This article was written by CandyOne day in August 2018, an ambulance drove into the emergency room with a patient clutching his chest. This is a 60-year-old man with chronic obstructive pulmonary disease (COPD) who also underwent coronary artery bypass surgery a year earlier. But he was sent to the emergency department this time because of dissection of the ascending aorta. After some examinations, the doctors decided to urgently operate the patient. Time has passed, and the operation is proceeding step by step. Doctors opened the patient’s chest cavity and found that his right lung was tightly adhered to the sternum, some of the lung tissue was over-inflated, and there was a bulla. This is due to the increased pressure in the alveolar cavity caused by chronic COPD, and the rupture of the alveolar walls fuses with each other in the lung tissue to form a cavity containing air sacs. The doctors carefully dissected, but accidentally punctured one of the bullae. The anesthesiologist responded quickly,increased the flow of anesthetic gas to 10 liters per minute and the oxygen ratio to 100%, Possible respiratory distress was avoided and the operation continued. Just when everyone thought the operation was about to be successful, an accident suddenly happened: the normally working electrosurgical scalpel suddenly sparked, igniting the surgical bag placed nearby, < strong>The operating table for rescuing the patient caught fire in the blink of an eye! Fire caused by a fartThis is June 2019 A real case brought by a hospital in Melbourne, Australia at the European Anesthesiology Annual Meeting. Fortunately, the chief surgeon put out the flames with saline in time, and the operation, which almost turned into a “heart burn”, was finally successful. 
report screenshot“This case tells us to be especially careful when using electrosurgery in an oxygen-rich environment.” “Doctors also need fire training, especially surgeons and anesthesiologists.During surgery, in the event of lung damage or for any reason The resulting air leakage may cause a fire.”The operating table catches fire, although it sounds very strange, but similar incidents are not limited to this case. In April 2016, a Japanese female patient was undergoing cervix surgery at the Tokyo Medical University Hospital when a fire broke out in the operating room, and the patient suffered burns to her waist and legs. After half a year of accident investigation, professionals finally determined that no flammable gas was mixed in the operating room when the accident occurred, and the surgical equipment was operating normally. The cause of the fire turned out to be that the patient had inadvertently farted during the operation. The flammable components such as methane contained in the gas in the intestinal tract are ignited by the laser used for surgery after being discharged from the human body, triggering an operation room fire. In 2006, a male patient in New Zealand accidentally burned his buttocks while undergoing hemorrhoid surgery. In 2019, a surgeon was treating a patient with acute intestinal perforation. The moment the peritoneum was cut open with a monopolar electrocautery, the operating room suddenly banged with an explosion. Fortunately, the patient was not injured and the operation was successfully completed. But there are others who don’t have such “lucky”. In 2014, when a patient on mechanical ventilation underwent tracheostomy,the doctor’s monopolar electrocautery ignited the high-flow oxygenated endotracheal tube, and the skin of the patient’s neck was deeply pierced. Burns, and ultimately failed to rescue. 
The patient’s neck skin was burntSource: Reference 4, 2020 A 24-week premature infant underwent laparotomy at 1 month of age due to congenital jejunal atresia. During surgery, the doctor wraps cotton around the child’s head, chest and limbs to maintain body temperature. However, when the monopolar electrocautery sliced open the peritoneum, sparks ignited the drape, which in turn ignited the cotton. Although the flames were extinguished in time, the child unfortunately died of sepsis a few days later due to surgical trauma and 40% skin burns. The Triangle of Fire in the Operating RoomOperating Room Fire , is it a misfortune or a safety hazard? This might start with “Triangle of Fire”. The fire triangle, that is, the three elements of combustion, simultaneously have combustion-supporting materials, combustible materials, and ignition sources (or the temperature reaches the ignition point), which is the combination of combustion and fire occurrence necessary conditions. In the operating room, all three are often present at the same time. 
Fire triangle in the operating roomSource: Reference 6First look at combustion In the operating room, the most common combustion aid is oxygen.During the operation, most patients need airway oxygen supply. In the event of a fire in the operating room, the head, neck and chest, which are closer to the airway oxygen supply, are more likely to be burned, endangering the patient’s life. Therefore,open delivery of air or FiO2≤30% oxygen is generally recommended during surgery. If supplemental FiO2≥30% oxygen is required, endotracheal intubation, Closed delivery methods such as laryngeal mask.However, closed delivery is not foolproof, because the endotracheal tube, laryngeal mask, etc. themselves still have the risk of being ignited. Secondly, let’s look at combustibles.Combustibles in the operating room can be divided intopatient-related fuels< /span>andPatient irrelevant fuels.Patient related fuels include hair, Intestinal gas, clothing, etc. Among them, the use of polyethylene glycol and oral sodium sulfate for bowel preparation helps to remove intestinal contents and combustible gas.And the patient Irrelevant fuels include surgical towels, sponges, gauze, endotracheal tubes, nasal tubes, etc.Data show that 49% of operating room fires in airway surgery are caused by the burning of the endotracheal tube, while the nasal Items made of polyvinyl fluoride, such as pipes, are also flammable when exposed to high temperatures.Lastly, look at the fire source.< span>In surgery, the most common is the scalpel. With the upgrading of medical equipment, high-frequency electrosurgery has become the most common and basic electrosurgical equipment in the operating room. ,it passes through the active electrode tip The high-frequency high-voltage current generated by the terminal heats the tissue when it is in contact with the body, so as to realize the separation and coagulation of the body tissue, so as to achieve the purpose of cutting and hemostasis. However, such a doctor’s right-hand man is also dangerous. From 2002 to November 2011, my country’s National Center for Adverse Drug Reaction Monitoring received a total of 316 reports of suspicious medical device adverse events related to high-frequency electrosurgery, of which 96 reported patient harm, of which This includes skin burns in the non-surgical area, electric shock injuries, and burning of the surgical field. Secondly, the ignition sources that are likely to cause fires are also lasers commonly used in facial beauty, oral and eye surgery. Studies have found thatwhen FiO2 reaches 100%, a laser can penetrate a bare endotracheal tube within 2 seconds, exposing it to combustible gas. When the Triangle of Fire gathers in the operating room, it may not be accidental. Accidents are frequent, how to prevent fire in operating room? In 2017, a literature review of 33 years of incidents related to operating room fires in the US medical malpractice claims database collected a total of 139 cases. According to data, the number of operating room fires in the United States is more than 650 each year, and it is increasing with each year. The phenomenon of operating room fire has gradually attracted the attention of the medical field, and some teams have also carried out related research. In 2017, Jones Edward L et al. exploredthe effect of skin disinfectants on operating room fires. They used 15x15cm sliced pigskin as the simulation object and divided them into two groups: alcohol-containing skin disinfectant and alcohol-free disinfectant. At 0min and 3min after disinfecting the skin, the researchers used a monopole The frequency electric knife device is used as a heat source to test whether it will cause combustion in the atmospheric environment. All alcohol-based skin disinfectants caused fires, and waiting 3 minutes after disinfection reduced the risk,while alcohol-free disinfectants No burning occurred in either 0min or 3min. 
