Operating room fires have occurred for decades. Recent reports in the medical literature suggest that the risk for surgical fires may be increasing due to more prevalent use of surgical lasers, electrocautery units, fiberoptic light sources and disposable drapes.1,2 The ECRI (formerly known as the Emergency Care Research Institute), an independent non-profit health research agency, estimates that approximately 100 surgical fires occur each year, causing 20 serious injuries and one or two deaths.3 Nearly all of these fires ignite on or within the patient.4 Fires that occur elsewhere, such as on linens or other materials within the operating room, may not be reported, although many states have legal requirements to report any fire, and organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require fire documentation as part of hospital accreditation standards.3 This article examines the role of surgical product selection as it relates to fire risk.

Fire components: An overview
The three components necessary to start a fire—an ignition source, oxygen and fuel—are referred to as the "fire triangle" and have been widely discussed in clinical guidelines and in the medical literature.2,4,5

Ignition:
The list of devices in the operating room that produce enough heat to ignite a fire is extensive (see Heat Sources).The tips of electrocautery units can reach several hundred degrees, and lasers focus intense heat into a small area and can ignite nearly any material in its path.2 Other devices can produce sparks.4 Depending on the heat source, combustion may occur after several minutes or even within a few seconds of exposure to a fuel source. Operating room staff must ensure that heat sources are not directed toward fuel.4,5

Oxygen:
Oxygen is found within the air in the operating room and from external sources, such as the anesthesia machine, ventilator and from oxygen canisters. An oxygen-rich environment increases the risk that combustion will occur when heat comes into contact with fuel.4

Fuel:
Fuel includes nearly anything. Obvious fuel sources consist of items that are known to be flammable, such as skin prepping agents, linens and paper products. But a heat source that is hot enough, especially in an oxygen-rich environment, will also ignite items that generally are not considered flammable, such as petroleum-based ointments, tubing and equipment casings.4

Reducing fire risk
Education of the operating room staff is critical to reducing the risk of fire and, importantly, providing swift, effective procedures for extinguishing fires that do occur. Several guidelines include extensive information about every aspect of controlling the fire triangle; essentially, if one of the three elements of the triangle is controlled, fire risk is reduced.2,4,5

Some of the components that contribute to fire risk are easier to control than others, however. For example, while proper handling of a laser device is of paramount importance, the device cannot be eliminated entirely, despite its potential risk as a source of ignition. The same is true of oxygen supplied with anesthesia or through a ventilator. Staff should evaluate the need for 100 percent oxygen, depending on the procedure.5

The component that allows the most choice in fire control is the fuel source. Although some fuel sources are found on or within the patient, such as body hair and gases, the operating room is stocked with abundant fuel sources largely necessary for infection control. These include:

• Antiseptic skin preparation agents

• Linens such as drapes, gowns, masks, caps, shoe covers and bedding

• Dressing materials and sponges

• Ointments

• Gloves

This is not an exhaustive list of fuels, of course, but infection control supplies may provide more choice than other components in terms of the range of products that can be purchased and the manner in which they are used. For example, ECRI guidelines include instructions for antiseptic skin preparation and materials handling that can minimize fire risks:4

• Do not allow flammable liquid preps to pool on the patient’s skin or in open containers

• Skin preps should be completely dry before the patient is draped; excess solution can be wicked into the draping

• Use a properly applied incise drape to isolate head and neck incisions from an oxygen-enriched atmosphere and flammable vapors trapped beneath drapes and to eliminate a channel for gas to escape into the surgical site

• Coat facial hair (including eyebrows, beard and mustache) near the surgical site with water-based surgical lubricating jelly, which is nonflammable

• Ensure that alcohol vapors have dissipated before allowing a heat source in proximity

• Be aware of the flammability of prepping agents and dressings during surgery

Based on these guidelines, some assumptions can be made: the type of applicator for antiseptic skin preparations is an important criterion for product selection, and water-based ointments are safer choices than petrolatum.

The need to control the application of flammable solutions during electrocautery procedures cannot be overstated. The Food and Drug Administration requires that solutions with alcohol must have an applicator that controls solution flow, allows alcohol vapors to dissipate and minimizes excess solution from collecting—single-use bottles with no applicators should not be used.

In addition to carefully evaluating flammable solutions, purchasers may wish to re-evaluate the use of disposable drapes. These materials are less expensive than cloth drapes but are much more flammable, even when treated with flame retardants.2

Conclusion
Preventing surgical fires requires attention from everyone in the operating room as well as hospital staff members who are responsible for researching and making purchasing decisions. The potential for surgical fire risk is another consideration in the process of selecting products. There may be more choice in evaluating infection control products, such as antiseptic skin preparations and draping materials, than there is in other components of the fire triangle. Understanding how a product should be used to minimize fire risk—such as the need to control the flow of a flammable solutions—is part of the product selection process. HPN