Operating Room Safety Fires Grand Rounds Presentation June 18, 2009 John Chi, MD

Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

UCLA Medical Center, 1990

UCLA Medical Center, 1990 • 26 year-old female struck by auto • Blunt injuries to abdomen, chest • Endotracheal intubation • Emergency surgery

OR Fire • Surgery completed

OR Fire • Surgery completed • Drapes ignited by cautery device

OR Fire • Surgery completed • Drapes ignited by cautery device • Flames spread rapidly and engulf patient

OR Fire • Surgery completed • Drapes ignited by cautery device • Flames spread rapidly and engulf patient • Smoke forces OR staff to evacuate

OR Fire • Surgery completed • Drapes ignited by cautery device • Flames spread rapidly and engulf patient • Smoke forces OR staff to evacuate • OR sprinkler system does not activate

OR Fire • Surgery completed • Drapes ignited by cautery device • Flames spread rapidly and engulf patient • Smoke forces OR staff to evacuate • OR sprinkler system does not activate • Fire Department arrives and controls fire

Outcome • Patient expires in the fire • Operating room staff treated for minor burns and smoke inhalation

Safety “If you don't know what is going to happen, there is no way to stop it.”

OR Fires •

Introduction

• Causes • Outcomes • Prevention

Epidemiology >30,000,000 surgeries per year >2,000 reported hospital fires 30 reported OR fires Source: American College of Surgeons,1997.

Locations of Fires Perineum Torso Airway Head & Neck Equipment 2 7 9 0 5 10 Number of Fires 15 Source: Tyco Healthcare Valleylab 2006.

15 18 20

Locations of Fires ~ 65% of fires occur in the Head & Neck region because of the O 2 rich environment Source: ECRI. Devastation of patient fires. Health devices. 1992.

OR Fires • Introduction •

Causes

• Outcomes • Prevention

Requirements for Fire

Oxidizer + Fuel + Ignition =

FIRE

Oxidizers

• Oxygen Oxidizers

Oxidizers • Oxygen – Oxygen is denser than air 1.308 g/L O 2

>

1.251 g/L N 2

Oxidizers • Oxygen – Oxygen is denser than air 1.308 g/L O 2

>

1.251 g/L N 2 – Collects in low-lying areas

Oxidizers • Oxygen – Oxygen is denser than air 1.308 g/L O 2

>

1.251 g/L N 2 – Collects in low-lying areas – Absorbed and retained by fabrics

Oxidizers • Oxygen – Oxygen is denser than air 1.308 g/L O 2

>

1.251 g/L N 2 – Collects in low-lying areas – Absorbed and retained by fabrics • Nitrous oxide

Oxidizers • Oxygen – Oxygen is denser than air 1.308 g/L O 2

>

1.251 g/L N 2 – Collects in low-lying areas – Absorbed and retained by fabrics • Nitrous oxide – Releases oxygen when heat is applied

OR Fuels Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

• Patient OR Fuels Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels • Patient • Prepping agents Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels • Patient • Prepping agents • Ointments Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels • Patient • Prepping agents • Ointments • Linens Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels • Patient • Prepping agents • Ointments • Linens • Equipment Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels - Patient • Hair • Surgical cap • Gown • GI tract gases

OR Fuels – Prepping Agents • Alcohol • Chlorhexidine • Acetone • Betadine

Betadine??

Betadine??

• Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

Betadine??

• Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

Betadine

Betadine Flammability of the Product: May be combustible at high temperature.

Glycerin

Glycerin Flammability of the Product: May be combustible at high temperature.

OR Fuels - Ointments • Petrolatum • Benzoin • Paraffin • Aerosols

OR Fuels - Linens • Drapes • Dressings, sponges • Surgical gowns, masks, caps • Mattresses • Sheets, blankets • Egg crates

OR Fuels - Equipment • Flexible endoscopes • ECG wires • Blood pressure cuff • Tubing • Gloves • Anesthesia machine

Flammability Standards • OR equipment • OR supplies • OR gowns, masks, caps • Anesthetics Source: Sommers JR. Flammability standards. SSM 1998;2:41-4.

Requirements for Fire

Oxidizer + Fuel + Ignition =

FIRE

OR Fire Survey Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires 2 respondents = 5 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

Fire Scenarios 27% Endoscopic Airway Surgery 24% Oropharyngeal Electrocautery Surgery 23% Electrocautery Surgery under MAC 18% Tracheotomy 7% Endoscopic Light Cables 1% Anesthesia Machine

Endoscopic Airway Surgery

Endoscopic Airway Surgery

OXIDIZER :

– Oxygen – Nitrous Oxide

Endoscopic Airway Surgery

OXIDIZER :

– Oxygen – Nitrous Oxide

FUEL :

– ET Tube, LASER ET Tube – Flexible Bronchoscope, Drapes

Endoscopic Airway Surgery

OXIDIZER :

– Oxygen – Nitrous Oxide

FUEL :

– ET Tube, LASER ET Tube – Flexible Bronchoscope, Drapes

IGNITION :

– LASER - CO 2 more often than KTP

Laser Ignition of Drapes Source: Wolf et al, 2004.

