Prasad, Rajnish MD; Quezado, Zenaide MD; St. Andre, Arthur MD; O'Grady, Naomi P. MD
Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
Accepted for publication July 29, 2005.
Address correspondence and reprint requests to Naomi P. O'Grady, MD, Medical Director, Procedures, Vascular Access, and Conscious Sedation Services, Critical Care Medicine Department, National Institutes of Health, Building 10, Room 7D43, 10 Center Dr., MSC 1662, Bethesda, MD 20892. Address e-mail to email@example.com.
Recent recommendations from the Centers for Disease Control (CDC) to use alcohol-based substances for hand hygiene and skin antisepsis could introduce new fire hazards in the operating room (OR) (1). This potential for an increase in the number of fires in the hospital setting with wide spread use of alcohol-based agents warrants heightened awareness of the risks and implementation of safety measures when using these agents.
A 74-year-old woman with history of diabetes mellitus, hypertension, aortic stenosis, congestive heart failure, chronic obstructive pulmonary disease, hypothyroidism, chronic renal insufficiency, and obesity was admitted because of dyspnea and hypoxemia. A cardiac catheterization showed severe coronary artery disease, and the patient required coronary artery bypass grafting and aortic valve replacement. The postoperative course in the intensive care unit was complicated by prolonged mechanical ventilation. Twenty days after cardiac surgery, she was taken to the OR for a tracheostomy.
The patient had an oral endotracheal tube and her lungs were ventilated with 40% fraction of inspired oxygen during the anesthetic. The surgical site was prepared according to institutional protocol with a one-step povidone iodine/isopropyl alcohol solution covering the face, neck, shoulders, and upper chest. Shortly after application of the antiseptic and placement of the surgical drapes, the surgeon used the electrosurgical unit on the incision. He immediately noted smoke around the incision site. The anesthesiologist then noted a flame on the right side of the patient's face. The fire was rapidly extinguished after the drapes were removed. Plastic surgeons evaluated the patient's lips, right facial, temporal, and shoulder region that sustained third-degree burns. The endotracheal tube was not affected or damaged by the fire, and otorhinolaryngologists determined that there was no evidence of airway burns. The tracheostomy was performed after the patient was draped again and the surgical site bathed with povidone iodine/isopropyl alcohol spray.
Ten days after the original burn, the patient underwent debridement of the right ear, nose, upper and lower eyelids, cheek, and shoulder. The right shoulder burn was 85 mm × 57 mm in size. TransCyte, a human fibroblast-derived temporary skin substitute, was applied to the right side of the face and ear.
The patient's postoperative course was complicated by prolonged respiratory failure, hemodynamic instability, enterococcal bacteremia, and acute respiratory distress syndrome thought to be related to her third-degree burns. She died 80 days after her coronary artery bypass graft and aortic valve replacement surgery.
Fires in the patient care setting can seriously injure a patient or the surgical staff, damage equipment, and even cause deaths. Despite all efforts from health care organizations to prevent such events (2), approximately 50–100 or more surgical fires are reported in the in the United States each year (3). The circumstances that lead to the onset of fires vary, but three elements are required to initiate and maintain a fire: an oxidizer, a combustible substance, and an ignition source (4).
In the case presented here, the use of povidone iodine/isopropyl alcohol solution was a critical factor and likely the fuel in this surgical fire. Some key observations support this conclusion. First, the initial site of fire corresponded to the distribution of povidone iodine/isopropyl alcohol solution used to prepare the surgical site. Second, the short time between the preparation of the surgical site with the alcohol-based solution and the use of the electrosurgical unit (the ignition source) might suggest that the solution in some areas of the surgical field was not yet entirely dry and that the amount of alcohol vapor was substantial. Third, the distribution of the burned area on the patient corresponded to the distribution of the antiseptic solution. Therefore, these observations strongly suggest that the ignition source (electrosurgical unit) initiated the fire, which was fueled by and spread according to the distribution of the flammable alcohol-based solution on the patient's skin.
