Recommendations to Reduce Surgical Fires and Patient Injury

Interviewer: Lauri R. Graham; Interviewee: Lila Bahadori, MD


May 29, 2018

Editorial Collaboration

Medscape &

Assessing the Risk for Surgical Fire

Medscape: What are the specifics of a fire risk assessment that you recommend be conducted prior to each surgical procedure?

Bahadori: Before any surgical procedure, all members of the surgical team need to know the type of procedure that will be performed and the risks associated with that procedure. Each member of the surgical team should be apprised of which surgical devices will be used during the procedure and if any of these devices increase the risk for harm to the patient. Much of this information comes from communication with and education of the staff, which includes everyone in the surgical setting (eg, physicians, nurses, operating room technicians).

Regarding the fire risk assessment, safety checklists are available from various organizations, including the Anesthesia Patient Safety Foundation (APSF) and ECRI. Although each checklist is different, they are all simple to follow and help guide the operating staff in assessing the type of surgery to be performed, taking into consideration any risk factors during the procedure (eg, amount of supplemental oxygen required).

Medscape: The Joint Commission promulgates a Universal Protocol to mitigate surgical risk. Is fire risk assessment incorporated into this protocol?

Bahadori: The Universal Protocol developed by the Joint Commission mainly relates to preventing surgical errors, such as operating on the wrong side of a patient. Although the Joint Commission has not incorporated a fire prevention checklist into its Universal Protocol assessment, it has a high interest in reducing the risk for surgical fires. Institutions and surgical teams participate in the use of the Universal Protocol and then, if appropriate, should perform a fire risk assessment.

Risk-Assessment Algorithms

Medscape: The Anesthesia Patient Safety Foundation (APSF) offers a fire prevention algorithm. Is a tool such as this sufficient for conducting a risk assessment? Are there other algorithms available?

Bahadori: Different types of algorithms are available, like the one from the APSF, and they provide an almost step-by-step approach to assessing a patient for his or her risk for surgical fire. The algorithms start with the procedure type (for example, a procedure involving the head, neck, or upper chest), followed by simple "yes" or "no" questions to guide the risk assessment. Operating staff must assess for related risks factors and take preventive measures—for example, determine the type of skin preparation that will be used for the procedure and ensure adequate drying time. Then they should determine the amount of supplemental oxygen that will be needed during the procedure. For example, if a patient will require more than 30% oxygen, the surgical staff must take precautions to reduce the risk for a fire.

Medscape: Should the fire risk assessment change based on the type of surgical procedure being performed?

Bahadori: The risks are higher for surgical procedures involving the airways, mostly owing to the need for an open oxygen source. In contrast, most patients undergoing cataract surgery will only require room air, not supplemental oxygen. The risk for surgical fire also increases when some form of an electrocautery, electrosurgical, or laser device is used in the presence of an open oxygen source. The typical recommendation is to consider an alternative form of oxygen delivery for those patients who will require an oxygen concentration of more than 30% during surgery. Alternative forms include intratracheal intubation or a laryngeal mask instead of an open oxygen source through a nasal cannula or a mask.

Medscape: Is that percentage of supplemental oxygen readily apparent to surgical personnel? Also, what are some of those options for controlling oxygen concentration in an open system?

Bahadori: Communication is important before and during the procedure. The anesthesiologist should inform the surgeon of the amount of oxygen that will be required during the procedure, and the surgeon should be aware of the type of oxygen delivery and whether it would be through an open system versus a closed system.

If the patient does require additional supplemental oxygen, and usually this is because the patient cannot be adequately oxygenated with either a lower oxygen level or room air, there must be constant communication among the surgical team. This is particularly important when the surgeon is using a laser, electrocautery, or electrosurgical unit because the oxygen may need to be temporarily turned off while these devices are in use.

During the procedure, the surgical team needs to ensure that there is no space underneath the drapes for oxygen pooling. Another preventive measure that might be taken in the presence of an open oxygen source is to deliver 5-10 L/min of air under the drapes to wash out excess oxygen.

An important preventive measure is communication between the operating room staff, surgeon, and anesthesiologist to ensure that precautions have been adequately taken to reduce risks during the procedure.