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TECHNOLOGY, COMPUTING, AND SIMULATION

Surgical Field Fire During a Repair of Bronchoesophageal Fistula

Aneesh K. Singla, MD, MPH^*, Jason A. Campagna, MD, PhD^*, Cameron D. Wright, MD, and Warren S. Sandberg, MD, PhD^*

Departments of *Anesthesia and Critical Care, and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Address correspondence to Jason A. Campagna, MD, PhD, Department of Anesthesia, University of Pennsylvania, 3620 Hamilton Walk, John Morgan Building 305, Philadelphia, PA 19104. Address e-mail to jcampagna{at}doctorsoffice.org.

	Abstract

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Most surgical fires involve the airway but they can also occur in the surgical field. Herein, we report an intraoperative fire in the surgical field during repair of a bronchoesophageal fistula. During the portion of the surgery after the fistula was divided and the bronchus was open to atmosphere, continuos positive airway pressure was applied to the nondependent lung, and in conjunction with the use of electrocautery and dry sponges in the field, resulted in a fire. Anesthesia for thoracic surgery carries unique risks of fire because these patients frequently require large oxygen concentrations, special interventions for improving oxygenation, and have variable degrees of airway disruption. This report highlights unique safety concerns during anesthesia for thoracic surgery, and addresses more general safety issues relating to fire risk in all surgical patients.

	Introduction

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Operating room fires, though rare, can involve substantial morbidity and mortality. The most commonly reported surgical fires occur during laryngeal, pharyngeal, tracheostomy, and bronchoscopy procedures. The majority of these fires occur in the airway (34%) and head and neck area (28%) and only a small fraction (14%) occur in the patient (1). Surgical fires require an ignition source, and oxidizer and fuel, provided generally by surgeons, anesthesia providers, and nurses, respectively. Ignition sources generally include (but are not limited to) lasers and electrocautery, oxidizers are usually oxygen, nitrous oxide, and ambient air, whereas fuels are classically surgical drapes, materials, and prepping agents (1–3). Herein, we present a case report of an intraoperative fire in the surgical field during repair of a bronchoesophageal fistula. This event draws attention to the need for all members of the patient care team in an operating room to understand the contribution of their actions to the development of a surgical fire.

	Case Report

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A 74-yr-old man was transferred to our hospital after an Ivor-Lewis esophagectomy for Barrett's adenocarcinoma of the esophagus. The surgical procedure for the treatment of esophageal cancer occurs in two stages. An abdominal incision is made first and if there is no evidence of metastatic disease, the stomach and distal esophagus are dissected free and the incision is closed in a standard manner. The patient is then repositioned in a left lateral decubitus position and a right thoracotomy incision is made. Through this incision, the diseased region of the esophagus is resected, an esophageal anastomosis is made, and the stomach and remaining esophagus is "pulled" into the mediastinum. The procedure requires lung isolation to facilitate surgical access to the esophagus. The patient had previously developed an aspiration pneumonia and an endoscopic examination showed two fistulous connections from the esophageal anastomosis to the region of the junction of the bronchus intermedius and right mainstem bronchus (Fig. 1). An operative repair of the bronchoesophageal fistula was performed.

View larger version (104K): [in this window] [in a new window]   Figure 1. Bronchoscopic image showing two bronchoesophageal fistulae (arrows) visualized before the surgical repair as described in the report. The bronchus intermedius is seen distal to the fistulas, and distal lip of the right upper lobe bronchus orifice is seen on the right side of the image.

General anesthesia was induced with propofol (2 mg/kg), succinylcholine (2 mg/kg). A left-sided, 39F double-lumen endotracheal tube was placed and position confirmed via fiberoptic visualization and one-lung (left) ventilation was initiated. The patient's oxygen saturation (Spo₂) was 97% while breathing 100% inspired oxygen. The patient was placed in the left lateral decubitus position. The patient's Spo₂ was 88%–92% on 100% inspired oxygen after a right thoracotomy incision was made and one-lung ventilation initiated. During the repair of the esophageal and bronchial stumps, an abrupt episode of hypoxemia ensued that was associated with decreased end-tidal carbon dioxide. The diagnosis was an acute pulmonary embolism that was later confirmed postoperatively. Arterial blood gas analysis during the event showed a Pao₂ of 55, with an Spo₂ of 82%–85%.

