April 29, 2008
ASA Practice Advisory on Operating Room Fires
We’ve talked a lot in the last 6 months about fires in hospitals. We had an extensive discussion in our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires, citing all the excellent work done by ECRI on surgical fires. And our January 29, 2008 Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” discussed a fire in a neonatal nursery incubator in Minnesota and the ongoing investigation into the causes, with further cases discussed in the April 2008 What’s New in the Patient Safety World column.
Now the American Society of Anesthesiologists has issued a timely release of a Practice Advisory for the Prevention and Management of Operating Room Fires. While it reiterates many of the important principles noted in our previous discussions, there are many good new recommendations that every facility should consider.
It stresses that all anesthesiologists (the intended audience, though it obviously should apply to everyone who works in an operating room or other facility area at risk for fires) should have fire safety education, specifically for OR fires, with an emphasis on the reisk created by an oxidizer-enriched atmosphere. OR fire drills should take place with the entire OR team. Very importantly, the advisory recommends that for each case, the OR team should formally (1) determine whether or not a high-risk situation exists and (2) have team discussion about strategy for prevention and management of a fire. And a protocol for prevention and management of fires should be placed visibly in each location where surgery/procedures might be done, along with all appropriate equipment for managing a fire. Each member of the team should be assigned a task and understand they should perform that task immediately without waiting for other team members to act. (Once they have completed their task, they can help other team members with other tasks). Though there is no evidence base to confirm that such a pre-case team discussion actually prevents or helps manage fires, it’s certainly good common sense. For those of you who like checklists, it’s a good item to add to your preoperative checklist.
The discussion on prevention of fires is excellent, with many practical tips. They discuss replacing oxygen with compressed air or discontinuing supplemental oxygen for a period of time (as tolerated and monitored by pulse oximetry). They discuss proper configuration of surgical drapes to avoid accumulation of oxygen and stress adequate drying time when alcohol-based skin preps are used. And sponges, gauze or other cottonoids used should be moistened when being used near an ignition source or near an oxygen-enriched area such as the airway. Scavenging the operating field with suction may help avoid buildup of oxygen (or nitrous oxide).
They discuss use of laser-resistant tracheal tubes (matching the tube type to the laser type) and note that the tracheal tube cuff should be filled with saline rather than air. The saline could also be tinted with methylene blue to help identify laser punctures. They also discuss the type of oxygen delivery system that should be used, based on the required depth of sedation and oxygen dependence.
Coordination between the anesthesiologist and surgeon are critical when it comes to using lasers, electrocautery tools, electrosurgical tools, or other potential sources of ignition. The surgeon should give adequate notice that he/she is about to use such a device and then adequate time should be allowed to elapse to allow the anesthesiologist to take steps to minimize the oxygen in the area.
Their discussion on management of an actual fire is a good one. They emphasize early recognition and that the early signs of a fire may not just be a flame or flash but might include unusual sounds (eg. “pop”, “snap”, or “foomp”), odors, smoke, heat, unexpected movement of the drapes or patient, or discoloration of the drapes or breathing apparatus. When a fire is determined, the fire should immediately be announced, the procedure halted, and fire management tasks should be begun. Each team member should do their assigned task as quickly as possible, not waiting if another team member has not been able to do their task in a predetermined order. The specific tasks are outlined in the document and depend on whether the fire is in the airway or breathing circuit or elsewhere on the patient. They discuss assessment and management of the patient after a fire and discuss more general fire responses as well.
The advisory is very well-referenced and levels of evidence are graded. They do provide a nice algorithm on operating room fires. It can be used as an educational tool and as part of the preoperative procedure, but it does not look like it would be of much use emergently during a fire.
This is another excellent tool. Well-coordinated teamwork is critical in the education about, preparation for, planning for and response to surgical fires.
American Society of Anesthesiologists Task Force on Operating Room Fires. Practice Advisory for the Prevention and Management of Operating Room Fires. Anesthesiology 2008; 108: 786-801 http://www.asahq.org/publicationsAndServices/orFiresPA.pdf