Chapter 32

Operating Room Fires and Personnel Injuries

Related to Sources of Ignition
P. 908


Al though f l ammabl e anesthet i cs have disappeared f rom operati ng rooms,
peri operat ive f i res cont inue to occur. They can have devastat i ng consequences,
preci pi tate l egal act ion, and t ake a great psychol ogi cal tol l on everyone i nvolved.
They usuall y come as a complete surprise to t he staff (1,2,3,4).
Most operat ing room fi res are of l i t tl e consequence and are not report ed, maki ng
t he actual i ncidence di f f i cul t to determi ne (2,5,6). Approximat el y 10% to 20% of
reported f i res resul t i n seri ous pati ent i nj ury (7, 8). Fuel s present i n the operat ing
room i nclude pl ast ics that produce dense bl ack smoke when i gni t ed. The smoke
may contain t oxi ns and may hinder safe evacuati on of t he pat i ent and staff f rom t he
room. Sudden i gni ti on can present secondary problems (9). It can cause a st art l e
ref l ex, causing t he surgeon' s hand t o jerk and potenti al l y cut i nto uni ntended t issue
or set other areas of the surgi cal si t e on fi re.
The Fire Triangle
For a f i re to occur, t here must be t hree f actors (f i re tri angl e or t ri ad) present : an
i gni ti on source, a fuel , and an oxidi zer to support combusti on together i n the proper
proport ions and under t he ri ght condi t ions (Fi g. 32.1).

View Figure

Figure 32.1 Three things are necessary for a fire to occur:
an ignition source, fuel, and an oxidizer.

Ignition Source
There are a number of igni ti on sources i n the operat ing room. Most are under the
surgeon' s cont rol .
Lasers
The acronym laser (l i ght ampl if icati on by sti mul ated emissi on of radi at ion) def ines
t he process by which a f orm of energy i s converted i nto l i ght energy
(10,11,12, 13, 14,15,16). The t erm can also ref er t o the devi ce that produces the
l i ght or t o the l i ght i tsel f .
Lasers use a col imated, coherent, monochromati c, i ntense beam of el ect romagneti c
radi ati on t o cut , coagul at e, or vapori ze ti ssue.
The rat e that the l aser energy i s del ivered is call ed power and i s measured i n
wat ts. The wat t age i s equal to t he amount of energy, measured in j oul es, divided by
t he durati on of exposure measured i n seconds. Laser power densi t y is the amount
of power dist ri buted wi t hi n an area and i s i ndi cated i n watt s per square cent i meter.
Components of a Laser System
The basi c components of a l aser system are t wo paral lel mi rrors encompassi ng the
l aser medi um and a power source (Fi g. 32.2). I n addi t ion, t here may be an aimi ng
beam f or deli veri ng laser energy that is outside t he vi si bl e range.
Laser Medium
The medium (head) hol ds the substance energi zed t o produce l aser l i ght. The
medi um, whi ch may be a sol i d, li qui d, or gas, determi nes t he wavelengt h of t he
emi tt ed radi ati on. The l aser is named f or t he materi al used as the medi um.
Power Source
The power (pumpi ng, pump, exci tati on) source suppl i es energy to t he laser medium
t o create the l i ght . When t he power source i s act i vated, energy is absorbed by
el ect rons of the atoms in t he l aser medium, whi ch are elevat ed to energy l evel s
above thei r ground stat e. They then decay to lower energy l evels and emi t photons
t hat are not i n phase wi t h one another and travel i n al l di recti ons.
Optical Cavity
The opti cal (resonator) cavi ty provides the envi ronment i n whi ch the l aser medi um
i s conf i ned. Energy rel eased f rom the medium t ravel s in al l di rect ions. Mi rrors are
used to ref l ect and i ncrease t he energy of emissi on. One of the mi rrors is not 100%
ref l ecti ve and al l ows a smal l port i on of the l i ght t o escape.
Light Guide
A l i ght gui de (del i very system) di rects the laser beam to the surgi cal si te (Fi g.
32.3). Fi ber-opti c bundles are a convenient f l exibl e condui t f or some wavel engt hs.
Ot her l asers ut i l i ze a hol low t ube wi th mi rrors al i gned t o refl ect the beam f rom i ts
source t hrough t he f ocusing l ens.
Aiming Beam
Wi th certain l asers, i t i s necessary t o use a l ow-powered visible beam as a marker.
Thi s i s usuall y a hel i um-neon gas l aser. I t passes through the same optical path as
t he l aser beam.
P. 909



View Figure

Figure 32.2 Components of a laser.

Laser Types
Types of medical l asers commonl y used i n surgery are shown i n Tabl e 32.1.
Laser Hazards
Lasers can cause si gni f i cant damage to operati ng room personnel (i ncluding the
anesthesi a provi der) and t he pat i ent . Hazards i nvolving l asers i ncl ude f i res,
at mospheric contaminati on, eye damage, organ or vessel perf orati on, and emboli sm
(10). Figure 32.4 shows a si gn used to warn personnel that a l aser i s i n use.

View Figure

Figure 32.3 This is a schematic representation of a CO
2

laser guide as might be found in either an operating
microscope or a handheld wand. The guide consists of
hollow tubes with hinged, aligned mirrors that reflect the
beam from its source through the focusing lens.

A recurrent probl em wi t h l asers i s that they may be acti vat ed when not i n use
(22,23). Of ten, a f oot swi t ch acci dental l y act ivates t he l aser. The l aser may be i n a
posi t i on where thi s i s not noti ced f or some ti me. When the l aser i s not actual l y i n
use, i t should be placed i n the STAND-BY mode.
A f i re may resul t when a laser beam hi ts a f uel or t he laser f iber becomes
damaged. Igni ti on can be al most i nstantaneous. Whi le most i gni ti on sources must
be i n cont act wi t h a materi al to cause i gni t ion, a laser can suppl y heat to a f uel
f rom a few centi meters t o several meters away, so i t can igni t e materi al close to the
t i p, at some distance f rom the ti p, or under several l ayers of other materi al . A
surf ace drape can be penet rated by the l aser but not i gni te. Materi al s under the
drape may t hen i gni te and burn wi t hout bei ng not iced f or several minutes (24). The
l aser beam can be ref lected f rom a met al surf ace, causi ng a burn or i gni t ing
materi al in a remote l ocati on.
Laser Risk Classification
A cl assif icati on syst em ref lecti ng l aser ri sk t o t he pati ent and personnel has been
devel oped (25,26, 27). The hi gher t he cl ass, the more st ri ngent the protecti on
needed.
P. 910


TABLE 32.1 Commonly Used Lasers and Associated Personnel Hazards
Laser
Medium
Features Potential Hazards to the
Eye
Special Considerations
CO
2
Readily absorbed
by all biologic
materials,
independent of
pigmentation.
Tissue destruction
is proportional to
its water content.
Produces a very
superficial tissue
effect.
Injury to the eye will
be confined to the
cornea. There is no
risk to the retina.
Since the laser is
absorbed by plastic
and glass, ordinary
eyeglasses with
sideguards can be
used for eye
protection.
Fires involving both
tracheal tubes and
supraglottic devices
have been reported
with this laser.
Nd-
YAG
Can be
transmitted
through fiber-
optic fibers.
Poorly absorbed
by water but well
absorbed by
pigmented tissue
(11).
Retinal damage can
occur. Opaque green
eyewear or eyewear
with clear lenses with
a special coating
should be worn.
Because it is taken up
by pigment, colored
markings on tracheal
tubes are more likely
to be damaged than
clear portions (12).
Blood or mucus on or
in the tracheal tube
makes the tube less
resistant to the laser
beam. Fires have been
reported from an Nd-
YAG laser passed
through the channel of
a flexible
bronchoscope (17,18).
The rigid
bronchoscope is
recommended for use
with this laser,
although the flexible
scope may be needed
to treat hard-to-reach
areas (19).
KTP Passes through
clear substances
but is absorbed by
hemoglobin and
other pigments
(11,20,22).
Retinal damage may
occur. Special
eyewear with red
filter should be worn.

Argon Beam is
selectively
absorbed by red,
orange, and
yellow pigment
and strongly
absorbed by
hemoglobin and
Retinal damage may
occur. Special
opaque orange
goggles/eyewear
should be worn.

melanin. Fiber-
optic bundles can
be used to
transmit the laser
beam.
From Klarr P. Laser complications. In: Atlee J, ed. Complications in Anesthesia.
Philadelphia: WB Saunders, 1999:588590.

Class 1 Lasers
Lasers t hat are t otall y encl osed or t hat emi t ext remely l ow out put f al l i nto cl ass 1.
These are saf e t o vi ew.
Class 2 Lasers
Low-ri sk l asers are in class 2. Thei r ri sk is approxi matel y equi val ent to st ari ng at
t he sun or other bri ght li ghts that can cause cent ral reti nal i nj ury. These are not
hazardous unl ess someone overcomes thei r natural aversi on response t o bri ght
l i ght.
Class 3 Lasers
Cl ass 3 l asers operate at a power l evel above 1 mW. Thi s is a hazard even i f
vi ewed onl y momentari l y. Cl ass 3 l asers are subdi vi ded i nto a and b subclasses.
The 3a subcl ass consists of l asers i n the 1 t o 5 mw power range. These l asers pose
a moderat e ocul ar hazard. Cl ass 3b i ncludes l asers that emi t bet ween 5 and 500
mW of output power. Even momentary vi ewi ng of t hese lasers i s potenti al l y
hazardous to the eye. They may al so be a hazard t o ski n.
P. 911



View Figure

Figure 32.4 Note that the laser class is on the sign.

Class 4 Lasers
Any cont inuous wave l aser wi th a power output above 500 mW i s i n cl ass 4. These
l asers pose seri ous ski n, eye, and f i re hazards.
I gni ti on ri sk i s relat ed to a number of factors beside the l aser cl assi f icati on. Class
3b and 4 l asers are considered t o be i gni ti on hazards. The i gni t ion ri sk of ot her
cl asses of l asers wi l l depend on how t hey are f ocused, the t i me of exposure, and
t he oxi di zers and f uel s that are present .
Met al i nst ruments can become overheated wi t h prol onged l aser use and coul d
cause a burn (28).
Electrosurgery Unit
El ect rosurgery (radi o f requency) apparatus i s so wi del y used that there is of ten
compl acency about readi ng the i nst ruct ion manual or f ol l owi ng saf e pract ices
(29,30). El ect rosurgery uni ts are t he most common i gni ti on source in surgi cal f i res
(6). The instructi on manual shoul d be studied at the begi nni ng of a t raini ng program
and revi ewed peri odi call y. A bri ef set of operat i ng i nstructi ons shoul d be readi ly
avai l able on the instrument (31).
Terminology
The vocabul ary concerni ng el ect rosurgery i s somewhat conf usi ng (32). Thi s chapter
wi l l def ine electrosurgery devices as those that empl oy a high-f requency (radi o
f requency) el ect ric current passi ng t hrough t i ssues to cut , coagul ate, or provide a
bl end of cut ti ng and coagulat i on. El ectrocautery ut i l i zes a heated wi re or bl ade,
usual l y at the end of a probe for coagul ati on. Most electrocautery devi ces are
bat tery-operated.
Physics
There are three modes avai l abl e on modern elect rosurgery devi ces.
Cutting Mode
The cutt i ng mode uses a conti nuous sine wave. Heati ng i s rapid and produces high
t emperat ures t hat expl ode cel ls that come in contact wi th t he el ect rode. This
produces a cut i n the ti ssue.
Coagulation Mode
The coagulat i on mode f eatures short bursts of a dampened si ne wave. Less heat is
produced si nce t he current i s not cont inuous. Tissue desi ccat i on occurs, and the
ends of bl ood vessels are thermal l y seal ed.
Blend Mode
The bl end (cut -coagul ati on) mode empl oys a wavef orm and vol tage between that of
t he cut ti ng and coagulati on cycle. The rel ati ve amount of cut ti ng or coagul at i on
depends on t he l engths of the bursts of vol tage. Several bl end sett ings may be
avai l able on an el ectrosurgi cal uni t (33).
Types
Monopolar
Wi th monopol ar (uni pol ar) el ect rosurgery uni ts, electrons f low f rom t he generator t o
t he act ive elect rode and through the pati ent to the dispersi ve (ret urn, i nact ive)
el ect rode, someti mes i ncorrect l y cal l ed t he grounding pad (Fi g. 32. 5). The current
di sperses f rom hi gh densi t y at the ti p of t he act ive electrode to a l ower densi t y vi a
t he l owest i mpedance pathway that i t can f ind.
Generator
The el ectrical l y powered generator (power uni t) creates a radi o f requency current
t hat passes t hrough t he acti ve el ect rode. The eff ect on ti ssue depends on the
current i ntensi t y, t he type of current employed, the durat i on of exposure to t he
current , the hand pi ece used, and the dispersive el ect rode (34). Coagul at ion
requi res l onger contact wi t h t he probe t han cut t ing. As el ect ri cal energy i s appl i ed
t o t he t issue, char f orms. Si nce char has higher i mpedance, more current dissipates
di rectl y t o the di spersive electrode and the ef fect i s reduced (34).
Active Electrode
The acti ve el ectrode has a handl e and i s connected to the generator by a f lexi bl e
wi re. It di rects current f l ow t o t he surgi cal si te. The ti p of t he act i ve el ect rode may
be a bl ade, spatul a, bal l , l ancet, loop, f orceps, needle point , or suct i on ti p. I t may
be di sposable or reusabl e. The t i p
P. 912

confi gurati on determi nes i ts abi l i ty t o desi ccate ti ssue. A needl e-ti p el ect rode
concentrates more power on t issue contact t han does a paddl e or ball -shaped
el ect rode (34). At a given el ect rode vol tage, t he paddl e-shaped t i p presents a
hi gher power at t he edge than on the fl at port i on. The el ectrode may be acti vated
by a hand cont rol or f oot swi t ch. The control may also be used to swi t ch f rom one
mode t o another.

View Figure

Figure 32.5 Monopolar electrosurgery unit.

Dispersive Electrode
The dispersive (i nacti ve, return) el ect rode (grounding or ground el ectrode, plate, or
pad) col l ects the current f rom t he pati ent and ret urns i t to the generat or t o
compl ete t he ci rcui t . The l arge cont act surface of the pad provi des l ow i mpedance.
Most pads present l y i n use are prej el l ed. Reusable metal plat es used in conj unct i on
wi th conducti ve gel are rarel y used today. Wi th some el ect rosurgery uni ts, two
di spersive electrodes shoul d be used (35).
Safety System
Modern el ect rosurgi cal uni ts possess a ret urn electrode (contact qual i ty) moni tori ng
system. Thi s ensures that the pati ent is connected t o the ret urn electrode (34, 36).
Current f l owi ng to the acti ve el ect rode i s measured and compared wi t h current
returni ng f rom the dispersi ve el ect rode. If the currents are not balanced, the uni t is
deactivated. A more recent i nnovati on i s active electrode moni t oring (AEM)
(37,38,39, 40). Thi s conti nuousl y moni tors the elect ri cal ci rcui t and automatical l y
shuts down the generator and sounds an alarm if dangerous electri cal l eakage
occurs. Newer generators can sense dramati c changes i n t issue i mpedance or
t emperat ure changes at t he return elect rode (33, 41). Some modern el ectrosurgery
machi nes are equi pped wi t h spl i t pads (42). The uni t wi l l not f uncti on unl ess both
halves of the pad are i n contact wi th t he pati ent.
Bipolar
The bi polar el ect rosurgery uni t is composed of a generator and two el ect rodes
l ocated wi thin mi l l i meters of each other. The energy f l ow i s between t he t wo
el ect rodes, and no current f l ows through the pati ent ' s body. Thi s al lows t he energy
t o be l ocal ized more preci sel y. The current densi ty i n the t i ssues surroundi ng the
acti ve el ect rode is substant i al l y l ess t han t hat f or monopol ar el ectrodes, and
deeper t i ssue l ayers are preserved wi th l ower vol tage and power requi rements. Thi s
t ype of electrosurgery uni t can coagul ate even when t he ti p i s i mmersed i n blood.
Bi pol ar uni ts cannot be used for cut ti ng.
Bi pol ar el ectrodes are produced in a vari et y of conf i gurat ions: hooks, spatul as,
scissors, f orceps, and needl es (29,43). Of ten, t hese devi ces are bat tery-operated.
There are reports that t he ON-OFF swi t ch on one of these devices di d not al ways
deactivate the device when i t was set asi de (44,45). The hot t ip coul d then set
drapes on f i re. At least one devi ce coul d be act ivated by another devi ce' s wi rel ess
remot e-cont rol uni t or by f l uorescent room l i ghts (46).
Hazards Associated with Electrosurgery
Mi shaps wi t h the el ectrosurgery uni t of ten invol ve f aul ty return el ect rodes, i mproper
el ect rode pl acement, or al ternate l ow-i mpedance outl ets. I nsuff i cient contact wi th
t he di spersi ve pad can resul t i n pati ent burns and/or burns t o ot hers who are i n
contact wi th t he pat ient . Among t he low-i mpedance al ternatives are
el ect rocardi ogram (ECG) moni tori ng electrodes, temperature probes, uri nary
catheters, metal l ic part s of surgi cal tabl es, heati ng pads, and oxi meters (47).
About 68% of report ed surgi cal f i res i nvolve electrosurgi cal equipment (48). Fi res
associ ated wi th t he el ect rosurgery uni t are of t en associ at ed wi t h an oxi di zer-
enri ched atmosphere. When t he el ect rosurgery uni t i s used, heat vapori zes t issue
or expel s ti ssue embers f rom the t i p. In room ai r, t i ssue vapors do not i gni te, and
embers are qui ckl y exti ngui shed. In an oxi di zer-enri ched atmosphere, the vapors
can i gni t e into a bri ef f l ame, and embers can fl y several i nches and burn unt i l they
are consumed. A f lare of evol ved gases can di rectl y i gni t e any convenient fuel . The
el ect rical wi res associated wi th t he el ect rosurgery elect rode may develop a short
ci rcui t, which coul d resul t in a f i re (49).
During l aparoscopic surgery, burns that are somet i mes f atal can occur outsi de t he
surgeon' s vi ew when usi ng an el ectrosurgery uni t (14,29, 33,38,40, 50,51,52). These
are usuall y caused by i nsulat i on fai l ure, di rect coupl i ng, or capaci t ive coupli ng.
I f a def ect occurs in t he acti ve el ect rode' s insul ati on, current can f l ow t hrough t he
defect. Defects can resul t f rom i mproper handl i ng or damage t o both reusabl e and
di sposabl e el ect rodes. A number of devi ces are avai labl e to detect i nsulati on
defects (33,40,51). Act i ve el ect rode moni t ori ng cont i nuousl y moni tors the el ectrical
ci rcui t and automati cal l y shuts down t he generat or and sounds an al arm i f
dangerous el ectrical l eakage occurs (37,38,39,40).
Capaci tati ve coupl i ng occurs when t he el ectrosurgi cal current i nduces stray
currents on other nearby conductors. It can occur even through i ntact insul at ion. It
occurs as a resul t of the active electrode cont acti ng or comi ng i nto very cl ose
proxi mi t y to a non-i nsulated metal i nstrument (such as a laparoscope) i n the
surgi cal fi el d. If the elect ri cal l y-energi zed laparoscope has been pl aced through a
metal cannul a, the current wi l l si mpl y f l ow t o t he pat ient' s abdominal wal l . However,
i f the l aparoscope has been pl aced through a nonconduct ive cannula, the current
cannot f l ow to t he abdomi nal wal l . I n this case, any pi ece of bowel or ot her i nt ernal
t i ssue touching t he laparoscope can be burned. Capaci tati ve coupl i ng i s al ways
present and cannot be total l y eli mi nated.
Argon Beam Coagulator
The argon beam (enhanced) coagul at or (ABC) i s sol el y a coagulati ng inst rument.
Radio f requency monopolar current is del i vered t hrough a f l ow of i oni zed argon
gas.
P. 913

