EDITORIAL
Only YOU Can Prevent OR Fires Stephanie B. Jones, MD,∗ † Daniel B. Jones, MD, MS,†‡ and Steven Schwaitzberg, MD†§
A
t first glance, it may not be obvious why the Annals of Surgery is featuring “Operating Room Fire Prevention: Creating an Electrical Surgical Unit Fire Safety Device” in this volume.1 Surely, fires in the operating room (OR) must be a very, very rare event. And why would such a prestigious journal devote pages to a premarket device? It all seems a bit bizarre until you learn more about the problem of OR fires, the horrific disfiguring harm inflicted on patients, and the anguish experienced by their families. There is significant underappreciation of this issue among most health care providers. Only after we acknowledge we have a serious problem in the OR, will surgeons, anesthesiologists, and nurses begin to seek out potential strategies for prevention and applaud the development of new devices. Every year there are approximating 600 fires in the OR and, sadly, 2 to 3 preventable fire-related deaths.2 OR fires and thermal injuries are every bit as harmful as more publicized safety issues such as retained foreign objects (0.7–1 per 1000 abdominal operations) and wrong-site surgery (1 in 9000 cases).3,4 The number of surgical claims related to OR fires has increased 5-fold, from less than 1% of all surgical claims between 1985 and 1989 to 4.4% between 2000 and 2009.5 Google the Web for “OR fires” and watch numerous chilling and disturbing reports of maimed patients. Yet, broach the topic members of your OR team and they will often look surprised, dubious that this sort of thing would ever happen in their OR. In the OR, 3 things are required to start a fire—fuel, oxygen, and an ignition source. This is known as the fire triad. In the OR, the fuel source can be alcohol-based preparatory solutions, paper drapes, and cloth towels. Oxygen, especially if administered by nasal prongs or facemask, will leak and accumulate under tented drapes, particularly during head and neck procedures. The electrosurgical unit (ESU) pencil is the ignition source in more than 90% of OR fires.6 Although this triad is well known, little has been done to reduce fire risk other than mandate 3-minute waits for preparatory solutions to dry before draping and some education around oxygen tenting under drapes causing explosions. In almost every case of an OR fire, the inciting spark stems from an ESU device (see Supplemental Video, available at http://links.lww.com/SLA/A595). A century ago, William T. Bovie invented an instrument that uses high-frequency alternating current (radio-frequency electrosurgery) to cut like a scalpel while coagulating tissue.7 Today the “Bovie” is one the most widely used energy-based devices, and there has been very little modification from its original design to make it safer. Understanding that carbon dioxide acts as a fire suppressant, Dr Culp and associates from the Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine, propose that a shroud of protective carbon dioxide covering the tip of the ESU pencil will displace oxygen, thereby preventing fire ignition. They blow carbon dioxide over the ESU pencil so that the tip is covered without obstruction of the surgical view. The authors investigated the viability of their polymer sleeve prototype by creating a highly flammable model in a protected test fixture. Escalating concentrations of oxygen can be applied to the chamber in a controlled fashion. Using their prototype fire safety device, they were unable to ignite a fire, even in the presence of 100% oxygen. This compares with seconds, or less, for fuel ignition with the unaltered ESU pencil. In addition to new devices, there is a major effort afoot with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate surgeons, anesthesiologists, and nurses about the safe use of energy in the OR. The Fundamental Use of Surgical Energy (FUSE) was published as a textbook in 2012, and SAGES released an online multimedia curriculum in 2013.8 The FUSE curriculum includes specific information on the prevention of adverse events during electrosurgery, with fire prevention receiving considerable emphasis. FUSE certification can be achieved by successfully passing a validated examination. This should be the goal of every provider routinely using energy-based devices. From the ∗ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; †Harvard Medical School, Boston, MA; ‡Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA; and §Department of Surgery, Cambridge Health Alliance, Cambridge, MA. Disclosure: The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: Stephanie B. Jones, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, CC470, Boston, MA 01778. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-0218 DOI: 10.1097/SLA.0000000000000729
218 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 2, August 2014
The authors established a proof of concept for further study of their prototype ESU pencil. A very simple method of using carbon dioxide to smother a potential flame has the potential to significantly reduce the risk of OR fire for most surgical procedures. Thank you for sharing your idea. Well done.
REFERENCES 1. Culp WC, Kimbrough BA, Luna S, et al. Operating room fire prevention: creating an electrical surgical unit fire safety device. Ann Surg. 2014;260:214–217. 2. Preventing fires in the operating room FDA patient safety news: show #105. 2010. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ psn/printer.cfm?id=1460. Accessed May 17, 2013.
