxygen concentration used. When the laser power level reached 8 W and the oxygen concentration was greater than 50%, the tube will easily burn. When the laser power level was 10 W, the tube burned at oxygen concentrations greater than 20%.

CONCLUSIONS

Burning of the tube during laryngeal surgery using a CO(2) laser could be effectively avoided when appropriate measures were taken, such as filling the endotracheal cuff with water, maintaining less than 40% oxygen concentration, using less than 8 W laser power, and using the intermittent stimulation mode.

Electrosurgery ignition of a pneumoperitoneum secondary to prior spontaneous perforation of the small bowel: a cautionary tale

We describe explosive combustion of a gas filled peritoneum from a handheld electrosurgery electrode used to enter the abdomen. The pneumoperitoneum was due to small bowel perforation and peritonitis had been established for at least two days. No injury was caused to either the patient or medical staff. This rare occurrence has only been described once before. Surgeons should be aware of the possible combustion of bowel gas, whether on opening bowel or the peritoneum after bowel perforation.

Operating room fires in otolaryngology: risk factors and prevention

PURPOSE

The aim of the study was to characterize the causes of operating room (OR) fires in otolaryngology.

MATERIALS AND METHODS

A questionnaire was designed to elicit the characteristics of OR fires experienced by otolaryngologists. The survey was advertised to 8523 members of the American Academy of Otolaryngology-Head and Neck Surgery.

RESULTS

Three hundred forty-nine questionnaires were completed. Eighty-eight surgeons (25.2%) witnessed at least one OR fire in their career, 10 experienced 2 fires each, and 2 reported 5 fires each. Of 106 reported fires, details were available for 100. The most common ignition sources were an electrosurgical unit (59%), a laser (32%), and a light cord (7%). Twenty-seven percent of fires occurred during endoscopic airway surgery, 24% during oropharyngeal surgery, 23% during cutaneous or transcutaneous surgery of the head and neck, and 18% during tracheostomy; 7% were related to a light cord, and 1% was related to an anesthesia machine. Eighty-one percent of fires occurred while supplemental oxygen was in use. Common fuels included an endotracheal tube (31%), OR drapes/towels (18%), and flash fire (where no substrate burned) (11%). Less common fuels included alcohol-based preparation solution, gauze sponges, patient's hair or skin, electrosurgical unit with retrofitted insulation over the tip, tracheostomy tube, tonsil sponge, suction tubing, a cottonoid pledget, and a red rubber catheter.

CONCLUSIONS

OR fire may occur in a wide variety of clinical settings; endoscopic airway surgery, oropharyngeal surgery, cutaneous surgery, and tracheostomy present the highest risk for otolaryngologists. Electrosurgical devices and lasers are the most likely to produce ignition.

Crisis in the operating room: fires, explosions and electrical accidents

Fires, explosions and electrical accidents in the operating theater are rare events, but are devastating in terms of structural damage to the equipment in theaters and to human lives. While various circumstances lead to these troubles, we can avoid and manage them by learning from the instructive cases accumulated so far. We describe operating room crises such as fires, explosions and electrical breakdowns, and discuss causes and countermeasures.

Suction cautery and electrosurgical risks in otolaryngology

BACKGROUND

Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature.

METHODS

FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries.

RESULTS

Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices.

CONCLUSIONS

Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.

Fatal inhalation injury caused by airway fire during tracheostomy

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

AIRWAY FIRE DURING TRACHEOTOMY

We report a case of airway fire during surgical tracheotomy using diathermy for the incision into the trachea. A literature review of airway fire during tracheotomy was carried out, and the management of airway fire is discussed. Recommendations are made to prevent this adverse outcome.

Electrocautery-induced fire during adenotonsillectomy: report of two cases

We describe two cases of flash fires in the oropharynx, secondary to electrocautery during adenotonsillectomies. We believe that in both cases, the leak around the uncuffed endotracheal tubes raised the oxygen concentration in the oropharynx. Cuffed endotracheal tubes provide many advantages, and their use should strongly be considered during adenotonsillectomy in children when electrocautery is to be used.

