Hazard [Health Devices Apr 1995;24(4):155-6]
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).
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.
- 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.
- 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
- Tent drapes to allow oxygen, which is slightly
heavier than air, to drain away from the patient's head and toward the
- Use suction to scavenge excess oxygen in the
oropharynx around the tracheal tube cuff.
- 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.
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
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.
- 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