Operating Room Fire Prevention: Creating an Electrosurgical Unit Fire Safety Device

Orthopaedic Operating Room Fire Risks: FDA Database and Literature Review

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Inadvertent activation of electrosurgical device was more likely to result in patient burns and harm.

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There are significant knowledge gaps in the orthopaedic surgery community relating to fire prevention, fire safety, and fire management.

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Arthroplasty was the most common procedure with reported fire events.

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It is the responsibility of the orthopaedic surgeon to understand the risks of surgical fire in the operating room and implement actions to reduce those risks.

Carbon dioxide can eliminate operating room fires from alcohol-based surgical skin preps

INTRODUCTION

Surgical fires are a rare event that still occur at a significant rate and can result in severe injury and death. Surgical fires are fueled by vapor from alcohol-based skin preparations in the presence of increased oxygen concentration and a spark from an energy device. Carbon dioxide (CO₂) is used to extinguish electrical fires, and we sought to evaluate its effect on fire creation in the operating room. We hypothesize that CO₂ delivered by the energy device will decrease the frequency of surgical fires fueled by alcohol-based skin preparations.

METHODS

An ex vivo model with 15 × 15 cm section of clipped, porcine skin was used. A commercially available electrosurgical pencil with a smoke evacuation tip was connected to a laparoscopic CO₂ insufflation system. The electrosurgical pencil was activated for 2 s at 30 watts coagulation mode immediately after application of alcohol-based surgical skin preparations: 70% isopropyl alcohol with 2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol with 0.7% iodine povacrylex (Iodine-IPA). CO₂ was infused via the smoke evacuation pencil at flow rates from 0 to 8 L/min. The presence of a flame was determined visually and confirmed with a thermal camera (FLIR Systems, Boston, MA).

RESULTS

Carbon dioxide eliminated fire formation at a flow rate of 1 L/min with CHG-IPA skin prep (0% vs. 60% with no CO₂, p < 0.0001). Carbon dioxide reduced fire formation at 1 L/min (25% vs. 47% with no CO₂, p = 0.1) with Iodine-IPA skin prep and fires were eliminated at 2 L/min of flow with Iodine-IPA skin prep (p < 0.0001).

CONCLUSION

Carbon dioxide can eliminate surgical fires caused by energy devices in the presence of alcohol-based skin preps. Future studies should determine the optimal technique and flow rate of carbon dioxide in these settings.

Operating Room Fires

Operating room fires are rare but devastating events. Guidelines are available for the prevention and management of surgical fires; however, these recommendations are based on expert opinion and case series. The three components of an operating room fire are present in virtually all surgical procedures: an oxidizer (oxygen, nitrous oxide), an ignition source (i.e., laser, “Bovie”), and a fuel. This review analyzes each fire ingredient to determine the optimal clinical strategy to reduce the risk of fire. Surgical checklists, team training, and the specific management of an operating room fire are also reviewed.

Risks and prevention of surgical fires : A systematic review

Surgically induced fire is a life-threatening hazard; this topic has received little attention, although only 3 factors, the so-called fire triad, are needed for surgical fires to occur: an oxidizer, fuel and an ignition source. This systematic review aims to determine the impact of each component and to delegate every staff member an area of responsibility, thus ensuring patient health through prevention or protection. The trial was registered in Prospero CRD42018082656. A database search of eligible, preferably evidence-based studies was conducted. The Robins-I tool for assessing the risk of bias revealed a moderate risk of bias. Due to insufficient data, the main findings of these studies could not be summarized through a quantitative synthesis; therefore, a qualitative synthesis is outlined. The results are summarized according to the roles of the fire triad and discussed. (1) Role of the oxidizer: oxygen is the key component of the triad. Safe oxygen delivery is important. An oxygen-enriched environment (ORE) is caused by draping and is preferably prevented by suctioning. Fuel characteristics are affected by varying oxygen concentrations. (2) Role of the ignition source: electrocauterization is the most common ignition source, followed by lasers. Less common ignition sources include fiberoptic cables and preparative solutions, petrol or acetone. (3) Role of the fuel: surgical drapes are one of the most common fuels for surgical fires followed by the patient's hair and skin. Skin preparation solutions are among the less common fuels. Many fire-resistant materials have been tested that do not remain fire resistant in ORE. It was concluded that the main problem is defining the real extent of this hazard. Exact numbers and exact condition protocols are needed; therefore, standardized registration of every fire and future studies with much evidence are needed. Immediate prevention consists of close attention to patient safety to prevent surgical fires from happening.