Fire and Laser Safety
Preventing an OR Catastrophe

By Kris Ellis

While rare, fires in the operating room (OR) can be devastating to patients and healthcare workers alike. It is estimated that as many as 100 minor surgical fires occur each year, with one or two fatalities.¹ Some feel that many fires go unreported as well. “We know that ignition sources for fire have historically had specific roles in surgical applications, and that the three things that must be present are the ignition source, the fuel, and the oxidizer,” says Vangie Dennis, RN, CNOR, CMLSO, advanced technology coordinator in surgical services support for the Gwinnett Hospital System. “We looked at the fire facts, and statistically the research said 50 to 100 fires in the United States each year — this is highly underestimated.”

Clinicians must first understand the fire hazard trilogy as the foundation for fire safety. It consists of ignition sources (e.g., electrosurgical units [ESUs], fiberoptics, lasers, electrocautery, endoscopes, defibrillators); fuel sources (e.g., sponges, gauze, drapes, gowns, preps, alcohol); and an oxygen-enriched atmosphere (exceeding 21 percent oxygen).

“Probably the biggest critical point is airway safety,” Dennis says. “We have all kinds of energy devices in the OR, but lasers and ESUs are probably the biggest two for airway. The main point is to encourage a collaborative team approach, because you have to establish safety proactively, and not after a fire occurs.”

Oftentimes, ESUs are initially blamed for an electrosurgical airway fire. Observers tend to attribute the sparking and/or flame seen at the surgical site immediately before the fire to an unexpected surge of electricity from the ESU. However, ECRI, a nonprofit health services research agency, reports that in more than 20 years of investigating such cases, this was never found to have occurred.² The flame and sparking are actually the accelerated burning of tissue and gases that have evolved from the electrosurgery. The true cause of the fire, rather than the ESU itself, is usually the misuse of the ESU in the oxygen-enriched atmosphere (OEA) that typically exists in the patient’s airway.

Oxygen and nitrous oxide are often used to ventilate and anesthetize patients during airway surgeries. Both gases support combustion, and both reduce the amount of energy needed to ignite flammable substances. Additionally, during airway surgery, these gases leak around the tracheal tube, creating an OEA in the oropharynx. Some fuels that will not burn in the 21 percent concentration of oxygen found in room air will burn readily in an OEA.³

At the first sign of a tracheal tube fire, ECRI recommends that the following steps be performed immediately and rapidly:³

1. Disconnect the breathing circuit from the tracheal tube.

2. Remove the tracheal tube.

• Have another team member extinguish it.
• Remove cuff-protective devices and any segments of burned tube that may remain smoldering in the airway.

3. Care for the patient.

• Reestablish the airway and resume ventilating with air until certain that nothing is left burning in the airway; then switch to 100 percent oxygen.
• Examine the airway to determine the extent of damage, and treat the patient accordingly. All materials and devices involved in the event should be saved for later investigation.

Dennis recommends establishing a guideline or a facility policy incorporating all members of the OR team. “You’ve really got to integrate service lines,” she says. “Anesthesia’s got to be able to communicate with the ENT physicians, because that’s where most of the oxygenation usually occurs — head and neck procedures as well as plastic surgery. Also, the nursing staff as well as the techs need to know what precautions they should take. I think if you integrate that kind of information collaboratively and go in there before an incident occurs instead of doing a root cause analysis after a fire, you’re going to get better results. Everybody needs to be on the same page as to what those safety standards are.”

Dennis also suggests that care and diligence should be used in identifying policies and standards around fire safety. “When you’re putting something in place, with physicians specifically, they’re scientists by nature; you can’t go in there with subjective data, and you can’t manage what you can’t make measurable,” she notes. “So, when I’m telling them not to put a dry tonsil sponge in the airway, their response is, ‘I’ve been doing it this way for years and nothing has ever happened.’”

In establishing guidelines at her facility, it was important for Dennis and her colleagues to make things measurable by pulling statistics, data, and research from different organizations. “What they would learn from their organizations, maybe some of the research was done in another area. For example, anesthesia did not know that nitrous oxide was a really big deal with lasers because it wasn’t supported very much in their literature, whereas any laser literature you read, it’s always a red flag for airways.”