The f low i s al tered as t he power i s changed. The t i p does not touch the ti ssue. I f
t he ti p is greater t han 1 cm f rom the t issue surf ace, onl y a gent l e stream of argon
wi l l f l ow. When the ti p i s 1 cm or l ess f rom the tissue surface, t he acti ve mode
occurs. If the nozzle t ip gl ows red, t he ti p i s t oo cl ose to the t i ssue or the power
sett ing i s too high.
Fiber-opti c Il luminati on System
A f i ber-opti c i l l umi nat ion system consists of a l i ght source and l ight-transmi t ti ng
cable. The cabl e i s connected to an endoscope or headli ght. The term cold l i ght ,
used to describe l i ght f rom a f i ber-opt ic source, i s incorrectl y assumed by many to
mean t hat heat i s not generated. Actual ly cold l ight ref ers to l i ght i n whi ch the
amount of i nf rared radi at ion has been reduced (53). These l i ght sources can
provi de several hundred wat ts of visibl e, inf rared, and ul t raviol et li ght . Al though
some of these wavelengths can be f i l tered out , the power i s typical l y f ocused i nto a
f iber-opt ic cabl e of smal l diameter t hat can del i ver a high-power densi ty.
A number of f i res have been i gni ted when the unprot ected end of the f i ber-optic
cable was al l owed t o rest on a drape (6,49,53,54,55,56,57). The cabl e end can
retain a si gni fi cant amount of heat af ter being disconnect ed f rom the l ight source.
Defi brillator
When a def i bri l lator i s act ivated, a spark may be generated i f i nsuf f i ci ent force i s
appli ed to t he paddl es; i f t he paddle pad is t oo smal l ; if paddl es are appl i ed over an
i rregul ar surf ace or bony promi nence or near an ECG el ect rode; when i nsuff i ci ent ,
excess or the wrong ki nd of gel i s used; or i f t here i s another conducti ve medi um
bet ween t he paddl es (6,58,59). I f di sposabl e def i bri l lati on pads are used to
i ncrease electri cal conducti on between the paddl e and the pati ent, an arc can occur
i f the surf ace of the paddl e i s not compl etel y on the pad, if t he pad i s smal l er than
t he paddle, if there is a f ol d i n the pad, or i f t he pad i s dry.
Pressure Regulators
When gas i s al l owed to f low f rom a hi gh-pressure to a l ow-pressure chamber,
recompressi on can cause a rapid rise i n temperature. Materi al s t hat cannot
wi thstand both 100% oxygen and hi gh temperatures wi l l i gni te. Thi s hazard i s
associ ated most l y wi t h aluminum oxygen regul ators (60,61,62,63,64, 65,66,67, 68).
Another cause of heat i n a pressure regulator i s part icl e i mpact f rom contami nants.
Tef l on tape, chi ps f rom seal materi als, or hydrocarbon contami nants may be
present (69).
Surgical Li ghts
Surgi cal l i ghts can be a source of igni ti on. I f t he li ght does not have the proper
mechani sm to di ssipate i nf rared radiati on or i f that mechani sm f ai l s, the pati ent or
personnel envi ronment can be exposed t o energy l evels hi gh enough t o cause
burns or f i res (70,71). The heat f rom a surgi cal l i ght can contact and rupt ure a hose
f rom the medi cal gas pi pel ine syst em (72).
Electrical Faults
An el ect ri cal f i re can occur i n any envi ronment where there i s elect ri cal equi pment .
A short ci rcui t can occur i n an anest hesi a machine (73,74,75). I n one report ed
case, a short ci rcui t i n a laryngoscope wi th a rechargeabl e handl e caused f l ames t o
shoot f rom t he chargi ng end of the handl e (76). El ectrical arci ng i n surgical booms
has been reported t o cause fi res (77, 78).
Other Ignition Sources
Ot her reported sources of igni t i on in operati ng room f i res i ncl ude resectoscopes,
heat l amps, heated probes, pneumati c tourni quets, dental and ort hopedic burs and
dri l l s, heated-wi re breathing t ubes, and humidif iers (1,79,80,81, 82, 83,84).
Fuels
Fuels abound i n the operati ng room. A fuel i s anyt hi ng that can burn, i ncl udi ng
most thi ngs t hat come i n contact wi t h pat ients as wel l as the pati ents themsel ves.
Tracheal Tubes
The risk and characteri st ics of a tracheal t ube f i re wi l l depend on t he type of t ube
used. In most cases, igni ti on requi res the t ube to be penet rated (85). The f i re
begins on the i nsi de ri m of t he penetrat i on area and t hen spreads both wi th and
against the fl ow of oxidizing gas.
Polyvinyl Chloride Tubes
Pol yvinyl chlori de (PVC) tubes are combusti bl e i n an oxidi zer-enriched atmosphere
wi th a carbon dioxi de (CO
2
) l aser. Once i gni ted and penetrated, a PVC tube can
sustain a torchli ke f lame. PVC tubes wi thout marki ngs are relat i vel y resistant to t he
Nd-YAG l aser, but marki ngs i ncrease the risk (86). I f t here i s bl ood, mucus, or
sali va on t he tube, t he ri sk of f i re i s i ncreased. The i njuri es associ ated wi th PVC
t ube f i res are more severe t han wi th other types of tubes (87,88).
Red Rubber Tubes
Red rubber tubes are combusti bl e wi t h the CO
2
, pot assi um t i tanyl phosphate (KTP),
and Nd-YAG l asers (86,87,88,89,90). A maj or problem i s the i nabi l i t y to see
t hrough the tube. Should an i nt ral umi nal f i re devel op, i t may go undetected f or a
l onger peri od of ti me than wi t h other t ubes.
Damage to the tracheobronchi al tree af ter an intral umi nal f i re may be l ess severe
wi th a red rubber t ube than a PVC t ube (87). Red rubber tubes are l ess l i kel y to
sof t en, deform, or f ragment if i gni t ed than are other tubes. Anot her advantage i s
t hat they can be qui ckl y
P. 914

removed f rom t he pat ient (91). The hi gh pressure i n the cuff causes i t t o def l ate
more qui ckl y than is possi bl e wi t h a l ow-pressure cuff .
Silicone Tubes
A si l i cone tube i s more resi st ant to penet rati on by a CO
2
l aser t han other t ubes
(87). If i gni ted, a si l icone tube rapi dl y becomes a bri tt l e ash that crumbl es easil y
and may be aspi rated, raising the possi bi l i ty of future probl ems wi t h si l i cosis
(87,90,92, 93). However, the acute i nj uri es are l ess severe than wi t h red rubber and
PVC tubes (88).
Laser-resistant Tubes
A number of ready-t o-use laser-resi st ant t ubes and t ube wraps are avai labl e and
are descri bed i n Chapter 19. They shoul d meet the requi rements of Internati onal
St andards Organi zati on (ISO) 14408 (93). It i s i mport ant to remember t hat laser-
resi st ant does not mean laser-proof . Laser-resi st ant tubes can i gni te, especi al l y i f
manuf acturer' s warni ngs, precauti ons, or directi ons for use are not f ol l owed. If a
l aser tube i s used wi t h a l aser ot her t han that f or whi ch i t was desi gned or a
f lammable part such as t he cuf f i s exposed, i t wi l l catch f i re (92,94). Laser-resist ant
t ubes are usual l y not resistant to other heat sources such as an el ect rocautery
penci l .
Supraglottic Airway Devi ces
The rel ati ve resi st ance of supraglot t ic ai rway devices depends on t hei r
composi ti on. Those devi ces that are made of si li cone rubber such as the LMA-
Cl assic, LMA-Flexi bl e, and LMA-ProSeal are si gnif icant l y more resistant t o t he CO
2

l aser than are PVC tracheal t ubes (95). Many disposabl e supragl ot ti c devices are
made of PVC and are probabl y as suscept i bl e to fi res as tracheal tubes of the same
composi ti on.
Surgical Products
Surgi cal drapes, t owels, and dressings are common fuels f or operati ng room f i res.
Of ten, the drape i s i gni ted f rom another f i re (24). Whi l e many drapes are resistant
t o i gni t i on i n room ai r, the oxi di zer-enri ched atmosphere that i s of ten present may
cause them to burn wi t h vi gor (49, 96,97,98, 99,100,101,102, 103,104).
Di sposabl e drapes may be part icul arl y di ff i cul t to deal wi t h duri ng a f i re because
t hey are water repel l ent. Addi ti on of water may even spread the f lame. Laser-
resi st ant drapes are avai lable. Some syntheti c drapes wi l l mel t away f rom the laser
rather than igni te (103).
There are numerous reports of surgi cal sponges, gauze pads, and swabs bei ng
i gni ted (49,105,106,107,108,109,110,111,112,113). Wet sponges may be used t o
protect a t racheal tube f rom a l aser beam. However, i f t hey are al l owed t o dry out ,
t hey become f l ammable.
Adhesive Substances
Adhesi ve tape can be the fuel f or a fi re (114). Coll odi on and benzoin are
f lammable.
Skin Preparatory Soluti ons
Fl ammabl e vol at i l e organi c solut i ons are of ten used to prepare the ski n pri or t o
surgery. If t he l i quid or vapor is contact ed by an i gni ti on source, a fl ame can resul t
(1,101,115,116,117,118,119,120,121). Al cohol -based sol ut ions are especiall y
f lammable. They can al so infi l t rate and pool under the drapes. When t hi s happens,
t hey are sl ow t o di ssi pate. Al cohol -based f i res have a f l ame that is dif f i cul t t o see.
Of ten, the resul t of the f l ame is t he f i rst t hing not iced.
Intestinal Gases
Gases that accumul ate i n the bowel (especi al l y hydrogen, hydrogen sul f i de, and
methane) can be the fuel f or a fi re or explosion i f an el ectrosurgery uni t i s used t o
open the bowel (105). Proper bowel preparati on may prevent this (122). Suf f icient
oxygen to support combusti on i s normall y not present i n i ntesti nal gas. However,
ni trous oxi de may di ff use i nto t he i ntest inal l umen, creati ng a f l ammabl e mixture.
Oxygen Cannulas
Oxygen cannul as are made of pl asti c that can burn. They carry 100% oxygen. If
t ouched by a hot electrosurgery probe or a l aser beam, t hey burn readi l y. Even if
not di rectl y contacted, the area around them may be so oxygen-ri ch that a smal l
spark can turn i nto a burni ng ember t hat can i gni te the cannul a.
Lubricants and Oi ntments
Pet roleum-based oi ntments that are used i n an oxi di zer-enri ched atmosphere wi l l
i gni te when enough heat i s present to cause vapori zat ion (105, 123,124). Water-
based l ubricants wi l l not burn and can be used to coat hai r t o make i t f i re-resi stant .
Body Hair
Body hai r, i ncl udi ng eyel ashes, moustaches, and beards can be i nvolved in a f i re
(105, 106,125,126). Coat i ng the hai r wi t h a water-based l ubri cant wi l l decrease the
ri sk.
Surface fl ame propagati on occurs where there are fi ne surface f i bers of f abri c or
body hai r (127). In t he presence of an oxidizer, t hese f i ne f i bers can be i gni t ed.
Of ten, the ski n or underl yi ng f abri c i s not burned. The surf ace f i re races i n t he
di recti on of the oxygen source, where t he oxygen suppl y tubi ng may be igni t ed
(58).
Other Combustibl e Substances
A number of arti cl es used in or near t he pati ent can serve as the f l ammabl e
materi al . These i ncl ude (but are not l i mi t ed to) oxygen tubi ngs, endoscopes, smoke
evacuator hoses, esophageal stethoscopes, breathing t ubes, reservoi r bags, eye
patches, stents, masks, nasogastri c t ubes, enteri c f eeding t ubes, rubber and pl asti c
nasopharyngeal ai rways, covers, paper products, bl ood pressure cuf fs, aerosol
adhesives, tourniquets, gl oves, stethoscope t ubi ng, throat packs, eggcrate f oam
P. 915

mat tresses, bandages, stocki net tes, dressi ngs, pi l l ows, gl ue, gowns, st raps, caps
and hoods, rubber el ectrosurgi cal uni t probe sheaths, shoe covers, l ocal anestheti c
spray, and organic gas f rom a necroti c tumor
(106, 116,128,129, 130, 131,132, 133, 134,135, 136,137).
Al cohol -based hand sani ti zers (gel s, f oams, and li quids) are highl y f lammabl e
(138). They should be stored in a cabinet t hat i s designed for fl ammabl e materi al s.
However, a study publ i shed in 2003 found no fi res att ri butable to hand sani t i zers,
and the Nati onal Fi re Prot ecti on Associ at ion now al l ows al cohol -based hand
sani t i zer dispensers i n corri dors and other publ ic areas, provi ded cert ai n
rest ri ct ions are observed (139). I f a dispenser i s mounted i n a hal l way, the corri dor
must be at l east 6 f eet wi de. The di spenser can proj ect up to 6 inches f rom the wal l
and must be i nst al led above handrai l hei ght.
Oxidizers
Wi th an oxi di zer-enriched atmosphere, a f i re i gni tes easi er, burns more vigorousl y,
spreads more rapi dl y, and i s more dif f i cul t to exti ngui sh. The oxi di zers of greatest
i nterest are oxygen and ni trous oxi de. Ni trous oxide supports combust ion and i n the
process rel eases the energy of i ts format ion, provi di ng increased heat . Thus, any
mi xture of oxygen and ni trous oxi de wi l l support combust ion. Ai r wi l l also support
combust i on, because i t contai ns oxygen.
Because oxygen i s heavi er t han ai r, i t col l ects i n low-l yi ng areas, i ncl uding drape
f olds. Some mat erials such as drapes and towel s absorb oxygen and retain i t for
some t i me (1, 127). Tenti ng drapes wi l l al low oxygen t o drain of f toward the f loor
and be dil uted by ai r ci rcul ati on.
Common Scenarios
Airway Fires
During ai rway surgery, all of the three necessary components are i n cl ose
proxi mi t y: a combusti bl e substance (t racheal tube, gauze, etc.), an i gni t ion source
(l aser or electrosurgery apparatus), and gas to support combusti on (oxygen wi th or
wi thout ni t rous oxi de). An ai rway f i re is part i cul arl y seri ous because a consi derable
amount of heat i s generated i n a smal l area, and t he smoke and gases f rom such
f i res can be blown deep into the pat ient' s l ungs.
Using El ectrosurgery duri ng Tracheostomy
Many ai rway f i res have occurred whi l e usi ng t he el ect rosurgery uni t during
t racheostomy
(9,105,128,130,140,141,142,143,144,145,146,147,148,149,150, 151, 152,153, 154).
Of ten, the pati ent is being given 100% oxygen i n ant ici pati on of i nt errupt ed
venti l ati on and/or because of the underl ying cli ni cal condi ti on. If the t racheal t ube
or cuff is contacted, an oxi di zer wi l l be rel eased. Current l y, there i s no tracheal
t ube that i s saf e f or use wi th el ect rosurgi cal devi ces or elect rocautery, al though
some are more resi stant to i gni ti on than others (155).
Using El ectrosurgery i n the Mouth
Usi ng el ect rosurgery in t he oral cavi ty may resul t i n a f i re
(6,156,157,158,159,160,161,162). The tracheal tube i s of ten t he f uel , but other
i tems such as sponges or pati ent t issue may be i nvolved. Of ten, wet gauze i s used
i n the throat t o catch secret i ons or t o protect the t racheal t ube. If there is a l eak
around the tube, the gauze can becomes oxi dizer-enri ched and dry out more
quickly.
Laser-induced Tracheal Tube Fires
The l i kel ihood that a l aser wi l l contact the tracheal tube duri ng ai rway procedures
i s high (163). Cuff ed tubes are more l ikel y to be contacted t han noncuff ed tubes.
The t ube may be exposed to ei t her t he di rect or ref l ected l aser beam. Flami ng
t i ssue i n close proxi mi t y to t he tube may cause i t t o igni te (164).
I n addi ti on t o l ocal damage i n the l arynx, i nj ury can occur t o the l ower ai r way and
t he parenchymal t i ssue i n the l ung. The products of combust ion may be blown i nto
t he l ungs.
The cuff is t he most vulnerabl e part of t he tracheal t ube. It cannot be wrapped, and
l aser-resist ant tubes do not have l aser-resistant cuf f s.
Wet cotton sponges are of ten used around the tube to prot ect the cuff f rom t he
l aser beam. If t hese dry out , they can become f uel f or a f i re (165). Tape t hat i s
used to secure t he t ube can i gni te.
During l ower ai rway surgery using a l aser, t he cabl e may be passed through t he
i nsi de of a t racheal tube. The t racheal t ube shoul d be pl aced j ust bel ow t he vocal
cords so that the t ip i s as far away f rom t he operat ive si t e as possi bl e.
Other Head and Neck Fires
Head and neck f i res can occur duri ng l ocal anesthesia procedures when
el ect rosurgery apparatus i s used (6, 49,56,126,166,167,168, 169,170, 171, 172,173).
Of ten, oxygen i s bei ng admi ni stered, and i t may di ff use i nt o the surgical area. Any
f lammable i tem i n the vicini t y can catch f i re.
Fires Involving Pressure Regulators
Whi le not a f requent occurrence, a f i re in a regul at or can be disast rous (174).
These fi res may resul t f rom adi abat i c compression or parti cl e igni t i on in whi ch
debri s is blown f rom t he cyl i nder i nt o the regul ator wi t h suf fi ci ent energy to cause
i gni ti on. Improper pressure regul ator assembl y may al so cause a f i re.
P. 916


