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Anesthesiology:
doi: 10.1097/01.anes.0000299343.87119.a9
Special Articles

Practice Advisory for the Prevention and Management of Operating Room Fires

A Report by the American Society of Anesthesiologists Task Force on Operating Room Fires

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PRACTICE advisories are systematically developed reports that are intended to assist decision making in areas of patient care. Advisories are based on a synthesis of scientific literature and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints.
The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions obtained from expert consultants and ASA members. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
The incidence of operating room (OR) fires is difficult to determine, due in part to the lack of a mandatory national reporting system for OR fires.1–3 Some estimates suggest that between 50 and 200 OR fires occur in the United States every year, with as many as 20% of reported fires resulting in serious injury or death.4,5
Fire requires the presence of three components, known as the “fire triad”: (1) an oxidizer, (2) an ignition source, and (3) fuel.
* Oxidizers used in the OR are oxygen and nitrous oxide. An oxidizer-enriched atmosphere increases the likelihood and intensity of combustion. An oxidizer-enriched atmosphere commonly exists within closed or semiclosed breathing systems, including the patient's airway. It can also be created locally when the configuration of the drapes and open oxygen sources (e.g., masks, nasal cannula) promote the trapping or pooling of oxygen or a mixture of oxygen and nitrous oxide.KEY CONCEPT: An oxidizer-enriched atmosphere occurs when there is any increase in oxygen concentration above room air level, and/or the presence of any concentration of nitrous oxide.
* Ignition sources include, but are not limited to, electrosurgical or electrocautery devices, lasers, heated probes, drills and burrs, argon beam coagulators, fiberoptic light cables, and defibrillator paddles or pads.
* Fuel sources include, but are not limited to, tracheal tubes; sponges; drapes; gauze; alcohol-containing solutions (e.g., certain prepping solutions); solutions containing other volatile compounds, such as ether or acetone; oxygen masks; nasal cannulae; the patient's hair; dressings; ointments; gowns; gastrointestinal tract gases; blankets; suction catheters; flexible endoscopes; fiberoptic cable coverings; gloves; and packaging materials.
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Methodology

A. Definition of OR Fires, High-risk Procedures, and OR Fire Drills
For this Advisory, operating room fires are defined as fires that occur on or near patients who are under anesthesia care, including surgical fires, airway fires, and fires within the airway circuit. A surgical fire is defined as a fire that occurs on or in a patient. An airway fire is a specific type of surgical fire that occurs in a patient's airway. Airway fires may or may not include fire in the attached breathing circuit.
A high-risk procedure is defined as one in which an ignition source (e.g., electrosurgery) may come in proximity to an oxidizer-enriched atmosphere (e.g., supplemental oxygen and/or nitrous oxide), thereby increasing the risk of fire. Examples of high-risk procedures include, but are not limited to, tonsillectomy, tracheostomy, removal of laryngeal papillomas, cataract or other eye surgery, burr hole surgery, or removal of lesions on the head, neck, or face.
An OR fire drill is defined as a formal and periodic rehearsal of the OR team's planned response to a fire. In this Advisory, the OR fire drill is characterized as a “formal and periodic rehearsal” to indicate that it takes place during dedicated education time, not during patient care. In other words, an OR fire drill is not the same as a discussion or plan about fire management that takes place during direct patient care.
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B. Purpose
The purposes of this Advisory are to (1) identify situations conducive to fire, (2) prevent the occurrence of OR fires, (3) reduce adverse outcomes associated with OR fires, and (4) identify the elements of a fire response protocol. Adverse outcomes associated with OR fires may include major or minor burns, inhalation injuries, infection, disfigurement, and death. Related adverse outcomes may include psychological trauma, prolonged hospitalization, delay or cancellation of surgery, additional hospital resource utilization, and liability.
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C. Focus
This Advisory focuses on a specific care setting and subset of fires. The specific care setting is any OR or procedure area where anesthesia care is provided. The specific subset is fires that occur on the patient, in the airway, or in the breathing circuit. This Advisory does not address fires away from the patient (e.g., in a trash can), institutional preplanning for fire, or the responses of fire personnel.
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D. Application
This Advisory is intended for use by anesthesiologists or other individuals working under the supervision of an anesthesiologist. Because prevention of OR fires requires close collaboration and prompt coordination between anesthesiologists, surgeons, and nurses, some responsibilities are shared among the disciplines. When shared responsibilities are described in this Advisory, the intent is to give the anesthesiologist a starting point for participating in the allocation and understanding of shared responsibilities. The Advisory may also serve as a resource for other physicians and healthcare professionals (e.g., technicians, safety officers, hospital administrators, biomedical engineers, industry representatives).
