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Surgical Fires Caused by Skin Preps and Ointments: Rare but Dangerous and Preventable

Surgical fires that ignite in or around patients can have devastating consequences, particularly if oxygen sources are present during head, face, neck, or upper chest surgeries.1 There are an estimated 200-240 surgical fires each year in the US, occurring in operating rooms or during procedures in physicians’ offices or clinics.2 Given the millions of surgical procedures performed each year, and a rate of fires ranging between 0.32 and 0.63 per 100,000 procedures,2 surgical fires are considered rare but very dangerous events. About 30 fires per year cause disfiguring or disabling injuries to patients, and one or two fires each year result in fatalities, most often from airway fires. 

Although a centralized database of surgical fires in the US does not exist, agencies such as the ECRI Institute, which has extensive experience in surgical fire investigation and prevention, suggest that the incidence of surgical fires has decreased in the last decade.3 The decline is due in large part to national initiatives promoted by professional organizations such as the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American College of Surgeons (ACS), American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), ECRI Institute, Association of periOperative Registered Nurses (AORN), The Joint Commission (TJC), and the US Food and Drug Administration (FDA).1 Despite this decline, attention must be paid to this very real threat to patient and staff safety, as virtually all surgical fires are preventable.1 2 3 4

How surgical fires start

Surgical fires occur when the three elements that support combustion—an ignition source, a fuel source, and an oxidizer—come together under the right conditions.4 Ignition sources, which are often under the control of the surgeon, can be anything that produces heat, such as electrosurgical units and electrocautery devices, lasers, fiberoptic cables and light sources, drills, saws, and defibrillators. Even static electricity can serve as an ignition for a flammable fuel source. Almost anything flammable can be a fuel source, including linens, drapes, gowns, hair, and flammable pharmaceutical products (Table 1). The primary oxidizers leading to surgical fires are oxygen and nitrous oxide.

Surgical fire pharmaceutical fuels
Table 1. Examples of common pharmaceutical-based fuels used during surgery and procedures

Most reported surgical fires involve electrosurgical units and lasers as the ignition source, oxygen-rich atmospheres as the oxidizer, and alcohol-based surgical preps as the fuel.1 However, because enriched oxygen and nitrous oxide environments can vastly increase the flammability of potential fuels,1 5 organizations investigating surgical fires have sometimes incorrectly assumed the fuel was a prep solution when it was actually a drape, gauze, or another flammable fuel source.3 Alcohol-based prep solutions that have not fully evaporated before draping can result in vapors under the drapes, also presenting a fire hazard. Alcohol fires may be difficult to detect because the flames may be invisible under bright surgical lights.

MERP reports of surgical fires

From time to time, surgical fires have been reported to the ISMP National Medication  Errors Reporting Program (ISMP MERP), mostly involving flammable medications in the form of surgical skin preps containing alcohol or alcohol-containing iodophors; eye lubricants and ointments containing petrolatum; wound dressings containing tincture of benzoin or collodion; and skin numbing agents containing ethyl chloride.

The most recent surgical fire reported in early 2018 involved GEBAUER’S ETHYL CHLORIDE spray, which had been applied as a numbing agent to a patient’s big toe prior to a minor surgical procedure. During the procedure, electrocautery was used, causing ignition of the ethyl chloride. The surgeon was able to quickly smother the flame; however, the patient suffered first-degree burns on his toe which required wound care. The front panel label on the ethyl chloride bottle includes a small icon of a flame (Figure 1), and the side panel of the outer carton warns, buried in dense text, that it should never be used in the presence of an open flame or electrical cautery equipment. However, the surgeon overlooked these inconspicuous warnings and was unaware of these risks. 

Gebauer's Ethyl Choride
Figure 1. Gebauer's Ethyl Chloride has a "flame" icon (bottom right) that was ineffective in communicating its flammability.

