Fire in the theatre: A cautionary tale

A 66-year-old woman presented with a multifocal superficial basal cell carcinoma on her right lateral canthus. She proceeded to Mohs surgery with delayed reconstruction by an oculoplastic surgeon. She was discharged from the Mohs unit with a petrolatum-based dressing as the immediate layer, a non-adherent dressing (Telfa; Johnsons Controls, Milwaukee, WI, USA) as the second layer and an adhesive fixation tape (Mefix; M€ olnlycke Healthcare, Sydney, NSW, Australia) as third layer. During the repair, monopolar diathermy was used for haemostasis and a flame erupted. This resulted in scorching her eyelashes, fortunately with no damage to the globe (Fig. 1). A triad of an oxidising agent, a heat source and fuel are required for fire. In this case, the most likely fuel culprit was the petrolatum dressing. The patient had it covering her eye for more than 24 h. It was likely that substantial residue remained on her eyelashes at the time of reconstruction. This, coupled with a rich oxygen source (provided via a nasal cannula) and diathermy provided all the elements necessary for fire. Another source of fuel could have been the disinfectant used. Both the Mohs and the oculoplastic surgeon used iodine without alcohol so the flammability was low. In addition, it was noted that the patient had significant oily blepharitis that could have contributed. The patient had not used mascara nor was an antibiotic ointment used. An American survey of 258 oculoplastic surgeons reveal that 32% had experienced at least one surgical fire in their careers. The most common scenario involved the delivery of oxygen by nasal cannula and had the consequence of singeing the patient’s facial hair. In the last two decades, seven related law suits were reported by an American insurance company, with the mean settlement being $145 285 (range $10 000– 474 994). In an experimental study the authors investigated the percentage of oxygen required to start a fire near an endotracheal tube. A fraction of inspired oxygen (FiO2) >50% was required, coupled with a high flow rate. Usually the administration of oxygen via nasal cannula at 2–4 L/min (equivalent to a FiO2 of 28–36%) does not produce conditions conducive to fire. However, when it is administered under surgical drapes, oxygen can pool around the patient’s face creating a local FiO2 well in excess of what one would expect. Fire is also possible in absence of a high oxygen environment, with two case reports of self-immolation after a forehead flap. Both patients were heavy smokers and sustained second and third-degree burns along the petrolatum dressing used. Surgeons should always be aware of the possibility of fire. Approaches to minimising operating room fires include: (i) recognising that petrolatum dressings are a fuel source and considering the use of a plain non-adherent dressing such as Telfa; (ii) minimising supplementary oxygen to use only enough to prevent patient’s desaturation; (iii) draping the patient in a configuration that minimises oxygen pooling; (iv) avoiding alcoholic skin preparation on the head and neck. If it is used, ensure adequate drying time and remove prep-soaked drapes and gauze from the operative field; and (v) moistening the gauze in close contact with electrocautery.