Dennis’s hospital system’s policies for electrosurgery contain a subsection devoted to head and neck procedures:

1. Operate the generator on the lowest possible watts as well as low voltage power.
2. All sponges that come in contact with the surgical site during ESU activation should be moistened.
3. Hair near the surgical area will be lubricated with a water-soluble lubricant.
4. If eye lubricant is to be used, a water-soluble lubricant is recommended.
5. A basin of water/saline will be readily available on the sterile field and a bottle of water is to be given to anesthesia.
6. Suction tubing should be placed under the drapes in close proximity to the anesthetic gases, including oxygen, delivery system.
7. The oxygen will be turned off for 60 seconds prior to the activation of the ESU or under the recommendation of the anesthetist /anesthesiologists to maintain patient’s oxygen saturation at 90 percent or better.

“We no longer provide petroleum-based lubricants,” Dennis says. “The reason is, for head and neck procedures, we didn’t want them to forget and say, ‘well we’re doing a foot so it’s OK to use petroleum-based,’ but then the next day the same team might do a head and neck case and somebody might’ve left the petroleum-based lubricant there and they put it on the eye. We felt like we needed to cater to the lowest common denominator and use a carboxymethylcellulose, which is a water-soluble eye lubricant that you can get in single doses.”

Other issues can cause problems as well, such as hair in the area of surgery. “If the laser or electrosurgical device comes in close contact with hair, we don’t shave them; we just use a surgi-lube or a water-soluble lubricant, or block with wet towels if it’s not an electrosurgical device,” Dennis explains. “If it’s a laser, we may even use a combination of both.” She notes that the presence of hairspray or other hair products on the patient should be considered because of the obvious flammability implications.

ECRI offers a number of steps to prevent surgical fires that should be considered for each patient.⁴ When performing electrosurgery, electrocautery, or laser surgery:

• Stop supplemental oxygen (if oxygen concentration is less than 30 percent) at least one minute before and during use of the unit, if possible.
• Activate the unit only when the active tip is in view (especially if looking through a microscope or endoscope).
• Deactivate the unit before the tip leaves the surgical site.
• Place electrosurgical electrodes in a holster or another location off the patient when not in active use (i.e., when not needed within the next few moments).
• Place lasers in standby mode when not in active use.
• Do not place rubber catheter sleeves over electrosurgical electrodes.

At Gwinnett Hospital System, fire safety is also incorporated into its Anesthesia Practice Guidelines for Upper Airway and Head and Neck Procedures. For oropharyngeal procedures that require an ESU:

• An endotracheal tube (ETT) with an occlusive cuff is preferable to an uncuffed ETT. For pediatric cases in which cuffed ETT usage is impractical or not available, an uncuffed tube with the smallest possible leak is indicated within accepted parameters; (i.e., 15 cm to 20 cm of water leak pressure is better than 5 cm).
• N2O (nitrous oxide) is to be avoided during the procedure if an uncuffed ETT is used. If nitrous oxide is used for induction, then it should be turned off and air substituted (with O2) as soon as possible to maintain the FiO2, to 0.3 or less.
• Normal saline with methylene blue (optional) will be instilled in the cuff. This will serve as an extinguisher and an indication that the cuff has been breached.
  Suction tubing will be placed under the drape when applicable to decrease the potential build up of O2.

“In head and neck procedures, if it’s not a critical area where you’re sterile, we’ll drop the drapes and not even put them on, because it just helps facilitate a fire,” Dennis says. “But for regular cases, the biggest key is to put the ESU tip in the holster, do not wrap it with anything metal that can catch it on fire, make sure the sponges are moist or removed upon activation, and even in that area, we always have water on our back table.”

Dennis also stresses the importance of a clean Bovie tip. “I can’t dictate the practice of the surgeon; obviously they say you should touch tissue and then activate, but you can’t control that in surgery,” she says. “We can control the fact that a clean tip needs to be passed off, because if you have tissue on the tip and the Bovie is activated, the spark will try to jump beyond the tip.”

Dennis explains the concept of active vs. a passive fire safety approach. The passive approach involves minimizing the possibility of fire and fire damage by assessing and adjusting available fuel load. For example, creating flame-spread barriers. The active approach refers to the actual method of extinguishing fires. Water droplet delivery is effective in that expansion to water vapor at the flame origin site reduces oxygen available to the flames. This technique also cools the flames.

