AAOS Now

Published 10/1/2012
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Terry Stanton

Banning the Flames

Academy partners with FDA, other organizations, to prevent surgical fires

People know that things can go wrong in the operating room. But most would probably not name fire as a potential hazard, especially fire burning on or near a patient. Yet such fires occur approximately 550 to 650 times a year, according to the Food and Drug Administration (FDA) and the ECRI Institute (formerly the Emergency Care Research Institute). Since 2011, the FDA, along with the AAOS and about two dozen other partners, has stepped up efforts to increase awareness of surgical fires and to promote safe practices to prevent them.

In August, the FDA presented its Group Recognition Award to the AAOS, recognizing the Academy’s contributions to the FDA’s Preventing Surgical Fires Initiative. Calin S. Moucha, MD, who, as a member and then the interim chairman of the Patient Safety Committee, spearheaded the Academy’s role in helping to launch the initiative in 2011, received special recognition.

“The number of fires is not particularly high, but if it happens to you and it leads to death, it is devastating,” said Dr. Moucha, associate chief of joint replacement surgery at Mount Sinai Medical Center in New York.

Dr. Moucha’s awareness of the hazard became acute after his own encounter with a surgical fire. The fire occurred when an alcohol-based skin preparation pooled on a patient and was accidentally ignited. “Fortunately it was a small fire,” he said. “We had saline right there and put it out. There was no injury. But it was scary.

“Before I saw it happen,” he continued, “I didn’t really think about it. We as surgeons have so many things to think about, such as preventing complications. We’re concentrating on doing the correct operation, on the correct side of the correct patient while minimizing complications like infections. For most of us, fires are not really on our radar screens. We have to be aware that fires can occur and know how to prevent them.”

Plan for prevention
Consideration of fire potential should be part of the surgical planning process, Dr. Moucha said. “While we are going through the universal checklist, we probably don’t notice the risk of a surgical fire. I know it doesn’t seem like a high priority, and we probably don’t have to think about it in every case, but if the elements are present for a higher risk, we should be thinking about what could happen and how we should react.”

The FDA notes that surgical fires may occur any time all three members of the fire triangle are present:

  • Ignition source (eg, electrocautery devices, lasers, fiber optic light sources, sparks from a motor or friction)
  • Fuel source (eg, surgical drapes, alcohol-based skin preparation agents, the patient)
  • Oxydizer (eg, supplemental oxygen, nitrous oxide, room air)

Supplemental oxygen is the primary factor in elevating risk of fire, especially for procedures in proximity to the mouth and nose, such as cervical spine surgery, and especially if high oxygen concentrations are used. “Use the minimum concentration,” Dr. Moucha advised. “If high concentrations are needed, a closed oxygen delivery system, like an endotracheal tube, should probably be used.” He also recommended using incise or fenestrated drapes, and the FDA suggests using oxygen absorbers or blowing air to wash out excess oxygen.

The other most significant fuel source to manage is alcohol-based skin solutions applied on the patient. They are at risk of ignition when they pool on the skin—as in the navel or elsewhere—or in skin folds.

“The data show that alcohol-based skin preps are the best for killing microorganisms,” Dr. Moucha said. “But the flip side is that they are flammable. You need to allow sufficient drying time, especially for skin folds or particularly hairy areas.” He noted that electrocautery devices are a prime potential ignition source in orthopaedic surgery and said they should always be put in a holster when not in use. Tools such as saws and burrs may also spark fires, he said.

The FDA advises removal of alcohol-soaked materials prior to surgery, and Dr. Moucha said care should be taken to avoid soaking any draping in alcohol. “Even though the drapes are ‘flame resistant,’ they can lead to a fire, especially if they are in a pool of the alcohol-based prep.”

One potential risk, not covered in the FDA’s prevention guidelines, that Dr. Moucha said he has observed may arise in patients with metal-on-metal (MoM) hip replacements. “Sometimes sparks can occur in MoM hips,” he said. “In revision surgeries, metallosis and metal debris may be present. Using the electrocautery may actually generate some sparks. It can be quite dramatic.”

Toward safer surgery
The FDA says that its Prevent Surgical Fires Initiative has been highly successful, with more than 12,000 subscribers. More than 48,000 viewers have watched a 5-minute video on how surgical fires start and how to prevent them. The comprehensive website (
www.fda.gov/preventingsurgicalfires) has been accessed 200,000 times.

Dr. Moucha, who received a certificate for his contribution, said the Initiative is ongoing, with conference calls for participants throughout the year. “This is about education, to make clinicians aware that operating room fires can happen. Just because it’s never happened to you doesn’t mean it’s not going to happen. In the coming years, I’m sure the collaborative efforts of anesthesia, nursing, and surgical groups will make a difference.

He adds, “The FDA also wants healthcare professionals to report surgical fires through the Medwatch adverse event reporting program (www.fda.gov/medwatch). That’s the only way we can learn more about how to prevent them.”

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Approximately 550 to 650 surgical fires occur each year.
  • The primary fuel sources for fires are supplemental oxygen and alcohol-based skin prep solutions, along with drapes.
  • Preventive measures include isolation and control of flowing supplemental oxygen, avoiding skin prep pooling, and safe use of potential ignition sources such as electrocautery devices.
  • The Academy is a partner in the FDA’s Surgical Fires Initiative; a comprehensive source of information is available at www.fda.gov/preventingsurgicalfires