Regulators wi th al umi num components are more l i kel y to burn than other
regul at ors. The Food and Drug Administrat ion (FDA) and the Nat i onal Insti t ute f or
Occupat i onal Saf ety and Heal th (NIOSH) now recommend t hat al umi num regul ators
be repl aced wi t h ones wi th brass component s (64, 66). A number of al umi num
oxygen regul at ors have been recal l ed (67).
Intraperitoneal Fires
Several explosi ons have been reported duri ng l aparoscopy when ni t rous oxi de was
used as the i nsuff l ati ng gas (122,175, 176, 177). Ni t rous oxi de in t he inspi red gases
wi l l di f f use i nto the peri t oneal cavi ty and may reach a high enough concent rat i on to
support combusti on (178,179). Fi res have al so resul ted f rom i nf l at i ng the peri toneal
cavi t y wi th an oxygen-CO
2
mi xt ure i nst ead of pure CO
2
(180,181). The Pi n Index
Saf et y System (Chapt er 1) wi l l not prevent thi s error, because t he index holes f or
t anks wi t h 100% CO
2
are the same as f or any t ank wi t h greater than 7% CO
2
.
Fires during Defibrillation
Oxygen i s al ways used duri ng resusci tati on, and the source is of ten di sconnected
and placed near the head (58,182, 183). Thi s may al l ow oxygen to f l ow over t he
defi bri l lati on el ect rodes (184). A spark caused by pl acement of the def i bri l l ator
paddl e or el ect rode cl ose to an ECG el ectrode or poor contact between the
pati ent 's ski n and the def i bri l l at or paddle or elect rode may i gni t e hai r or other
combust i ble materi als i n the area (183,185).
Fires in Canisters
Fi res i n CO
2
absorbent cani st ers have been report ed
(186, 187,188,189, 190, 191,192, 193). These are discussed i n more detai l i n Chapter
9.
Personnel Risks
Smoke Hazards
Pot ent i al ly hazardous ai rborne cont ami nants are f ormed f rom ti ssue vapori zati on
when a l aser is used. These by-products have t he potent i al t o be mutageni c,
carci nogeni c, t eratogeni c, or a vector f or vi ral i nf ect ion (10,194). El ectrosurgery
devices and bone saws al so produce vapori zed f ragments that have the same
hazards (25).
I nhal i ng potent ial l y hazardous ai rborne contami nants can be kept to a mi ni mum by
scavengi ng the smoke. Thi s wi l l hel p to gi ve t he surgeon a clearer vi ew of the
surgi cal fi el d and removes off ensi ve and i rri tati ng odors. Vari ous smoke evacuators
are avai l abl e (103,195). To be most eff ect ive, t he evacuator nozzle shoul d be
posi t i oned as close as possi bl e to the operati ve f ield and be f uncti onal bef ore,
duri ng and f or 30 seconds af t er t issue i s vapori zed (196).
Personnel masks shoul d be removed and di scarded as soon as possible af ter use
(196). St andard surgi cal masks f i l ter out parti cl es down t o about 3 microns i n
di ameter. The l aser plume has parti cl es as smal l as 0.31 mi crons. High-eff ici ency
masks can f il ter parti cl es down t o 0. 30 microns, but they are di f f i cul t t o breathe
t hrough and l ose t hei r ef f i ci ency when wet (10,103).
Ocular Injuries
The l aser beam may be di rect ed over some di stance. The area of hazard may not
be l imi ted to t he immediat e surgi cal area and may present ri sk to operati ng room
personnel (25). The surgeon i s not hi ghl y suscepti bl e to i nj ury because of t he
saf ety devices bui l t into the instrument . However, i f the i nstrument i s accident al l y
acti vated, he is exposed to the same hazards as other personnel .
The eye is especi al l y vul nerabl e to i nj ury. Because CO
2
l aser beams are absorbed
wi thi n t he fi rst 200 m of t issue, they are a hazard t o the cornea (197). Argon, KTP,
and Nd-YAG l asers are more li kel y t o cause damage to the reti na. The extent of
damage wi l l depend on which part of the reti na is af f ected. Permanent vi sual l oss
may resul t (25).
Al l personnel i n the area where a l aser is used should wear appropri at e protect i ve
eyewear. Thi s may i ncl ude goggl es, f ace shi elds, spect acl es, or prescri pti on
eyewear usi ng special mat eri al s or refl ecti ve coati ngs (or a combi nati on of both),
selected to reduce the pot ent i al ocular exposure. The saf ety eyewear should be
marked accordi ng to the wavel ength (l aser t ype) (Fi g. 32.6). I t shoul d be not ed that
l aser saf ety eyewear is not designed f or looki ng di rectl y at a l aser beam (16). The
pati ent 's eyes shoul d be cl osed and covered wi th sal i ne-soaked gauze or a
nonshi ny metal shiel d. Awake pati ents shoul d wear goggl es speci f i c for t he l aser
bei ng used. Wi ndows i n t he room shoul d be covered and a warni ng si gn pl aced
P. 917

on the operat ing room door at eye l evel (Fi g. 32.4). Spare eyeware shoul d be
avai l able at al l ent rances.

View Figure

Figure 32.6 All laser-protective eyewear should be clearly
and permanently labeled.

Electrical Shock
Another concern i s el ect ri cal shock f rom the electrosurgery device. A common
pract i ce among surgeons i s to al low an assi stant to touch t he di stal end of a
f orceps wi th t he act ive el ect rode f rom the el ect rosurgery apparatus. Thi s act ion
makes the f orceps the acti ve el ect rode. A gl ove may not of f er suf fi ci ent protecti on
f rom the electri cal ci rcui t . Hol es appear i n as many as 15% of gloves.
There are ways to mi ni mize the shock potenti al whi l e usi ng el ect rosurgery. The
acti ve el ect rode should be f i rml y i n contact wi th t he forceps bef ore i t i s energi zed.
The person hol di ng the f orceps shoul d try to contact i t i n as large an area as
possi bl e t o spread t he concent rati on of the charge.
Fire Prevention
The best way t o deal wi t h fi res is to prevent t hem f rom start i ng (127, 198). Fi res can
be avoi ded by not all owi ng t he three el ements of the f i re tri angl e to come together
at t he same t i me.
Controlling Ignition Sources
One way t o reduce f i res i s to properl y use equi pment that mi ght act as an i gni ti on
source. I t is i mportant t o read i nst ruct ion manual s and to al t er t echniques t o f i t
t hese i nst ructi ons.
Lasers
Personnel who use l asers shoul d take a cert i f ied l aser course (6,23,26, 103). They
shoul d practi ce thei r t echnique on i nani mate objects and gai n experi ence at the
hands of an experi enced cli ni ci an. Speci f ic personnel should be desi gnat ed to
moni tor and prevent l aser hazards.
A laser protocol should be devel oped and fol l owed. Lasers shoul d be test f i red onto
a saf e surface bef ore use to ensure that the beams are properl y al i gned. Lasers
shoul d al ways be kept i n the st andby mode except when needed. The l owest power
densi ty and shortest pulse durati on that wi l l do the j ob shoul d be used. The l aser
shoul d be activated onl y when the ti p is under t he surgeon' s di rect vision. The l aser
shoul d be pl aced i n standby mode bef ore removi ng i t f rom the surgical si te.
Laser f ibers shoul d not be cl i pped to drapes because the f i bers may be broken. The
l aser fi ber shoul d be caref ul l y passed through an endoscope before introducing the
scope i nto the pat i ent to mi ni mi ze the risk of f iber damage. The f i ber' s f unct i onal i ty
shoul d be verif ied bef ore i nsert i ng t he endoscope i nto the pat i ent .
I f a l aser contact t ip i s used, the t i p wi l l remai n hot f or several seconds. Bl ind ent ry
i nto cavi ti es wi th t hi s ti p shoul d be avoi ded (199). The ri sk of tracheal t ube i gni ti on
wi l l be lowered i f t he laser i s acti vated during the expi rat ory pause (200).
Electrosurgery Unit
The el ectrosurgery uni t shoul d not be used duri ng tracheostomy
(31,34,50, 111, 171,201, 202, 203,204). Bleedi ng shoul d not be t reated wi th
el ect rosurgery af ter f l ammabl e dressi ngs have been appl ied.
A bi pol ar el ect rosurgery uni t shoul d be used whenever possi ble. Thi s wi l l reduce
t he current densi ty i n t he t issues surrounding the acti ve el ect rode and mi ni mi ze t he
potenti al f or di rect coupl i ng. Bi pol ar uni ts work at l ower vol t ages and are not
associ ated wi th i nsul ati on fai l ure.
Monopol ar uni ts should have a means to moni tor the return el ect rode or acti ve
el ect rode. Using active electrode moni tori ng wi l l mini mi ze the ri sk of stray
el ect rosurgi cal burns (38). Before each use, t he el ect rosurgery uni t and associated
saf ety features shoul d be i nspected for si gns of damage and t ested to ensure that
t he uni t i s f uncti oni ng correct l y. If i t i s not worki ng properl y or i s damaged, t he
el ect rosurgi cal apparat us shoul d be i mmedi at el y removed f rom servi ce. The uni t
shoul d be protected f rom spil l s. Uni ntenti onal act ivati on may occur i f f lui ds enter
t he generator. The al arm system shoul d be checked pri or t o appl yi ng t he di spersive
el ect rode. The act ive el ect rode shoul d have a t i p that is secure, because a l oose
t i p may cause a spark. Prej el l ed di spersi ve el ect rode pads shoul d be checked f or
unif orm gel di stri buti on and absence of exposed wi res bef ore bei ng appl i ed t o the
pati ent . Outdat ed or previ ousl y opened but unused di spersive electrode pads
shoul d not be used, because the gel can undergo el ect rol ysi s and/or desi ccati on. If
a di spersi ve el ectrode pad requi ring gel i s used, the pad should be checked
caref ul l y to identi f y any dry spots on i ts surf ace before i t is pl aced on the pati ent .
Af ter the pati ent has been posi ti oned, t he connect i on bet ween the pat i ent and t he
uni t shoul d be establ i shed by placi ng the di spersive elect rode on a nonhai ry area of
cl ean, dry ski n. The dispersi ve el ect rode shoul d be t he appropri ate si ze f or a
pati ent (i . e. , neonate, i nf ant , pediat ric, adul t ) and never be cut to reduce i ts si ze.
The dispersive elect rode shoul d be appli ed t o clean, dry ski n over a large, wel l -
perf used muscl e mass as cl ose t o the operati ve si te as practi cal , avoi di ng bony
promi nences, scar t issue, ski n over a metal prosthesi s, or di stal t o a tourni quet .
Excessive hai r should be removed bef ore appl ying t he di spersive electrode,
because hai r wi l l i nsulate the pad f rom the pati ent . The pad' s ent i re surface area
shoul d maintai n uni f orm body contact . There shoul d not be any tenti ng, gapi ng, or
moi st ure under t he pad. Thi s wi l l i nt erf ere wi t h adhesi on to t he ski n and decrease
t he cont act surf ace. The dispersi ve el ect rode
P. 918

shoul d not be moved to another si te af ter i ni ti al appl icati on. The status of the
di spersive electrode shoul d be checked i f any t ensi on i s appl i ed t o t he cord or i f
t he pat ient i s reposi ti oned af ter t he pad i s appl i ed. A used dispersi ve el ect rode
shoul d not be reappli ed.
El ect rocardi ographi c el ect rodes shoul d be pl aced as f ar as possi bl e f rom the
operati ve si te to mi ni mi ze the al t ernate f l ow of current t hrough the el ect rodes and
moni tor t o ground.
I f insul at ed el ect rosurgical el ectrode probes are requi red, onl y commerci al l y
avai l able i nsul at ed probes shoul d be used (9). I nsul ati ng sl eeves cut f rom catheters
or other materi al s should not be used to sheathe probes.
The l owest power set ti ngs that are ef f ective f or t he surgi cal procedure, as
determined by the surgeon i n conj uncti on wi th t he manuf acturer's recommendat i on,
shoul d be used. The ent i re ci rcui t shoul d be checked i f the operator requests hi gher
power set t ings because of i neff ectual resul ts.
The el ectrosurgery uni t shoul d be act i vated onl y when the ti p is under t he
surgeon' s di rect vi si on and onl y by the person usi ng i t . Cords should not be
cl amped wi t h or wound around any obj ects. The el ect rosurgery probe shoul d be
kept cl ean to mini mi ze the ri sk of adherent t i ssue i ncandesci ng or f l ami ng. The
el ect rosurgi cal penci l shoul d be pl aced i n a hol st er when i t i s not i n act i ve use. The
el ect rosurgi cal uni t shoul d be pl aced in standby mode whenever i t is not in acti ve
use. Unnecessary foot swi tches shoul d be removed so that t hey are not
acci dent al l y acti vated.
During l aparoscopic surgery, al l -metal or all -pl asti c cannul as shoul d be used and
not a hybrid cannul a system (i .e. , a combi nati on of pl asti c and metal cannul as)
(37). Elect rosurgery el ectrodes shoul d not be used i nsi de metal suct ion i rri gators.
The el ectrosurgi cal uni t shoul d be deacti vated bef ore removi ng i t f rom t he surgi cal
si te. Even af t er deact ivati on, the probe t i p may ret ai n enough heat f or a f ew
seconds to mel t pl ast ics or i gni te some f uel s, so i t should be pl aced inside a cl ean,
wel l -i nsul ated hol der or broken off . In addi ti on to prot ecti ng the t i p, this makes i t
more dif f icul t t o accident al l y acti vat e the swi t ch. The t i p shoul d be broken, and a
saf ety cover shoul d be placed over the ti p and act ivati on swi tch bef ore the devi ce
i s discarded (205).
Argon-enhanced Coagulati on
Al l safet y measures observed f or t he el ect rosurgi cal uni t should be observed f or
argon-enhanced coagul ati on (31). The el ectrode should not be pl aced i n di rect
contact wi th t issue. The hand pi ece shoul d be moved away f rom t he pat ient' s t issue
af ter each acti vati on. The argon gas f l ow and the argon coagulator shoul d be
acti vated si mul taneousl y. The argon gas l i ne shoul d be purged of ai r before each
procedure and by act i vat ing t he system af ter moderate del ays between act ivat ions.
Fiber-opti c Light Sources
Al l connecti ons shoul d be made bef ore the l i ght source is acti vat ed, because t he
end of the cabl e can cause a f i re (53). An act ive f i ber-opti c cable shoul d not be
pl aced on fl ammabl e materi al . The l ight source should be t urned OFF bef ore
di sconnecti ng the cable. The end of a f i ber-opti c cabl e can retain a si gni f icant
amount of heat af ter being di sconnect ed f rom t he l ight source (206). Therefore, i t i s
i mportant to be caref ul where one pl aces the end of a f i ber-opti c cord.
Heated Humidifiers
Onl y a breathing t ube and heat ing ci rcui t l abel ed f or use wi t h a specif i c humidif i er
shoul d be used (207). Heated breathi ng ci rcui ts shoul d not be covered wi th sheets,
bl ankets, towel s, cl othi ng, or other materi al . They shoul d not rest on surf aces such
as t he pati ent , operat ing t abl e, bl ankets, or medi cal equi pment. I nstead, a boom
arm or tube t ree should be used to support t hem. A heated-wi re breat hi ng ci rcui t
shoul d not be t urned ON bef ore f l ow has been i ni ti at ed. I f there i s no f l ow (as
duri ng cardi opul monary bypass), t he heater shoul d be t urned OFF (208).
Defi brillators
When using a defi bri l l ator, care shoul d be taken to hold the paddles f i rml y and
posi t i on them properl y. Di sposabl e conducti ve pads shoul d be l arger t han t he metal
surf ace of the paddl e and be wi thi n thei r expi rati on date. Thi s wi l l prevent arci ng
when t he paddl es are acti vated (58). ECG el ect rodes should be appl ied as far as
possi bl e f rom the def i bri l lat i on pads.
Electrical Faults
Al l el ect ri cal cords shoul d be regul arl y i nspected f or cuts and ni cks i n the
i nsul at i on, f rayed i nsul at ion, and l oose connections at t he pl ug or receptacle ends
(209). Al l pl ugs shoul d be pushed compl etel y i nto t he recept acl es to prevent prong-
t o-prong arci ng (210).
Managing Fuels
Tracheal Tubes
Non-intubation Techniques
Si nce t he tracheal t ube i s of ten t he f uel f or t he f i re, anestheti c techniques that do
not requi re a tracheal t ube wi l l el imi nate one component of the f i re t ri ad (92).
These incl ude apnea, j et vent i l at ion, and spontaneous breat hi ng.
Apnea
Wi th the apnei c techni que, t he pat ient i s vent i lated by using a mask or t racheal
t ube, and these are wi t hdrawn as t he laser i s used (92,93,211). Af t er a peri od of
t i me, vent i lat i on is rei nstated. This i s repeat ed as l ong as needed to perf orm the
surgery.
Insufflation
Pat i ents may be al lowed to spont aneousl y breathe a combi nat ion of oxygen and
anesthet ic agents whi l e l aser procedures are undertaken. The gases are
admi ni stered through a cathet er or hook in the
P. 919

