So where'd the oxygen come from? The cuff on the patient's anesthe-
sia endotracheal tube was inflated. The heat from the disconnected
light cable melted the inflation tube. Once the tube melted, the cuff
deflated, which caused oxygen to leak past the cuff and build up under
the drapes around the patient's head. Right then I knew that some-
where on the floor, there had to be a Luer connector that had come
loose from the inflation tube when it melted. I started looking around
for the luer like a contact lens, and sure enough, found it. Case closed.
Could this fire have been prevented? Yes, had the OR team placed
the light source in standby when the surgeon disconnected the light
cable. For most outpatient surgeries, these 3 preventative measures
will help minimize the risk of a surgical fire.
1. Question the need for 100% oxygen delivered on the
face.
A surprisingly high number of OR staff members think alcohol-
based skin preps are the biggest cause of surgical fires, but that's not
the case. Skin preps make up only 4% of all surgical fires in ECRI
Institute's experience. You'd also be wrong if you guessed draping
technique or ignition source power were the leading causes. No, the
most significant factor leading to most surgical fires is using 100%
supplemental oxygen delivered openly on the face by mask or nasal
cannula. Historically that has been common during surgery performed
under monitored anesthesia care (MAC). Fortunately, that mindset is
changing.
More than 70% of fires involve oxygen enrichment. Most patients
undergoing MAC procedures don't need 100% oxygen on the face, so
always question how much the patient requires before you enter the OR
and during initial patient prepping. You can safely sedate most patients
without any open oxygen supplementation, using air instead via the face
mask or nasal cannula. However, the use of air versus supplemental oxy-
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