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Thinking Outside the Triangle: A New Approach to Preventing Surgical Fires

Feldman, Jeffrey M. MD, MSE*; Ehrenwerth, Jan MD; Dutton, Richard P. MD

doi: 10.1213/ANE.0000000000000127
Editorials: Editorial

From the *Department of Anesthesiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois.

Accepted for publication January 6, 2013.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Jeffrey M. Feldman, MD, MSE, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to

The combination of a fuel, an oxidizer, and a heat source is required for a fire to start (Fig. 1). Strategies for preventing surgical fires have included recommendations directed toward 1 or more limbs of this triangle.1–4 Heat sources such as lasers are to be placed in standby; cautery devices holstered. Fuels (prep solutions) that contain alcohol need to dry before starting a procedure: gauze and pads moistened. Most importantly, the concentration of oxygen in the surgical field needs to be controlled because commonly used surgical textiles become fuels in the presence of enriched oxygen and will burn hotter and faster than they would in room air. This last recommendation can be problematic, for example, when a patient with a high oxygen requirement presents for tracheostomy. In that case, prevention focuses on eliminating the use of electrocautery when entering the trachea and the use of suction, wet packs, and bipolar cautery if necessary.5

Figure 1

Figure 1

Surgical fires are almost 100% preventable. However, despite large scale efforts to educate practitioners, including publication of practice advisories and guidelines by organizations such as the American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation, the Association of periOperative Registered Nurses, and the ECRI Institute, hundreds of preventable surgical fires continue to occur each year. Is it reasonable to assume that efforts by our organizations will permanently change practice patterns, or as Eichhorn opined will practitioners continue to justify their actions because “That’s what I was taught; it’s the way we always do it”?6

Clearly what is needed is a new paradigm, an engineering solution. In this issue of the journal, Culp et al.7 describe a unique engineering solution to preventing surgical fires. These authors modified a common type of electrocautery pencil to include a cone at the end of the pencil that is connected to a constant flow of carbon dioxide (CO2). Their testing included igniting surgical gauze using an electrocautery pencil in the presence of different oxygen concentrations with or without CO2 flowing into the cone. When no CO2 was flowing, the gauze ignited in 2.9, 0.58, and 0.48 seconds on average in the presence of 21%, 50%, and 100% oxygen, respectively. When CO2 was flowing, it was not possible to ignite the gauze with the cautery pencil even in the presence of 100% oxygen.

The current recommendations for preventing surgical fires during high-risk surgical procedures should be quite effective, especially if the oxygen concentration in the surgical field is controlled.1–3 For patients being sedated for a procedure above the xiphoid with a natural airway, it is recommended to have the patient breathe room air or to limit the oxygen concentration administered to 30% as long as hypoxemia does not result. When >30% inspired oxygen is required to prevent hypoxemia, it is recommended to control the airway in an effort to exclude the oxygen from the surgical field. One difficult clinical scenario was described above. Another occurs when caring for a patient who requires significantly enriched oxygen to avoid hypoxemia, but in whom, it is undesirable or contraindicated to control the airway. Examples include pacemaker insertion in a frail patient, or a patient with oxygen dependence who needs to be responsive during a procedure such as carotid endarterectomy or awake craniotomy. In these cases, alternate strategies like open draping or insufflating air under the drapes are recommended, but oxygen is still present close to the surgical field. The reality is that since oxygen is invisible and the concentration is not measured in the surgical field, it may not be possible to know with certainty that an enriched oxygen concentration does not exist close to the heat source. Insufflating air is technically inconvenient in most operating rooms, and draping techniques may not reliably exclude oxygen from the field. Finally, the common practice of performing minor procedures above the xiphoid with sedation, a natural airway, and 100% oxygen by cannula or facemask is pervasive, and current recommendations for prevention are not universally followed.

The approach developed by Culp et al.7 is a unique new strategy designed to help prevent surgical fires. The closed claims project reviewed surgical fire claims in the closed claims database and found electrocautery to be the heat source in 90% of the fire claims in the database.8 The preliminary data from the in vitro study suggest that CO2 flow around the tip of the electrocautery pencil can prevent fires even in the presence of 100% oxygen. Additional investigation is required to determine whether this approach would be clinically useful. For procedures around the face or in the airway, the potential for hypercarbia from inspired CO2 would need to be understood. Capnography can be challenging with a natural airway, and we need to understand the impact on the capnogram of additional CO2 flowing near the capnography sampling site. Quantitative capnography is not reliable with a natural airway, but at the very least, it is important to obtain a capnogram sufficient to assess continued gas exchange during sedation. There were no surgeons involved with the testing to evaluate the impact of the modification on the ability to operate, although presumably, a refined design could make the device a useful surgical tool.

One lesson from the surgical fire experience is that oxygen is like any other drug, with the potential for serious side effects. It should be used in the lowest concentration necessary when there is a risk for fire. If it becomes feasible to insufflate CO2 around the tip of an electrocautery pencil, it should not become a license to continue the common practice of administering 100% oxygen in high-risk procedures. There are other potential sources of ignition besides electrocautery. Oxygen and sedation should still be administered prudently, avoiding concentrations that are greater than required to prevent hypoxemia. CO2 insufflation then becomes another layer of protection for the patient. We also need to continue the growing trend of integrating devices such as air-oxygen blenders into our workspace to make it convenient to control the oxygen concentration of oxygen delivered.

Culp et al.7 are to be congratulated for taking a unique approach to surgical fire prevention. The technique of insufflating CO2 around the heat source effectively breaks the fire triangle by excluding the oxidizer from the heat source. This approach is different from the current recommendations to simply limit the oxygen concentration delivered but requires additional investigation before it can be considered suitable for clinical practice. This technique may provide another layer of prevention for high-risk procedures where electrocautery is used and be a more reliable solution than draping techniques or insufflating air for delivering increased oxygen concentrations safely when needed to avoid hypoxemia in cases where it is undesirable to control the airway. Further research might also demonstrate whether a similar approach could be used with surgical lasers, another important initiator of surgical fires.

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Name: Jeffrey M. Feldman, MD, MSE.

Contribution: This author prepared the manuscript.

Attestation: Jeffrey M. Feldman approved the final manuscript.

Name: Jan Ehrenwerth, MD.

Contribution: This author prepared the manuscript.

Attestation: Jan Ehrenwerth approved the final manuscript.

Name: Richard P. Dutton, MD.

Contribution: This author prepared the manuscript.

Attestation: Richard P. Dutton approved the final manuscript.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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