11 These issues with edema result from changes in Starling forces, starting with decreased interstitial hydrostatic pressure in the burned tissue. Unfortunately, a significant amount of humoral mediators (cytokines, prostaglandins, oxygen free radicals, histamine, complement) are released that can cause vasoconstriction, vasodilation, increased capillary permeability, and edema locally as well as in distant organs. 10 Skin is an effective barrier in the case of surgical fires, most of the initial damage is confined to epidermis and dermis. This thermal energy may cause irreversible tissue damage by denaturing and coagulating proteins. The initial response primarily results from the direct transfer of energy to the tissues. Patient burns cause an immediate response to the involved tissues, which is seen as a coagulative necrosis, with the degree of involvement depending on the temperature to which the skin is exposed and the duration of the exposure. The importance of timely management during intraoperative fires cannot be overstressed. If this cannot be done, the device may need to be extinguished in the room. The first step is to safely unplug the equipment and remove it from the OR. In fires that occur in the room but do not involve the patient, electrical equipment is usually involved. Then switch to 100% oxygen for the patient. Reintubate and ventilate the patient with medical air until no smoldering materials remain. Also remove any residually burning items, and pour saline or water into the airway. At the first sign of a fire, discontinue all gases and remove the endotracheal tube. Airway fires are handled differently than other OR fires. This type of fire accounts for 1 to 2 deaths annually in the United States. 9Īnother type of common fire occurs in the patient's airway. Patting a fire will only encourage the flames to spread. If saline is not available, another technique involves using moist surgical towels draped across the operator's forearms to smother the flames, with a sweeping motion away from the patient's airway. 3 Commonly, drapes are waterproof thus, the saline must hit all inflamed areas. Certain items identified in Table 3 should be immediately available in the OR to extinguish a fire. The surgeon typically recognizes the fire first and thus is involved in extinguishing and removing the fire, primarily by dousing the area with saline. If the fire is not controlled quickly, then evacuation from the room, notification using the facility's fire detection equipment (such as visual and audible alarms, the emergency operator, and the OR desk), and immediate notification of the fire department should occur. Once the fire is controlled, care for the patient should resume, and further management should be based on the degree of danger from smoke in the area. All gases (specifically oxygen and nitrous oxide) should be discontinued immediately. Another team member may need to use a CO 2 extinguisher to put out the fire. If the fire occurs on the patient, the first priority is extinguishing the flames and/or removing the burning material from the patient. OR fires may be subdivided into (1) fires occurring on the patient and (2) fires occurring in the OR environment. However, in OR fires this sequence may not be appropriate depending on the type of fire. In non-OR fires, the RACE acronym is a reminder for practitioners to rescue, alarm, confine, and extinguish fires. 4 Following this closure, all OR employees had to take a course on surgical fire prevention (with a focus on those involving alcohol-based cleaning solutions) now all personnel involved in surgery undergo monthly fire drills. Fortunately, only 3 of these cases involved patients. 3 Within the past year, the Centers for Medicare & Medicaid Services shut down surgical operations at the Cleveland Clinic because of 6 fires that occurred in operating suites. Supplemental oxygen was also present in most cases. The most common sites of fires were the head, face, neck, and upper chest. 2 Surgical fires involved electrosurgical equipment 68% of the time. 2 Researchers estimated that surgical fires occur between 550 and 650 times in the United States annually, making them as common as wrong-sided surgeries. 1 A 2009 edition of ECRI's Health Devices guide listed the top 10 technology hazards, with surgical fires ranked as number 3. The Emergency Care Research Institute (ECRI) is a nonprofit research group that investigates procedures, medical devices, and medications to determine the processes and products that provide the best patient outcomes.
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