1. Operating Room Safety Fires Grand Rounds Presentation June 18, 2009 John Chi, MD Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

2. UCLA Medical Center, 1990

3. 26 year-old female struck by auto Blunt injuries to abdomen, chest Endotracheal intubation Emergency surgery

4. OR Fire Surgery completed

5. OR Fire Surgery completed Drapes ignited by cautery device

6. OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient

7. OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate

8. OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate OR sprinkler system does not activate

9. OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate OR sprinkler system does not activate Fire Department arrives and controls fire

10. Outcome Patient expires in the fire Operating room staff treated for minor burns and smoke inhalation

11. Safety “If you don't know what is going to happen, there is no way to stop it.”

12. OR Fires Introduction Causes Outcomes Prevention

13. Epidemiology >30,000,000 surgeries per year >2,000 reported hospital fires 30 reported OR fires Source: American College of Surgeons,1997.

14. Locations of Fires Source: Tyco Healthcare Valleylab 2006.

15. Locations of Fires ~ 65% of fires occur in the Head & Neck region because of the O 2 rich environment Source: ECRI. Devastation of patient fires. Health devices. 1992.

16. OR Fires Introduction Causes Outcomes Prevention

17. Requirements for Fire Oxidizer + Fuel + Ignition = FIRE

18. Oxidizers

19. Oxygen

20. Oxidizers Oxygen –Oxygen is denser than air 1.308 g/L O 2 > 1.251 g/L N 2

21. Oxidizers Oxygen –Oxygen is denser than air 1.308 g/L O 2 > 1.251 g/L N 2 –Collects in low-lying areas

22. Oxidizers Oxygen –Oxygen is denser than air 1.308 g/L O 2 > 1.251 g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics

23. Oxidizers Oxygen –Oxygen is denser than air 1.308 g/L O 2 > 1.251 g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics Nitrous oxide

24. Oxidizers Oxygen –Oxygen is denser than air 1.308 g/L O 2 > 1.251 g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics Nitrous oxide –Releases oxygen when heat is applied

25. OR Fuels Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

26. OR Fuels Patient Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

27. OR Fuels Patient Prepping agents Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

28. OR Fuels Patient Prepping agents Ointments Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

29. OR Fuels Patient Prepping agents Ointments Linens Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

30. OR Fuels Patient Prepping agents Ointments Linens Equipment Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

31. OR Fuels - Patient Hair Surgical cap Gown GI tract gases

32. OR Fuels – Prepping Agents Alcohol Chlorhexidine Acetone Betadine

33. Betadine??

34. Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

35. Betadine?? Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

36. Betadine

37. Flammability of the Product: May be combustible at high temperature.

38. Glycerin

39. Flammability of the Product: May be combustible at high temperature.

40. OR Fuels - Ointments Petrolatum Benzoin Paraffin Aerosols

41. OR Fuels - Linens Drapes Dressings, sponges Surgical gowns, masks, caps Mattresses Sheets, blankets Egg crates

42. OR Fuels - Equipment Flexible endoscopes ECG wires Blood pressure cuff Tubing Gloves Anesthesia machine

43. Flammability Standards OR equipment OR supplies OR gowns, masks, caps Anesthetics Source: Sommers JR. Flammability standards. SSM 1998;2:41-4.

44. Requirements for Fire Oxidizer + Fuel + Ignition = FIRE

45. OR Fire Survey Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

46. OR Fire Survey 8,523 questionnaires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

47. OR Fire Survey 8,523 questionnaires 349 respondents Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

48. OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

49. OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

50. OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires 2 respondents = 5 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

51. Fire Scenarios 27% Endoscopic Airway Surgery 24% Oropharyngeal Electrocautery Surgery 23% Electrocautery Surgery under MAC 18% Tracheotomy 7% Endoscopic Light Cables 1% Anesthesia Machine

52. Endoscopic Airway Surgery

53. OXIDIZER: –Oxygen –Nitrous Oxide

54. Endoscopic Airway Surgery OXIDIZER: –Oxygen –Nitrous Oxide FUEL: –ET Tube, LASER ET Tube –Flexible Bronchoscope, Drapes

55. Endoscopic Airway Surgery OXIDIZER: –Oxygen –Nitrous Oxide FUEL: –ET Tube, LASER ET Tube –Flexible Bronchoscope, Drapes IGNITION: –LASER - CO 2 more often than KTP

56. Laser Ignition of Drapes Source: Wolf et al, 2004.

57. Laser Ignition of Drapes Surgical drapes tested for time to ignition Source: Wolf et al, 2004.

58. Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec Source: Wolf et al, 2004.

59. Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec 21% O 2 50% O 2 95% O 2 Source: Wolf et al, 2004.

60. Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec 21% O 2 50% O 2 95% O 2 Primary ignition – drapes Secondary ignition – drapes on filter paper Source: Wolf et al, 2004.

61. Drapes Tested Nonwoven cellulose/polyester blend Polypropylene Reusable woven cotton/polyester blend Huck cotton towel drape adjunct Phenol polymer

62. Time to Primary Ignition 21% MaterialIgnited / TestedTTI Phenol polymer0 / 10N/A Polypropylene0 / 10N/A Huck towel8 / 1011.9 sec Cotton-poly10 / 104.0 sec Cellulose-poly10 / 102.7 sec

63. Time to Primary Ignition 50% MaterialIgnited / TestedTTI Phenol polymer10 / 104.9 s Polypropylene9 / 100.14 s Huck towel10 / 102.3 s Cotton-poly10 / 101.1 s Cellulose-poly10 / 10< 0.1 s

64. Time to Primary Ignition 95% MaterialIgnited / TestedTTI Phenol polymer10 / 100.68 s Polypropylene10 / 100.18 s Huck towel10 / 10< 0.1 s Cotton-poly10 / 100.65 s Cellulose-poly10 / 10< 0.1 s

65. Time to Secondary Ignition 21% MaterialIgnited / TestedTTI Polypropylene & Filter Paper 10 / 104.7 s Filter Paper alone 10 / 105.2 s Filter paper was placed beneath the test material.

66. Laser Study Conclusions Time to ignition decreases with increasing O 2 concentration Polypropylene assumes the ignition characteristics of materials it contacts

67. Oropharyngeal Electrocautery

68. OXIDIZER: –Oxygen

69. Oropharyngeal Electrocautery OXIDIZER: –Oxygen FUEL: –ET Tube– Bovie Tip –Tonsil Sponge– Red Rubber Catheter

70. Oropharyngeal Electrocautery OXIDIZER: –Oxygen FUEL: –ET Tube– Bovie Tip –Tonsil Sponge– Red Rubber Catheter IGNITION: –Monopolar Electrocautery

71. Fire risk: Monopolar v. Coblator Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

72. Fire risk: Monopolar v. Coblator Monopolar –Coagulate: 15 W Coblator –Ablate: 9, 7, 3 –Coagulate: 5, 3 Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

73. Fire risk: Monopolar v. Coblator Degutted raw chicken 6.0 ET Tube 100% oxygen at 10 L/min 3 tonsil sponges Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

74. OP Fire Study Setup

75. Monopolar Electrocautery

76. After 45–55 secs of Monopolar

78. After the fire

79. Coblator Electrocautery

80. After 4 minutes of Coblator

82. After 20 minutes of Coblator

84. Back to Monopolar for 25 secs

86. OP Fire Study Conclusions Monopolar Electrocautery (>15 W) poses a fire risk Coblator Electrocautery did not produce fires

87. Electrocautery Surgery (MAC)

88. OXIDIZER : –Oxygen

89. Electrocautery Surgery (MAC) OXIDIZER : –Oxygen FUEL : –Flash Fire– Drapes –EtOH Prep– Sponges

90. Electrocautery Surgery (MAC) OXIDIZER: –Oxygen FUEL: –Flash Fire– Drapes –EtOH Prep– Sponges IGNITION: –Monopolar Electrocautery– LASER –Thermocautery –Oxidizer to ignition source <5cm