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E. Task Force Members and Consultants
The ASA appointed a Task Force of nine members. These individuals included four anesthesiologists in private and academic practice from various geographic areas of the United States, an otolaryngologist, a perioperative registered nurse, a professional engineer/fire investigator, and two consulting methodologists from the ASA Committee on Standards and Practice Parameters. Two Task Force members are former firefighters.
The Task Force developed the Advisory by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, a systematic review and evaluation was performed on original, published, peer-reviewed and other research studies related to OR fires. Third, a panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various strategies for fire prevention, detection, and management and (2) review and comment on a draft of the Advisory developed by the Task Force. Fourth, opinions about the Advisory were solicited from a random sample of active members of the ASA. Fifth, the Task Force held an open forum at a major national meeting to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing this Advisory. Seventh, all available information was used to build consensus within the Task Force to formulate the advisory statements (appendix 1).
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F. Availability and Strength of Evidence
Preparation of this Advisory followed a rigorous methodological process (appendix 2). Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.
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Scientific Evidence.
Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g., randomized controlled trials, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e., level 1, 2, or 3) within each category is included in the summary.
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Category A: Supportive Literature.
Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.
Level 1: The literature contains multiple randomized controlled trials, and the aggregated findings are supported by meta-analysis.§
Level 2: The literature contains multiple randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of this Advisory.
Level 3: The literature contains a single randomized controlled trial.
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Category B: Suggestive Literature.
Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.
Level 1: The literature contains observational comparisons (e.g., cohort, case-control research designs) of two or more clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.
Level 2: The literature contains noncomparative observational studies with associative (e.g., relative risk, correlation) or descriptive statistics.
Level 3: The literature contains case reports.
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Category C: Equivocal Literature.
The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.
Level 1: Meta-analysis did not find significant differences among groups or conditions.
Level 2: There is an insufficient number of studies to conduct meta-analysis and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings.
Level 3: Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.
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Category D: Insufficient Evidence from Literature.
The lack of scientific evidence in the literature is described by the following terms.
Silent: No identified studies address the specified relationships among interventions and outcomes.
Inadequate: The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the “Focus” of the Advisory or it does not permit a clear interpretation of findings due to methodologic concerns (e.g., confounding in study design or implementation).
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Opinion-based Evidence.
All opinion-based evidence relevant to each topic (e.g., survey data, open-forum testimony, Web-based comments, letters, editorials) is considered in the development of this Advisory. However, only the findings obtained from formal surveys are reported.
Opinion surveys were developed by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to two groups of respondents: expert consultants and ASA members.
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Category A: Expert Opinion.
Survey responses from Task Force-appointed expert consultants are reported in summary form in the text. A complete listing of consultant survey responses is reported in appendix 2.
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Category B: Membership Opinion.
Survey responses from a random sample of members of the ASA and, when appropriate, responses from members of other organizations with expertise in the selected topics of interest are reported in summary form in the text. A complete listing of ASA member survey responses is reported in appendix 2.
Survey responses are recorded using a five-point scale and summarized based on median values.
Strongly Agree: Median score of 5 (at least 50% of the responses are 5)
Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5)
Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contains at least 50% of the responses)
Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2)
Strongly Disagree: Median score of 1 (at least 50% of responses are 1)
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Category C: Informal Opinion.
Open-forum testimony, Web-based comments, letters, and editorials are all informally evaluated and discussed during the development of the Advisory. When warranted, the Task Force may add educational information or cautionary notes based on this information.
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Advisories

I. Education
Operating room fire safety education includes, but is not limited to, knowledge of institutional fire safety protocols and participation in institutional fire safety education. Case reports indicate that lack of education can result in severe injury and death from uncontrolled OR fires.6,7 [Category B3 evidence.]
The consultants and ASA members strongly agree that every anesthesiologist should have knowledge of institutional fire safety protocols for the OR, and should participate in OR fire safety education. The consultants and ASA members strongly agree that OR fire safety education for the anesthesiologist should emphasize the risk created by an oxidizer-enriched atmosphere.
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Advisory Statements.
All anesthesiologists should have fire safety education, specifically for OR fires, with emphasis on the risk created by an oxidizer-enriched atmosphere.
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II. OR Fire Drills
A case report indicates that OR fire drills and simulation training can result in improved staff response to a fire.8 [Category B3 evidence.]
The consultants strongly agree and ASA members agree that all anesthesiologists should periodically participate in OR fire drills with the entire OR team. The consultants and ASA members strongly agree that participation should take place during dedicated educational time, not during patient care.
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Advisory Statements.
Anesthesiologists should periodically participate in OR fire drills with the entire OR team. This formal rehearsal should take place during dedicated educational time, not during patient care.
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III. Preparation
Preparation for OR fires includes (1) determining whether or not a high-risk situation exists and (2) a team discussion of the strategy for the prevention and management of an OR fire in a high-risk situation. The literature is silent regarding whether a preoperative determination of a high-risk situation or a team discussion of OR fire strategy reduces the incidence or severity of an OR fire. [Category D evidence.]