corner of t he mout h that is wel l out of the way of the l aser beam. The sucti on
channel of a l aryngoscope may be used to i nsuff l ate oxygen. Operat i ng room
pol l ut ion wi t h anesthet i c agents may be hi gh wi th t hi s t echni que. Oxi di zers shoul d
be used as spari ngl y as possi bl e si nce the i nsuff l ated gas could support
combust i on.
Jet Ventilation
Jet vent i lati on techni ques ei ther vi a a metal bronchoscope or a catheter i nsert ed
t hrough the cri cothyroi d membrane may be used (212). A high-veloci ty j et of oxygen
or hel i um and oxygen can be di rected i nto the ai rway above or bel ow t he glott i s by
using vari ous apparat us (21,92,93,196,213,214).
There has been a f i re report ed wi t h this t echni que (215). An errant l aser st ri ke
i gni ted the surgeon' s gl ove. The resul tant burni ng vapors were ent rained int o the
pati ent 's ai rway. The pati ent' s mustache was al so i gni ted, and the pat ient suff ered
f aci al burns.
Filling the Cuff with Saline
The cuff is t he most vulnerabl e part of t he tracheal t ube, regardl ess of the tube or
cuff mat erial . If a l aser beam penetrates an ai r-f i l l ed cuff , gas can leak i nto the
operati ve fi el d, and if the oxygen concentrat i on i s hi gh, the risk of f i re i s great .
Fl ui d i n a cuf f acts as a heat si nk and makes the cuf f less easy to perf orate
(216, 217). Fi l li ng t he tracheal t ube cuff wi t h a l i docai ne j el l y-pl us-sal i ne mi xt ure not
onl y prevents the cuf f f rom bei ng i gni ted but may pl ug small hol es in the cuf f
resul ti ng f rom a laser hi t (218).
I f the cuf f is perf orated, a j et of f l ui d may exti nguish t he f i re. If perforated, fl ui d-
f il l ed cuf fs retain t hei r shape longer t han ai r-f i l l ed cuf fs. Care must be taken to
remove al l ai r f rom the cuf f , because any remai ni ng ai r wi l l sett l e i n the most
superior part of the cuf f , which is t he part most l i kel y to be hi t by the l aser beam.
Addi t ion of methyl ene bl ue or other bi ocompati bl e and hi ghl y vi si bl e dye to t he
sali ne wi l l hel p t he surgeon to recogni ze a perf orat ed cuf f . Some surgeons obj ect t o
t he addi t ion of methyl ene bl ue because i f t he cuf f i s punctured, the col or of the
t i ssues i s al tered, maki ng i t dif f icul t to recogni ze pathol ogy.
Protective Wrappi ngs
The t ube can be covered wi t h a prot ective wrapping. These are discussed i n
great er detai l i n Chapter 19.
Merocel wrap (Laser-Guard
TM
) was f ound t o be accept abl e for surgical l evels of
CO
2
, KTP, and Nd-YAG l asers (219,220,221,222). Merocel -wrapped tubes are not
more combusti bl e if t hey are coated wi t h blood (223). Ref l ected l aser beams have
not been a probl em wi t h this wrap (224). Thi s product i s easier to appl y than
metal l i c tapes (225).
Al umi num and copper t apes are ef f ective f or use wi t h the CO
2
and Nd-YAG l asers i f
t he tube is met icul ousl y wrapped (226,227,228). However, a f i re can occur i f t he
l aser cont acts part of t he tube that i s not wr apped (229,230). A wrapped red rubber
t ube does not of f er protection f rom t he KTP l aser (86). The adhesive backi ng or
surf ace coati ng of some tapes can be i gni ted by l aser beams (92). The presence of
bl ood on t he surf ace of f oi l -wrapped tubes makes combusti on more l ikel y to occur
(223). Tape-wrapped tubes may unravel , l eavi ng porti ons of the t ube exposed. I f
t he wrappi ng is di sl odged, i t coul d obst ruct t he ai rway. A wrapped tube may catch
f i re (231,232). Metall i c tapes may ref l ect t he l aser to nontargeted areas (224).
Spi ral wrappi ngs may cause the tube to ki nk. Any wrappi ng adds thi ckness to the
t racheal tube, whi ch coul d be a probl em for the surgeon.
Protecting the Cuff with Wet Covers
As a furt her precaut ion, moi st cott onoids, sponges, or pl edgets can be pl aced on
t he cuf f (92,233, 234). Cot ton gauze is a good choi ce because i t stays wet l onger
t han ot her covers and has l ow energy t ransmi ssi on (235). Wet gauze wi l l also
protect t he shaf t (236). These have been f ound to be especi al l y helpful wi t h the
CO
2
l aser (234). The Nd-YAG, KTP, and argon l asers may al l ow some energy to
penet rate the pl edget and rupture the cuf f (235).
I t i s i mportant that wet covers be kept moi st. Laser beam hi ts may dry t hem, and if
t hat happens, they l ose t hei r protect ive eff ect . Further hi ts can cause the
cott onoi ds and/or cuf f t o i gni te. Al l these must be retri eved af t er surgery.
Special Tracheal Tubes
Ready-to-use l aser-resistant t ubes are di scussed i n Chapter 19. Laser resi st ant
means that the materi al can wi t hst and l imi ted l aser energy wi t h l i tt le or no damage.
The use of a speci al l aser tube does not necessari l y prevent a f i re duri ng l aser
surgery (237). Even t hough the tube i s l abel ed l aser-resi stant , the cuf f wi l l not be
resi st ant , and speci al precauti ons need t o be taken to protect i t . A fi re may occur i f
t he protecti ve wet gauze over t he cuf f dri es or i s displ aced.
No l aser-resi st ant tracheal t ube i s compl etel y saf e f rom al l t ypes of l asers under al l
condi ti ons. Al l of these tubes can be damaged or i gni ted by l asers for whi ch they
are not i ntended or by hi gh l aser energi es (238,239). Some are made more
combust i ble by bl ood (223). Tubes sold f or use wi t h l asers shoul d i ndi cate the t ype
of l aser f or whi ch they are sui ted as wel l as the condi ti ons (power, power densi t y,
spot si ze, oxygen concent rati on) under whi ch the t ube i s saf e to use. St ri ct
adherence t o manuf acturer' s warni ngs and di recti ons is essenti al .
I f the Nd-YAG l aser i s used through a f i ber-opti c bronchoscope passed through a
t racheal tube, i t is best to use an unmarked PVC tube (240). The t racheal tube
shoul d be pl aced j ust bel ow t he vocal cords so that the t i p is as f ar away f rom t he
operati ve si te as possi bl e. I t shoul d be remembered t hat the cover on the f i ber-
opti c endoscope i s pl ast i c and can burn.
Some l aser-resistant tubes are more resi st ant t o f i re than conventi onal tracheal
t ubes when contacted by el ectrosurgi cal i nst ruments (155).
P. 920


When l aser cont act ti ps are used, there i s an even greater opport uni ty f or i gni ti on.
They can get hot enough t o mel t and burn pl ast ics even when the l aser is i nactive
(241).
Double-cuff t ubes are not more resi stant to l eaks that wi l l occur af ter cuf f puncture
but do al low a seal to be maint ai ned i f one cuff remai ns i ntact . The second cuff is
st i l l vul nerabl e to puncture (239).
There are disadvant ages associated wi th l aser-resistant tubes. They are more
expensive than PVC and red rubber tubes. Si nce t hese tubes are of ten used f or
pati ents who have had previ ous l aryngeal surgery, t he anatomy may be distort ed,
maki ng i ntubat i on di ff icul t . Some l aser-resistant tubes are so st if f t hat i t i s dif f icul t
t o pass a st yl et or use wi th a speciali zed l aryngoscope such as the Bull ard
l aryngoscope (Chapter 18). Theref ore, a di ff icul t i ntubati on may become even more
chal l engi ng when these t ubes are needed.
Using Smaller Tracheal Tubes
Smal l -di ameter t racheal tubes requi re hi gher power densi t i es for i gni t i on than
l arge-diameter tubes because the hi gher gas f l ow cools smal l er t ubes more quickly
t han l arger tubes. Also, the smal ler the t racheal tube, the l ess l ikel y i t i s to be hi t
by an i gni t ion source.
Making the Tracheal Tube Easy to Remove
The t ube shoul d be f i xed so t hat i t can be removed rapi dl y, i f necessary. If the t ube
i s to be removed, this shoul d be done i mmedi at el y af ter i gni ti on to mini mi ze
damage to t he ai rway and lungs. If t he tube conti nues to burn, i t may be very
di ff i cul t to remove. Some t racheal tubes break apart as they burn. If the t ube i s
wrapped, t he wrappi ng may break i nto pi eces that could l odge i n the ai rway.
Some t ubes are easi er to remove than others (91). PVC tubes wi t h sal ine-f il l ed
cuff s are more di ff icul t to remove t han red rubber t ubes. The f ast est way to defl ate
a fl ui d-f i l l ed cuff i s to remove the contents wi t h a syri nge rather t han cutt ing the
pi l ot bal l oon. Uncl ampi ng the i nf l ati on tube on a red rubber t ube wi l l resul t in rapi d
rel ease of the cuff cont ents.
Wetting Fuels
The use of wet t owel s, packers, or sponges around t he surgi cal si te can prevent
i gni ti on of materi als near t he si te. Gauze or sponges used wi t h uncuff ed t racheal
t ubes to mi ni mi ze gas l eakage into the pharynx and sponges, gauze, and pl edges
(and thei r stri ngs) used t o protect the t racheal t ube cuf f shoul d be moi stened and
not al l owed to dry.
Hai r t hat i s near the operati ve si t e (e. g., eyebrows, beards, and moustaches)
shoul d be made nonfl ammabl e by coati ng i t thoroughl y wi th a wat er-sol ubl e
l ubricati ng j el l y.
Proper Preparation Practices
Water-based sol ut ions should be used to decontami nat e the ski n pri or t o surgery
whenever possi bl e. If alcohol -cont ai ni ng sol ut ions must be used, a mi ni mum of the
agent shoul d be used and appl i ed l i ke pai nt, not in a t hi ck, runny coat . The soluti on
shoul d not be appl i ed i n a manner that al l ows dri ppi ng, pool i ng, or wi cki ng. I f
solut i on dri ps away f rom the surgi cal si te, i t shoul d be i mmedi ately bl ot ted wi t h a
gauze sponge bef ore i t can soak i nto any absorbent materi al . Any soaked mat erial s
shoul d be removed. Daubi ng of prep pool ed on ski n (i n the umbil i cus or cri coi d
notch) may be needed. Drapi ng shoul d be del ayed to al low t he sol uti on to f ull y
vapori ze and become dil ut ed in room ai r. This coul d t ake 10 mi nutes or l onger
(1,117). Incise (adhesi ve, occlusive) drapes shoul d be used, i f possi bl e, to i solate
head and neck i ncisions f rom oxygen-enriched atmospheres and f rom fl ammabl e
vapors beneath the drapes (120). I f the i nci se materi al does not adhere t o the
pati ent , the prep i s l i kel y sti ll wet, and the pat ient shoul d be redraped once the
prep is f ul l y dry.
Correct Product Choices
I t i s i mportant to consi der the f i re potent i al when choosing equi pment. The
anesthesi a provi der shoul d be aware of the ci rcumst ances under whi ch a f i re can
occur and stri ve to use t he product that wi l l have the l owest fl ammabi l i t y under
condi ti ons where i t wi l l be used.
Fi re/l aser-resistant drapes shoul d be used when exposure to i gni ti on i s possible. It
i s i mport ant t hat t he drape i s tested wi t h the t ype of i gni t i on source that i s to be
used. A standard f or t esting drapes usi ng the CO
2
laser has been publ i shed (242).
Laser-resi stant anesthesia ci rcui t prot ectors and drapes are avai l abl e. These are
al umi ni zed to def l ect the l aser beam. There i s sti l l the possi bi l i t y that the beam may
be refl ected onto a fl ammable surf ace and start a f i re (243).
The use of a met all i c Y-pi ece and el bow wi l l ensure that tracheal tube combusti on
wi l l not spread to t he anesthesi a breathi ng system (244).
Other Measures
A number of ot her measures may be benef icial i n prevent ing a f i re. The t racheal
t ube shoul d be wi t hdrawn to above the si te of surgery duri ng t racheot omy. The use
of posi ti ve end-expi ratory pressure (PEEP) may decrease t he ri sk of ai rway f i re i n
some cases (245,246). Nursing personnel can reduce the combust i bl e l oad i n the
room by removi ng disposabl e paper wrappers and covers before the start of the
case. Not onl y does t hi s reduce t he fuel i n t he room, but i t also reduces the wast e
t hat must be di sposed as red bag wi th i ts hi gher di sposal costs (2).
Minimizing Oxidizer Concentrations
The f i re ri sk can be reduced by removing or i solati ng the oxi di zer f rom the surgi cal
area or mi ni mi zi ng i ts concentrat ion.
P. 921


During def ibri l l at ion, al l sources of oxygen shoul d be completel y removed f rom the
area around t he pat ient .
Oxygen shoul d be admi nistered onl y when i ndicated and in no higher concentrati on
t han i s needed (as guided by oxygen saturat i on moni t oring).
There are several ways of supplying a gas wi t h an oxygen concent rati on greater
t han 21% but l ess than 100% to t he pat ient. An oxygen and an ai r f l owmeter can be
connected by usi ng a Y-pi ece (Fi g. 32.7), or a bl ender can be used. If the machine
has an ai r f l owmeter, a mi xture of oxygen i n ai r can be set and del i vered to
common gas outl et (247). If the common gas outl et can be accessed, a nasal
cannul a can be mated to t he outl et by using a 5-mm t racheal tube connector. I f the
common gas outl et cannot be accessed, a ci rcl e system can be attached to the
machi ne, t he adj ustabl e pressure l i mi ti ng (APL) valve closed, and t he sel ect or
swi t ch set to BAG. A nasal cannul a can then be at t ached to the Y-pi ece. Thi s
arrangement may cause the cont inuous posi ti ve pressure al arm t o be acti vated. A
f orced-ai r convect ion machi ne can be used t o provide a hi gh f low of ai r around the
pati ent 's head whi l e a nasal cannula del i vers a low f l ow of 100% oxygen to t he
pati ent .

View Figure

Figure 32.7 Gas from an oxygen flowmeter and an air
flowmeter can be connected to produce a gas with an
oxygen concentration of less than 100%.