C 2014 Lippincott Williams & Wilkins
Editorial
3. Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J. 1982;75:657–660. 4. Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353–358. 5. Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a closed claims analysis. Anesthesiology. 2013;118:1133–1139. 6. Fuchshuber P, Jones SB, Jones DB, et al. Ensuring safety in the operating room—the “Fundamentals Use of Surgical Energy” FUSE Program. Int Anesthesiol Clin. 2013;51:65–80. 7. O’Connor JL, Bloom DA, William T. Bovie and electrosurgery. Surgery. 1996;119:390–396. 8. Feldman L, Fuchshuber P, Jones DB. The SAGES Manual on Fundamental Use of Surgical Energy (FUSE). New York: Springer; 2012.
www.annalsofsurgery.com | 219
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Only YOU Can Prevent OR Fires Stephanie B. Jones, MD,∗ † Daniel B. Jones, MD, MS,†‡ and Steven Schwaitzberg, MD†§
A
t first glance, it may not be obvious why the Annals of Surgery is featuring “Operating Room Fire Prevention: Creating an Electrical Surgical Unit Fire Safety Device” in this volume.1 Surely, fires in the operating room (OR) must be a very, very rare event. And why would such a prestigious journal devote pages to a premarket device? It all seems a bit bizarre until you learn more about the problem of OR fires, the horrific disfiguring harm inflicted on patients, and the anguish experienced by their families. There is significant underappreciation of this issue among most health care providers. Only after we acknowledge we have a serious problem in the OR, will surgeons, anesthesiologists, and nurses begin to seek out potential strategies for prevention and applaud the development of new devices. Every year there are approximating 600 fires in the OR and, sadly, 2 to 3 preventable fire-related deaths.2 OR fires and thermal injuries are every bit as harmful as more publicized safety issues such as retained foreign objects (0.7–1 per 1000 abdominal operations) and wrong-site surgery (1 in 9000 cases).3,4 The number of surgical claims related to OR fires has increased 5-fold, from less than 1% of all surgical claims between 1985 and 1989 to 4.4% between 2000 and 2009.5 Google the Web for “OR fires” and watch numerous chilling and disturbing reports of maimed patients. Yet, broach the topic members of your OR team and they will often look surprised, dubious that this sort of thing would ever happen in their OR. In the OR, 3 things are required to start a fire—fuel, oxygen, and an ignition source. This is known as the fire triad. In the OR, the fuel source can be alcohol-based preparatory solutions, paper drapes, and cloth towels. Oxygen, especially if administered by nasal prongs or facemask, will leak and accumulate under tented drapes, particularly during head and neck procedures. The electrosurgical unit (ESU) pencil is the ignition source in more than 90% of OR fires.6 Although this triad is well known, little has been done to reduce fire risk other than mandate 3-minute waits for preparatory solutions to dry before draping and some education around oxygen tenting under drapes causing explosions. In almost every case of an OR fire, the inciting spark stems from an ESU device (see Supplemental Video, available at http://links.lww.com/SLA/A595). A century ago, William T. Bovie invented an instrument that uses high-frequency alternating current (radio-frequency electrosurgery) to cut like a scalpel while coagulating tissue.7 Today the “Bovie” is one the most widely used energy-based devices, and there has been very little modification from its original design to make it safer. Understanding that carbon dioxide acts as a fire suppressant, Dr Culp and associates from the Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine, propose that a shroud of protective carbon dioxide covering the tip of the ESU pencil will displace oxygen, thereby preventing fire ignition. They blow carbon dioxide over the ESU pencil so that the tip is covered without obstruction of the surgical view. The authors investigated the viability of their polymer sleeve prototype by creating a highly flammable model in a protected test fixture. Escalating concentrations of oxygen can be applied to the chamber in a controlled fashion. Using their prototype fire safety device, they were unable to ignite a fire, even in the presence of 100% oxygen. This compares with seconds, or less, for fuel ignition with the unaltered ESU pencil. In addition to new devices, there is a major effort afoot with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate surgeons, anesthesiologists, and nurses about the safe use of energy in the OR. The Fundamental Use of Surgical Energy (FUSE) was published as a textbook in 2012, and SAGES released an online multimedia curriculum in 2013.8 The FUSE curriculum includes specific information on the prevention of adverse events during electrosurgery, with fire prevention receiving considerable emphasis. FUSE certification can be achieved by successfully passing a validated examination. This should be the goal of every provider routinely using energy-based devices. From the ∗ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; †Harvard Medical School, Boston, MA; ‡Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA; and §Department of Surgery, Cambridge Health Alliance, Cambridge, MA. Disclosure: The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: Stephanie B. Jones, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, CC470, Boston, MA 01778. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-0218 DOI: 10.1097/SLA.0000000000000729
218 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 2, August 2014
The authors established a proof of concept for further study of their prototype ESU pencil. A very simple method of using carbon dioxide to smother a potential flame has the potential to significantly reduce the risk of OR fire for most surgical procedures. Thank you for sharing your idea. Well done.
REFERENCES 1. Culp WC, Kimbrough BA, Luna S, et al. Operating room fire prevention: creating an electrical surgical unit fire safety device. Ann Surg. 2014;260:214–217. 2. Preventing fires in the operating room FDA patient safety news: show #105. 2010. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ psn/printer.cfm?id=1460. Accessed May 17, 2013.
C 2014 Lippincott Williams & Wilkins
Editorial
3. Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J. 1982;75:657–660. 4. Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353–358. 5. Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a closed claims analysis. Anesthesiology. 2013;118:1133–1139. 6. Fuchshuber P, Jones SB, Jones DB, et al. Ensuring safety in the operating room—the “Fundamentals Use of Surgical Energy” FUSE Program. Int Anesthesiol Clin. 2013;51:65–80. 7. O’Connor JL, Bloom DA, William T. Bovie and electrosurgery. Surgery. 1996;119:390–396. 8. Feldman L, Fuchshuber P, Jones DB. The SAGES Manual on Fundamental Use of Surgical Energy (FUSE). New York: Springer; 2012.
www.annalsofsurgery.com | 219
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