The consultants strongly agree and ASA members agree that anesthesiologists should participate with the entire OR team in assessing the risk of an OR fire for each case and determining whether a high-risk situation exists. The consultants strongly agree and ASA members agree that all team members should jointly agree on how a fire will be prevented and managed for each particular procedure. The consultants and ASA members strongly agree that a protocol for the prevention and management of fires should be posted in each location where a procedure is performed.
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Advisory Statements.
For every case, the anesthesiologist should participate with the entire OR team (e.g., during the surgical pause) in determining whether a high-risk situation exists. If a high-risk situation exists, all team members—including the anesthesiologist—should take a joint and active role in agreeing on how a fire will be prevented and managed. Each team member should be assigned a specific fire management task to perform in the event of a fire (e.g., removing the tracheal tube, stopping the flow of airway gases). Each team member should understand that his or her preassigned task should be performed immediately if a fire occurs, without waiting for another team member to take action. When a team member has completed a preassigned task, he or she should help other team members perform tasks that are not yet complete.
Fig. 1
Fig. 1
Image Tools
In every OR and procedure area where a fire triad can exist (i.e., an oxidizer-enriched atmosphere, an ignition source, and fuel), an easily visible protocol for the prevention and management of fires should be displayed (fig. 1).
Table 1
Table 1
Image Tools
Equipment for managing a fire should be readily available in every procedural area where a fire triad may exist. Table 1 provides an example of fire management equipment that should be in or near the OR or procedural area.
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IV. Prevention
Prevention of OR fires includes (1) minimizing or avoiding an oxidizer-enriched atmosphere near the surgical site, (2) safely managing ignition sources, and (3) safely managing fuels.
Comparative studies indicate that a wide range of material ignites more readily in an oxygen-enriched atmosphere than in room air.9–13 [Category B1 evidence.] One comparative study with awake volunteer subjects showed that the configuration of surgical drapes can result in oxygen buildup, increasing the risk of fire.14 [Category B1 evidence.] This study also indicated that replacing oxygen with compressed air or discontinuing supplemental oxygen for a period of time reduces oxygen buildup without significantly reducing oxygen saturation levels. Similarly, a randomized controlled trial comparing supplemental oxygen and compressed air in sedated patients undergoing cataract surgery found no differences in oxygen saturation.15 [Category C2 evidence.]
Observational studies and case reports indicate that electrocautery or electrosurgical devices and lasers are common sources of ignition for many OR fires, particularly when used in an oxidizer-enriched atmosphere.16–68 [Category B2–3 evidence.]
Case reports indicate that alcohol-based skin-prepping agents generate volatile vapors that ignite easily. These reports suggest that insufficient drying time after application of alcohol-based skin-prepping agents is a cause of fires on patients.23,69–73 [Category B3 evidence.] Comparative studies show that conventional tracheal tubes, when exposed to a laser beam, are more likely to ignite or melt than laser-resistant tracheal tubes.74–84 [Category B1 evidence.] Case reports indicate that dry sponges and gauze are common sources of fuel.7,19,33,43,45,55,64,83–87 Comparative studies demonstrate that the flammability of sponges, cottonoids, or packing material is reduced when wet rather than dry or partially dry.88–91 [Category B1 evidence.]
For all procedures, the consultants and ASA members strongly agree that flammable skin prepping solutions should be dry before draping. They strongly agree that surgical drapes should be configured to prevent oxygen from accumulating under the drapes or from flowing into the surgical site. They strongly agree that sponges should be moistened when used near an ignition source, particularly when used in or near the airway.
For high-risk procedures (i.e., proximity of an ignition source and an oxidizer-enriched atmosphere), the consultants and ASA members strongly agree that anesthesiologists should collaborate with the procedure team for the purpose of preventing and managing a fire. They strongly agree that the surgeon should be notified whenever an ignition source is in proximity to an oxidizer-enriched atmosphere or when the concentration of oxidizer has increased. They strongly agree that the fraction of inspired oxygen (Fio2) delivered to the patient should be kept as low as clinically feasible when an ignition source is in proximity to an oxygen-enriched atmosphere. They strongly agree that the reduction of Fio2 delivered to the patient should be guided by monitoring patient oxygenation (e.g., pulse oximetry). Task Force members agree that the reduction of Fio2 should be monitored, if feasible, by measuring inspired, expired, and/or delivered oxygen concentration. They strongly agree that the use of nitrous oxide should be avoided in settings that are considered high risk for fire. The consultants strongly agree and ASA members agree that oxygen or nitrous oxide buildup may be minimized by either insufflating with medical air or scavenging the operating field with suction.
