Leave it to the “news of the weird” to provide us with our anesthesia insight for the day. This headline could have been lifted straight from the National Enquirer, but there it was plain as day on all the major news outlets recently:
It’s hard not to chuckle at the headline at first glance and even more difficult to resist clicking on the link to read the whole article. But as anesthesia people, you quickly realize how real this story is and how it could very well happen in the operating room you are assigned to on any given day.
So the story goes that a 30-year-old woman was undergoing a gynecologic surgery involving the use of a laser. It’s not reported, but I’m guessing they were doing some kind of ablation procedure on the cervix…maybe for condylomata or cancerous lesions. At some point, intestinal gases escaped from the patient and were ignited by the laser. The ensuing flame spread to the surgical drapes covering the patient, causing severe burns to the patients legs, perineum, and abdominal areas.
This case is a tragedy, not only because of the burn injury and disfigurement of the patient, but mainly because 100% of surgical fires are preventable – and yet they still occur. The fire triangle is a representation of the three components that must be present in order to have a fire.
We usually think of it in terms of a forest fire, and wonder at how simple a concept it is…you get a forest full of wood, a bunch of oxygen in the air, and lightning strikes during a storm and boom! You get a forest fire that destroys the forest, property, and life and takes days and days to put out again. Forest fires happen all the time and are part of the life cycle of a healthy forest – and they are not necessarily preventable.
But back inside the OR, that same fire triangle holds true. What surprises most people is recognizing that all three elements of starting and sustaining a roaring fire are present inside every modern operating room by design. Perhaps if we assign roles (aka. blame) to the components of the fire triangle, the significance might strike closer to home:
- Heat – Surgeons
- Fuel – Nurses
- Oxygen – Anesthesia
Makes sense right? Everything you need to start a nice warm fire is right there at your disposal in the OR… Naturally, anesthesia brings the oxygen. The nurses bring fuel in the form of flammable stuff like all the linens and surgical drapes and prepping solutions. And all it takes is one spark from the surgeons electrocautery or laser or light source and we’ve recreated man’s greatest discovery:
100% of surgical fires are preventable
Only by being continuously aware of the availability of the elements of fire production can surgical fires be prevented. Turn off unnecessary oxygen sources and oxygen concentrating conditions: use lower oxygen concentrations, turn off auxiliary oxygen ports when not using, ventilate the drapes when possible to prevent pooling of oxygen, consider eliminating nitrous use, turn off laminar flow when not needed. Reduce the availability of fuels by limiting their use to only what is necessary: minimize the amount of alcohol-containing prep solutions used by both controlling the amount used and limiting the area of prep, allow prep to dry completely before draping, only use as many blankets and drapes as necessary, dispose of unused prep and linens and drapes as soon as possible away from the patient. Limit ignition heat sources and keep them away from flammable fuel sources: minimize the intermittent duration of use of cautery or lasers or other heat-based cutting devices, allow time for these instruments to cool at their point of use before holstering, holster these instruments in designated and visible places off the surgical field if possible. Of course, this is far from an exhaustive list of factors and interventions, but my point is that it’s all pretty obvious and easy stuff to do. We just have to keep doing it.
Once a fire starts, it may go unnoticed for a time because it is burning under the drapes or simply because no one is expecting a fire. Rather than go into the details of what you should do in the case of a surgical fire, I think this summary from the ECRI Institute is most succinct:
Back to the news story and our anesthetic take home message…
Most everyone seems to know or have heard that the methane produced by cows is flammable. The important thing to remember is that human intestinal gases can be high in methane and therefore are flammable, too. There have been many reported cases of explosions and fires during procedures due to poor bowel prep. And in this gynecologic case, I doubt that any bowel prep was performed preoperatively. By no means am I suggesting that every patient gets a bowel prep to prevent fires. But what I am speculating about is that this patient may have moved or “bucked” during the procedure, and THAT is what led to the expulsion of flammable intestinal gas in the immediate vicinity of where the laser surgery was occurring.
Undoubtedly this tragic surgical fire was a freak occurrence. Usually these type of bowel gas fires occur during colonoscopies or during surgeries that involve actual cutting into the bowel and causing the gases to escape – And as rare as these fires are, I think most GI docs and surgeons operating on bowel are keenly aware of the possibility, likely more so than the anesthesia clinician behind the drapes. We must be more aware and include the possibility in our vigilance.
In our lifetimes, natural orifice surgery may become a mainstay for certain kinds of surgical issues. And depending on which orifice the surgical activity is gathered around, the risk of intestinal gas expulsion – and therefore fire risk – must be taken into account. Even though we are at the head of the bed (thank goodness), we still have a role in mitigating this risk by keeping the patient from expelling intestinal gas. How? Perhaps, anything that causes patients NOT to valsalva or otherwise increase intra-abdominal pressure will help…adequate general anesthesia, spinal or epidural anesthesia (these also cause relaxation of intestinal smooth muscle), muscle relaxant…LMA instead of ETT if amenable…etc, etc.
Update: Several readers have commented that perhaps NPO after midnight before surgery for aspiration risk should not be our only concern in light of this news article. Perhaps we should be thinking about what patients are eating for their last meals before going NPO. Do foods that produce excess methane gas lead to greater intraoperative fire risk? It sounds ridiculous, I know, but I’ll leave that for you to ponder!
Can you think of any other ways we as anesthesia providers can help prevent surgical fires? Leave me a comment with your ideas below! As always, thank you for reading “Having a Gas Passing Gas”! I hope you’ve enjoyed the content!