I f possi ble, the oxygen fl ow shoul d be di scont inued f or at l east 1 minute bef ore
heat-producing surgical i nst ruments are used (248,249). When the heat source i s
no l onger used and any t issue embers are ext ingui shed, oxygen admi ni st rati on can
be resumed.
During head and neck surgery, a barri er shoul d be establ ished bet ween t he oxygen-
enri ched atmosphere beneath t he drapes and the surgi cal fi el d, i f possi bl e. This
can of ten be accompl ished wi th an adhesive (i nci se, occl usi ve) drape (2, 117).
When gas i s used to venti l ate t he area under the drapes and prevent CO
2

accumul at ion, t he lowest acceptable concentrat i on of oxygen shoul d be used (250).
Formi ng an open t ent wi t h t he drapes wi l l prevent gases f rom col l ecti ng and al l ow
oxygen to dissi pat e (56,170). Si nce oxygen i s sl i ght l y heavier than room ai r as l ong
as t here is some way f or t he oxygen to get i n and out of a space, i t wi l l tend to f l ow
t oward t he f loor. Acti vely scavengi ng the space beneath drapes wi t h a suct ion
device wi l l l ower oxygen concent rat i ons si gnif icant l y (251). Devices that combine
oxygen del i very wi th sucti on t o prevent oxygen bui ldup under the drape have been
descri bed (252,253). A f an can be used t o bl ow t he accumul at ed oxygen away f rom
t he pat ient. Di rect i ng the f low of nasal oxygen through a nasal ai rway wi l l l ower t he
oxygen concentrati on at the ski n (254).
Heal th care i nsti tuti ons shoul d consi der purchasi ng anesthesi a workstat ions that
i ncl ude i nt ernal pi pel i nes and f l owmet ers f or ai r (248). Thi s makes i t easy to swi t ch
pati ent venti l at ion beneath the drapes f rom oxygen to ai r bef ore the use of heat -
producing surgical i nst ruments. An external f l owmet er can be added t o an
anesthesi a machine i f pi ped ai r i s avail abl e (Fi g. 32.7).
Ni trogen, ai r, or hel i um may be used to reduce the i nspi red oxygen concentrat ion t o
t he l owest l evel that wi l l provi de acceptabl e pati ent oxygenati on. Ni t rous oxi de
supports combusti on and shoul d not be used as the di luent gas (255,256,257).
Hel i um i s a good heat conductor and may of fer a sl i ght protective ef f ect wi t h t he
CO
2
but not t he KTP l aser (258,259). The use of hel ium may decrease the
resi st ance of the gases passi ng t hrough the tracheal t ube (260,261).
P. 922


Ni trogen i nsuff l ati on can signi f i cantl y reduce t he incidence of laser-i nduced
t racheal tube cuf f f i res (262). Thi s can be accompl ished by at t achi ng a cathet er
covered wi t h a l aser-resi stant wrap to the tracheal tube. Ni trogen i s then i nsuf f l ated
t hrough the catheter. Thi s techni que shoul d be undert aken wi t h caut i on, as a
hypoxi c mixture may possi bl y be admi nistered.
Al though usi ng l ower i nspi red oxygen concent rat i ons wi l l reduce the ri sk of i gni t ion,
i t wi l l not t otal l y prevent i t . If there i s a signi fi cant leak around t he tracheal t ube
cuff , the anesthesi a provider may f i l l t he reservoi r bag by pushi ng the oxygen f l ush.
Thi s wi l l resul t in an el evated oxygen concent rati on. A more appropriate response
woul d be to i ncrease the f resh gas f low whi l e maintaini ng the same i nspi red oxygen
concentrati on or to repl ace the tracheal tube.
When el ectrosurgery is used i n t he oral cavi ty, the use of a cuff ed tracheal tube wi l l
mi nimi ze t he oxi di zer l evel . Leaks around the tube may resul t in f i res (161,263). I f
an uncuf fed t ube must be used, an occl usi ve pharyngeal pack moistened wi t h a
nonf l ammable l iquid wi l l reduce the gas f low i nt o t he oral cavi ty (264). I nsuff lati ng
t he mouth wi t h gases such as hel i um, CO
2
, or ni t rogen wi l l reduce the oxi dizer
concentrat ion. The oropharynx can be scavenged wi th separate suct ion.
Pneumatic power t ool s should be operated wi t h ni t rogen or ai r. Inf l atabl e
t ourniquets shoul d be i nf l ated wi th ai r or ni trogen but not oxygen or ni trous oxide
(56,79,265). Ni trous oxide shoul d not be used f or i nsuff lati ng the abdomi nal cavi ty
duri ng laparoscopy (266, 267, 268).
Preventing Pressure Regulator Fires
Fi res i n regul ators can be mini mi zed by not al lowi ng them to become contaminated
wi th oi l , grease, or other combusti bl e materi al s or cl eaned wi t h a f l ammabl e agent
such as al cohol (122, 269). Before a regul ator i s f i t ted t o a cyl i nder, parti cl es shoul d
be cl eared f rom the cyl inder outl et by removing t he protect ive cap or seal and
sl owl y and bri efl y openi ng (cracki ng) the val ve wi th t he port poi nted away f rom
t he user and any other persons. A cyl inder valve shoul d al ways be opened sl owl y t o
al l ow heat t o be di ssi pated as the gas i s recompressed. Consi derati on shoul d be
gi ven t o replacing aluminum regul ators wi t h those made f rom brass. Rul es for
handl i ng cyl inders are di scussed i n Chapter 1.
Fire Plan
Each heal th care f aci l i t y shoul d f ormulat e a pl an for deal i ng qui ckl y wi th an
operati ng room f i re (1,6,56, 58,127,171,202,206,240,270,271,272,273,274). Surgi cal
t eams shoul d be t rained in and practi ce dri l l s for keepi ng mi nor f i res f rom gett ing
out of control and managing f i res that do get out of control . They shoul d know t he
l ocat i on and proper use of alarm boxes, gas shut -off valves, and fi re exti nguishers.
Evacuati on procedures shoul d be revi ewed peri odi cal l y.
I t i s i mportant to i mmedi atel y cal l f or hel p, deci de who i s goi ng to f ight t he fi re,
when i t wi l l be appropri ate to leave the room, and how t o care f or t he pat ient duri ng
t he f i re.
Burni ng mat eri al on or in t he pat i ent of ten can be exti nguished ef fecti vel y and
saf el y by hand or wi th a nonfl ammabl e li quid (e.g., sali ne f rom a basin on the scrub
t abl e) or wet cl oth. Wi th laser surgery i n the ai rway, at l east t wo syri nges f il l ed wi t h
sodium chlori de shoul d al ways be avai l abl e to exti nguish t he f i re (275). Larger
areas can be smothered wi t h a blanket or wet t owel . Fi re blankets are not
recommended (8,276). If t he drape i s water-resistant, water poured on i t wi l l be
i nef f ecti ve (277). The f i re wi l l burn on the underside. The onl y ef f ect ive techni que
i s to pul l t he burni ng mat eri al s f rom the pati ent .
Fi res that invol ve el ect ri cal components are best handl ed by disconnect ing t he
device f rom i ts el ectri c power suppl y and removi ng the device f rom t he room.
The f low of oxygen, ni t rous oxi de, or ai r to any invol ved equi pment shoul d be
t urned OFF, i f this can be accompl ished wi t hout i nj ury t o personnel or t he pat i ent .
Most pat ients can tol erat e short peri ods of oxygen deprivati on. The pati ent shoul d
be venti l ated wi t h ai r and i ntravenous agents used to mai ntain anesthesi a unt i l al l
possi bl e sources of f i re or rei gni t ion are suppressed. It may be necessary t o close
t he oxygen and ni t rous oxi de shut -off val ves to the af f ected room (58, 278,279).
Cyl i nder val ves shoul d be cl osed and all cyl i nders removed f rom the area. If
suppl emental oxygen is necessary t o oxygenate the pat i ent, the pati ent shoul d be
moved to the nearest area where oxygen can be saf el y used (56).
I f an ai rway f i re occurs, the breathing syst em should be di sconnected f rom the
t racheal tube t o stop gas f low. If thi s si te i s not easi ly accessi bl e or the operator
may be burned i n the process of di sconnecti ng the t ube, the breathi ng system can
be di sconnected at the absorber (280).
The t racheal tube should not be undul y secured so that i t can be removed qui ckl y.
Al though i mmedi at e removal of the t racheal tube and protective devi ces i s usuall y
recommended wi th an ai rway f i re, this may not al ways be the best course of act ion
(148, 281). The ri sk: benefi t rati o of extubat ion needs to be considered. A st yl et or
ai rway exchange catheter can be used to subst i tut e a new tube the burned t ube f or.
I f the deci si on to remove the tube has been made, sal ine-f i ll ed cuf f s on plast ic
t ubes can be def l ated f aster by aspi rati ng the f l ui d than by cutt i ng the pil ot tube
(91). Wi th red rubber tubes, uncl ampi ng t he pi l ot t ube i s fast est .
P. 923


The ai rway shoul d be re-establ i shed and t he pati ent vent il ated wi th ai r unt i l i t is
cert ai n t hat nothing remai ns burni ng. Then, 100% oxygen shoul d be admi ni stered.
A search f or f ragments that remain i n t he t rachea and assessment of damage to the
l arynx and t racheobronchi al t ree should be made.
Extinguishing a Fire
Al though most operat ing rooms have a sprinkl er system, spri nkl ers are f requent l y
not eff ecti ve wi th operat i ng room f i res (206). Thi s i s because the sprinklers are
rarel y l ocat ed over t he operati ng room tabl e and are heat acti vat ed. Operati ng room
f i res tend to gi ve of f a l ot of smoke and toxi c products but not necessari l y enough
heat to i mmedi atel y activate t he spri nkl ers. Theref ore, i t is i mportant the al l
operati ng room personnel are f ami l i ar wi t h f i re exti ngui shers.
Location
St rategical l y pl aced port abl e fi re ext ingui shers are an i mportant part of any f i re
protect ion program (1,282, 283). They should be l ocat ed i n conspi cuous, readi l y
accessible l ocati ons t hat are known by al l operat ing room st af f (Fig. 32.8).
Hands-on experi ence wi t h f i re exti nguishers i s essent i al to a f i re saf et y educati on
program (284). Sett i ng up real f i res in a parki ng l ot and providi ng practi ce wi th
exti nguishers can have val uabl e payoff s duri ng an act ual f i re.
Use
Use of any f i re exti ngui sher can be recal l ed by the acronym, pass. Pul l the pin. Ai m
t he horn or nozzl e at the base of t he f i re. Squeeze t he t ri gger or handle whi l e
hol di ng the ext ingui sher upright. Sweep t he ext ingui sher f rom side t o si de, coveri ng
t he area of the f i re. Instruct i ons are f ound on the f i re ext i ngui sher (Fi g. 32. 9). The
pi n and hose are shown i n Figures 32.10 and 32.11.
Choice of Extinguisher
The choi ce of exti nguisher shoul d be based on the predicted f i re ri sk f or t hat
l ocat i on (282,285,286). Fi res are cl assi f i ed according to thei r fuel . Class A f i res
i ncl ude small masses of ordi nary combusti bl es-cloth, paper, and most pl asti cs.
Fi res i nvol ving f l ammabl e l i quids or grease are in cl ass B. Elect ri cal l y energi zed
f i res are cl ass C. Two standard sets of f i re cl ass l abel s exi st : a t radi ti onal lett ering
system and a newer universal pi ct ograph system that does not requi re t he user to
be f ami l i ar wi th t he al phabet f i re class codes (Fig. 32.9).

View Figure

Figure 32.8 Fire extinguishers should be in conspicuous
locations, well known to all operating room staff.

Halogenated Agents
Hal ogenated ext i ngui shi ng agents are l i qui ds that upon discharge under rel ati vely
hi gh pressure surround a f i re wi t h a combi nat i on of vapor and l i qui d dropl ets (mist).
Hal ogenated agents are ideal l y sui ted f or f ighti ng f i res i nvol vi ng el ect roni c
equipment and f i res i n areas where el ect ri cal or el ect roni c equi pment is nearby.
Hal on was the agent of choi ce for operati ng room f i res f or many years (202). I t has
t he abi li t y t o penetrate burning materi al and t o smot her and cool the chemi cal
react i on of the fi re. Whil e usual l y marked f or cl ass B and C f i res, i t i s al so ef fecti ve
against cl ass A f i res f ound i n the operati ng room. Unf ortunat ely, because of
envi ronmental concerns, hal on ext ingui shers are no longer avai labl e. If present in
an operati ng room, they may be used but cannot be recharged. The Nat ional Fi re
Protect ion Associ ati on requi res that nonrechargeabl e
P. 924


P. 925

exti nguishers be removed f rom servi ce 12 years f rom the date of manuf act ure
(287). I n response t o the prohi bi ti ons on the use of halon, a number of
exti nguishi ng agents have been devel oped to replace i t (282,288,289) (Fi g. 32.12).

View Figure

Figure 32.9 The instructions for using the fire extinguisher
are printed on the extinguisher.


View Figure

Figure 32.10 The pin that needs to be pulled to activate the
extinguisher is in the handle at the top of the extinguisher.
The hose is normally attached to the side of the
extinguisher. This figure also shows the pressure gauge,
which indicates that the extinguisher is usable, and the
monthly checkout list, which shows that the extinguisher
has been checked, the extinguisher and hose is undamaged,
and the pressure is in the use range.


View Figure

Figure 32.11 Close-up of pin and pressure gauge at top of
extinguisher.


View Figure

Figure 32.12 There are several substitutes for halon
available.

Carbon Dioxi de
CO
2
exti nguishers emi t a f og of CO
2
gas wi t h l i qui d and sol i d parti cl es that rapi dl y
vapori ze t o cool and smot her a f i re. Al though they carry a B and C rat ing, they can
be used to exti nguish smal l cl ass A fi res. CO
2
f i re ext i ngui shers are heavier and
bulki er t han halon-t ype devi ces. CO
2
ext i ngui shers do not l eave a resi due but do
emi t l iquid and sol id components t hat rapidl y vapori ze. Thi s causes rapi d cool i ng
t hat mi ght cause f reezi ng i f i t comes i nt o cont act wi t h exposed skin or i nt ernal
organs (283,290).
Water
Pressuri zed-water ext ingui shers are chi efl y ef fecti ve agai nst cl ass A f i res. They are
more dif f icul t t o use t han CO
2
and hal on-type exti ngui shers. To put out fi res on
wat er-repel l ant drapes, a f inger must be pl aced over t he nozzl e to produce a f i ne
spray. A stream or spl ash of wat er coul d fan t he f i re (1). A non-magneti c wat er mist
exti nguisher i s avai l abl e for use in the MRI uni t magnet room.

View Figure

Figure 32.13 All operating room personnel must know
where the fire alarm is located. The instructions for
activating it are printed on the fire alarm.

I f the f i re starts to get out of control , the f i re al arm (Fig. 32.13) shoul d be sounded,
and the f i re depart ment shoul d be not if i ed to gi ve f i ref ighters ampl e ti me to respond
(1). Fi ref ighters woul d rather f i nd that a smal l f i re has been ext i ngui shed than see
smoke bi l l owi ng out of a bui ldingespeci al l y i n a heal th care faci l i ty.
The pati ent and st af f shoul d be evacuated if t he f i re and smoke are excessive
(210). I n some si tuati ons, however, i t may be more hazardous to move t he pat ient
t han to attempt t o ext ingui sh or contain t he f i re. The at t endi ng physi ci an must
determine whi ch woul d present the l esser hazard.
The doors shoul d be cl osed to contai n the smoke and isol ate t he f i re. Wet sheets or
t owel s can be stuf f ed under t he doors to reduce the spread of smoke f rom the
room.
Whatever steps are necessary shoul d be t aken to prot ect or evacuat e pat ients i n
adj acent areas.
Af ter the f i re, i nvolved materi al s and devices shoul d remai n in pl ace f or t he f i re
department invest i gat ors. Notes shoul d be made as soon as possibl e af ter the f i re
and an i ncident report completed.
P. 926


