A fire may not be the first thing that comes to mind when people consider what could go wrong in the operating room. In this video, Max Feinstein, MD, explains the training anesthesiologists receive in managing this unlikely scenario.
Following is a transcript (note errors are possible):
Feinstein: What would you do if you were an anesthesiologist in the middle of an uneventful surgery and you notice something strange — some smoke is coming from under the drapes, and on further inspection you realize your patient’s mouth is actually on fire?
My name is Max Feinstein and I’m an anesthesiology resident at the Mount Sinai Hospital in New York City. In this video, we are going to be talking about what happens during an airway fire and what exactly an anesthesiologist should do about it. If you find this video interesting or helpful, I’d really appreciate it if you liked it and subscribe to the channel. Let’s dive in.
Believe it or not, this is actually not just sensationalism or clickbait, but airway fires are an actual issue that not only come up in anesthesiology training and is tested on our board exams, but actually happens an estimated 50 to 200 times per year in the United States. It’s really important for anesthesiologists to be aware of exactly what they can do to recognize and address airway fires and also be aware of all of the prevention strategies that exist to make sure that they just don’t happen in the first place.
Airway fires can happen when there is the perfect unfortunate combination of three components, which are: an ignition source — for example, electrocautery like a Bovie that’s commonly used by surgeons. Second is a fuel source, which is anything that will just continue to burn. Believe it or not, there are a lot of different fuel sources in an operating room, including many different types of endotracheal tubes as well as things like the surgical drapes.
The third component that’s necessary for an airway fire is an oxidizer. Guess what oxidizer is plentiful in an operating room? Oxygen. For the anesthesiology trainees who are watching this video, be prepared for those three components to come up on your board exams throughout your training.
If an airway fire does occur, the very first things that need to happen are the surgery needs to stop immediately; the amount of oxygen that the patient is receiving needs to be turned down as much as possible; and then if an endotracheal tube is in place, that actually needs to be taken out right away.
The reason why we turn down the oxygen concentration and then remove the endotracheal tube is because if the endotracheal tube is indeed on fire and we pull it out of the patient with 100% oxygen blasting through the tube, then it basically just becomes a flamethrower. We need to make sure to turn down the amount of oxygen that’s going through the endotracheal tube before we pull it out in the event of a fire.
As counterintuitive as it sounds to remove an endotracheal tube from a patient who is under general anesthesia, the reason we do that in the event of an airway fire is to reduce the likelihood that that tube actually melts into the patient’s airway and causes further damage. Keep in mind that because an endotracheal tube can actually be a fuel source for a fire, we want to remove that fuel source from the patient so it doesn’t cause harm inside of their airway.
Once the endotracheal tube has been removed, the next thing that needs to happen is the fire needs to be extinguished. The best way to do that in the operating room on short notice is using any sort of saline or water-based solution that’s obviously not flammable.
The surgeon should actually already have saline available on the field if they’re working in a situation with a slightly elevated risk of an airway fire, but alternatively there is another source of something that’s pretty close to saline that we can access very easily on the anesthesiologist’s side of the drapes. In a dire situation, you can actually just reach for the bag of lactated Ringer’s or Isolyte, or whatever you happen to have right next to you, and open that bag up right onto the fire to try to extinguish it. If that doesn’t work, there should be a carbon dioxide-based fire extinguisher available to put out the fire.
If an airway fire has occurred, then it’s reasonable to consider using bronchoscopy to evaluate the patient’s airway for any sort of damage or residual portions of the endotracheal tube that may have burnt off while the fire was happening. Of course, this should only be done once the fire has been extinguished and ventilation has safely been re-established.
Once the fire has been extinguished, the next step is to re-establish ventilation, which is preferably done with something like a self-inflating resuscitation bag.
One aspect of anesthesiology that I commonly tell people is that a lot of my job entails anticipating, preventing, and trying to think about how I would address any sort of very rare, but life-threatening event that could happen in or around the operating room. To that end, prevention strategies are a routine part of anesthesia practice to ensure that we just don’t end up with an airway fire in the first place.
Thinking back to the three components that are necessary for an airway fire to occur — namely, an ignition source, an oxidizer, and a fuel source — we can think about trying to reduce the presence of each one of those. It’s worth pointing out that there are multiple different types of ignition sources that surgeons can use including electrocautery like Bovies or lasers. In the particular case of lasers, there are specially designed reinforced endotracheal tubes that are recommended to reduce the risk of a fire.
What’s more is when a surgeon is using a laser and the anesthesiologist uses a laser-resistant endotracheal tube, the cuff on the tube should actually not be filled with air, but rather with saline and methylene blue so that in the event that the cuff pops, then methylene blue is sprayed all over the place and it’s immediately evident that there was a puncture to the endotracheal tube.
As far as an oxidizer is concerned, when there is surgery that’s happening near a patient’s mouth we can actually just try to turn down the amount of oxygen that the patient breathes in. This is called the fraction of inspired oxygen or FiO2.
The tradeoff, of course, is that reducing the amount of oxygen that’s delivered to a patient might not necessarily be tolerated and does decrease the amount of reserve that a patient has in the event that we’re not able to continue delivering oxygen to the patient for a period of time — for example, if the endotracheal tube becomes kinked or disconnected.
Max Feinstein, MD, is a PGY-4 anesthesiology resident at the Mount Sinai Hospital in New York City, where he is also chief resident of teaching. His YouTube channel focuses on perioperative medicine, especially the role of the anesthesiologist.