Abstract
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.
1
Introduction
The initiation and propagation of any fire requires an ignition source, fuel, and an oxidizer. Electrosurgical units, lasers, and fiber optic light cords are all well-described ignition sources for surgical fires. Common sources of “fuel” in an operating room (OR) include endotracheal tubes (ETTs), drapes or towels, sponges, and alcohol-based preparation solutions . The presence of an oxidizing agent, such as oxygen or nitrous oxide, is the final critical factor in the triad. Patients undergoing head and neck surgery are at particular risk of fire because of the proximity of the surgical field to high concentrations of oxidizing agents (oxygen or nitrous oxide). In addition, lasers, electrosurgical devices, and high-powered light cables are commonly used by otolaryngologists. To minimize the risk, it is imperative that surgeons understand the common causes of surgical fires and how to prevent them.
There have been numerous case reports describing OR fires occurring in association with monopolar electrosurgical devices and lasers and a few reports involving fiber optic light cables . These reports have described fire during adenotonsillectomy , endoscopic laser surgery , facial surgery , or tracheotomy . Interestingly, surgical fire represents the second most common cause of injury resulting in liability during monitored anesthesia care (MAC) cases and represents the most common major complication of endoscopic laser surgery . To our knowledge, no systematic study has been performed to characterize the common causes of OR fires in head and neck surgery. In this report, we set out to describe what conditions actually contribute to fire formation by surveying otolaryngologists regarding their experiences with OR fire.
2
Materials and methods
An Internet-based questionnaire was designed to elicit the characteristics of OR fires experienced by otolaryngologists (questionnaire). A link to the survey was included in the bulletin e-mailed to all 8523 members of the American Academy of Otolaryngology—Head and Neck Surgery. Typically, approximately 2300 members open the e-mail containing the bulletin. The project was reviewed by the institutional review board for the North Shore—Long Island Jewish health system and deemed exempt from institutional review board approval.
2
Materials and methods
An Internet-based questionnaire was designed to elicit the characteristics of OR fires experienced by otolaryngologists (questionnaire). A link to the survey was included in the bulletin e-mailed to all 8523 members of the American Academy of Otolaryngology—Head and Neck Surgery. Typically, approximately 2300 members open the e-mail containing the bulletin. The project was reviewed by the institutional review board for the North Shore—Long Island Jewish health system and deemed exempt from institutional review board approval.
3
Results
Of the 2300 members who typically open the bulletin, 349 questionnaires were completed for a response rate of 15.2%. Fifty percent of the responders were in private practice, 35% were in academic practice, 10% were residents or fellows, and 5% did not fit any of the above categories. A wide distribution of years in practice was noted among respondents ( Fig. 1 ). The most common number of years in practice was 15 to 20, representing 20% of respondents. Table 1 describes the subspecialty interest among responders. The highest percentage of responders practiced general otolaryngology (44.1%), with pediatric otolaryngology (20.9%) and head and neck surgery (13.2%), being second and third most common, respectively. Otology/Neurotology (6.6%), facial plastics (3.7%), laryngology (2.9%), and rhinology (2.6%) were also well represented. Only a couple of responders described themselves as practicing primarily allergy (0.6%) or sleep medicine (0.3%).
| Subspecialty | % | n |
|---|---|---|
| General otolaryngology | 44.1 | 154 |
| Pediatric otolaryngology | 20.9 | 73 |
| Head and neck | 13.2 | 46 |
| Otology/Neurotology | 6.6 | 23 |
| Facial plastics | 3.7 | 13 |
| Laryngology | 2.9 | 10 |
| Rhinology | 2.6 | 9 |
| Allergy | 0.6 | 2 |
| Sleep medicine | 0.3 | 1 |
| Resident/fellow | 5.2 | 18 |
| Total | 100.0 | 349 |
Eighty-eight surgeons (25.2%) have experienced at least one OR fire in their career, 10 experienced 2 fires each, and 2 surgeons reported 5 fires each. Of the 106 reported fires, details were available for 100. The most common ignition sources were a monopolar electrosurgical unit (59%), a laser (32%), and a light cord (7%) ( Table 2 ). One respondent each reported a fire in association with either a bipolar electrosurgical unit or possibly an anesthesia machine.