91. Arizona Medical Center,1998

92. 73 year-old male with SDH for bilateral burr holes Oxygen via face mask at 6 L/min Iodofor surgical prep –(0.7% iodine, 74% Isopropyl EtOH) Drapes: Towels, Paper surgical drapes Monopolar Electrocautery

93. OR Fire

94. “Pop”

95. OR Fire “Pop” Smoke appears from beneath the drapes

96. OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed

97. OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head

98. OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire

99. OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire Fire smothered with drapes

100. OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire Fire smothered with drapes Oxygen flow turned off

101. Outcome Intubation 2 nd degree burns of face, neck ICU x 2 months Pneumonia, Respiratory Failure Inpatient rehabilitation

102. Simulated OR Fire

103. Life size manikin Oxygen supplied via face mask Positioned, prepped, and draped Monopolar electrocautery

104. Simulation Setup

105. Monopolar Electrocautery- POP

106. Smoke – POP + 5 seconds

107. Fire – POP + 13 seconds

108. Fire – POP + 24 seconds

109. Beneath the drapes

113. Simulation Fire Requirements Source: Barker SJ, Polson SJ, 2001.

114. Simulation Fire Requirements Supplemental oxygen Source: Barker SJ, Polson SJ, 2001.

115. Simulation Fire Requirements Supplemental oxygen Closed space formed by drapes (Tenting) Source: Barker SJ, Polson SJ, 2001.

116. Simulation Fire Requirements Supplemental oxygen Closed space formed by drapes (Tenting) Alcohol-based preparation solution –Manufacturer’s label drying time 2-3 minutes –Drying time > 5 minutes  No fire Source: Barker SJ, Polson SJ, 2001.

117. Oxygen Face Masks

118. Melt when exposed to open flame

119. Oxygen Face Masks Melt when exposed to open flame Do NOT burn without oxygen flow

120. Oxygen Face Masks Melt when exposed to open flame Do NOT burn without oxygen flow Ignite, burn with oxygen flow > 3 L/min

121. Tracheotomy

122. OXIDIZER: –Oxygen

123. Tracheotomy OXIDIZER: –Oxygen FUEL: –Flash Fire, ET Tube, Drape, Airway

124. Tracheotomy OXIDIZER: –Oxygen FUEL: –Flash Fire, ET Tube, Drape, Airway IGNITION: –Monopolar electrocautery Electrocautery to enter trachea Electrocautery after airway incision

125. Endoscopic Surgery

126. OXIDIZER : –Oxygen

127. Endoscopic Surgery OXIDIZER: –Oxygen FUEL: –Drapes Cellulose-based: IGNITE Polypropylene-based: MELT

128. Endoscopic Surgery OXIDIZER: –Oxygen FUEL: –Drapes Cellulose-based: IGNITE Polypropylene-based: MELT IGNITION: –Endoscopic Light Cable –Temperature > 200º Celcius

131. OR Fires Introduction Causes Outcomes Prevention

132. Outcomes

133. Analysis of Closed Claims Source: Bhananker et al, 2006.

134. Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies Source: Bhananker et al, 2006.

135. Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies 121 MAC-related claims reviewed 20 OR fires leading to burns Source: Bhananker et al, 2006.

136. OR Fires 95% involved head, neck, face

137. OR Fires 95% involved head, neck, face 50% cited for substandard care

138. OR Fires 95% involved head, neck, face 50% cited for substandard care 89% resulted in payment to plaintiff –Median $71,375 –Range $8,175 to $321,323

139. OR Fires Introduction Causes Outcomes Prevention

141. Communication with OR Staff, Anesthesia

142. Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk

143. Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers

144. Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2

145. Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2 Prep Solutions – proceed with caution

146. Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2 Prep Solutions – proceed with caution Fire Safety Training

147. Summary

148. OR fires are preventable

149. Summary OR fires are preventable Be aware of your surroundings

150. Summary OR fires are preventable Be aware of your surroundings Oxidizer + Fuel + Ignition = FIRE

151. Thank You Lee Smith, MD James Kearney, MD Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870