Last year, ISMP received another report about a surgical fire involving CHLORAPREP One-Step with Tint (2% chlorhexidine gluconate, 70% isopropyl alcohol), an antiseptic surgical skin prep solution that provides a long-lasting antimicrobial effect. The patient had been prepped for a temporal artery biopsy using a 26 mL applicator. After waiting about 10 minutes for the prep to dry, towels and a sterile tenting drape were placed. While the patient was receiving oxygen at 8 L per minute via a face mask, the surgeon used an electrosurgical unit to access the artery, which caused a spark and subsequent fire. The patient sustained second- and third-degree burns on her earlobe, lower neck, chest wall, and left upper extremity. Although other sources of fuel were available in the operating room, in this case, it was suspected that some of the ChloraPrep had seeped into the patient’s hair. The label states to avoid drapes and ignition sources such as cautery until the solution is completely dry, a minimum of 3 minutes on hairless skin and up to 1 hour in hair (Figure 2). The label also warns not to use the 26 mL applicator for head and neck surgery. Another factor was the lack of communication between the surgeon and anesthesiologist to stop the flow of oxygen before the electrosurgical unit was used. 

Figure 2. Warnings appear on the label of ChloraPrep One-Step with Tint but were overlooked, leading to a surgical fire.

In 2001 and 2004, ISMP published several reports of surgical fires in our newsletters. One involved an ocular lubricant (white petrolatum and mineral oil ophthalmic ointment [LACRI-LUBE S.O.P.]) used for a young child during laser surgery to remove warts near his eyes.6 The child suffered burns to his eyelids and periorbital area. Two other surgical fires involved Gebauer’s Ethyl Chloride spray. One case happened in a physician’s office, where a 6-year-old child was undergoing a procedure for an infected toe.7 A nurse practitioner had sprayed the toe with ethyl chloride and then lanced the area using electrocautery, which caused the pad under the child’s foot to ignite in flames. The child’s mother immediately pulled her son away from the fire, so he did not suffer any burns. The nurse practitioner had observed a physician performing the same procedure on another child without problems, and she was unaware of the fire hazard when using ethyl chloride. In the other case, a physician applied ethyl chloride spray to an abscess on a girl’s forehead and waited for it to dry.8 He then used electrocautery to drain the abscess. Due to hair loss, the teenager was wearing a flammable synthetic wig, which ignited after the cautery was applied to her forehead. The patient sustained first-degree burns to her ear.

Another surgical fire reported to ISMP happened in an ambulatory surgery facility.7 An assistant surgeon had prepared an operative incision for bandaging by spraying it with tincture of benzoin. The primary surgeon had nearly completed suturing the patient’s incision, but he noticed a small bleeding area along the incision line and decided to cauterize it. The flammable benzoin ignited briefly, but fortunately, the patient was not harmed.

Safe Practice Recommendations

In recent years, a growing awareness of the risks leading to surgical fires has led to an increasing number of organizations that are incorporating surgical fire safety into formal patient safety initiatives. In-depth resources to guide these initiatives are freely available from various professional organizations, many of which have been compiled on the ECRI Institute, Council on Surgical & Perioperative Safety, and APSF websites. When using pharmaceutical products that may serve as a fuel source for surgical fires, consider the following recommendations.

Take inventory 

Make a list of all potentially flammable pharmaceutical products (e.g., surgical skin preps and ointments) used in your organization’s procedural locations (including operating room suites, doctors’ offices, clinics, and ambulatory surgery units).

Evaluate the list

 Evaluate the need for each flammable pharmaceutical product used in your facility, as there may be safer alternatives, especially for topical anesthetics. While selection of an appropriate topical anesthetic or surgical skin prep solution is beyond the scope of this article, factors such as flammability should be a consideration to ensure the safe care of patients.

Ensure awareness

 Ensure that physicians, anesthesia providers, nurse practitioners, nurses, surgical assistants, and other practitioners know about the dangers of any flammable pharmaceutical products used in your facility, as well as the potential for burns when these products are used in conjunction with an ignition source and oxidizer.

Affix auxiliary labeling. If the manufacturers’ labels on flammable skin preps and ointments are not prominent or distinctive (e.g., Gebauer’s Ethyl Chloride containers), consider affixing auxiliary labels to the packages prior to dispensing to warn about flammability and the directions for proper use (e.g., not to use 26 mL applicators of ChloraPrep for head and neck procedures).