To improve oxygenation during the remaining part of the procedure, 100% oxygen was used to deliver continuous positive airway pressure (CPAP) of 5 cm H₂O to the nondependent lung. Electrocautery was in use near the area of the bronchial opening, and surgical sponges that were not soaked in saline, but were slightly bloody, were present in the field. The surgical team did not notice any evidence of high-flow gases exiting via the bronchial opening. During electrocautery, a sponge was seen to ignite and burn. Only a small area of the sponge burned, and the color of the flame was not noted. The fire was quickly extinguished with saline, and CPAP to the nonventilated lung was discontinued until after closure of the bronchial stump. There were no adverse consequences related to the fire.

	Discussion

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CPAP is a simple, safe, and effective maneuver that can improve oxygenation in the setting of hypoxemia during one-lung ventilation (4–6). The use of 100% oxygen during episodes of hypoxemia is a cornerstone of anesthetic management, but as this case report and others point out, its use is not without risks (7,8). The lateral decubitus position, which increases perfusion and decreases ventilation to the dependent lung, the open chest with compression of the dependent lung by mediastinal contents, the attenuation of hypoxic pulmonary vasoconstriction by inhaled anesthetics, and a frequent prevalence of coexisting pulmonary disease contribute to frequent ventilation/perfusion mismatching resulting in hypoxemia (9). The benefits of CPAP relate to the expansion of distal alveoli, not the delivery of large oxygen concentrations (5,10,11). When the possibility of an open airway in the surgical field exists (tracheal and carinal resections, sleeve resections, airway-esophageal fistulas), CPAP with air is preferable to 100% oxygen because simply distending the airway and opening collapsed alveoli would still improve oxygenation without increasing the risk of fire (12). Nitrous oxide, like oxygen, is an oxidizer that increases fire risks and should not be used in place of oxygen for this purpose (1,13,14). Alternatively, positive end-expiratory pressure can be applied to the nondependent, ventilated lung but is less effective than CPAP because it may increase shunt fraction by increasing pulmonary vascular resistance and diverting blood flow away from the ventilated lung and toward the nonventilated lung (5,6,15).

Whereas the above recommendations give attention to the role of oxidizers in fire ignition, other recommendations for reducing fire risk relate to the ignition source and fuel. When electrocautery is needed in areas enriched by large concentrations of oxygen, surgical sponges should be wet and rung out with saline or water before use in the field. Because wetted sponges can still absorb blood, this option would render the "fuel" source unsuitable for fire propagation whereas allowing maximal flexibility in management of the patient (1). Skin prepping solutions also may contribute to ignition of a surgical fire. At our institution, alcohol-based agents are used for this purpose and are flammable. If alcohol is used for skin prepping, it should be allowed to dry completely before draping. The application of an incise drape also decreases fire risk by preventing vapor channels from forming under cloth drapes (1,16).

All fires require three elements: an oxidizing agent, an ignition source, and fuel (1). During airway procedures, these are supplemental oxygen, electrocautery, and the endotracheal tube, respectively (17–20). Anesthetic technique may increase the risk of airway fires when combustible endotracheal tubes are used or when the Fio₂ is unnecessarily high. In thoracic surgical procedures in which an open airway is present, simply supplying oxygen via CPAP can convert the surgical field into an oxygen-enriched environment that supports combustion of otherwise nonflammable fuels (sponges) (1,2). This fire occurred concomitantly with a difficult period of the anesthetic (acute hypoxemia), limiting our options for adequately oxygenating the patient. Fortunately, the disrupted, open airway could be quickly closed allowing the reinstitution of CPAP with high Fio₂.

In summary, anesthesia for thoracic surgery carries unique risks of fire because these patients frequently require large supplemental oxygen concentrations, special interventions for improving oxygenation, and can have disrupted airways allowing large concentrations of oxygen to enter the surgical field. In this case, an operative field fire occurred in a critically ill patient when CPAP with 100% oxygen was used to treat intraoperative hypoxemia during one-lung ventilation.

	Footnotes

 
This Case Report received financial support from general departmental funds.

Accepted for publication September 7, 2004.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (4) Citing Articles via Google Scholar Google Scholar Articles by Singla, A. K. Articles by Sandberg, W. S. Search for Related Content PubMed PubMed Citation Articles by Singla, A. K. Articles by Sandberg, W. S. Related Collections Airway Complications