Laser Ignition of Drapes • Surgical drapes tested for time to ignition Source: Wolf et al, 2004.

Laser Ignition of Drapes • Surgical drapes tested for time to ignition • CO 2 laser 15 W, 2 mm spot x 30 sec Source: Wolf et al, 2004.

Laser Ignition of Drapes • Surgical drapes tested for time to ignition • CO 2 laser 15 W, 2 mm spot x 30 sec

21%

O 2

50%

O 2

95%

O 2 Source: Wolf et al, 2004.

Laser Ignition of Drapes • Surgical drapes tested for time to ignition • CO 2 laser 15 W, 2 mm spot x 30 sec

21%

O 2

50%

O 2

95%

O 2 Primary ignition – drapes Secondary ignition – drapes on filter paper Source: Wolf et al, 2004.

Drapes Tested • Nonwoven cellulose/polyester blend • Polypropylene • Reusable woven cotton/polyester blend • Huck cotton towel drape adjunct • Phenol polymer

Time to Primary Ignition 21% Material Phenol polymer Ignited / Tested 0 / 10 Polypropylene 0 / 10 Huck towel Cotton-poly Cellulose-poly 8 / 10 10 / 10 10 / 10 TTI N/A N/A 11.9 sec 4.0 sec 2.7 sec

Time to Primary Ignition 50% Material Phenol polymer Ignited / Tested 10 / 10 Polypropylene 9 / 10 Huck towel Cotton-poly Cellulose-poly 10 / 10 10 / 10 10 / 10 TTI 4.9 s 0.14 s 2.3 s 1.1 s < 0.1 s

Time to Primary Ignition 95% Material Phenol polymer Ignited / Tested 10 / 10 Polypropylene 10 / 10 Huck towel Cotton-poly Cellulose-poly 10 / 10 10 / 10 10 / 10 TTI 0.68 s 0.18 s < 0.1 s 0.65 s < 0.1 s

Time to Secondary Ignition 21% Material Polypropylene & Filter Paper Filter Paper alone Ignited / Tested 10 / 10 10 / 10 TTI 4.7 s 5.2 s Filter paper was placed beneath the test material.

Laser Study Conclusions • Time to ignition decreases with increasing O 2 concentration • Polypropylene assumes the ignition characteristics of materials it contacts

Oropharyngeal Electrocautery

Oropharyngeal Electrocautery

OXIDIZER :

– Oxygen

Oropharyngeal Electrocautery

OXIDIZER :

– Oxygen

FUEL

: – ET Tube – Tonsil Sponge – Bovie Tip – Red Rubber Catheter

Oropharyngeal Electrocautery

OXIDIZER :

– Oxygen

FUEL

: – ET Tube – Tonsil Sponge – Bovie Tip – Red Rubber Catheter

IGNITION :

– Monopolar Electrocautery

Fire risk: Monopolar v. Coblator Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator • Monopolar – Coagulate: 15 W • Coblator – Ablate: 9, 7, 3 – Coagulate: 5, 3 Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator • Degutted raw chicken • 6.0 ET Tube • 100% oxygen at 10 L/min • 3 tonsil sponges Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

OP Fire Study Setup

Monopolar Electrocautery

After 45 –55 secs of Monopolar

After 45 –55 secs of Monopolar

After the fire

Coblator Electrocautery

After 4 minutes of Coblator

After 4 minutes of Coblator

After 20 minutes of Coblator

After 20 minutes of Coblator

Back to Monopolar for 25 secs

Back to Monopolar for 25 secs

OP Fire Study Conclusions • Monopolar Electrocautery (>15 W) poses a fire risk • Coblator Electrocautery did not produce fires

Electrocautery Surgery (MAC)

Electrocautery Surgery (MAC)

OXIDIZER :

– Oxygen

Electrocautery Surgery (MAC)

OXIDIZER :

– Oxygen

FUEL :

– Flash Fire – EtOH Prep – Drapes – Sponges

Electrocautery Surgery (MAC)

OXIDIZER :

– Oxygen

FUEL :

– Flash Fire – EtOH Prep – Drapes – Sponges

IGNITION :

– Monopolar Electrocautery – LASER – Thermocautery – Oxidizer to ignition source <5cm

Arizona Medical Center,1998

Arizona Medical Center,1998 • 73 year-old male with SDH for bilateral burr holes • Oxygen via face mask at 6 L/min • Iodofor surgical prep – (0.7% iodine, 74% Isopropyl EtOH) • Drapes: Towels, Paper surgical drapes • Monopolar Electrocautery