“Gwinnett policies seek to help keep down ignition sources for fires in general,” Dennis continues. “You have to document the drying time of your surgical prep, whether or not it’s flammable. It’s standardized by saying there is a three-minute drying time, even though there are companies out there that claim to have no more than a 30-second drying time, because you have so many different types of preps. We also talk about how the electrosurgical device and the laser need to be used at the lowest possible wattage and voltage.

“We also put a fire extinguisher in every OR and removed the fire blankets,” Dennis continues. “Every place that has the possibility of an ignition source being in that room, including endoscopy, which doesn’t use a whole lot of electro-surgery; it’s better to be safe than sorry and there is a fire extinguisher in there. Even something as simple as an eye laser — we just kept it standardized. This was huge for our center to be able to move toward this.”

Lasers

Given the prevalence of lasers in many healthcare environments, a standardized approach to laser safety can be beneficial in preventing adverse events that may occur with laser use, such as fire and thermal injuries, eye injuries, and other biological and electrical hazards. Many facilities designate a laser safety officer (LSO) to be responsible for evaluation, monitoring, and oversight of laser hazards. The LSO may also perform other functions such as selecting appropriate eye protection products and approving laser systems and equipment before they are placed in service and after they are evaluated for electrical hazards.

The Association of periOperative Registered Nurses (AORN)’s Recommended Practices for Laser Safety in Practice Settings describe many measures that should be considered by facilities using lasers.

1. It is suggested that facilities in which laser procedures are performed develop a laser safety program to include:

• Delegation of authority and responsibility for supervising laser safety to a laser safety officer.
• Establishment of use criteria and authorized procedures for all healthcare personnel working in laser nominal hazard zones.
• Identification of laser hazards and appropriate control measures.
• Education of personnel (i.e., operators and others) regarding assessment and control of hazards.
• Management and reporting of accidents or incidents related to laser procedures, including action plans to prevent recurrences.

2. Incidents of safety regulation violation should be reported to the laser safety officer and reviewed by the safety committee.

3. People working in a laser environment should have knowledge of the established laser safety program.⁶

“What was really important for us with lasers is that with our laser log, we took the next step up,” Dennis explains. “In the American National Standards Institute (ANSI) standards, they say that you should have a laser log, but it doesn’t specifically get into much detail, and neither does AORN.” At Gwinnett, an actual laser on/off time for head and neck procedures is noted, which Dennis says is very unusual for most laser logs. “If it’s not a head and neck procedure, it’s not so important to put the on time or off time in there, but for head and neck it needed to be that collaborative communication with anesthesia that the oxygen was off prior to the activation of the laser, and we make sure that’s communicated.”

A laser log should be completed for every laser procedure, whether as a part of the surgical record or as a separate component. If it is a separate notebook kept with the laser, the log forms should be retained for the same amount of time as patient records, as specified by state law.⁷ In addition to the required patient identification information, recommended items to be documented in the laser log include:

• Type of laser
• Model number
• Procedure
• Names of individuals in the room
• Information that protective glasses were offered to and worn by all (or list exceptions)
• Completed laser checklist
• Number of joules used
• Wattage⁸

The laser log can be used for collecting statistics on laser usage, noting deviations from policies and procedures, and documenting the types of procedures and training needs of physicians and staff members. A report to the safety committee outlining any safety concerns and anticipated laser needs is recommended at least every six months.

References:

1. Bruley ME. Surgical fires: perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care. 2004 Dec;13(6):467-71. Review.

2. Electrosurgical airway fires still a hot topic. Health Devices. 1996 Jul;25(7):260-2.

3. Ibid.

4. http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8272 

5. ECRI. A clinician’s guide to surgical fires: how they occur, how to prevent them, how to put them out [guidance article]. Health Devices 2003 Jan; 32(1):5-24.

6. Recommended practices for laser safety in practice settings. AORN J. 2004 Apr;79(4):836-8, 841-4.

7. Andersen K. Safe use of lasers in the operating room-what perioperative nurses should know. AORN J. 2004 Jan;79(1):171-88. Review.

8. American National Standards Institute, Laser Institute of America, American National Standard for Safe Use of Lasers in Health Care Facilities (Orlando, Fla: The Laser Institute of America, 1996).

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