Fire Prevention and Safety During Surgical Procedures

Ignition Sources ::

Electrosurgical unit

Electrocautery unit

Laser

Sparks — tissue embers

Electrosurgical electrodes and battery-operated electrocautery devices are frequently ignition sources for surgical fires.

ECRI describes how an electrosurgical pencil caused a drape fire because it was not placed in a non-conductive holster. In this incident, a pencil fell off the sterile field, was not removed and instead was left dangling. A surgical team member leaned against the pencil, causing it to activate, arc through the drapes to an instrument table and ignite the drapes. The flame spread rapidly up the drapes vertically from the point of ignition, about two feet off the floor, to the patient. By this time, the fire was burning with such intensity that all other flammable materials on and around the patient ignited and quickly burned. This fire was fatal to the patient. It should be pointed out that materials burn more quickly when vertical. Buoyant convection of hot gases makes the fire spread quickly upward even in ambient air.

In another example, a disposable electrocautery pencil caused a drape fire. The surgeon asked for a disposable electrocautery pencil to cauterize a bleeder, and was given a device with a 2-inch shaft rather that the 1/2-inch shaft he was accustomed to using. He could not see that he had been given the wrong instrument because he was using the operating microscope. He turned the electrocautery on at the instant that the device was handed to him so that it would be hot by the time it reached the operative site seconds later. As the device approached the operative site, the now red-hot tip grazed the drapes over the patient's nose. Oxygen was being delivered through a nasal cannula. When the tip touched the drapes a large ball of flame erupted on the patient's face. In a startle reaction, the surgeon scratched the patient's cornea with the tip. The patient was also burned along the right nostril and right orbit. When the fireball occurred, the anesthesiologist immediately turned off the oxygen, and the surgeon ripped the drapes off the patient's face. Their quick reactions minimized injury to the patient.

For a few seconds after deactivation, a heated electrosurgery or electrocautery tip, fiber-optic cable tip or laser contact tip can retain enough heat to melt plastic or ignite some fuels. An example of this type of fire was reported to a medical device manufacturer. In this surgery, a Cesarean section, smoke was seen coming from under the patient's arm. The surgical staff pulled back the drapes and flames erupted. The fire was smothered, but not before the patient sustained a second degree burn to her arm. Investigation by the hospital biomedical department revealed that the fire most likely started when an electrosurgical pencil tip that was still hot from use inadvertently touched the drape.

When using a laser there is always the danger of instantaneous ignition of a fuel source. There is also danger of a fire secondary to a beam being reflected off instruments or from damaged laser fibers. Lasers do not have to be in contact with a fuel to ignite it. In fact, the laser can ignite a fire at some distance from the tip or through several layers of material.

The following example describes a fire that occurred when a surgeon used a laser to cauterize cervical polyps. During the procedure the surgeon placed the laser handpiece against the patient's left thigh pointing toward her left buttock. The surgeon then slid the laser footswitch out of the way with a foot just a moment before the nurse placed the laser in standby mode. During this maneuver, the surgeon accidentally activated the laser. The laser penetrated the outer drapes, which did not ignite because of the flow of clearing gas from the handpiece. However, the dry area of the absorbent towels under the patient's left buttock ignited. The fire burned slowly for a minute or two, concealed by the outer drapes. Subsequently, flames erupted from the legging drapes. The patient suffered significant burns to her left inner thigh.

Sparks can also ignite fuels. In an oxygen-enriched atmosphere, even glowing embers of charred tissue are enough to ignite some fuels. As an example, the ECRI describes a throat fire secondary to ignition of a dry sponge. In this case, surgery was being performed in the back of the throat of a patient under general anesthesia with an endotracheal tube. The area above the tube cuff had been packed with wet gauze. The sponge dried out during the course of surgery, and became oxygen-enriched because of a minor leak around the cuff. During the use of the electrosurgical pencil, a glowing ember of charred tissue floated down into the back of the patient's throat, ignited the sponge and caused flames to briefly erupt from the patient's mouth. The patient sustained minor burns.

< Previous | Next >