OR Fire

• “Pop” OR Fire

OR Fire • “Pop” • Smoke appears from beneath the drapes

OR Fire • “Pop” • Smoke appears from beneath the drapes • Drapes quickly removed

OR Fire • “Pop” • Smoke appears from beneath the drapes • Drapes quickly removed • “Ball of flame” engulfs the patient’s head

OR Fire • “Pop” • Smoke appears from beneath the drapes • Drapes quickly removed • “Ball of flame” engulfs the patient’s head • Oxygen mask on fire

OR Fire • “Pop” • Smoke appears from beneath the drapes • Drapes quickly removed • “Ball of flame” engulfs the patient’s head • Oxygen mask on fire • Fire smothered with drapes

OR Fire • “Pop” • Smoke appears from beneath the drapes • Drapes quickly removed • “Ball of flame” engulfs the patient’s head • Oxygen mask on fire • Fire smothered with drapes • Oxygen flow turned off

Outcome • Intubation • 2 nd degree burns of face, neck • ICU x 2 months • Pneumonia, Respiratory Failure • Inpatient rehabilitation

Simulated OR Fire

Simulated OR Fire • Life size manikin • Oxygen supplied via face mask • Positioned, prepped, and draped • Monopolar electrocautery

Simulation Setup

Monopolar Electrocautery- POP

Smoke – POP + 5 seconds

Fire – POP + 13 seconds

Fire – POP + 24 seconds

Beneath the drapes

Beneath the drapes

Beneath the drapes

Beneath the drapes

Simulation Fire Requirements Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements • Supplemental oxygen Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements • Supplemental oxygen • Closed space formed by drapes (Tenting) Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements • Supplemental oxygen • Closed space formed by drapes (Tenting) • Alcohol-based preparation solution – Manufacturer’s label drying time 2-3 minutes – Drying time > 5 minutes  No fire Source: Barker SJ, Polson SJ, 2001.

Oxygen Face Masks

Oxygen Face Masks • Melt when exposed to open flame

Oxygen Face Masks • Melt when exposed to open flame • Do NOT burn without oxygen flow

Oxygen Face Masks • Melt when exposed to open flame • Do NOT burn without oxygen flow • Ignite, burn with oxygen flow > 3 L/min

Tracheotomy

OXIDIZER :

– Oxygen Tracheotomy

Tracheotomy

OXIDIZER :

– Oxygen

FUEL :

– Flash Fire, ET Tube, Drape, Airway

Tracheotomy

OXIDIZER :

– Oxygen

FUEL :

– Flash Fire, ET Tube, Drape, Airway

IGNITION :

– Monopolar electrocautery • Electrocautery to enter trachea • Electrocautery after airway incision

Endoscopic Surgery

Endoscopic Surgery

OXIDIZER :

– Oxygen

Endoscopic Surgery

OXIDIZER :

– Oxygen

FUEL :

– Drapes • Cellulose-based: IGNITE • Polypropylene-based: MELT

Endoscopic Surgery

OXIDIZER :

– Oxygen

FUEL :

– Drapes • Cellulose-based: IGNITE • Polypropylene-based: MELT

IGNITION :

– Endoscopic Light Cable – Temperature > 200º Celcius

OR Fires • Introduction • Causes •

Outcomes

• Prevention

Outcomes

Analysis of Closed Claims Source: Bhananker et al, 2006.

Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies Source: Bhananker et al, 2006.

Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies • 121 MAC-related claims reviewed • 20 OR fires leading to burns Source: Bhananker et al, 2006.

OR Fires • 95% involved head, neck, face

OR Fires • 95% involved head, neck, face • 50% cited for substandard care

OR Fires • 95% involved head, neck, face • 50% cited for substandard care • 89% resulted in payment to plaintiff – Median $71,375 – Range $8,175 to $321,323

OR Fires • Introduction • Causes • Outcomes •

Prevention

Prevention

Prevention • Communication with OR Staff, Anesthesia

Prevention • Communication with OR Staff, Anesthesia • Assess the OR fire risk

Prevention • Communication with OR Staff, Anesthesia • Assess the OR fire risk • Electrocautery – avoid Fuels + Oxidizers

Prevention • Communication with OR Staff, Anesthesia • Assess the OR fire risk • Electrocautery – avoid Fuels + Oxidizers • Minimize available O 2

Prevention • Communication with OR Staff, Anesthesia • Assess the OR fire risk • Electrocautery – avoid Fuels + Oxidizers • Minimize available O 2 • Prep Solutions – proceed with caution

Prevention • Communication with OR Staff, Anesthesia • Assess the OR fire risk • Electrocautery – avoid Fuels + Oxidizers • Minimize available O 2 • Prep Solutions – proceed with caution • Fire Safety Training

Summary

Summary • OR fires are preventable

Summary • OR fires are preventable • Be aware of your surroundings

Summary • OR fires are preventable • Be aware of your surroundings

Oxidizer + Fuel + Ignition =

FIRE

Thank You • Lee Smith, MD • James Kearney, MD

Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870