References
1. Anonymous. Understandi ng t he f i re hazard. Technol Anesth 1992; 12(9): 16.
2. Lees DE. Operati ng room f i res: st i l l a probl em? ASA Newsl et t 2002;66:3334.
3. Anonymous. JCAHO warns about surgi cal f i res. Outpat ient Surgery Magazine
2003; 4:8.
4. Nati onal Fi re Protect ion Associ ati on. Fi re saf ety i n heal t h care f aci l i t i es. Qui ncy,
MA: Author, 2003.
5. Rodri guez JG, Sat t in RW. I nj uri es as an adverse react ion to cl inical l y used l aser
devices. Lasers Surg Med 1987;7: 457460.
[CrossRef ]
[Medli ne Li nk]
6. Anonymous. A cl i ni ci an' s gui de to surgi cal f i res. How t hey occur, how t o prevent
t hem, how t o put them out . Heal th Devi ces 2003; 32:524.
7. Wol f GL. Danger f rom OR f i res st i l l a seri ous probl em. J Cl i n Moni t Comput
2000; 16:237238.
[CrossRef ]
[Medli ne Li nk]
8. Wasek S. Preventi ng surgi cal f i res. Outpat i ent Surgery Magazi ne 2003;4:28
35.
9. Anonymous. Electrosurgi cal fi res sti l l a hot t opi c. Technol Anesth 1996;17(4):1
2.
10. Rampi l IJ. Anesthet ic consi derat ions for l aser surgery. Anest h Anal g
1992; 74:424435.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
11. Garry B, Bi vens HE. Laser saf et y in t he operati ng room. I. Administering
anesthesi a. Cancer Bul leti n 1989;441:219223.
12. Sosi s MB. Hazards of l aser surgery. Semi nars in Anesthesi a 1990;9:9097.
13. Van Der Spek AFL, Spargo PM, Norton ML. The physics of l asers and
i mpl i cati ons f or t hei r use duri ng ai rway surgery. Br J Anaest h 1988;60:709729.
[CrossRef ]
[Medli ne Li nk]
14. Bal l KA. Lasers. The peri operati ve chal l enge. St . Louis: Mosby, 1995.
15. Absten GT. The fundament al s of medical l aser technol ogy. Bi omed Inst rum
Technol 2002;36:203207.
[Medli ne Li nk]
16. Ameri can Nati onal Standards Inst i tut e. Safe use of lasers in heal th care
f aci li t ies (ANSI Z-136.3). New York: Author, 2005.
17. Denton RA, Dedhi a HV, Abrons HL, et al . Long-t erm survi val af ter
endobronchi al f i re duri ng t reatment of severe mali gnant ai rway obstruct ion wi t h the
Nd: YAG laser. Chest 1988;94:10861088.
[CrossRef ]
[Medli ne Li nk]
18. Krawtz S, Mehta AC, Wi edemann HP, et al . Nd-YAG l aser-i nduced
endobronchi al burn. Management and l ong t erm f ol l ow-up. Chest 1989;95:916
918.
[CrossRef ]
[Medli ne Li nk]
19. Brut i nel WM, Cortese DA Edel l ES, et al . Compl i cat ions of Nd:YAG l aser
t herapy. Chest 1988; 94:902903.
[CrossRef ]
[Medli ne Li nk]
20. Lobrai co RV. Laser safety i n heal th care f aci l i ti es. Am Col l Surg Bul l
1991; 76:1622.
[Medli ne Li nk]
21. Sosi s M. Anesthesi a for laser surgery. Cl i n Anesth Updates 1993; 4(5):112.
22. Anonymous. The devastat ion of pat i ent f i res. Heal th Devices 1992;21:3.
23. Brodman M, Port M, Fri edman F, et al . Operati ng room personnel morbi di t y f rom
carbon dioxi de laser use duri ng preceptored surgery. Obst et Gynecol 1993;81:607
609.
[Full text Li nk]
[Medli ne Li nk]
24. Anonymous. Laser i gni ti on of surgical drapes. Heal t h Devi ces 1992; 21:1516.
[Medli ne Li nk]
25. Sli ney DH. Laser saf et y. Lasers Surg Med 1995;16:215225.
[CrossRef ]
[Medli ne Li nk]
26. Nati onal Fi re Prot ecti on Associati on. Standard for l aser f i re protecti on (NFPA
115). Quincy, MA: Author, 2003.
27. Nati onal Fi re Prot ecti on Associati on. Standard for l aser f i re prevent ion (NFPA
115). Quincy, MA: Author, 2003.
28. Asai T. Burn in t he mouth duri ng oral l aser surgery. Anaest hesi a 1997;52:806
807.
[Full text Li nk]
[Medli ne Li nk]
29. Tucker RD, Voyl es CR. Laparoscopic electrosurgi cal compl i cat i ons and thei r
preventi on. AORN J 1995; 62: 5278.
30. Pfenni nger J. ABCs of el ect rosurgery. Out pat ient Surgery Magazi ne 2004; 5:45
50.
31. Anonymous. Recommended pract i ces f or el ect rosurgery. Ci t y, STATE:
Associ at ion of Operat ing Room Nurses, Inc., 1999.
32. Klein SL, Leonard PF. Buzz em or burn em. Anesth Analg 1991;73: 358359.
[CrossRef ]
[Medli ne Li nk]
33. Lee J. Updat e on el ect rosurgery. Out pati ent Surgery Magazine 2002;3: 4453.
34. Bel l AF, Shagets FW, Barrs DM. Pri nci pl es and hazards of el ectrocautery i n
ot ol aryngol ogy. Ot ol aryngol Head Neck Surg 1986;94: 504507.
[Medli ne Li nk]
35. Anonymous. Prevent i ng pat ient burns at t he return-el ect rode si te duri ng hi gh-
current el ectrosurgi cal procedures. Heal th Devi ces Al erts 2005; 29:13.
36. Mel t zer B. Issues i n el ect rosurgery. Outpati ent Surgery Magazi ne 2001;11:51
61.
37. Denni s V. Pref l i ght i ng your act ive electrodes. Out pat i ent Surgery Magazi ne
2003; 4:6268.
38. Denni s V. Prot ect ing pat ients f rom l aparoscopi c burns. Outpati ent Surgery
Magazi ne 2004;5:8485.
39. Denni s V. 7 hot spots i n electrosurgery. Outpati ent Surgery Magazi ne
2005; 6:4953.
40. Denni s V. Toward safer l aparoscopi c electrosurgery. Outpat ient Surgery
Magazi ne 2006;7:3840.
41. Anonymous. Ret urn-el ectrode-si te burns associated wi th Ri ta Medical Systems
Model 1500 and 1500X radi o-f requency generators. Heal th Devi ces Al erts 2005;29:
34.
42. Gross JB. Less jol ts f rom your vol tselectrical safety i n the operati ng room
(ASA Ref resher Course #126). Park Ridge, I L: ASA, 2005.
43. Lohmann G. Faul t wi th an Ohmeda Excel 410 machi ne. Anaesthesia
1991; 46:695.
[CrossRef ]
[Medli ne Li nk]
44. Bortol ussi ME, Hunter JG. Fi re hazard of t he ophthal mi c cautery. Pl ast
Reconst r Surg 1989;83:753.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
45. Curt i n JW. The di sposabl e cautery: a f i re hazard. Pl ast Reconstr Surg
1989; 84:853.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
46. Anonymous. Hazard report. Fl uorescent l i ghts can acti vate Val l ey Forge
Sci enti f i c Mal is CM CII I bi pol ar electrosurgi cal uni t . Heal th Devi ces 1999; 28(5
6):230231.
[Medli ne Li nk]
47. Ashman MN, Mathasko MJ. Electri cal and fi re saf et y i n the operat i ng room.
Semi nars in Anest hesi a 1993;12:276281.
48. Anonymous. Traini ng paramount i n reduci ng ri sk of surgi cal f i res. Technol
Anesth 2003; 24:57.
49. Mi l l i ken RA, Bi zzarri DV. Fl ammabl e surgi cal drapesa pat i ent and personnel
hazard. Anesth Anal g 1985;64: 5457.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
50. Tucker RD. Laparoscopi c el ect rosurgical i nj uri es: survey resul ts and thei r
i mpl i cati ons. Surg Laparosc Endosc 1995; 5:311317.
[Medli ne Li nk]
51. McKee K. A guide t o testi ng your el ect rosurgery i nstruments. Outpati ent
Surgery Magazine 2001;11: 5964.
52. Denni s V. Choosi ng your act i ve el ect rodes wi th care. Outpati ent Surgery
Magazi ne 2003;4:6567.
53. Anonymous. OR f i res caused by f i beropt i c i l l umi nati on systems. Heal t h Devi ces
1982; 11:148149.
54. Tayl or I R. Hazards of l aparoscopi c surgery. Br J Anaest h 1999;82:651.
[Medli ne Li nk]
55. Eggen MA, Brock-Utne JG. Fiberopti c i ll umi nat ion systems can serve as a
source of smol deri ng f i res. J Cl in Moni t 1994; 10:244246.
[Medli ne Li nk]
56. Anonymous. OR f i res: preventi ng them and put ti ng t hem out . Heal th Devi ces
1986; 15:132136.
57. Anonymous. Laparoscopy l i ght cabl e igni tes operati ng room f i re. Bi omed Safe
St and 1994; 24:162163.
58. Anonymous. Fi res f rom def i bri l l ati on duri ng oxygen admi ni strati on. Technol
Anesth 1994; 15:12.
59. Anonymous. Saf ety noti ce. Anaesthesi a 1995;50:581.
60. Anonymous. Oxygen regul ator fi re caused by use of t wo yoke washers. Technol
Anesth 1990; 11:12.
61. French Mi nistry of Empl oyment and Soli dari ty. Wi thdrawal f rom t he market of
some pressure regulators for medi cal use. September 1, 1998.
62. Anonymous. High-pressure gas regul ators. Technol Anesth 1999;19(10): 89.
63. Anonymous. High-pressure gas regul ators. Technol Anesth 1999;19(11): 6.
64. Anonymous. Are al umi num regul ators saf e? Technol Anesth 1999;11(11):45.
65. Expl osi ons and f i res in al umi num oxygen regul ators. FDA and NI OSH Publ ic
Heal th Advi sory, 1999.
66. Anonymous. Al ert . www. hosmat.com, 2000.
67. Anonymous. Fi res, expl osions lead to recal l of alumi num oxygen regul ators.
Bi omed Saf e Stand 1999;29:5758.
68. Anonymous. Wi thdrawal f rom the market of some pressure regul ators f or
medi cal use. www. hosmat .com, 2000.
69. Anonymous. The pati ent is on f i re! A surgi cal f i res pri mer. Heal th Devices
1992; 21:1923.
70. Eisenbaum SL. Faci al burns as a compl i cat i on of of fi ce surgery l ighti ng. Pl ast
Reconst Surg 1989;83: 155159.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
71. Bourke DL, Yee K, Mark L. Severe burn caused by an operati ng room l i ght .
Anesthesi ol ogy 1993; 79:171173.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
72. Anderson EF. A potent ial igni t i on source i n the operati ng room. Anesth Anal g
1976; 55:217218.
[CrossRef ]
[Medli ne Li nk]
73. Rogers S, Davies MW. My anaesthesia machi ne' s on f i re. Anaesthesi a
1997; 52:505.
[Full text Li nk]
[Medli ne Li nk]
74. Anonymous. Anesthesi a machi ne f i re hazard update. Biomed Saf e Stand
2003; 33: 7374.
75. Usher AG, Cave DA, Finegan BA. Cri ti cal inci dent wi t h Narkomed 6000
anesthesi a machine. Anesthesi ol ogy 2003;99: 762.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
76. Alexander PD, Meurer-Laban M. Rechargeabl e opti ma l aryngoscopes. Br J
Anaesth 1995;74:724725.
[CrossRef ]
[Medli ne Li nk]
77. Anonymous. Risk of f i re i n surgi cal booms. Heal th Devi ces Al erts 2005;29.
78. Anonymous. Risk of f i re i n surgi cal booms. Technol Anesth 2005;25:56.
79. Anonymous. Overvi ew of pneumat ic tourni quets. Technol Anesth 2001;22(4):1
3.
80. Ri ta L, Sel eny F. Endotracheal tube i gni ti on duri ng laryngeal surgery wi t h
resectoscope. Anesthesi ol ogy 1982; 56:6061.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
81. Cel inski M. Expl osi ons i n anaesthesi a. Br J Anaesth 2005; 94:691692.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
82. Anonymous. Incompat i bi li ty of di sposabl e heat ed-wi re breathi ng ci rcui ts and
heated-wi re humidif iers. Technol Anesth 1993;14:45.
83. Anonymous. Anesthesi a breathi ng ci rcui ts any overheat & mel t t ubing. Bi omed
Saf e Stand 1994;24:85.
84. Anonymous. Fi sher & Paykel Dual -heat ed adul t respi ratory vent i l ator ci rcui ts:
ri sk of fi re. Heal th Devi ces Al erts 2006;30: 4.
85. Gaba DM. More on ni trous oxide and l aser surgery. Anesth Anal g 1988;67: 488
489.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
86. Geff i n B, Shapshay SM, Bel l ack GS. Fl ammabi li t y of endotracheal t ubes during
Nd-YAG l aser appl icati on i n t he ai rway. Anesthesi ol ogy 1986;65: 511515.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
87. Ossoff RH, Duncavage JA, Ei senman TS, et al . Compari son of tracheal damage
f rom laser i gni ted endotracheal t ube f i res. Ann Otol Rhi nol Laryngol 1983;92: 333
336.
[Medli ne Li nk]
88. Duncavage JA, Ossoff RH, Rouman WC, et al . Inj uri es to t he bronchi and l ungs
caused by l aser-i gni ted endot racheal tube fi res. Otolaryngol Head Neck Surg
1984; 92:639643.
[Medli ne Li nk]
89. Pat el KF, Hicks JN. Preventi on of f i re hazards associ at ed wi t h use of carbon
di oxi de l asers. Anesth Anal g 1981;60:885888.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
90. Fri ed MP, Mal l ampat i R, Cami near DS. Comparati ve anal ysi s of the saf et y of
endot racheal tubes wi t h the KTP l aser. Laryngoscope 1989;99:748751.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
91. Sosi s MB, Braverman B. Advant age of rubber over pl asti c endotracheal t ubes
f or rapi d extubat ion i n a laser f i re. J Cl i n Laser Med Surg 1996; 14:9395.
[Medli ne Li nk]
92. Anonymous. Gui dance on ai rway management duri ng l aser surgery of upper
ai rway. Techni cal Report I SO TR 11991, 1995.
93. Anonymous. Upper ai rway management gui de provi ded f or l aser ai rway surgery.
APSF Newslett 1993;8: 1316.
94. Anonymous. Endotracheal tube mel ts and igni t es i nsi de pat i ent 's t rachea.
Anesthesi a Mal practi ce Preventi on 2001; 6:914.
95. Bri macombe J. The i ncendi ary characteri sti cs of the l aryngeal and rei nforced
l aryngeal mask ai rway to CO
2
l aser st ri kea compari son wi t h t wo pol yvinyl chl ori de
t racheal tubes. Anaesth Intens Care 1994;22: 694697.
[Medli ne Li nk]
96. Gal apo S, Wol f GL, Si debotham GW, et al . Laser i gni ti on of surgical drapes in
an oxygen enri ched atmosphere. Anesthesiology 1998;89:A560.
97. Anonymous. Fi re! Technol Anesth 1996;16:45.
98. Gi bbs JM. Combust ible pl ast i c drape. Anaesth Intens Care 1983; 11:176.
[Medli ne Li nk]
99. Lazard JL, Wolf GL, Charchofl i eh J, et al . Surgical drape combusti on in FI O2-
0. 21, FIO2-0.50 and FI O2-0.95. Poster presentat ion, ASA Meet i ng, New Orl eans,
2001.
100. Lazard JL, Wol f GL, Charchaf li ch J, et al . Surgi cal drape combusti on i n FIO2-
0. 21, FIO2-0.50 and FI O2-0.95. Poster presentat ion, Ameri can Societ y of Cri t i cal
Care Anesthesi ol ogi sts, New Orl eans, 2001.
101. Barker SJ, Pol son JS. Fi re i n the operati ng room: a case report and laboratory
study. Anesth Analg 2001;93: 960965.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
102. Ott AE. Di sposabl e surgi cal drapesa potent i al f i re hazard. Obstet Gynecol
1983; 61:667668.
[Full text Li nk]
[Medli ne Li nk]
103. Domi n MA. Saf et y precaut i ons for l aser surgery. J Heal thc Mater Manage
1991(June); 9:2025.
104. Wol f GL, Si debotham GW, Lazard JLP, et al . Laser i gni ti on of surgical drape
materi al s i n ai r, 50% oxygen, and 95% oxygen. Anest hesiol ogy 2004;100:1167
1171.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
105. Anonymous. Surgi cal f i re case summari es. Heal th Devi ces 1992;21(1):3134.
P. 927


