Doctors Accidentally Start Fire During Open Heart Surgery

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Gives a whole new meaning to the word “heartburn”, doesn’t it? We’ll start at the end. The patient, a 60-year-old male with lung disease, emerged from the surgery uninjured. No malpractice suit has been filed – yet. We’re not holding our breath, but the patient does not seem hostile. With that said, there are plenty of take-home points regarding the placement of potentially volatile tools within the operating suite.

Anyone can imagine this incident taking a turn for the deadly.

Here’s what happened: The patient was undergoing emergency surgery to address a torn aorta. The patient also had an “enlarged” lung, a symptom of the patient’s pulmonary disease. The patient’s lung was fixed to his sternum, and the surgeons needed to crack his sternum to access his heart. In doing so, a bulla within the lung was punctured.

The anesthesiologist responded by increasing the amount of oxygen in the patient’s anesthetic inhalant.

The inciting spark was discharged from an electrocautery device, used by the surgeons to control the bleeding of the patient’s wounds. The device was laying close to dry surgical packs, swathed in highly oxygenated vapors. A spark was ignitied when the electrocautery device made contact.

The fire was quickly extinguished and neither the patient nor the surgeon was injured. Is extinguishing a fire concentrated within the patient’s chest cavity part of the standard of care? Perhaps not explicitly, but we wager it’s implied.

This is not the first time this has happened – at least seven other similar incidents have been reported. While the precise circumstances vary, the stories share several common threads. Each incident involved a patient with chronic lung disease. And each incident involved an increased flow of oxygen into the patients’ lungs, dry surgical packs, and electrocautery devices, as stated by the presiding surgeon, Dr. Ruth Shaylor.

“While there are only a few documented cases of chest cavity fires–three involving thoracic surgery and three involving coronary bypass grafting–all have involved the presence of dry surgical packs, electrocautery, increased inspired oxygen concentrations, and patients with COPD or pre-existing lung disease”, explains Dr. Shaylor.

“This case highlights the continued need for fire training and prevention strategies and quick intervention to prevent injury whenever electrocautery is used in oxygen-enriched environments. In particular surgeons and anaesthetists need to be aware that fires can occur in the chest cavity if a lung is damaged or there is an air leak for any reason, and that patients with COPD are at increased risk.”

The take-home point: Recognize how mundane tools may interact in dangerous ways. Each item that contributed to the fire is, in isolation and in the hands of a surgeon, virtually harmless. They become dangerous when they are combined under specific circumstances – elevated oxygen levels, a punctured bulla, etc. The dangers are easy to identify in retrospect, but during the “heat” of surgery, they can be easy to overlook. Take these stories to “heart” so you (and your patients/colleagues) don’t get “cooked.”

What do you think? Let us know your thoughts in the comments below.

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First, the fact that an increased oxygen concentration was required, indicates that this was pre bypass. Otherwise increased oxygen could be handled by the oxygenator of the bypass machine. Second, the fact that dry lap pads were used indicates that the operating room scrub nurse or assistant was inadequately trained.
Third, suction should have been employed to suck up fumes from the cautery plume. Had suction been present then the leak of oxygen from the ruptured lung bleb, leading to an increased oxygen concentration at the site of the cautery tip, would not have occurred.
The anesthesiologist was doing what he needed to do to treat the patient’s declining oxygen saturation due to the ruptured lung bleb, and decreased ability to ventilate.
The cardiac surgeon should have been aware of the leak of oxygen from the ruptured bleb, packed the area with wet lap pads (which would have also helped the anesthesiologist to ventilate the patient), and taken care to suction up excess oxygen pooling in the wound. There was a clear lack of recognition on the part of the cardiac surgeon about the potential hazards of fire in the operating room the causes, ignition source, flammable substrate (dry lap pads), and the enriched oxygen concentration causing an increased ability to support combustion.
It is unknown if the patient suffered harm, because burns to the inside of the chest cavity or the lungs might have been subtle. If the pericardium was closed, there would be little damage to the heart, except perhaps for thermal injury.
Treatment would have been turning down oxygen flow, removing the dry lap pads from the field that likely ignited, and dousing the field with saline.
Also if the cardiac surgeon had clamped across the bleb promptly to minimize oxygen leak, the need to increase the oxygen saturation would have been decreased.

