Prevention of surgical fires in facial plastic surgery

Conclusion: Summary recommendations for the prevention of surgical fires are presented. Preventing the development of an oxidiserenriched environment is the main risk-reducing measure. Identifying high-risk cases and improving communication between the surgical, anaesthetic and nursing staff who control the arms of the fire triangle are very important measures in avoiding theses catastrophic events.


Introduction
Operating room fires are imminently preventable, devastating events with physical and psychological consequences that can last a lifetime for patients.
They also represent a potential cause of litigation. [1][2][3] The vast majority of surgical fires occur during surgery of the head and neck region, including

Fire triangle
A surgical fire is defined as a fire that occurs on or in a patient. An airway fire is a specific type of surgical fire that occurs in a patient's airway. 1,12 Fire requires the presence of three components: an oxidiser, an ignition source and fuel, 2, [8][9][10]14,15 ( Figure 1). Together these are known as the 'fire triangle' or 'fire triad'.
There are many different types of oxidisers, ignitors and fuels documented in the literature.
This review seeks to highlight causative factors, detail preventive measures and raise surgical staff awareness of this hazard.

Methods
The review was conducted according to the PRISMA search criteria and checklist (Figure 2). After applying inclusion and exclusion criteria, 30

Sources of information
articles remained for the purpose of this review.

Results
Our

Oxidisers
The oxidiser component of the fire triangle is so important to fire creation that it is unusual for a surgical fire to occur in the absence of oxygen enrichment. 6 Oxygen-enriched environments occur far more frequently around patients receiving supplemental high-flow oxygen (>3-4 L/ min) compared with those receiving supplemental oxygen at low flow rates (2 L/min). 2,7,8,16,17 The proximity of the oxidiser to the ignition source plays an important role, 7   Flammability differs from one material to another, with polypropylene drapes being less flammable than cellulose drapes. In all cases the time to ignite shortens with higher oxygen concentrations. 12 Culp showed that this oxygen delivery method reduced the oxygen concentration in the operative field to a level consistent with ambient air. 11,27 The nasopharyngeal tube was used only in deeply sedated patients to avoid pharyngeal irritation being felt by the patient. 27 Contrary to these findings, another study showed no advantage to the use of nasopharyngeal tubes compared with nasal cannulae, and patients experienced discomfort when using nasopharyngeal tubes. 17

Ignition (heat) source
Diathermy is the most common type of therapeutic equipment involved in burn incidents. 12,26,28 An experimental study comparing the power of electrocoagulation required to ignite a fire at different distances from a malplaced nasal cannula has shown that at an oxygen flow rate of 2 L/min, 30 W of coagulation level created a burn 5 cm from the malplaced nasal cannula. 7 Other experiments showed that electrocautery at 15 W did not ignite any fire when the oxygen concentration was below 50 per cent. 20 Buildup of a crust on the tip of an electrosurgical device can contribute to increased heat and in turn to increased fire risk. 20 Monopolar and thermal hand-held cautery were the most common devices associated with fire accidents compared with bipolar cautery and carbon dioxide laser. 8,10 Case reports have suggested the 'spray' modality of electrocautery to be a contributing factor, 29 however, no definitive evidence in the literature supports this assertion.

Recommendations
The accumulated experience of surgical fires and the conditions that predispose to them have led to many sets of recommendations in the literature.
We present a consensus summary of these findings to guide the practice of plastic surgeons.

Use of supplemental oxygen
When indicated, oxygen supplementation should be administered intermittently when an electrosurgical unit is not in use. 12 Keep the oxygen flow rate low (2-3 L/min) and cease supplementation 60 seconds before starting electrocautery. 2, 8,12,17 The FiO2 should be kept as low as possible (less than 30%) well in advance of electrosurgical unit use. 6,9,16,19,20 Supplemental oxygen delivery Avoid using face masks to deliver supplemental oxygen. Nasal cannulae are safer 8,12 but they should be properly placed 7,18 and never covered by drapes. 1,2, 8,9,18 Use of a scavenger system reduces the risk. Hold preoperative time out with nursing, anaesthetic and surgical team acknowledging the fire prevention measures considered.

4
Use open face draping.

5
Use a supplemental oxygen flow of 2 L/min, and cease supplementation 60 seconds before using electrocautery.

6
Use suction to reduce oxygen concentration.

7
Ensure oxygen is delivered through a properly placed nasal cannula.

8
Use an electrocautery device, preferably bipolar, less than 15 W, with a clean tip and held at least 5 cm from the oxygen source.

9
Moisten all swabs and sponges before use.
10 Have available a carbon dioxide fire extinguisher in the operating theatre and ensure all staff are trained in its use. We recommend a checklist of 10 points to be considered during the preoperative time out process whenever surgery is planned to be conducted under sedation with the use of supplemental oxygen and electrocautery (Figure 3).