For laser surgery, consultants and ASA members strongly agree that laser resistant tracheal tubes should be used, and that the tube choice should be appropriate for the procedure and laser. They both strongly agree that the tracheal cuff of the laser tube should be filled with saline rather than air, when feasible. The consultants strongly agree and the ASA members agree that saline in tracheal tube cuff should be tinted with methylene blue to act as a marker for cuff puncture by a laser.
Surgery inside the airway can bring an ignition source into proximity with an oxidizer-enriched atmosphere, thereby creating a high-risk situation. For cases involving surgery inside the airway, consultants and ASA members both agree that a cuffed tracheal tube should be used instead of an uncuffed tracheal tube when medically appropriate. Because an elevated Fio2 is often necessary during tracheostomy, the Task Force strongly agrees that surgeons should be advised not to enter the trachea with an ignition source such as an electrosurgical device. If an electrosurgical device must be used, the anesthesiologist should request that the surgeon provide adequate warning to allow the concentration of oxidizer to be minimized before the trachea is entered. Consultants and ASA members were asked to report the time that they believe is needed to reduce oxygen or nitrous oxide concentration to a safe level before using an ignition source. For patients being ventilated with a tracheal tube, consultants report a range of time of less than 1 min to 5 min (mean = 1.8 min), and ASA members report a range of time of less than 1 min to 10 min (mean = 2.9 min). For patients wearing a facemask or nasal cannula, both the consultants and ASA members report a range of time of less than 1 min to 5 min (mean = 1.7 min for consultants, and mean = 2.3 min for ASA members). The consultants and ASA members both agree that the oropharynx should be scavenged with suction during oral procedures.
Surgery around the face, head, or neck can bring an ignition source into proximity with an oxidizer-enriched atmosphere, thereby creating a high-risk situation. When monitored anesthesia care is considered for surgery around the face, head, or neck, the Task Force strongly agrees that two specific factors should be considered: (1) the required depth of sedation and (2) oxygen dependence. The Task Force agrees that a sealed gas delivery device (e.g., cuffed tracheal tube or laryngeal mask) should be considered if moderate or deep sedation is required or used, or if the patient exhibits oxygen dependence. If neither factor is present, an open gas delivery device (e.g., facemask or nasal cannula) may be considered. If an open gas delivery system is used, the Task Force agrees that before an ignition source is activated around the face, head, or neck, the surgeon should give the adequate notice that the ignition source will be activated. The anesthesiologist should (1) stop the delivery of supplemental oxygen or reduce the delivery to the minimum required to avoid hypoxia, and (2) wait a few minutes between decreasing the flow of supplemental oxygen and approving the activation of the ignition source. In the unlikely event of nitrous oxide delivery with an open system (e.g., facemask or nasal cannula), the Task Force agrees that the anesthesiologist should (1) stop the delivery of nitrous oxide, and (2) wait a few minutes between stopping the nitrous oxide and approving the activation of the ignition source.
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Advisory Statements.
To the extent that is medically appropriate, the following basic principles should be applied to the management of oxidizers, ignition sources, and fuels:
* The anesthesiologist should collaborate with all members of the procedure team throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source.
* Surgical drapes should be configured to minimize the accumulation of oxidizers (oxygen and nitrous oxide) under the drapes and from flowing into the surgical site.
* Flammable skin prepping solutions should be dry before draping.
* Gauze and sponges should be moistened when used in proximity to an ignition source.
For high-risk procedures, the anesthesiologist should notify the surgeon whenever there is a potential for an ignition source to be in proximity to an oxidizer-enriched atmosphere or when there is an increase in oxidizer concentration at the surgical site. Any reduction in supplied oxygen to the patient should be assessed by monitoring (1) pulse oximetry and, if feasible, (2) inspired, exhaled, and/or delivered oxygen concentration.
For laser procedures, a laser-resistant tracheal tube should be used, and the tube should be chosen to be resistant to the laser used for the procedure (e.g., carbon dioxide [CO2], Nd:YAG, Ar, Er:YAG, KTP). The tracheal cuff of the laser tube should be filled with saline and colored with an indicator dye such as methylene blue. Before activating a laser, the surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated. The anesthesiologist should (1) reduce the delivered oxygen concentration to the minimum required to avoid hypoxia, (2) stop the use of nitrous oxide, and (3) wait a few minutes after reducing the oxidizer-enriched atmosphere before approving activation of the laser.
For cases involving an ignition source and surgery inside the airway, cuffed tracheal tubes should be used when clinically appropriate. The anesthesiologist should advise the surgeon against entering the trachea with an ignition source (e.g., electrosurgery unit). Before activating an ignition source inside the airway, the surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated. The anesthesiologist should (1) reduce the delivered oxygen concentration to the minimum required to avoid hypoxia, (2) stop the use of nitrous oxide, and (3) wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source. In some cases (e.g., surgery in the oropharynx), scavenging with suction may be used to reduce oxidizer enrichment in the operative field.