The cardiac surgeon likely needs retraining on operating room fires, and their prevention. While these fires are rare events, they do occur, and it is quite possible that each operating room physician will see this at least once in his life. That is the reason why vigilance is so important. For those of us who have experienced such fires (two for myself) the training and vigilance required for the entire OR team is important.
The two fires that I saw were terribly frightening.
Case one — overseas, a room air conditioner cooling an OR caught fire and caused billowing smoke to pour out into the OR along the ceiling and rain soot down on the entire team, patient, and patient’s abdominal cavity. The air conditioner was turned off, but continued to smolder. We moved the OR table with the patient on it, and anesthesia machine out of that OR into another OR.
Case two — 30 years ago a laparoscopic tower with the insufflator, TV monitor, cautery unit, and laparoscopic camera caught fire and started smoking. It was unplugged and removed from the OR quickly, whereupon surgery continued unabated with no harm to the patient. I am not sure that a cause was ever determined, other than the laparoscopic camera box was defective.

Training for airway fires and cavity fires is something that has been lectured on at the American Society of Anesthesiologist meetings for 30 years. Jan Ehrenwerth, MD emeritus professor of Anesthesiology at Yale, is a subject expert in OR fires. I highly recommend that the physicians reading this column familiarize themselves with his work.

1 thought on “Doctors Accidentally Start Fire During Open Heart Surgery”

retired

October 29, 2021 at 11:42 pm

First, the fact that an increased oxygen concentration was required, indicates that this was pre bypass. Otherwise increased oxygen could be handled by the oxygenator of the bypass machine. Second, the fact that dry lap pads were used indicates that the operating room scrub nurse or assistant was inadequately trained.
Third, suction should have been employed to suck up fumes from the cautery plume. Had suction been present then the leak of oxygen from the ruptured lung bleb, leading to an increased oxygen concentration at the site of the cautery tip, would not have occurred.
The anesthesiologist was doing what he needed to do to treat the patient’s declining oxygen saturation due to the ruptured lung bleb, and decreased ability to ventilate.
The cardiac surgeon should have been aware of the leak of oxygen from the ruptured bleb, packed the area with wet lap pads (which would have also helped the anesthesiologist to ventilate the patient), and taken care to suction up excess oxygen pooling in the wound. There was a clear lack of recognition on the part of the cardiac surgeon about the potential hazards of fire in the operating room the causes, ignition source, flammable substrate (dry lap pads), and the enriched oxygen concentration causing an increased ability to support combustion.
It is unknown if the patient suffered harm, because burns to the inside of the chest cavity or the lungs might have been subtle. If the pericardium was closed, there would be little damage to the heart, except perhaps for thermal injury.
Treatment would have been turning down oxygen flow, removing the dry lap pads from the field that likely ignited, and dousing the field with saline.
Also if the cardiac surgeon had clamped across the bleb promptly to minimize oxygen leak, the need to increase the oxygen saturation would have been decreased.

The cardiac surgeon likely needs retraining on operating room fires, and their prevention. While these fires are rare events, they do occur, and it is quite possible that each operating room physician will see this at least once in his life. That is the reason why vigilance is so important. For those of us who have experienced such fires (two for myself) the training and vigilance required for the entire OR team is important.
The two fires that I saw were terribly frightening.
Case one — overseas, a room air conditioner cooling an OR caught fire and caused billowing smoke to pour out into the OR along the ceiling and rain soot down on the entire team, patient, and patient’s abdominal cavity. The air conditioner was turned off, but continued to smolder. We moved the OR table with the patient on it, and anesthesia machine out of that OR into another OR.
Case two — 30 years ago a laparoscopic tower with the insufflator, TV monitor, cautery unit, and laparoscopic camera caught fire and started smoking. It was unplugged and removed from the OR quickly, whereupon surgery continued unabated with no harm to the patient. I am not sure that a cause was ever determined, other than the laparoscopic camera box was defective.

Training for airway fires and cavity fires is something that has been lectured on at the American Society of Anesthesiologist meetings for 30 years. Jan Ehrenwerth, MD emeritus professor of Anesthesiology at Yale, is a subject expert in OR fires. I highly recommend that the physicians reading this column familiarize themselves with his work.

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