106. Axel rod EH, Kusnet z AB, Rosenberg MK. Operat i ng room f i res i ni t i ated by hot
wi re cautery. Anesthesi ology 1993;79:11231126.
[CrossRef ]
[Medli ne Li nk]
107. Bennet t JA, Agree M. Fi re i n the chest. Anesth Anal g 1994;78:406.
[Medli ne Li nk]
108. Ort ega RA. A rare cause of fi re i n the operati ng room. Anest hesi ol ogy
1998; 89:1608.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
109. Lai A, Ng KP. Fi re duri ng thoraci c surgery. Anaesth Intens Care 2001;29:301
303.
[Medli ne Li nk]
110. Bl anchard DL. Fi re in surgery. Ophthal Plast Reconst r Surg 1987;3:59.
[CrossRef ]
[Medli ne Li nk]
111. St ouf fer DJ. Fi res duri ng surgery: t wo f at al i nci dents i n Los Angeles. J Burn
Care Rehabi l 1992;13:114117.
[CrossRef ]
[Medli ne Li nk]
112. Wood DK, Holl i s R. Thermocautery causes a gauze pad f i re. JAMA
1993; 270: 22992300.
[CrossRef ]
[Medli ne Li nk]
113. Kat z JA, Campbel l L. Fi re during t horacotomy: a need t o cont rol t he inspi red
oxygen concentrati on. Anesth Anal g 2005; 101:612.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
114. Santos P, Ayuso A, Lui s M, et al . Ai rway i gni t ion duri ng CO
2
l aser l aryngeal
surgery and hi gh f requency jet venti lati on. Eur J Anaesthesi ol 2000; 17:204207.
[CrossRef ]
[Medli ne Li nk]
115. Anonymous. $200,220 awarded i n pat ient burn case. Bi omed Saf e Stand
1995; 25:133.
116. Anonymous. Use of acetone & eggcrate mat tress ci ted i n operati ng room fi re.
I ndi ana hospi tals advised to revi ew i nternal pol icies. Bi omed Saf e St and
1989; 19:26.
117. Anonymous. Fi re hazard created by the mi suse of DuraPrep sol ut ion. Heal th
Devices 1998;27(5): 400402.
[Medli ne Li nk]
118. Pl uml ee JE. Operat i ng-room f lash f i re f rom use of cautery af ter aerosol spray:
a case report . Anesth Anal g 1973;52:202203.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
119. Sebben J. Fi re hazard and el ect rosurgery. J Dermatol Surg Oncol
1990; 16:421424.
[Medli ne Li nk]
120. Anonymous. Improper use of al cohol -based ski n preps can cause surgi cal
f i res. Tech Anesth 2003;24:36.
121. Prasad R, Quezado Z, St. Andre A, et al . Fi res in t he operat ing room and
i ntensi ve care uni t : awareness is the key to preventi on. Anesth Anal g
2006; 102: 172174.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
122. Macdonal d AG. A brief histori cal review of non-anaesthet ic causes of f i res and
explosi ons i n t he operati ng room. Br J Anaesth 1994;73:847856.
[CrossRef ]
[Medli ne Li nk]
123. Green JM, Sonbol ian N, Gonzal ez RM, et al . CO
2
l aser resistance of vari ous
oi nt ments and tapes. Anesthesi ology 1991;74:964965.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
124. Dat ta TD. Fl ash f i re hazard wi t h eye oi nt ment . Anesth Analg 1984;63: 700
701.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
125. Chestl er RJ, Lemke BN. Int raoperat i ve f l ash f i res associ ated wi th di sposable
cautery. Ophthal Pl Reconst Surg 1989;5:194195.
126. Marti n L, Dol man P. Fi re! Can J Anaest h 1994;46: 909.
127. de Ri chmond AL, Bruley ME. Head and neck surgi cal f i res. I n: Ei sel e DW, ed.
Compl i cat i ons i n Head and Neck Surgery. St . Loui s: MosbyYear Book, 1993;311
312.
128. Mandych A, Mi ckelson S, Ami s R. Operat i ng room f i re. Arch Otol aryngol Head
Neck Surg 1990;116:1452.
[Medli ne Li nk]
129. Anonymous. Inf ant di es af ter operat i ng room fl ash f i re. Biomed Safe Stand
1988; 18:154.
130. Bowdl e TA, Gl enn M, Colston H, et al . Fi re f ol lowi ng use of el ect rocautery
duri ng emergency percutaneous transtracheal venti l at ion. Anesthesi ol ogy
1987; 66:697698.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
131. Anonymous. Laser-i gni ted l at ex gl ove causes ai rway f i re. Bi omed Saf e Stand
1992; 22:51.
132. Si mpson JI , Wol f GL. Flammabi l i ty of esophageal stethoscopes, nasogastri c
t ubes, feedi ng tubes, and nasopharyngeal ai rways i n oxygen- and ni trous oxi de-
enri ched atmospheres. Anesth Anal g 1988;67:10931095.
[Medli ne Li nk]
133. Demos JE. Fi re i n the operati ng room. Pl ast Reconstr Surg 1995; 95: 419
420.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
134. Bropuwers JW. Col l odi on and el ectrocautery do not mix. Anesth Anal g
1998; 67:718.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
135. Carter R, Smi t h JS. Oesophageal prostheti c i gni t ion f ol l owi ng acci dental
exposure to t he Nd. YAG l asera real or potenti al hazard. Lasers i n Medical
Sci ence 1988;2:229232.
[CrossRef ]
136. Anonymous. Anesthesi a f i re burns young boy. Bi omed Saf e Stand 2003;33:65
66.
137. Kanno TA, Aso C, Sai to S, et al . A combust ive destruct ion of expi rat ion val ve
i n an anestheti c ci rcui t . Anesthesi ol ogy 2003; 98:577579.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
138. Mayworm D. How to prevent i nf ect ion f rom surgical i nst ruments. Outpati ent
Surgery Magazine 2002; Speci al edi ti on:3844.
139. Barl as S. TIA cleans up hand-sani ti zer cont roversy. NFPA J 2004;98:36.
140. Anonymous. Venti lator & ESU i nvol ved i n el ect rosurgi cal f i re. Bi omed Safe
St and 1991; 21:114115.
141. Rogers SA, Mi l ls KG, Tufai l Z. Case report . Ai rway f i re due t o diathermy
duri ng tracheostomy i n an int ensive care pat i ent. Anaesthesi a 2001; 56:441446.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
142. Li m HJ, Mi l l er GM, Rai nbi rd A. Ai rway f i re duri ng electi ve t racheotomy.
Anaesth Intens Care 1997;25:150152.
[Medli ne Li nk]
143. Bai l ey MK, Bromley HR, Al l i son JG, et al . El ect rocaut ery-i nduced ai rway f i re
duri ng tracheostomy. Anest h Anal g 1990;71: 702704.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
144. Al y A, McI l wai n M, Duncavage JA. El ectrosurgery-i nduced endotracheal t ube
i gni ti on duri ng tracheot omy. Ann Otol Rhinol Laryngol 1991; 100:3133.
[Medli ne Li nk]
145. Lew EO, Mi tt l eman RE, Murray D. Endot racheal tube i gni ti on by el ectrocautery
duri ng tracheostomy: case report wi th autopsy f indings. J Forensi c Sci
1991; 36:15861591.
[Medli ne Li nk]
146. LeCl ai r J, Gart ner S, Hal ma G. Endot racheal tube cuf f i gni ted by
el ect rocautery during t racheost omy. J Am Assoc Nurs Anesth 1990;58:259261.
147. Thompson JW, Col i n W, Snowden T, et al . Fi re i n the operat ing room duri ng
t racheostomy. South Med J 1998;91:243247.
[Full text Li nk]
[Medli ne Li nk]
148. Chee WK, Benumof JL. Ai rway f i re duri ng tracheostomy: extubati on may be
contrai ndi cat ed. Anesthesi ology 1998;89:15761578.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
149. Marsh B, Ri ley RH. Doubl e-lumen tube f i re duri ng tracheostomy.
Anesthesi ol ogy 1992; 76:480481.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
150. Michel s AMJ, Stot t S. Expl osi on of t racheal tube duri ng t racheostomy.
Anaesthesia 1994;49: 1104.
[CrossRef ]
[Medli ne Li nk]
151. Wi l son PTJ, Igbasei mokumo U, Marti n J. Igni t ion of the t racheal t ube duri ng
t racheostomy. Anaesthesi a 1994;49:734735.
[CrossRef ]
[Medli ne Li nk]
152. Bowdl e TA, Gl enn M, Colston H, et al . Fi re f ol lowi ng use of el ect rocautery
duri ng emergency percutaneous transtracheal venti l at ion. Anesthesi ol ogy
1987; 66:697698.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
153. Baur DA, But ler RC. El ect rocautery-i gni ted endot racheal tube f i re: case report .
Br J Oral Maxi l lof ac Surg 1999;37:142143.
[CrossRef ]
[Medli ne Li nk]
154. Awan MS, Ahmed I. Endot racheal tube f i re duri ng tracheostomy: a case report .
Ear Nose Throat J 2002; 81: 9092.
[Medli ne Li nk]
155. Sosis MB, Braverman B. Prevent ion of cautery-i nduced ai rway f i res wi th
speci al endot racheal tubes. Anesth Anal g 1993;77:846847.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
156. Gupte SR. Gauze f i re i n the oral cavi t y: a case report . Anesth Anal g
1972; 51:645646.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
157. Si mpson JI , Wol f GL. Endot racheal tube fi re i gni ted by pharyngeal
el ect rocautery. Anesthesiology 1986;65:7677.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
158. Kel l er C, El l i ot t W, Hubbel l RN. Endotracheal tube saf ety duri ng
el ect rodi ssecti on t onsi l lectomy. Arch Otolaryngol Head Neck Surg 1992;118:643
645.
[Medli ne Li nk]
159. Col l ee GG. A f i re i n t he mouth. Anaesthesi a 1984;39: 936.
[CrossRef ]
[Medli ne Li nk]
160. Macdonal d MR, Wong A, Wal ker P, et al . El ectrocautery-i nduced i gni ti on of
t onsi l lar packi ng. J Otolaryngol 1994;23: 426429.
[Medli ne Li nk]
161. Kaddoum RN, Chi di ac EJ, Zest os MM, et al . El ectrocautery-i nduced f i re duri ng
adenot onsil l ectomy: report of two cases. J Cl i n Anesth 2006;18:129131.
[CrossRef ]
[Medli ne Li nk]
162. Mat tucci KF, Mil i tana CJ. The prevention of f i re duri ng oropharyngeal
el ect rosurgery. Ear Nose Throat J 2003;82:107109.
[Medli ne Li nk]
163. Pashayan AG, Gravenstei n N. Hi gh inci dence of CO
2
l aser beam contact wi t h
t he tracheal t ube duri ng operat i ons on the upper ai rway. J Cl i n Anesth 1989; 1:354
357.
[CrossRef ]
[Medli ne Li nk]
164. Hi rshman CA, Smi th J. Indi rect i gni t ion of the endot racheal tube duri ng carbon
di oxi de l aser surgery. Arch Otolaryngol 1980; 106:639641.
[Medli ne Li nk]
165. Cozi ne K, Rosenbaum LM, Askanazi J, et al . Laser-i nduced endotracheal t ube
f i re. Anest hesi ol ogy 1981; 55:583585.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
166. Eade GG. Hazard of nasal oxygen duri ng aesthet ic f aci al operati ons. Pl ast
Reconst r Surg 1986;78:539.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
167. Brecht el sbauer P, Carrol l W, Baker S. I ntraoperati ve f i re wi t h el ect rocautery.
Ot olaryngol Head Neck Surg 1996;114:328331.
[CrossRef ]
[Medli ne Li nk]
168. Chang BW, Pett y P, Manson PN. Pati ent fi re saf et y i n the operat i ng room.
Pl ast Reconstr Surg 1994; 93: 519521.
[Medli ne Li nk]
169. Reyes RJ, Smi th AA, Mascaro JR, et al . Supplemental oxygen: ensuri ng i ts
saf e del ivery during f aci al surgery. Pl ast Reconst r Surg 1995; 95: 924928.
[CrossRef ]
[Medli ne Li nk]
170. Anonymous. Fi res f rom oxygen use duri ng head and neck surgery. Heal th
Devices 1995;24:155157.
[Medli ne Li nk]
171. Anonymous. Prepari ng f or and managing surgical f i res. Heal th Devices
1992; 21(1): 2431.
[Medli ne Li nk]
172. Aston SJ, Bornstein SJ. An unusual compl i cat ion associ ated wi t h
bl epharopl ast y. Aestheti c Pl ast Surg 1978; 2:451453.
[CrossRef ]
173. Lederman IR. Fi re hazard duri ng ophthal mic surgery. Opht hal mic Surg
1985; 16:577578.
[Medli ne Li nk]
174. Garf i el d JM, Al len GW, Si lverstei n P, et al . Fl ash f i re in a reduci ng valve.
Anesthesi ol ogy 1971; 34:578579.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
175. Gunati l ake DE. Case report : f atal i ntraperi toneal expl osi on duri ng
el ect rocoagul at ion via l aparoscopy. Int J Gynaecol Obstet 1978;15:353357.
[Medli ne Li nk]
176. El -Kady AA, Abd-El Razek M. I nt raperi t oneal explosion duri ng f emal e
steri l i zat ion by l aparoscopic el ectrocoagul ati on. A case report . Int J Gynaecol
Obstet 1976;14:487488.
[Medli ne Li nk]
177. Robi nson JS, Thompson JM, Wood AW. Fi re and expl osi on hazards i n
operati ng theat res: a repl y and new evi dence. Br J Anaesth 1979;51:908.
[CrossRef ]
[Medli ne Li nk]
178. Di emunsch PA, Torp KD, Van Dorssel aer T, et al . Ni trous oxide f racti on i n the
carbon dioxi de pneumoperi t oneum duri ng l aparoscopy under general i nhal ed
anesthesi a i n pi gs. Anesth Analg 2000;90: 951953.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
179. Neuman GG, Si debot ham G, Negoianu E, et al . Laparoscopy expl osi on
hazards wi t h ni trous oxide. Anesthesi ol ogy 1993; 78:875879.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
180. Anonymous. Use of wrong gas i n l aparoscopi c i nsuf f lat or causes f i re. Heal th
Devices 1994;23:5556.
[Medli ne Li nk]
181. Greil i ch PE, Grei l i ch NB, Froel i ch EG. I ntraabdomi nal f i re duri ng laparoscopic
cholecystectomy. Anesthesi ol ogy 1995; 83:871874.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
182. Anonymous. Def ibri ll ator sparks f l ames i n ambul ance. Heal th Devi ces Al erts
2004; 28:12.
183. Anonymous. Usi ng external def i bri ll ators i n oxygen-enri ched atmospheres can
cause f i res. Heal th Devices Alert s 2006;30:12.
184. Robert shaw H, McAnul ty G. Ambi ent oxygen concentrat ions duri ng simulat ed
cardi opul monary resusci t ati on. Anaesthesi a 1998;53:634637.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
185. Anonymous. Pat i ent set af i re by def ibri l l ator paddl es. Biomed Safe Stand
2004; 34:25.
186. Castro BA, Freedman A, Crai g WL, et al . Expl osi on wi thi n an anesthesi a
machi ne: Baral yme, high f resh gas f lows and sevof l urane concentrat ion.
Anesthesi ol ogy 2004; 101: 537539.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
187. McKeskey CH. Let ter t o heal th care prof essi onal s. 2003.
188. Laster M, Roth P, Eger EI . Fi res f rom the i nteracti on of anest heti cs wi th
desiccated absorbent . Anesth Anal g 2004; 99: 769774.
[Full text Li nk]
[CrossRef ]
189. Wu J, Previ te JP, Adl er E, et al . Spontaneous i gni t ion, explosion, and f i re wi th
sevof lurane and bari um hydroxi de l i me. Anesthesi ol ogy 2004;101:534537.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
190. Ol ympi o MA, Morel l RC. Cani ster f i res become a hot safet y concern. APSF
Newslett 2004;18: 4548.
191. Anonymous. Anesthesi a carbon di oxi de absorber f i res. Technol Anesth
2003; 24:13.
192. Fatheree RS, Leighton BL. Acute respi ratory di st ress syndrome af t er an
exothermi c Baral yme-sevofl urane react ion. Anesthesi ol ogy 2004; 101:531533.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
193. Hol ak EJ, Mei DA, Dunni ng MB, et al . Carbon monoxi de producti on f rom
sevof lurane breakdown: modeli ng of exposures under cl i ni cal condi t i ons. Anesth
Anal g 2003;96:757764.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
194. Gat ti JE, Bryant CJ, Noone RB, et al . The mutageni ci t y of el ect rocaut ery
smoke. Pl ast Reconst r Surg 1992; 89:781784.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
195. Bal l K. No smoki ng in the OR. Outpatient Surgery Magazine 2003;4:6267.
196. American Soci et y of Anesthesi ol ogi sts. Recommendat ions f or inf ecti on control
f or the practi ce of anesthesi ol ogy. Park Ri dge, IL: ASA, 1998.
197. Paes ML. General anaesthesi a f or carbon di oxi de l aser surgery wi t hi n t he
ai rway. Br J Anaesth 1987;59:16101620.
[CrossRef ]
[Medli ne Li nk]
198. Anonymous. The el ements of surgical f i res. Technol Anesth 2003;23:17.
199. Anonymous. Laser contact t ips and tracheal t ubes. Heal t h Devi ces
1992; 21:18.
[Medli ne Li nk]
200. Wol f GL, Si debotham GW, Stern JB. I nt ral umi nal f l ame spread i n t racheal
t ubes. Laryngoscope 1994;104:874879.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
201. Moak E. Electrosurgi cal uni t saf et y. AORN J 1991; 53:744752.
[CrossRef ]
[Medli ne Li nk]
202. McCrani e J. Fi re safety i n the operati ng room. Today' s OR Nurse 1994;16:33
37.
[Medli ne Li nk]
203. Anonymous. Laser starts f i re i n OR. Technol Anesth 1988;8: 34.
204. Dennis V. I mprovi ng your el ect rosurgery saf et y. Out pat ient Surgery Magazi ne
2003; 4:4448.
205. Anonymous. El ect rocaut ery uni ts: improper di sposal can cause f i res. Heal t h
Devices Alert s 2005;29.
P. 928