Duraprep and the risk of fire during tracheostomy

BACKGROUND

DuraPrep is a widely used, alcohol-based surgical prep solution. The risk of surgical fire associated with incomplete drying of this agent in the context of electrosurgical procedures has been described previously. To date, there have been no reports of fire during tracheostomy associated with a flammable prep agent before entering the airway. We describe an operating room fire occurring during awake tracheostomy associated with the use of DuraPrep.

METHODS

A 62-year-old man with copious body hair underwent tracheostomy in the operating room. The neck was prepared with DuraPrep surgical solution, and after at least 3 minutes, the operative field was draped. Activation of electrocautery ignited a fire, and the patient was burned on his neck and shoulders.

RESULTS

The fire was extinguished, and the patient recovered from both the tracheostomy and the burns.

CONCLUSION

This case illustrates that DuraPrep should be avoided in the hirsute patient, because body hair interferes with drying of this solution and increases the risk of fire.

Surgical Field Fire During a Repair of Bronchoesophageal Fistula

Most surgical fires involve the airway but they can also occur in the surgical field. Herein, we report an intraoperative fire in the surgical field during repair of a bronchoesophageal fistula. During the portion of the surgery after the fistula was divided and the bronchus was open to atmosphere, continuous positive airway pressure was applied to the nondependent lung, and in conjunction with the use of electrocautery and dry sponges in the field, resulted in a fire. Anesthesia for thoracic surgery carries unique risks of fire because these patients frequently require large oxygen concentrations, special interventions for improving oxygenation, and have variable degrees of airway disruption. This report highlights unique safety concerns during anesthesia for thoracic surgery, and addresses more general safety issues relating to fire risk in all surgical patients.

Value of endotracheal tube safety in laryngeal laser surgery

BACKGROUND AND OBJECTIVES

Due to the increased popularity of laryngeal laser therapy, surgeons and anesthesiologists are inevitably confronted with questions concerning the choice of the most efficient endotracheal tube (ETT) for laryngeal laser surgery, especially with regard to possible endolaryngeal tube fires, or combustions. The purpose of this study was to determine the current practice in endolaryngeal laser surgery in Germany.

STUDY DESIGN/MATERIALS AND METHODS

A questionnaire was sent to 152 ENT Departments in Germany, care was taken that the responders could send back the questionnaire anonymously. Among other questions the participants were asked for the number of lasersurgical treatments of the larynx performed in the past, the usual type of ETTs in use, whether other safety precautions were taken during CO2 laser surgery of the larynx and for intraoperative complications like tube ignition, fires or combustions.

RESULTS

Eighty six of the 152 addressed ENT departments replied. In laryngeal laser surgery, 59/86 departments regularly use special laser tubes in daily routine (74.5%). In about 20,000 lasersurgical procedures, 15 incidents of ETT fire have been reported. In six of the reported 15 cases a tube fire occurred despite the fact that special laser tubes had been utilized.

CONCLUSIONS

The present study could demonstrate that the use of special laser tubes does not necessarily protect against ETT fire. Thus, even when using special laser tubes other safety measures should be taken. In view of the maximum safety for the patient it has to be stated, that the safety during surgery correlates definitely with the experience of the surgeon. The weakest point of ETTs is usually situated in the cuff region.

Electrophysical properties of electrosurgery and capacitive induced current

BACKGROUND

Although electrosurgery is one of the most commonly used technologies in the operating room, its electrophysical properties, including the potential for complications, are poorly understood by many surgeons.

METHODS

We describe the experimental simulation of a highly unusual complication that occurred during a surgical procedure requiring concurrent use of monopolar and bipolar electrosurgery.

RESULTS

Capacitive induced current from an activated monopolar electrode to the bipolar cord was reproduced and consistently led to full-thickness burns in our experiments.

CONCLUSIONS

Surgeons should be familiar with the principles of electrosurgery, its electrophysical properties, and possible complications.