Source: Reference 6 1cm circular skin lesions were poured into different types of disinfectants to simulate the possible accumulation of disinfectants in human skin folds (such as the umbilicus). In 2020, Culp William C et al. exploredwhether oxygen permeability of surgical drape is related to fire risk. First, they tested the oxygen permeability of different materials, and found that cotton or towel had the highest oxygen permeability, followed by AAMI4 and AAMI3 surgery The best isolation is the sterile surgical drape. They then used a mannequin to simulate the situation during surgery, delivering oxygen at 10L/min mask oxygen, and detecting the oxygen concentration at the surgical site (denoted by an “X”) and under the surgical drape closest to the surgical site. 
Source: Reference 7The results show that, in addition to cotton surgical towel, the other three types of surgical towel can effectively reduce the risk of oxygen contamination, especially sterile towel Most obvious. In 2013, the American College of Anesthesiologists issued a series of systematic recommendations for avoiding operating room fires, extending three principles based on the “Triangle of Fire”:Minimize or avoid oxidant-rich air near the surgical site; manage ignition sources safely; manage fuels safely. In 2019, Jones Teresa S et al. published a review summarizing practical recommendations for effective prevention of operating room fires, including: Choose an alcohol-free skin disinfectant that should be used for 3 minutes After drying, spread the towel to avoid the accumulation of disinfectants; when intestinal surgery is required, use non-mannitol intestinal preparation, and choose to use antibiotics at the same time. 
A series of suggestions for avoiding operating room firesSource 6 span>At the same time of prevention, medical staff must also learn how to deal with emergencies. In the event of a fire, first stop all airway gas flow and disconnect the breathing circuit. In the event of an airway fire, the endotracheal tube needs to be removed immediately and saline injected into the airway. After the fire is extinguished, it is also necessary to remove all burning and charred substances from the patient’s body, and allow the patient to resume breathing with air as soon as possible. (Planning: z_popeye, Leu., gyouza)Acknowledgements: This article was approved by Yu Minhao, Deputy Chief Physician of Gastrointestinal Surgery, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine Professional reviewImage source: YouTube video screenshotReferences:[1 ]McSweeney William T,Kirkby Brian,Combustion of pneumoperitoneum: a rare danger in the operating room.[J] .J Surg Case Rep, 2019, 2019: rjz323.[2]Apfelbaum Jeffrey L,Caplan Robert A,Barker Steven J et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires.[J] .Anesthesiology, 2013, 118: 271-90 .[3]Choudhry Asad J, Haddad Nadeem N, Khasawneh Mohammad A et al. Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation.[J] .Am J Surg , 2017, 213: 558-564.[4]Kim MS, Lee JH, Lee DH, Lee YU, Jung TE. Electrocautery-Ignited Surgical Field Fire Caused by a High Oxygen Level during Tracheostomy. Korean J Thor ac Cardiovasc Surg. 2014 Oct;47(5):491-3. doi: 10.5090/kjtcs.2014.47.5.491. Epub 2014 Oct 5. PMID: 25346908; PMCID: PMC4207107.[5]Rasul Laraib,Liaqat Naeem,Imran Raja et al. Surgical Field Fire Involving a Premature Neonate.[J] .J Coll Physicians Surg Pak, 2020, 30: 760-761.[6]Jones Edward L, Overbey Douglas M,Chapman Brandon C et al. Operating Room Fires and Surgical Skin Preparation.[J] .J Am Coll Surg, 2017, 225: 160-165.[7]Culp William C,Muse Kenisha W,Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field.[J] .J Patient Saf, 2020.[8] Jones Teresa S,Black Ian H,Robinson Thomas N et al. Operating Room Fires.[J] .Anesthesiology, 2019, 130: 492-501. Lilac Garden RecruitmentJob Name: New Media Operation (Lilac Garden)Complete original content planning independentlyAssist in the operation of Lilac Garden official account WeiboWork location: HangzhouClick here to send your resume directlyYou can also send your resume to the mailboxhujiafeng@ dxy.cnSubject: Post Name-Name