For cases involving moderate or deep sedation, an ignition source, and surgery around the face, head, or neck, the anesthesiologist and surgeon should develop a plan that accounts for the level of sedation and the patient's need for supplemental oxygen.
* If moderate or deep sedation is required or used, or if the patient exhibits oxygen dependence, the anesthesiologist and surgeon should consider a sealed gas delivery device (e.g., cuffed tracheal tube or laryngeal mask).
* If moderate or deep sedation is not required, and the patient does not exhibit oxygen dependence, an open gas delivery device (e.g., facemask or nasal cannula) may be considered. Before activating an ignition source around the face, head, or neck, the surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated. The anesthesiologist should (1) stop the delivery of supplemental oxygen or reduce the delivered oxygen concentration to the minimum required to avoid hypoxia, and (2) wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source.
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V. Management of OR Fires
Management of OR fires includes (1) recognizing the early signs of fire, (2) halting the procedure, (3) making appropriate attempts to extinguish the fire, (4) following an evacuation protocol when medically appropriate, and (5) delivering postfire care to the patient.
Case reports indicate that early signs of a fire may include a flame or flash, unusual sounds, odors, smoke, or heat.22–24,41,42,46,53,62,73,92 [Category B3 evidence.] One case report indicates that removing the tracheal tube and stopping the flow of oxygen can minimize patient injury.53 [Category B3 evidence.] One case report demonstrated that pouring saline into the patient's tracheal tube was effective in extinguishing the fire.93 [Category B3 evidence.] One case of a patient death from an OR fire indicated that fire extinguishers were available but not used by the OR staff on the patient.7
When early warning signs of a fire are noted, the consultants and ASA members strongly agree that there should be an immediate halt to the procedure. When a fire is definitely present, the consultants and ASA members strongly agree that there should be an immediate announcement of fire, followed by an immediate halt to the procedure.
For a fire in the airway or breathing circuit, the consultants and ASA members strongly agree that, as quickly as possible, the tracheal tube should be removed and all flammable and burning materials should be removed from the airway. The consultants strongly agree and ASA members agree that the delivery of all airway gases should stop, and they both agree that saline should be poured into the patient's airway to extinguish any residual embers and cool the tissues.
For a fire elsewhere on or in the patient, the consultants agree and ASA members are equivocal regarding whether the delivery of all airway gases should stop. They both strongly agree that all burning and flammable materials (including all drapes) should be removed from the patient, and that all burning materials in, on, or around the patient should be extinguished (e.g., with saline, water, or a fire extinguisher).
Seventy-one percent of the consultants and 77% of the ASA members indicated that the preferred means for safely responding to an OR fire is for each team member to immediately perform a fire management task in a predetermined sequence. Twenty-nine percent of the consultants and 23% of the ASA members indicated that the preferred means of safely responding to an OR fire is for each team member to immediately perform a preassigned task, without waiting for others to act. The Task Force believes that a predetermined sequence of tasks can be attempted when a fire occurs, but that team members should not wait for each other if there are impediments to following the predetermined sequence of tasks in a rapid manner. The Task Force agrees that a team member who has completed a preassigned task may assist another team member whose task is not yet complete.
If the first attempt to extinguish the fire in, on, or around the patient is not successful, the consultants and ASA members both agree that a CO2 fire extinguisher should be used. If fire persists after use of a CO2 fire extinguisher, consultants and ASA members both strongly agree that the fire alarm should be activated and the patient should be evacuated, if feasible. The consultants and ASA members both agree that the door to the room should be closed and not reopened. The consultants strongly agree and the ASA members agree that the medical gas supply to the room should be turned off after evacuation.
The consultants and ASA members strongly agree that after a fire has been extinguished, the patient's status should be assessed and a plan should be devised for ongoing care of the patient. When an airway or breathing circuit fire has been extinguished, consultants and ASA members both agree that ventilation should be reestablished, avoiding supplemental oxygen and nitrous oxide, if possible. Both the consultants and ASA members strongly agree that the tracheal tube should be examined to assess whether fragments have been left behind in the airway. The consultants strongly agree and the ASA members agree that rigid bronchoscopy should be considered to assess thermal injury, look for tracheal tube fragments, and aid in the removal of residual materials. If the fire did not involve the airway and the patient was not intubated before the fire, the consultants and ASA members both strongly agree that the patient should be assessed for injury related to smoke inhalation.
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Advisory Statements.
When an early warning sign is noted, halt the procedure and call for an evaluation of fire. Early signs of a fire may include unusual sounds (e.g., a “pop,” “snap,” or “foomp”), unusual odors, unexpected smoke, unexpected heat, unexpected movement of drapes, discoloration of drapes or breathing circuit, unexpected patient movement or complaint, and unexpected flash or flame.