| Ignition source | % | n |
|---|---|---|
| Electrosurgical unit (monopolar) | 59 | 59 |
| Laser | 32 | 32 |
| Carbon dioxide laser | 27 | 27 |
| Other laser (not carbon dioxide) | 5 | 5 |
| Light cord | 7 | 7 |
| Electrosurgical unit (bipolar) | 1 | 1 |
| Anesthesia machine | 1 | 1 |
| Total | 100 | 100 |
Table 3 illustrates the surgical scenarios during which a fire occurred. Twenty-seven percent of fires occurred during endoscopic laryngeal or airway surgery, 24% during oropharyngeal surgery (eg, adenotonsillectomy or uvulopalatopharyngoplasty), 23% during cutaneous or transcutaneous surgery, and 18% during tracheostomy; 7% were related to a light cord, and 1% was related to an anesthesia machine. In 6 of the 7 cases where a light cord was involved in the “fire,” respondents stated that the exposed end of a fiber optic light cable had melted through drapes but not actually ignited them. Details were not available for the other case involving a light cord. Eighty-one percent of fires (including incidents involving the light cables) occurred while supplemental oxygen was in use.
| Surgical scenario | % | n |
|---|---|---|
| Endoscopic airway surgery | 27 | 27 |
| Oropharyngeal surgery | 24 | 24 |
| Cutaneous/Transcutaneous surgery | 23 | 23 |
| Tracheostomy | 18 | 18 |
| Light cord melted drapes | 7 | 7 |
| Anesthesia machine caught fire | 1 | 1 |
| Total | 100 | 100 |
Table 4 details the conditions that produced an OR fire in each of the 4 most common surgical scenarios. During endoscopic airway and laryngeal procedures, a laser was the ignition source in 26 (96%) of 27 fires. The carbon dioxide laser was by far the most common laser involved in OR fires, representing 22 (81%) of the involved scenarios. More than half (55%) of the cases involved ignition of an ETT. Three respondents volunteered that a “laser safe” tube was being used; 2 of whom stated that a hole in the ETT was responsible for the fire. Suction tubing was the fuel for 3 of the fires. In each of these cases, laser bronchoscopy was being performed. In 2 of these cases, a broken potassium-titanyl-phosphate laser fiber ignited the suction catheter within the substance of the bronchoscope.
| Endoscopic laryngeal or airway surgery | |||||
|---|---|---|---|---|---|
| Ignition source | Fuel | Oxygen | |||
| Carbon dioxide laser | 22 | ETT | 15 | Yes | 25 |
| Potassium-titanyl-phosphate laser | 3 | Flash | 5 | No | 2 |
| Other laser | 1 | Suction tubing | 3 | ||
| Light cord | 1 | Pledget | 2 | ||
| Tracheostomy | 1 | ||||
| Light cord | 1 | ||||
| Total | 27 | Total | 27 | Total | 27 |
| Oropharyngeal surgery | |||||
|---|---|---|---|---|---|
| Ignition source | Fuel | Oxygen | |||
| Electrosurgical unit (monopolar) | 24 | ETT | 9 | Yes | 22 |
| Tonsil sponge | 4 | No | 2 | ||
| Electrosurgical tip (bovie) | 4 | ||||
| Electrosurgical tip (bovie) (with retrofitted insulation) | 2 | ||||
| Red rubber catheter | 2 | ||||
| Flash fire (ie, nothing burned) | 1 | ||||
| Unknown (not reported) | 1 | ||||
| Total | 24 | Total | 24 | Total | 24 |
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