Anesthesia Awareness

Update on Fire Safety Issues in the Operating Room

Haven’t We Been Here Before?

Haven’t We Been Here Before?Anesthesiology: March 1941 - Volume 2 - Issue 2 - ppg 144-160

Armour and Burtnett

Haven’t We Been Here Before?Electrical Burns During Laparoscopy

JAMA1973;226(12):1465

Intraabdominal Fire during Laparoscopic Cholecystectomy

Anesthesiology: October 1995 - Volume 83 - Issue 4 - pp 871-874

Airway Fire during Tracheostomy: Extubation May Be Contraindicated

Anesthesiology: December 1998 - Volume 89 - Issue 6 - p 1576–1578

Renewed Interest or Recurrence of Old Problem

AANA Journal August 2004Vol. 72, No. 4

Practice Advisory for the Prevention and Management of Operating Room Fires ASA Task Force On Operating Room Fires

EducationOR Fire DrillsPreparationPreventionManagement

Inquiring minds want to know.

Operating Room Fire Victim Awarded $1.3 Million in Ohio Medical Malpractice Lawsuit

Mole removed (2006)Trial in April 2009.

Before Post-burn

Woman Accidentally Set On Fire During C-Section

Haaretz newspaper reported. (2008)

OR Fire Occurs in Absence of Oxygen Enriched Environment: A Case ReportAPSF Volume 23, No. 1, Spring 2008

Obese adult patient Femoral distal bypass graft under GETAAlcohol-based solution may have

saturated skin folds over time producing vapors under the drapes.

A sterno-like fire burned the patients' leg after the vapors were exposed to the electrocautery.

Woman Sues Tulsa Doctor For Being Set On Fire During Surgery

NewsOn6-KOTVTulsa, OKMay 29, 2010

Post Accident (12/09) March 2010

Cathy Lake's mother, Catherine Reuter, 74, suffered second- and third-degree burns

Cleveland Clinic reports six operating room fires in past year, three patients injured. 

The Cleveland Plain DealerMay 01, 2010

Dr. Toby Cosgrove, Cleveland Clinic CEO On April 30, officials at the

Cleveland Clinic confirmed that six fires had broken out in Clinic operating rooms in the 12-month period that ended in March.

“Patients suffered ‘superficial burns’ in three of the fires,” they said. "And no one was harmed in the other three.”

Dr. Toby Cosgrove, Cleveland Clinic CEO

“the three injured patients suffered superficial burns that resulted from ignition of flammable skin-preparation or other chemicals used during surgery.

Each of the six fires,” the hospital explained, “was started by an electrocautery device…”

How Are You To Know?

Where’s The Data?

HAC payment provision - July 2008

Foreign Object Retained After Surgery

Air Embolism Blood Incompatibility Stage III and IV Pressure

Ulcers Falls and Trauma

◦ Fractures◦ Dislocations◦ Intracranial Injuries◦ Crushing Injuries◦ Burns◦ Electric Shock

Manifestations of Poor Glycemic Control

Catheter-Associated Urinary Tract Infection         

Vascular Catheter-Associated Infection

Surgical Site Infection◦ Coronary Artery Bypass Graft

(CABG) - Mediastinitis◦ Bariatric Surgery ◦ Orthopedic Procedures

Spine, Neck, Shoulder, Elbow Deep Vein Thrombosis/Pulmonary

Embolism ◦      Total Knee Replacement◦       Hip Replacement

Adverse Events in Hospitals: Public Disclosure of Information About Events Deputy Inspector General for Evaluation and Inspection, March 2008

State Adverse EventAgency for Healthcare Research and Quality(AHRQ)

Patient Safety OrganizationsCMS

Data Collecting Organizations

25 states and DC have reporting systems

72 PSOs

AHRQ creating and will maintain Network of Patient Safety Databases. (2012)

“Smart people learn from their mistakes.

Wise people learn from the mistakes of others. “

Norm Brodsky

APSFVideo

The ChloraPrep Advantage Rapid acting: Rapidly kills microorganisms versus free iodine,

which requires two minutes to begin antimicrobial activity. Persistent: Maintains antimicrobial activity for at least 48

hours compared to two hours for free iodine. Broad spectrum: Effective against microorganisms including

gram-positive and gram-negative bacteria, Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), Clostridium difficile, Acineobacter, and most viruses and fungi.

Active in protein-rich biomaterials: Remains active in the presence of blood, serum and other protein-rich biomaterials unlike traditional iodophors, which are neutralized.

Garcia R, Mulberry G, Brady A, Hibbard JS. Comparison of ChloraPrep and Betadine as preoperative skin preparation antiseptics. Poster presented at: 40th Annual Meeting of the Infectious Disease Society of America; October 25, 2002.

Characteristics of Antiseptics

Reviews in Obstetrics and Gynecology 2009 Fall; 2(4):212-221.

Br J Surg. 1976 Dec;63(12):981-3.Inflammable antiseptics and theatre fires.Briscoe CE, Hill DW, Payne JP

Delivery of Air/Oxygen for MAC

Delivery of Air/Oxygen for MAC

Delivery of Air/Oxygen for MAC

Delivery of Air/Oxygen for MAC

Delivery of Air/Oxygen for MAC

Flow Rates and FiO2

Oxygen Air FiO21 1 0.611 3 0.411 5 0.341 7 0.310.5 3 0.320.3 3 0.28

Prevention Thru Communication

Does potential exist?◦Alcohol-based prep◦FiO2 > 21%

◦ElectrocauterySteps taken to minimize

potential?◦No tenting of drapes◦Air flush or suction

Roles should potential become reality.◦Who does what

References Fires in the Operating Room and Intensive Care Unit: Awareness is the Key to Prevention, Rajnish Prasad,

MD, Zenaide Quezado, MD, Arthur St. Andre, MD, and Naomi P. O’Grady, MD; Anesth Analg 2006;102:172–4.

Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert. Issue 29, June 24, 2003.

ECRI. A clinician’s guide to surgical fires. Health Devices 2003;32:5–24. ECRI. Fires from oxygen use during head and neck surgery. Health Devices 1995;24:155–6. Barker SJ, Polson JS. Fire in the operating room: a case report and laboratory study. Anesth Analg

2001;93:960–5. Briscoe CE, Hill DW, Payne JP. Inflammable antiseptics and theatre fires. Br J Surg 1976;63:981–3. Bruley ME, de Richemond AL. Supplemental oxygen versus latent alcohol vapors as surgical fire

precursors. Anesth Analg 2002;95:1464. Wolf GL, Sidebotham GW, Lazard JL, Charchaflieh JG. Laser ignition of surgical drape materials in air, 50%

oxygen, and 95% oxygen. Anesthesiology 2004;100:1167–71. Aly A, McIlwain M, Duncavage JA. Electrosurgery-induced endotracheal tube ignition during tracheotomy.

Ann Otol Rhinol Laryngol 1991;100:31–3. Macdonald AG. A brief historical review of non-anaesthetic causes of fires and explosions in the operating

room. Br J Anaesth 1994;73:847–56. ECRI. Improper use of alcohol-based skin preps can cause surgical fires. Health Devices 2003;32:441–3. https://www.ecri.org/Press/Pages/Preventing_Surgical_Fires.aspx Department of Health & Human Services. Memorandum Report: Adverse Events in Hospitals: Public

Disclosure of Information about Events. March 12, 2008