Surgical Fire Prevention and Operating Room Extinguisher Recommendations

Surgical fires, though rare, can have devastating consequences for patients, staff, and the healthcare facility as a whole. Adverse outcomes for patients can be both physical and psychological. The physical ones include burns, inhalation injuries, infection, disfigurement and death. Psychological trauma, prolonged hospitalization, delay or cancellation of surgery may also occur. Surgical fires that ignite in or around a patient during surgery continue to be a real danger, and are especially devastating if open oxygen sources are present during surgery of the head, face, neck, and upper chest. Fortunately, surgical fires are rare and they occur in only an extremely small percentage of the approximately 65 million surgical cases each year. Extrapolating from data published by the Pennsylvania Patient Safety Authority in 2007, approximately 550 to 650 surgical fires occur nationally each year, making the frequency of their occurrence comparable to that of other surgical mishaps (e.g., wrong-site surgery or retained instruments). It is important to know how such fires can be prevented—and how to handle them if they occur. Through awareness of the hazards—and with an emphasis on following safe practices—virtually all surgical fires can be prevented.


In a Practice Advisory for the Prevention and Management of Operating Room Fires, an updated report from the 2007/2008 edition of the American Society of Anesthesiologists (ASA), new evidence from scientific literature was presented, but the new findings did not necessitate a change in recommendations. The specific care setting is any operating room (OR) or procedure area where anesthesia care is provided.


OR fires are defined as fires that occur on or near patients who are under anesthesia care, including surgical fires, airway fires and fires within the airway circuit. Fire requires the presence of three components: (1) an oxidizer, (2) an ignition source, and (3) fuel. Oxidizers used in the OR are oxygen and nitrous oxide. An oxidizer-enriched atmosphere commonly exists within closed or semi-closed breathing systems including the patient’s airway. It can also be created locally when the configuration of the drapes and open oxygen sources (masks, nasal cannulas) promote the trapping or pooling of oxygen or nitrous oxide. Ignition sources include electrosurgical or electrocautery devices, lasers, heated probes, drills and burrs, argon beam coagulators, fiberoptic light cables and defibrillator paddles. Fuel sources include tracheal tubes, sponges, drapes, gauze, alcohol-containing solutions, other volatile compounds such as ether or acetone, oxygen masks, nasal cannulae, the patient’s hair, dressings, gowns, blankets, suction catheters, fiberoptic cable coverings, gloves and packaging materials.


High risk procedures are ones in which an ignition source (electrosurgery) can come in proximity to an oxidizer-enriched atmosphere (oxygen or nitrous oxide). These could be tonsillectomy, tracheostomy, removal of laryngeal papillomas, cataract or other eye surgery, burr hole surgery, or removal of lesions on the head, neck or face.


The consultants and ASA members strongly agree that every anesthesiologist should have knowledge of institutional fire safety protocols for the OR and should participate in OR fire safety education which should emphasize the risk created by an oxidizer-enriched atmosphere. Studies indicate that OR fire drills and simulation training can result in improved staff response to a fire.


For every case, the anesthesiologist should participate with the entire OR team in determining whether a high-risk situation exists. If it does, all team members should take a joint and active role in agreeing on how a fire will be prevented and managed. Each team member should be assigned a specific fire management task to perform in the event of a fire (e.g., removing the trach tube, stopping the flow of airway gases, getting the CO2 fire extinguisher from the wall). These tasks are performed immediately without waiting for another team member to take action.


Communication between the anesthesiologist and surgeon is critical. Studies indicate that an OR fire occurred during oxygen administration by mask when the anesthesiologist was not informed of the impending use of electrocautery. Surgeons should be advised not to enter the trachea with an ignition source such as an electrosurgical device. If it must be used, the anesthesiologist should request that the surgeon provide adequate warning to allow the concentration of oxidizer to be minimized before the trachea is entered.


For all procedures the consultants and ASA members strongly agree that flammable skin-prepping solutions should be dry before draping, that surgical drapes be configured to prevent oxygen from accumulating under the drapes or from flowing into the surgical site, and that sponges should be moistened when used near an ignition source especially near the airway.


For laser surgery, it is recommended that laser resistant tracheal tubes be used and that the tracheal cuff of the laser tube be filled with saline rather than air. If the saline is tinted with methylene blue, it acts as a marker for cuff puncture by the laser.


The Emergency Care Research Institute has recommended carbon dioxide (CO2) extinguishers for use in the OR for more than twenty years. This recommendation is supported by the ASA and Anesthesia Patient Safety Foundation (APSF). The recommendation has also been published in the June 2006 issue of AORN Journal from the Association of peri-Operative Registered Nurses.


For fires on the patient in the OR, an extinguisher should be safe during external and internal exposure for the patient. CO2 readily dissipates, is not toxic, and is not likely to result in thermal injury when used in an actual fire. This is due to two reasons, which are not readily apparent until you actually use a CO2 extinguisher in a fire. The first is the delivery of CO2 is self-limited because the lever and the handle become so cold, the user can actually experience frostbite. The other is the heat of the fire, which keeps you far enough away from the fire source so that thermal injury is unlikely. Since the patient's tissues would be hot (130 degrees) for a burn injury, a cold injury from application of CO2 would also be unlikely.


A fire extinguisher is one of those pieces of equipment that operating room personnel seldom think about until needed or asked about during an inspection or site visit. Choosing the correct extinguisher type for a specific fire or for purchasing can be made simple by reviewing a few basic concepts. Operating room fires occur in three possible locations: 1) in the airway, 2) fires in, on, or around the patient, and 3) fires elsewhere in the operating room. Carbon dioxide (CO2) extinguishers are very effective for the first two types of fires.


Fires not specifically on the patient are handled differently depending upon the presence of sprinkler or suppression systems and approaches to suppression are usually comprehensive taking into account all situations even those occurring outside of patient care. Management of the third type usually varies per state or municipality, and is best left to the direction of local fire codes and National Fire Protection Agency (NFPA) codes. What has worked well at one institution is a CO2 extinguisher, mounted in a consistent location (i.e., near the main door and on the left) in every OR and with the laser cart, an A rated extinguisher in the hall cabinets, an AC rated water mist for the MRI suite, and a Halon and CO2 in the fire hose cabinets.


See the FDA Report on Preventing Surgical Fires


See the Emergency Care Research Institute Report


See the Anesthesia Patient Safety Foundation Report


See the American Society of Anesthesiologists Report


See also Medical Law Perspectives, August 2012 Report: Anesthesiology Errors: Complications, Malpractice, and Catastrophe