The fact that alcohol-based antiseptic solution can provide fuel for surgical fires has been demonstrated both by reports of surgical fires in ORs and in a laboratory study (5). In that study, alcohol vapors from surgical preparation solutions combined with a large concentration of oxygen delivered by face mask afforded the fuel and oxidizer components of a surgical fire triggered by the use of an electrosurgical unit. Further, even before the CDC recommendation for the use of alcohol-based antiseptic, the flammability of these products has been a major safety concern. Briscoe et al. (6) in 1976 investigated the role of flammable antiseptics in OR fires. The antiseptics (mainly chlorhexidine) based in 70 percent alcohol ignited at 900°C. In a 100% oxygen environment, the ignition point was 30°C–70°C lower. Decreasing the alcohol concentration of the solution to as small as 20% still led to ignition in room air at 940°C and 890°C in 100% oxygen environment. These temperatures are easily reached with the use of typical electrosurgical units (6). In our patient, the overwhelming physical evidence of the case and the pattern of burn observed, strongly suggest that the use of povidone iodine/isopropyl alcohol solution was an important factor and the fuel for the surgical fire.
ECRI (formerly the Emergency Care Research Institute), an independent nonprofit health services research agency, reports that most surgical fires occur in the airway (34%) and head or face (28%), and that in 74% of all cases of surgical fires, an oxygen-enriched environment is a contributing factor (3). In fact, a common contributor as the oxidizer in many surgical fires during head and neck surgery is the delivery of large concentrations of oxygen via a face mask (4). Drapes covering a patient then result in accumulation of concentrated oxygen under them (tenting). Therefore, in an oxygen-rich environment, application of an ignition source such as an electrosurgical unit, a defibrillator, a hot fiberoptic light source, or surgical laser can readily initiate a fire (7–8). In fact, a laboratory simulation of an operating room fire demonstrated that without the closed space formed by a tent of surgical drapes, the fire could not be initiated (5). However, unlike most reports of surgical fire, in our patient, it is unlikely that an oxygen-rich environment contributed to the surgical fire, because the delivery of a large concentration of oxygen (40% fractional inspired oxygen) was confined to a closed breathing circuit. In addition, the circumstances of this surgical fire suggest that a large oxygen concentration did not contribute to the initiation and maintenance of the fire. First, the fire occurred in the setting where the patient had an endotracheal tube in place, which was attached to a closed breathing circuit. Therefore, a large oxygen concentration was not delivered openly in spaces surrounding the surgical site as is often seen in patients undergoing monitored anesthesia care when tenting can occur. Second, the lack of fire in the airway would suggest that high oxygen concentration was confined to the breathing circuit and was not in continuity with the area exposed to the electrosurgical unit.
Our report along with that of others (5) brings to light the fact that with increased use of alcohol-based skin antiseptics for hand hygiene and preparation of the site of invasive procedures, the potential for fire may increase in the hospital setting. Recognition that these flammable agents are associated with fire hazards warrants implementation of measures to increase awareness and to prevent fires in the OR. Chlorhexidine and povidone-iodine solutions are the most frequently used skin antiseptics. Both solutions contain isopropyl alcohol, a combustible substance. Although there is no available documentation describing fires involving chlorhexidine solutions, one can infer that because chlorhexidine is only available in an alcohol-based solution, it poses a potential risk for fires. Povidone-iodine solution is also flammable, and similar caution needs to be taken during its use. The potential for fire is augmented when the alcohol-based skin antiseptic is applied in ways that allow the solution to run off and wick into the patient's hair, pool on the skin, or wick into the surrounding linens. Attention to these details demands prolongation of the required drying time. If the patient is draped before the solution is completely dry, alcohol vapors can be trapped and channeled to the surgical site, where a heat source could ignite the vapors (3).
The use of ignition sources coupled with the increased use of alcohol-based antiseptics also calls for increasing awareness of the increased fire hazard. Electrosurgical units, surgical lasers, and fiberoptic light sources are very frequently used in the OR and have substantial heating power that can ignite a fire in an oxygen-enriched environment. Fiberoptic light sources can transmit enough heat to cause charring of surgical drapes that may lead to its ignition and fire in the presence of high oxygen or nitrous oxide concentrations (4,8–10). Once again, awareness that using more alcohol based substances in proximity to ignition sources increases the risk of surgical fire is pivotal for its prevention. Further, the use of alcohol-based antiseptics calls for strict adherence to the proper use of these substances, including observation of required drying time. This may take a few minutes or more until the field is completely dry (11).
In summary, with the new CDC recommendations to use alcohol-based gel solutions for hand hygiene and alcohol-based chlorhexidine solutions for skin antisepsis before procedures, new risks are introduced. In June 2003, the Joint Commission on Accreditation of Healthcare Organizations issued a Sentinel Event Alert on fires, calling on health care organizations to educate their staff in preventing them. The report underscores that education emphasizing how and why fires start is the first and most important step to take to reduce the risk of fires in the patient care setting.
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