Provide and select proper applicator sizes. Select properly sized prefilled applicators of alcohol-based surgical skin prep solutions for the area needing coverage to prevent pooling and reduce the amount of excess prep requiring disposal and removal.

Avoid pooling. Ensure pooling, spilling, or wicking of a flammable surgical skin prep does not occur during or after application.

Ensure adequate drying time. Allow adequate drying time of the skin prep before application of the drapes or surgical barriers, or before beginning the procedure (e.g., at least 3 minutes for most alcohol-based skin preps, unless applied to hairy skin or in body folds, which may take up to 1 hour to dry). If possible, keep alcohol-containing prep solutions out of the patient’s hair. Consider including drying times on a surgical safety checklist to encourage communication between surgical team members.

Dispose of flammable surgical skin prep agents properly. Soak up spilled or pooled skin prep agents and remove any excess or remaining flammable prep solutions or ointments from the room prior to the use of any ignition source. Dispose of unused flammable skin prep agents in a manner to decrease the risk of fire.

Minimize the use of supplemental oxygen. Given the extensive role that oxygen plays as an oxidizer and accelerant in surgical fires, avoid the delivery of supplemental oxygen as a matter of routine. Use only air for open delivery to the face if the patient can maintain a safe blood oxygen saturation without supplemental oxygen.1 5 If the patient cannot maintain a safe oxygen saturation without supplemental oxygen, secure the airway with a laryngeal mask airway or tracheal tube.5 For cases in which open oxygen delivery is essential, deliver only the minimum concentration of oxygen necessary to maintain an adequate oxygenation.1

Promote communication. Consider adding a “Surgical Fire Risk Assessment Score”9 to the preoperative time-out process that requires the surgical team to identify if flammable materials (including skin preps and ointments), oxidizers (e.g., supplemental oxygen), and potential ignition sources will be used during the procedure to assess the risk of a surgical fire, and to develop a plan to mitigate any risk.5 Such a tool can also promote intra-procedure communication between providers. For example, after reviewing the risk of a surgical fire, anesthesia providers may be more likely to make the surgeon aware of any open oxygen use with the patient, and surgeons may be more likely to notify anesthesia providers prior to using electrical devices so the oxygen concentration can be lowered (preferably to 21%) at least 1 minute before using the electrical device.1

Provide annual training. Conduct annual training on the causes, prevention, and extinguishment of surgical fires. Review the specific directions for use of all potentially flammable surgical skin preps and ointments that might be used in your organization. Provide directions for controlling heat sources (ignitions), managing potential fuels (including surgical skin preps and ointments), and minimizing oxygen- and nitrous oxide-enriched environments. Require all physicians, anesthesia providers, nurse practitioners, nurses, surgical assistants, and other professionals who work in procedural areas to attend the annual training program. Consider holding a surgical fire drill immediately after training to evaluate effectiveness.    

  • 1 a b c d e f g h ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire-here’s how to keep them safer. Health Devices. 2009;38(10):314-32.
  • 2 a b c Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pa Patient Saf Advis. 2012;9(4):130-5.
  • 3 a b c Lucas S. Personal communication from Director, Accident and Forensic Investigation, ECRI Institute, to Cohen M, President, ISMP. March 2, 2018.
  • 4 a b Association of periOperative Registered Nurses (AORN). AORN guidance statement: fire prevention in the operating room. AORN J. 2005;81(5):1067-75.
  • 5 a b c d Cowles CE, Chang JL. Flammable surgical preps require vigilance. APSF Newsletter. 2014;29(2):25, 27-8.
  • 6ISMP. Safety briefs. ISMP Medication Safety Alert! 2001;6(11):1.
  • 7 a b ISMP. Worth repeating…extreme caution needed with flammable products. ISMP Medication Safety Alert! 2004;9(5):4.
  • 8ISMP. Worth repeating…ethyl chloride ignites. ISMP Medication Safety Alert! 2004;9(17):3.
  • 9Mathias JM. Scoring fire risk for surgical patients. OR Manager. 2006;22(1):19-20.