When a fire is definitely present, immediately announce the fire, halt the procedure, and initiate fire management tasks.
Team members should perform their preassigned fire management tasks as quickly as possible. Before the procedure, the team may identify a predetermined order for performing the tasks. If a team member cannot rapidly perform his or her task in the predetermined order, other team members should perform their tasks without waiting. When a team member has completed a preassigned task, he or she should help other members perform tasks that are not yet complete.
The following lists are shown in an order that the team may wish to consider in its discussion of a predetermined sequence.
For a fire in the airway or breathing circuit, as fast as possible:#
* Remove the tracheal tube.
* Stop the flow of all airway gases.
* Remove all flammable and burning materials from the airway.
* Pour saline or water into the patient's airway.
For a fire elsewhere on or in the patient, as fast as possible:
* Stop the flow of all airway gases.
* Remove all drapes, flammable, and burning materials from the patient.
* Extinguish all burning materials in, on and around the patient (e.g., with saline, water, or smothering).
If the airway or breathing circuit fire is extinguished:
* Reestablish ventilation by mask, avoiding supplemental oxygen and nitrous oxide, if possible.
* Extinguish and examine the tracheal tube to assess whether fragments were left in the airway. Consider bronchoscopy (preferably rigid) to look for tracheal tube fragments, assess injury, and remove residual debris.
* Assess the patient's status and devise a plan for ongoing care.
If the fire elsewhere on or in the patient is extinguished:
* Assess the patient's status and devise a plan for ongoing care of the patient.
* Assess for smoke inhalation injury if the patient was not intubated.
If the fire is not extinguished after the first attempt (e.g., after performing the preassigned tasks):
* Use a CO2 fire extinguisher in, on, or around the patient.
* If the fire persists after use of the CO2 fire extinguisher:
- Activate the fire alarm.
- Evacuate the patient if feasible, following institutional protocols.
- Close the door to the room to contain the fire, and do not reopen it or attempt to reenter the room.
- Turn off the medical gas supply to the room.
Follow local regulatory reporting requirements (e.g., report fires to your local fire department and state department of health). Treat every fire as an adverse event, following your institutional protocol.
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Appendix 1: Primary Findings of the Advisory Task Force
I. Education
* All anesthesiologists should have fire safety education, specifically for OR fires, with emphasis on the risk created by an oxidizer-enriched atmosphere.
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II. OR Fire Drills
* Anesthesiologists should periodically participate in OR fire drills, with the entire OR team. This formal rehearsal should take place during dedicated educational time, not during patient care.
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III. Preparation
* For every case, the anesthesiologist should participate with the entire OR team (e.g., during the surgical pause) in assessing and determining whether a high-risk situation exists.
* If a high-risk situation exists, all team members—including the anesthesiologist—should take a joint and active role in agreeing on how a fire will be prevented and managed.
* Each team member should be assigned a specific fire management task to perform in the event of a fire (e.g., removing the tracheal tube, turning off the airway gases).
* Each team member should understand that his or her preassigned task should be performed immediately if a fire occurs, without waiting for another team member to take action.
* When a team member has completed a preassigned task, he or she should help other team members perform tasks that are not yet complete.
* In every OR and procedure area where a fire triad can exist (i.e., an oxidizer-enriched atmosphere, an ignition source, and fuel), an easily visible protocol for the prevention and management of fires should be displayed.
* Equipment for managing a fire should be readily available in every procedural location where a fire triad may exist.
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IV. Prevention
* The anesthesiologist should collaborate with all members of the procedure team throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source.
* For all procedures:
- Surgical drapes should be configured to minimize the accumulation of oxidizers (oxygen and nitrous oxide) under the drapes and from flowing into the surgical site.
- Flammable skin prepping solutions should be dry before draping.
- Gauze and sponges should be moistened before use in proximity to an ignition source.
* For high-risk procedures:
- The anesthesiologist should notify the surgeon whenever there is a potential for an ignition source to be in proximity to an oxidizer-enriched atmosphere or when there is an increase in oxidizer concentration at the surgical site.
- Any reduction in supplied oxygen to the patient should be assessed by monitoring (1) pulse oximetry and, if feasible, (2) inspired, exhaled, and/or delivered oxygen concentration.
* For laser procedures:
- A laser-resistant tracheal tube should be used.
▪ The laser-resistant tracheal tube used should be chosen to be resistant to the laser used for the procedure (e.g., CO2, Nd:YAG, Ar, Er:YAG, KTP).
- The tracheal cuff of the laser tube should be filled with saline and colored with an indicator dye such as methylene blue.
- Before activating a laser:
▪ The surgeon should give the anesthesiologist adequate notice that the laser is about to be activated.
▪ The anesthesiologist should:
· Reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.
· Stop the use of nitrous oxide.
· Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving activation of the laser.
