Cause of Device-Related Incident
Device factors; External factors; Support system failures; User errors

Clinical Specialty or Hospital Department
Anesthesia; Clinical/Biomedical Engineering; Emergency Medicine; Neurological Surgery; OR / Surgery; Otolaryngology; Pulmonary / Respiratory Therapy

Device Factors
Device interaction

Document Type
Hazard Reports

External Factors
Medical gas and vacuum supplies

Mechanism of Injury or Death
Fire

Support System Failures
Failure to train and / or credential; Use of inappropriate devices

Tampering and/or Sabotage
*Not stated

User Errors
Failure to read label; Incorrect clinical use

UMDNS
Anesthesia Units [10-134]; Cannulae, Nasal Oxygen [12-700]; Masks [12-447]; Electrosurgical Units [11-490]; Electrocautery Units [11-418]; Lasers [12-296]

Fires from Oxygen Use during Head and Neck Surgery



Hazard [Health Devices Apr 1995;24(4):155-6]

Problem

We have seen an increase in the frequency of fires during head and neck surgery. Some are small and easy to extinguish, while others are large and cause extensive patient injury, and sometimes death. The majority of these fires are caused by oxygen enrichment of the surgical field from various types of oxygen-delivery devices and are ignited by heat-producing surgical instruments (e.g., electrosurgical unit [ESU] or electrocautery unit pencils, lasers).

Background

Since the mid-1970s, ECRI has frequently investigated and published articles on surgical fires (see References). We suspect that the increased use of pulse oximetry to ensure that the patient is being properly ventilated has spawned the almost unquestioned use of supplemental oxygen from open sources under the surgical drapes to achieve and maintain a patient-oxygen-saturation level of 100%. However, 100% oxygenation is typically not required, and many oxygen-delivery devices exhaust oxygen near the patient's nose and mouth as a matter of course or through an inadvertent leak (e.g., in the tracheal cuff or nasal oxygen cannula; through an ill-fitting anesthesia mask). When the patient is covered by surgical drapes, excess oxygen can be directed into the surgical field (e.g., through folds in the drapes, through a mask at the margin of the surgical site), enriching this space.

In oxygen-enriched atmospheres (OEAs), a phenomenon called "surface fiber flame propagation" (SFFP) can occur. In this phenomenon, the fine surface fibers of fabric, nap of cloth, or body hair (e.g., vellus) can be ignited, causing a flame front to rapidly flash over the surface and ignite more massive fuels at the edges of the surface. Nitrous oxide also supports combustion and can be a source of oxygen enrichment. Even in only 50% oxygen concentrations, heat from many surgical instruments and procedures is sufficient to initiate SFFP, often beginning with a spark or flame and an audible pop at the ignition point.

Most often, an ESU pencil is the ignition source, as the heat from its action vaporizes tissue or expels tissue embers from the tip. In room air, the tissue vapors do not ignite, and the embers quickly extinguish. However, in an OEA, the vapors will ignite into a brief flame, and the embers can fly several inches, burning until consumed. The heat from these small fires is sufficient to ignite an SFFP fire or nearby ignitable material. Similarly, the action of electrocautery (i.e., heated wire) pencils, lasers, or other heat-producing surgical devices can ignite an SFFP fire. In addition, when in the airway, a tissue ember or tissue vapor flame can ignite dry sponges or gauze in the airway.

The key to preventing fires during head and neck surgery is to limit the oxygen concentration to that of room air (i.e., 21%) beneath the drapes, in the oropharynx, and in the vicinity of the surgical field.

Recommendations

  1. During head and neck surgery, use an open oxygen source (e.g., oxygen cannula, mask) only when absolutely indicated. Indications for use should be formally reviewed by the hospital's anesthesia department. If supplemental oxygen is needed, use the lowest concentration possible. Pulse oximetry can be used to help determine when additional oxygen is needed to maintain the blood oxygenation within a safe range; 100% oxygenation is typically not needed.
  2. If an open oxygen source must be used, the surgeon should be warned of the fire hazard. The risk of fire can be minimized by switching patient ventilation to air or a low oxygen concentration at least one minute before the use of heat-producing surgical instruments (e.g., ESUs, lasers) to allow oxygen enrichment of the surgical site to dissipate. When use of the heat source is completed and any tissue embers are extinguished, enriched oxygen ventilation can continue. This procedure requires good communication among the surgical team and may not always be practical.
  3. Tent drapes to allow oxygen, which is slightly heavier than air, to drain away from the patient's head and toward the floor.
  4. Use suction to scavenge excess oxygen in the oropharynx around the tracheal tube cuff.
  5. Use occlusive drapes (also known as incise drapes) when possible to help separate the surgical field from the under-drape space. Recognize, however, that an OEA will still exist under the surgical drapes.

References

From Health Devices

Fires from defibrillation during oxygen administration [Hazard Report]. 1994 Jul;23(7):307-9.

"The patient is on fire!"—A surgical fires primer [Guidance Article]. 1992 Jan;21(1):19-34.

Airway fires: Reducing the risk during laser surgery [Clinical Perspective]. 1990 Apr;19(4):109-11.

Book Chapters by ECRI Staff

Bruley ME, Lavanchy C. Oxygen-enriched fires during surgery of the head and neck. In: Stoltzfus J, Benz F, Stradling J, eds. Flammability and sensitivity of materials in oxygen-enriched atmospheres: Fourth volume. ASTM STP 1040. Philadelphia: American Society for Testing and Materials (ASTM), 1989:392-405.

de Richemond AL, Bruley ME. Chapter 37: Head and neck surgical fires. In: Eisele DW, ed. Complications in head and neck surgery, St. Louis: Mosby–Year Book, 1992:492-508.

de Richemond AL, Bruley ME. Insidious iatrogenic oxygen-enriched atmospheres as a cause of surgical fires. In: Janoff DD, Stoltzfus JM, eds. Flammability and sensitivity of materials in oxygen-enriched atmospheres: Sixth volume. ASTM STP 1197. Philadelphia: American Society for Testing and Materials (ASTM), 1993:66-73.

UMDNS Terms

  • Anesthesia Units [10-134]
  • Cannulae, Nasal Oxygen [12-700]
  • Masks [12-447]
  • Electrosurgical Units [11-490]
  • Electrocautery Units [11-418]
  • Lasers [12-296]

Cause of Device-Related Incident

Device factor: Device interaction

User errors: Failure to read label; Incorrect clinical use

External factor: Medical gas and vacuum supplies

Support system failures: Failure to train and/or credential; Use of inappropriate devices

Mechanism of Injury or Death

Fire


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