206. Ehrenwert h J. A f i re i n the operati ng room: i t can happen t o you (ASA
Ref resher Course #144). Park Ri dge, IL: ASA, 2005.
207. Anonymous. FDA issues saf ety alert on heated-wi re breathing ci rcui t hazards.
Bi omed Saf e Stand 1993;23(19): 146147.
208. Gowardman JR, Mori arty B. Expl osi on and f i re i n the expi rat ory l i mb of a
Fi sher and Paykel t hree i n one respi ratory care system. Anaesth Intens Care
1998; 26:427430.
[Medli ne Li nk]
209. Sommers JR. Fl ammabi l i ty standards for surgical drapes and gowns. Past,
present, and future. Surgi cal Servi ces Management 1998;4:4144.
210. McCrani e J. Fi re safety i n the operati ng room. Todays OR Nurse 1992;14:33
37.
211. Hawkins DB, Joseph MM. Avoi di ng a wrapped endot racheal tube i n l aser
l aryngeal surgery: experi ences wi t h apneic anesthesia and metal Laser-Flex
endot racheal tubes. Laryngoscope 1990;100:12831287.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
212. Kwan A. The use of St orz bronchoscope in preventi on of ai rway f i re. Anaesth
I ntens Care 2004;32:720.
[Medli ne Li nk]
213. Kj el dsen L, Andersen APD, Hj ort h A. Laser surgery i n the ai rway. Anaesthesia
1986; 39:1146.
[CrossRef ]
[Medli ne Li nk]
214. Hunsaker DH. Anesthesi a for mi crol aryngeal surgery: the case for subgl ottic
j et venti l ati on. Laryngoscope 1994;104: 130.
[Medli ne Li nk]
215. Wegrzynowi cz ES, Jensen NF, Pearson KS, et al . Ai rway f i re during jet
venti l ati on f or l aser exci si on of vocal cord papi l lomata. Anesthesi ol ogy
1992; 76:468469.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
216. Sosis MB, Di l l on FX. Sal ine-f i l l ed cuf f s hel p prevent l aser-i nduced
pol yvinyl chl ori de endot racheal tube f i res. Anesth Anal g 1991;72:187189.
[Medli ne Li nk]
217. LeJeune FE, Gui ce C, LeTard F, et al . Heat sink protecti on agai nst l aseri ng
endot racheal cuf fs. Ann Otol Rhi nol Laryngol 1982;92:606607.
[Medli ne Li nk]
218. Wal sh M, Schubert A, Al Haddad S. The addi t ion of li docai ne jel l y to sal i ne i n
t he cuf f of the endotracheal tube duri ng l aser surgery of the ai rway. Am J Anest h
1997; 24:189193.
219. Sosis MB, Di l l on F. Prevent ion of CO
2
l aser-i nduced wi th t he Laser-Guard
protect ive coat ing. J Cl in Anesth 1992;4: 2527.
[CrossRef ]
[Medli ne Li nk]
220. Sosis MB. Eval uat ion of f oi l coveri ngs f or protect ing plasti c endotracheal
t ubes f rom t he potassi um-ti t anyl -phosphate l aser. Anesth Anal g 1993;77: 589591.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
221. Sosis MB. Why i s the Laser-guard protecti ve coati ng bet ter t han the f oi l
t apes? I n response. Anesth Anal g 1994;78:1030.
[Full text Li nk]
[CrossRef ]
222. Van De Merwe W. Si l ver protecti ve tape resists burni ng better t han al umi num.
Cl in Laser Mon 1989;7: 2122.
223. Sosis MB, Pri ti ki n JB, Cal darel l i DD. The ef f ect of bl ood on l aser-resi stant
endot racheal tube combusti on. Laryngoscope 1994;104:829831.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
224. Sosis M, Di l l on F. Refl ecti on of CO
2
l aser radiati on f rom l aser-resi stant
endot racheal tubes. Anesth Anal g 1991;73:338340.
[CrossRef ]
[Medli ne Li nk]
225. Sosis M, Di l l on F. Prevent ion of CO
2
l aser t racheal t ube f i res wi t h the Laser-
Guard protective coat ing. Can J Anaesth 1989;36:S88S89.
226. Sosis M, Di l l on F. What i s t he saf est foi l tape f or endot racheal tube protecti on
duri ng Nd-YAG l aser surgery? Anest hesi ol ogy 1990; 72:553555.
227. Sosis MB. Whi ch i s the safest endot racheal tube f or use wi t h the CO
2
laser? A
comparati ve study. J Cli n Anesth 1992;4: 217219.
[CrossRef ]
[Medli ne Li nk]
228. Wal ker P, Temperl ey A, Thel f ol S, et al . Avoidance of l aser i gni ti on of
endot racheal tube by wrappi ng in al umi num f oi l tape. Anaesth I ntens Care
2004; 32:108112.
[Medli ne Li nk]
229. Kuo CH, Tan PH, Chen JJ, et al . Endotracheal f i res duri ng carbon di oxi de
l aser surgery on the l arynxa case report . Acta Anaest hesi ol Si n 2001;39:5356.
[Medli ne Li nk]
230. DeVane CC. Laser i ni ti at ed endotracheal t ube explosi on. AANA J
1996; 58:188192.
231. DeVane GG. Case report: laser i ni ti ated endotracheal tube expl osi on. J Am
Assoc Nurs Anesth 1990;58:188192.
232. Ko C-H, Tan P-H, Chen J-J, et al . Endotracheal tube f i res during carbon
di oxi de l aser surgery on the l arynxa case report. Acta Anaesthesiol Sin
2001; 39:5356.
[Medli ne Li nk]
233. Fontenot R, Bai l ey BJ, Sti ernberg CM, et al . Endot racheal tube saf ety duri ng
l aser surgery. Laryngoscope 1987;97:919921.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
234. Sosis MB. Sali ne soaked pl edgets prevent carbon di oxi de l aser-i nduced
endot racheal tube cuf f inf l at ion. J Cl i n Anesth 1995;7:395397.
[CrossRef ]
[Medli ne Li nk]
235. Anonymous. Do pl edgets prot ect t he t racheal tube cuf f f rom l asers? Heal th
Devices 1992;21:17.
236. Mi l l er G, Li mb R. The CO
2
l aser and l at ex armoured t ube (l etter). Anaesth
I ntens Care 1995;23:517518.
[Medli ne Li nk]
237. Sesterhenn AM, Dunne AA, Braulke D, et al . Val ue of endotracheal tube safet y
i n l aryngeal l aser surgery. Lasers Surg Med 2003; 32:384390.
[CrossRef ]
[Medli ne Li nk]
238. Anonymous. Laser-resi stant t racheal tubes. Heal th Devices 1992;21:414.
[Medli ne Li nk]
239. Anonymous. Laser-resi stant endot racheal tubes and wraps. Heal th Devi ces
1990; 19:112139.
240. Ehrenwert h J. Fi re safet y i n t he operati ng room (ASA Ref resher Course). Park
Ri dge, IL: Author, 2002.
241. Anonymous. Ai rway f i res: reduci ng t he ri sk duri ng laser surgery. Technol
Anesth 1990; 11:13.
242. Internati onal Standards Organi zati on. Lasers and l aser-rel ated equi pment: test
method f or det ermi ni ng the CO
2
l aser resistance of surgi cal drapes and/or pat ient
protect ive covers (I SO 11810). Geneva, Swi tzerl and: Author, 2002.
243. Sosis M. Evaluat ion of a new l aser-resi stant anesthesi a ci rcui t protector.
drape and pati ent eye shield. J Cl i n Moni t 1991;7:132.
244. Sosis M, Braverman B, Ivankovich AD. Metal anesthesi a ci rcui t components
stop l aser f i res. Anesthesi ol ogy 1991; 75:A396.
[Full text Li nk]
[CrossRef ]
245. Anonymous. Increased PEEP l evel s may reduce laser-i nduced t racheal tube
f i re ri sks. Bi omed Saf e Stand 1993;23:123.
246. Pashayan AG, San Gi ovanni C, Davis LE. Posi tive end-expi ratory pressure
l owers the risk of l aser-i nduced pol yvi nyl chl ori de t racheal -tube f i res.
Anesthesi ol ogy 1993; 79:8387.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
247. Lampotang S, Gravenstein N, Paulus DA, et al . Reduci ng t he inci dence of
surgi cal fi res: suppl yi ng nasal cannul ae wi t h sub-100% O
2
gas mi xtures f rom
anesthesi a machines. Anesth Anal g 2005;101:14071412.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
248. Anonymous. Reduci ng the ri sk of f i res duri ng head and neck surgery. Technol
Anesth 2002; 22:12.
249. Lowry RK, Noone RB. Fi res and burns duri ng pl astic surgery. Ann Pl ast Surg
2001; 46:7276.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
250. Greco RJ, Gonzal ez R, Johnson P, et al . Potenti al dangers of oxygen
suppl ementat ion duri ng f aci al surgery. Pl ast Reconstr Surg 1995; 95:978984.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
251. Barnes AM, Frant z RA. Do oxygen-enri ched atmospheres exist beneath
surgi cal drapes and cont ri but e to f i re potenti al i n the operat i ng room? AANA J
2000; 68:153161.
252. Ramanathan S, Capan L, Chalon J, et al . Mi ni envi ronment al cont rol under the
drapes duri ng operati ons on the eyes of consci ous pati ents. Anesthesi ology
1978; 48:286288.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
253. Ri nder CS, Dabu-Bondoc S, Sal gar V. A device to reduce O
2
accumul at ion and
reduce f i re hazard duri ng MAC anesthesi a. Anesthesi ol ogy 2005; 103:A804.
254. Borkowski RG, Meneghett i C, Morgan MM, et al . A compari son of methods for
del i veri ng suppl emental oxygen duri ng pl asti c surgery. Anesthesi ol ogy
2005; 103:A841.
255. Sosis M. Ni trous oxide is contrai ndi cated i n endoscopic surgery. Can J
Anaesth 1987;34:539.
[Medli ne Li nk]
256. Sosis M. Ni trous oxide should not be used duri ng l aser endoscopic surgery.
Anesth Anal g 1987;66:10541055.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
257. Shapi ro JD, El -Baz NM. N
2
O has no place duri ng oropharyngeal and
l aryngot racheal procedures. Anesthesiol ogy 1987; 66:447448.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
258. Si mpson JI , Schi ff GA, Wolf GL. The ef f ect of hel ium on endotracheal tube
f lammabi l i ty. Anesthesi ol ogy 1990;73:538540.
[Ful l text Li nk]
[CrossRef ]
[Medli ne Li nk]
259. Al haddad S, Brenner J. Hel i um and lower oxygen concentrat ions do not
prol ong t racheal tube i gni t ion t i me duri ng potassi um t i tanyl phosophate laser use.
Anesthesi ol ogy 1994; 80:936938.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
260. Rampi l IJ. Heli um and gas f l ow. Anesth Analg 1993; 76:S453.
261. Ei senkraf t JB, Barker SJ. Hel ium and gas fl ow. Anesth Anal g 1993;76:452
453.
[Medli ne Li nk]
262. Sosis MB. Eval uat ion of a techni que of ni t rogen i nsuf f lat i on to decrease
pl ast i c endotracheal t ube cuff f lammabi li t y duri ng carbon dioxi de laser surgery. J
Cl in Anesth 1993; 5:468470.
[CrossRef ]
[Medli ne Li nk]
263. Pashayan AG, Gravenstei n JS. Ai rway f i res duri ng surgery wi t h t he carbon
di oxi de l aser. Anesthesiol ogy 1989;71: 478.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
264. Sommer RM. Prevent ing endot racheal t ube f i re duri ng pharyngeal surgery.
Anesthesi ol ogy 1987; 66:439.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
265. Inappropri ate use of oxygen t o inf l ate or power medi cal devi ces. Heal th
Devices 1983;3:3.
266. Coral l IM, Eli as JA, Struni n L. Laparoscopy expl osion wi t h ni t rous oxi de. Br
Med J 1975;1:288.
[Medli ne Li nk]
267. Robi nson JF, Thompson JF, Wood AW. Laparoscopy expl osi on wi t h ni trous
oxide. Br Med J 1975;3:764765.
[Medli ne Li nk]
268. Robi nson JS, Thompson JM, Wood AW. Laparoscopy expl osion hazards wi th
ni trous oxi de. Br Med J 1975;4:760761.
[Medli ne Li nk]
269. MDA SN 2000(07), Medi cal gas cyl i nders: ri sk of f i re. MDA Adverse Inci dent
Center, ai c@medi cal -devi ces.gov.uk/sn2000(07). htm
270. Moxon MA, Readi ng ME, Ward MB. Fi re i n t he operati ng theat re. Evacuat ion
pre-planni ng may save l i ves. Anaesthesi a 1986;41:543546.
[CrossRef ]
[Medli ne Li nk]
271. Weston CJ. The operat ing t heatre' s on f i re. Heal th Serv Manage
1988; 84(3): 2023.
[Medli ne Li nk]
272. Fennel l M. A mul ti di sci pl i nary approach t o i nt raoperat ive f i re saf et y. AORN J
1995; 62:636637.
[CrossRef ]
[Medli ne Li nk]
273. Vi dor K, Puterbaugh S, Wi l l i s C. Fi re saf et y trai ni ng: a program f or t he
operati ng room. AORN J 1989; 49:10451049.
[CrossRef ]
[Medli ne Li nk]
274. Anonymous. Recogni zi ng and exti nguishi ng medi cal gas fi res. Heal th Devi ces
Al erts 2003;27: 5.
275. Li erz P, Hei nat z A, Gustorff B. Management of i ntratracheal f i re duri ng laser
surgery. Anest h Anal g 2002;93: 502.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
276. Anonymous. Fi re bl ankets i n the OR? Technol Anesth 2000;20: 3.
277. Bruner JMR. Fi re i n t he operat i ng room. ASA Newsl et t 1990;54: 2225.
278. Anonymous. Respondi ng to fi res i n areas of oxygen use. Heal th Devices
1994; 23:306309.
[Medli ne Li nk]
279. Anonymous. Recogni zi ng and exti nguishi ng medi cal gas fi res. Heal th Devi ces
Al erts 2003;27(A14):5.
280. Deboer GE. Endot racheal tube f i res. Can Anaesth Soc J 1993;40:10031004.
281. Wol f G, Si debotham GW. Endotracheal t ube f i re: comments on the advi sabi l i ty
of not extubati ng. Anesthesi ol ogy 1999;91:888.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
282. Nat ional Fi re Protect i on Associ at ion. NFPA gui de to port abl e f i re
exti nguishers. Qui ncy, MA: Author, 2003.
283. Anonymous. Tal k to the speci al ist . Technol Anesth 1996;17(4): 34.
284. Fi nnegan J. St af f educat ion can prevent OR f i res. Todays OR Nurse
1994; 16(3): 2426.
[Medli ne Li nk]
285. Nat ional Fi re Protect i on Associ at ion. Standard f or portable f i re ext ingui shers
(NFPA 10), 2002 ed. www. nf pacat al og.org. Qui ncy, MA: Author, 2002.
286. Nat ional Fi re Protect i on Associ at ion. Standard f or portable f i re ext ingui shers
(NFPA 10), 2002 ed. Qui ncy, MA: NFPA, 2002.
287. Anonymous. 10 quest ions about NFPA 10. What you mi ght want t o know about
mai ntai ning and usi ng port abl e fi re exti nguishers. NFPA J 2001;95:26, 92.
288. Freestone A. Fi nding a hal on al ternat ive. NFPA J 2002; 96:6873.
289. Gi bson J. Findi ng a hal on al t ernati ve. NFPA J 2002;96: 18, 20.
290. Anonymous. Sel ect i ng fi re exti nguishers for the operati ng room. Heal th
Devices 1996;25:261, 263.
P. 929


Questions
For the f ol lowing quest ions, sel ect t he correct answer
1. The percentage of operating room fi res that resul t i n pati ent i nj ury i s
A. 10% to 20%
B. 20% to 30%
C. 30% t o 40%
D. 40% t o 50%
E. 50% to 75%
Vi ew Answer2. Which of the foll owing i s most commonly i nvol ved i n
operating room fi res?
A. Lasers
B. El ectrosurgery equi pment
C. Argon beam coagul ators
D. Fi ber-opt ic i l l umi nat i on systems
E. Def i bri l lators
Vi ew Answer3. Which type of tracheal tube wi ll cause the most severe
damage to the tracheobronchial tree if i t catches fi re?
A. Red rubber
B. Si l icone
C. Laser resi st ant
D. PVC
Vi ew Answer4. In order to fil ter out potential ai rborne contaminants, the
surgical mask must be able to fi l ter particl es of which size?
A. 30 mi crons
B. 3 mi crons
C. 0.3 microns
D. 0. 03 microns
E. 0.003 mi crons
Vi ew Answer5. Wet cotton gauze wil l protect the shaft and cuff of a tube
best with which l aser?
A. Argon
B. KTP
C. Nd-YAG
D. CO
2

Vi ew Answer6. A clear, unmarked PVC tube is relati vely resistant to be
used wi th which l aser?
A. Argon
B. KTP
C. Nd-YAG
D. CO
2

Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
7. The factors necessary to start a fire i ncl ude
A. I gni ti on source
B. Fuel
C. Oxi di zers
D. Lasers
Vi ew Answer8. The characteri stics of laser l ight include
A. Coherency
B. Monochromat i ci ty
C. Col l imated
D. Ul traviol ent
Vi ew Answer9. Which factors determi ne the igni tion risk wi th a laser?
A. Laser medi um bei ng used
B. How t he l aser i s focused
C. Cl ass of l aser
D. Exposure t i me
Vi ew Answer10. Common errors when using electrosurgical equipment
i ncl ude
A. I mproper placement of di spersive el ectrode
B. I nsuff ici ent di spersive el ectrode contact
C. Faul t y return el ect rode
D. I nsulat i ng the pati ent f rom the operati ng room t abl e
Vi ew Answer11. Measures to mi ni mize the ri sk of a tracheal tube fi re
from a l aser include
A. Fi l l i ng t he cuf f wi th sal i ne
B. Mi ni mi zing the l aser power densi ty and durat ion
C. Using a l aser-resistant tube
D. Using l ow oxygen concentrati ons i n the inspi red gas
Vi ew Answer12. Concerni ng laser-i nduced tracheal tube fires
A. The tube may be cont acted by a ref l ected l aser beam
B. The cuf f is l aser-resistant
C. Cot ton sponges that protect the cuff may dry out
D. Use of an uncuff ed t ube i ncreases the risk
Vi ew Answer13. Which l aser(s) is(are) l ikely to damage the retina?
A. KTP
B. Nd-YAG
C. Argon
D. CO
2

Vi ew Answer14. Which l aser(s) is(are) l ikely to damage onl y the cornea?
A. KTP
B. Nd-YAG
C. Argon
D. CO
2

Vi ew Answer