* For cases involving an ignition source and surgery inside the airway:
- Cuffed tracheal tubes should be used when clinically appropriate.
- The anesthesiologist should advise the surgeon against entering the trachea with an ignition source (e.g., electrosurgery unit).
- Before activating an ignition source inside the airway:
▪ The surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated.
▪ The anesthesiologist should:
· Reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.
· Stop the use of nitrous oxide.
· Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source.
- In some cases (e.g., surgery in the oropharynx), scavenging with suction may be used to reduce oxidizer enrichment in the operative field.
* For cases involving moderate or deep sedation, an ignition source, and surgery around the face, head, or neck:
- The anesthesiologist and surgeon should develop a plan that accounts for the level of sedation and the patient's need for supplemental oxygen.
▪ If moderate or deep sedation is required or used, or if the patient exhibits oxygen dependence, the anesthesiologist and surgeon should consider a sealed gas delivery device (e.g., cuffed tracheal tube or laryngeal mask).
▪ If moderate or deep sedation is not required, and the patient does not exhibit oxygen dependence, an open gas delivery device (e.g., facemask or nasal cannula) may be considered.
- Before activating an ignition source around the face, head, or neck:
▪ The surgeon should give the anesthesiologist adequate notice that the ignition source is about to be activated.
▪ The anesthesiologist should:
· Stop the delivery of supplemental oxygen or reduce the delivered oxygen concentration to the minimum required to avoid hypoxia.
· Wait a few minutes after reducing the oxidizer-enriched atmosphere before approving the activation of the ignition source.
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V. Management of OR Fires
* When an early warning sign is noted, halt the procedure and call for an evaluation of fire.
* When a fire is definitely present, immediately announce the fire, halt the procedure, and initiate fire management tasks.
* Team members should perform their preassigned fire management tasks as quickly as possible.
- Before the procedure, the team may identify a predetermined order for performing the tasks.
- If a team member cannot rapidly perform his or her task in the predetermined order, other team members should perform their tasks without waiting.
- When a team member has completed a preassigned task, he or she should help other members perform tasks that are not yet complete.
* For a fire in the airway or breathing circuit, as fast as possible:
- Remove the tracheal tube.
- Stop the flow of all airway gases.
- Remove all flammable and burning materials from the airway.
- Pour saline or water into the patient's airway.
* For a fire elsewhere on or in the patient, as fast as possible:
- Stop the flow of all airway gases.
- Remove all drapes, flammable, and burning materials from the patient.
- Extinguish all burning materials in, on, and around the patient (e.g., with saline, water, or smothering).
* If the airway or breathing circuit fire is extinguished:
- Reestablish ventilation by mask, avoiding supplemental oxygen and nitrous oxide, if possible.
- Extinguish and examine the tracheal tube to assess whether fragments were left in the airway.
▪ Consider bronchoscopy (preferably rigid) to look for tracheal tube fragments, assess injury, and remove residual debris.
- Assess the patient's status and devise a plan for ongoing care.
* If the fire elsewhere on or in the patient is extinguished:
- Assess the patient's status and devise a plan for ongoing care of the patient.
- Assess for smoke inhalation injury if the patient was not intubated.
* If the fire is not extinguished after the first attempt (e.g., after performing the preassigned tasks):
- Use a CO2 fire extinguisher in, on, or around the patient.
- If the fire persists after use of the CO2 fire extinguisher:
▪ Activate the fire alarm.
▪ Evacuate the patient if feasible, following institutional protocols.
▪ Close the door to the room to contain the fire and do not reopen it or attempt to reenter the room.
▪ Turn off the medical gas supply to the room.
* Follow local regulatory reporting requirements (e.g., report fires to your local fire department and state department of health).
* Treat every fire as an adverse event, following your institutional protocol.
Cited Here...
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Appendix 2: Methods and Analyses
A. State of the Literature
For this Advisory, a literature review was used in combination with opinions obtained from experts and other sources (e.g., professional society members, open forums, Web-based postings) to provide guidance to practitioners regarding OR fire prevention and management. Both the literature review and opinion data were based on evidence linkages, or statements regarding potential relationships between fire prevention and management interventions and OR fire outcomes.** The evidence linkage interventions are listed below.
