Fire in the Operating Room

Abstract

 A 72 year-old man was scheduled for aortic valve replacement surgery for aortic stenosis and regurgitation complicated by infective endocarditis. The operation lasted longer than scheduled and was not uneventful due to second pump run to repair perivalvular leakages. Shortly after weaning the patient off of cardiopulmonary bypass, the staff members observed the fire in the OR. Within seconds, the fire burned down the pulmonary artery catheter, surgical drapes and the breathing circuits. We immediately stopped all the fresh air supply lines and the team succeeded in extinguishing the fire using bottled saline. After examining the patient's trachea using the fiber optic scope, we connected the patient to the new breathing circuit and restarted mechanical ventilation. After making sure that the patient was not harmed in any way, chest closure was started. The postoperative course was uneventful. The subsequent investigation by the fire department revealed that the cause of the fire was a malfunctioning of the electrocautery devise. The incidence of operating room fire is not negligible, and therefore, it requires constant vigilance and periodic training on the part of caregivers working in the OR. According to the Practice Advisory for the Prevention and Management of Operating Room Fires published by the American Society of Anesthesiologists, appropriate physical condition of caregivers, installation of the carbon dioxide fire extinguisher in the OR, and knowledge of operating room fire procedures shared by all the staff members are of the essence to prevent and manage operating room fires.