A 60-70-year-old ASA Physical Status 4 woman with a BMI of 36.9 and past medical history significant for coronary artery disease (CAD), status post-myocardial infarction (MI) and coronary artery bypass graft (CABG), congestive heart failure (CHF), asthma, chronic obstructive pulmonary disease (COPD), chronic and current smoking, diabetes mellitus (DM), obstructive sleep apnea (OSA), and hypothyroidism was scheduled for a temporal artery biopsy for severe headaches. Monitored anesthesia care (MAC) was planned. ASA standard monitors were placed. The anesthesiologist was supervising multiple rooms. Oxygen was administered at 12 L/min by non-rebreathing face mask. The patient was sedated with a propofol bolus and propofol infusion (at unknown concentrations). The patient’s face was draped, the surgeon made an incision and started to cauterize the incision. The anesthesiologist reentered the room at the same time that a spark was observed under the drapes. Unfortunately, the potential for a patient fire was not discussed between the anesthesia providers and the surgeon or other individuals in the room. The anesthesiologist rushed to turn off the oxygen, the surgeon removed the drapes, which had caught on fire, and the facemask was removed. The fire was extinguished with water. The patient was intubated, and general anesthesia was administered with sevoflurane, fentanyl and propofol (unknown doses). The procedure was completed, and bacitracin was administered to burns on the patient’s face. After the conclusion of the procedure, the patient was transferred to the intensive care unit. The patient underwent a bronchoscopy that indicated she did not have airway burns. She suffered 5% total body surface area second-degree burns of face, ear, neck, shoulder, and upper chest. The following day she was transferred to the burn center at a university medical center. On admission to the burn center, her eyes, mouth, and nose were noted to be swollen, and her left eye was completely closed. She remained intubated and received propofol and fentanyl infusions for sedation. She was evaluated by an ophthalmologist who documented that she had singed eyelashes bilaterally and had partial thickness burns on her left upper and lower eyelid. There was no sign of corneal abrasion or ocular injury. The patient was extubated on the second postoperative day (POD) and was discharged on the fourth POD. The patient healed well with no evidence of permanent damage to her skin, eyes, or airway.

Figure: Operating Room Fires Algorithm (Anesthesiology 2013;118:271-90)

Figure: Operating Room Fires Algorithm (Anesthesiology 2013;118:271-90)

In 2009, OR fires were ranked number 3 in the top 10 technology hazards by the Emergency Care Research Institute, or ECRI, a nonprofit research group that investigates procedures, medical devices, and medications to determine the processes and products that provide the best patient outcomes (asamonitor.pub/4aTopiz). While the incidence of OR fires has decreased significantly over the past decade, these fires remain a potentially devastating patient safety threat (asamonitor.pub/4aTorab). OR fires traditionally require three components, known as the “fire triad”: 1) an oxidizer, 2) an ignition source, and 3) fuel (Anesthesiology 2008;108:786-01). Recognizing the potential risk of fire in the OR, preventing it, and managing a fire should one occur is a multifactorial process involving education, communication, and teamwork. The Anesthesia Patient Safety Foundation (APSF) created an important and helpful training video that can assist with education and prevention of OR fires (asamonitor.pub/3UgXl7m). ASA has published guidelines for the prevention and management of OR fires, and the APSF conducted a further review that provides the following recommendations (Anesthesiology 2013;118:271-90; asamonitor.pub/43YbTvT):

  • Anesthesiologists should participate in fire safety education for the OR that includes information about institutional fire safety protocols as well as information about procedures and conditions that increase fire risk.
  • Preparation to avoid OR fires: determining whether the situation is high-risk and discussing the strategy to prevent and manage an OR fire with the full team in the OR.
  • Prevention of OR fires: minimizing or avoiding an oxidizer-enriched atmosphere near the surgical site and managing ignition sources and fuels; limiting oxygen use for the patient, using room air when possible, and maintaining oxygen below 30% using a blender.
  • Management of OR fires: recognizing the early signs of fire, stopping the procedure in the event of a fire, making appropriate attempts to extinguish the fire, following an evacuation protocol and emergency checklist (Stanford Anesthesia Cognitive Aid Program, Emergency Manual: Cognitive aids for perioperative crises) when medically appropriate, and delivering postfire care to the patient.

There were numerous procedural and systems factors in the case under review. There was a failure to address the significant risk of fire in this procedure, particularly in the mode of oxygen delivery via non-rebreathing mask during the use of electrocautery. The anesthesiologist and surgeon should discuss the patient’s history and planned procedure to determine whether there is a high risk for fire. If so, they should discuss the procedure and the plan for fire prevention and for managing one should it occur (Anesthesiology 2013;118:271-90). In this case, it appeared there was little communication between the surgeon and the anesthesiologist about the risk, there was little coordination, and they failed to document their efforts to prevent the fire. They also failed to conduct and document that they and the OR team had conducted a fire safety briefing and timeout. Importantly, they failed to document any effort to minimize the amount of oxygen administered to the patient, particularly at the time electrocautery was used, and at that point in time to coordinate with the surgeon.

In addition to failing to prepare for the potential risks of fire for this procedure, the OR team also failed to properly manage the fire when it occurred. The patient should have been appropriately draped to minimize the collection of oxygen under the drapes, and fluids should have been immediately available to douse any fire that occurred.

While anesthesia malpractice filings related to OR fires have been decreasing over the past decade, this is a catastrophic complication that often results in severe and disfiguring injuries, but that can be prevented with minimal cost and effort. As such, these cases almost certainly result in payouts on behalf of the anesthesiologist, as these fires should be “never” events. It would be nearly impossible to demonstrate that the proximate cause(s) represented standard of care on the part of the anesthesia care team. In a 2013, review of surgical fires in the AQI Closed Claims Database revealed that, unfortunately, the circumstances surrounding these cases have remained unchanged over time; it is usually the use of open delivery of oxygen via nasal cannula or face mask, coupled with the use of a monopolar electrical surgical device within the area of the head and neck. Most claims occur in outpatient settings, involve the upper body (85%), and utilize MAC (81%) (Anesthesiology 2013;118:1133-9).

This review has focused on identifying the risk of OR fires and preventing them; however, when a fire does occur, there should be appropriate approaches, checklists, and equipment to properly treat and rescue the patient (Anesthesiology 2013;118:1133-9). Careful attention to the principles of fire prevention and management outlined in the referenced ASA guidelines are important steps to preventing this devastating complication.

Case files prepared by the AQI-Closed Claims Steering Committee are derived from the Closed Claims Project Registry and intended to offer learning opportunities from the potential rare and serious consequences encountered. Multiple clinical decisions and medicolegal issues may be relevant, only some of which can be discussed in the space available and may evolve with time. Absence of commentary should not be construed as agreement with the clinical decisions described, and the conclusions and recommendations of the authors should not be construed as ASA policy, endorsement of a local standard of care, or legal advice. More information on the Closed Claims Project is available at aqihq.org.

This entry was written by Amanda Burden, MD, FASA, FSSH, Assistant Dean for Clinical Skills and Simulation, Cooper University Healthcare, on behalf of the Closed Claims Oversight Committee.