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I. Education
1. Fire safety education, with an emphasis on an oxidizer-enriched atmosphere
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II. OR Fire Drills
2. Periodic participation in OR fire drills
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III. Preparation
3. Display of an easily visible protocol for the prevention and management of fires
4. Preoperative determination of a high-risk situation
5. OR team discussion of OR fire strategy
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IV. Prevention
6. Surgical drape configuration to minimize the accumulation of oxidizers
7. Drying of flammable skin prepping solutions
8. Moistening of sponges and gauze when used in proximity to an ignition source
9. Reducing the concentration of supplied oxygen for high-risk procedures
10. Avoidance of nitrous oxide for high-risk procedures
11. Cuffed versus uncuffed tracheal tubes for cases in or around the airway
12. Insufflating with medical air during cases in or around the airway
13. Scavenging with suction during cases in or around the airway
14. Laser-resistant versus non-laser-resistant tracheal tubes during laser surgery
15. Filling the tracheal cuff of the laser tube with saline colored with an indicator dye
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V. Management
16. Early signs of a fire include a flame or flash, unusual sounds, odors, smoke, or heat (observational)
17. Removing the tracheal tube and stopping the flow of oxygen to minimize patient injury after an airway or breathing circuit fire
18. Pouring saline into the patient's tracheal tube to extinguish an airway fire
For the literature review, potentially relevant studies were identified via electronic and manual searches of the literature. The literature search covered a 56-yr period from 1952 through 2007. More than 400 citations were initially identified, yielding a total of 340 articles that addressed topics related to the evidence linkages and met our criteria for inclusion. After review of the articles, 240 studies did not provide direct evidence and were subsequently eliminated. A total of 100 articles contained direct linkage-related evidence.†† No evidence linkage contained enough studies with well-defined experimental designs and statistical information to conduct a quantitative analysis (i.e., meta-analysis).
Interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. Agreement levels using a κ statistic for two-rater agreement pairs were as follows: (1) type of study design, κ = 0.63–0.82; (2) type of analysis, κ = 0.40–0.87; (3) evidence linkage assignment, κ = 0.84–1.00; and (4) literature inclusion for database, κ = 0.69–1.00. Three-rater chance-corrected agreement values were (1) study design, Sav = 0.69, Var (Sav) = 0.013; (2) type of analysis, Sav = 0.57, Var (Sav) = 0.031; (3) linkage assignment, Sav = 0.89, Var (Sav) = 0.004; and (4) literature database inclusion, Sav = 0.79, Var (Sav) = 0.025. These values represent moderate to high levels of agreement.
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B. Consensus-based Evidence
Consensus was obtained from multiple sources, including (1) survey opinion from consultants who were selected based on their knowledge or expertise in OR fire prevention and management, (2) survey opinions solicited from active members of the ASA, (3) testimony from attendees of a publicly held open forum at a national anesthesia meeting, (4) Internet commentary, and (5) Task Force opinion and interpretation. The survey rate of return was 52% (n = 38 of 73) for the consultants, and 64 surveys were received from active ASA members. Results of the surveys are reported in tables 2 and 3 and in the text of the Advisory.
Table 2
Table 2
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Table 2
Table 2
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Table 3
Table 3
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Table 3
Table 3
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The consultants were asked to indicate which, if any, of the evidence linkages would change their clinical practices if the Advisory was instituted. The rate of return was 18% (n = 13 of 73). The percent of responding consultants expecting a change in their practice associated with each linkage topic was as follows: (1) education, 77%; (2) OR fire drills, 69%; (3) team discussion of fire strategy, 69%; (4) minimizing or avoiding an oxidizer-enriched atmosphere near the surgical site, 38%; (5) managing ignition sources, 38%; (6) managing fuels, 31%; (7) identification of a high-risk procedure, 85%; (8) management of a high-risk procedure, 31%; and (9) OR fire management, 77%. Eighty-five percent of the respondents indicated that the Advisory would have no effect on the amount of time spent on a typical case, and 15% indicated that there would be an increase of 1–5 min in the amount of time spent on a typical case with the implementation of this Advisory. Cited Here...
† Some of these items only burn in an oxidizer-enriched atmosphere. Cited Here...
‡ Society for Ambulatory Anesthesia, 22nd Annual Meeting, San Diego, California, May 5, 2007. Cited Here...
§ All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included. Cited Here...
∥ When an even number of responses are obtained, the median value is determined by a calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula. Cited Here...
# Some experts and educators recommend an initial step that involves two simultaneous actions: removal of the tracheal tube and stopping the flow of medical gases (e.g., by disconnecting the breathing circuit at the Y-piece or the inspiratory gas limb). The intent is to prevent a “blowtorch” effect caused by continued gas flow through a burning tracheal tube. This “blowtorch” effect can spread fire to other locations on or near the patient, and may cause additional burns on the patient or other members of the OR team. The Task Force has carefully considered this concern and agrees that these simultaneous actions represent an ideal response. However, the Task Force is concerned that, in actual practice, the simultaneous actions may be difficult to accomplish or may result in delay when one team member waits for another. Therefore, the Task Force recommends that the actions take place as fast as possible. Cited Here...
** Unless otherwise specified, outcomes for the listed interventions refer to the occurrence of fire or adverse sequela. Cited Here...
†† A complete list of references used to develop this Advisory is available on the Anesthesiology Web site, www.anesthesiology.org, or by writing to the American Society of Anesthesiologists. Cited Here...

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