Fires in the Operating Room and Intensive Care Unit:
Awareness is the Key to Prevention
Rajnish Prasad, MD, Zenaide Quezado, MD, Arthur St. Andre, MD, and
Naomi P. O’Grady, MD
Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
Recent recommendations from the Centers for Disease
Control (CDC) to use alcohol-based substances for
hand hygiene and skin antisepsis could introduce new
tial for an increase in the number of fires in the hospital
setting with wide spread use of alcohol-based agents
warrants heightened awareness of the risks and
implementation of safety measures when using these
tomy, sustained severe burns resulting from a fire in the
could introduce new fire hazards in the operating
room (OR) (1). This potential for an increase in the
number of fires in the hospital setting with wide
spread use of alcohol-based agents warrants height-
ened awareness of the risks and implementation of
safety measures when using these agents.
ecent recommendations from the Centers for
Disease Control (CDC) to use alcohol-based sub-
stances for hand hygiene and skin antisepsis
A 74-year-old woman with history of diabetes mellitus, hy-
pertension, aortic stenosis, congestive heart failure, chronic
obstructive pulmonary disease, hypothyroidism, chronic re-
nal insufficiency, and obesity was admitted because of dys-
pnea and hypoxemia. A cardiac catheterization showed se-
vere coronary artery disease, and the patient required
coronary artery bypass grafting and aortic valve replace-
ment. The postoperative course in the intensive care unit
was complicated by prolonged mechanical ventilation.
Twenty days after cardiac surgery, she was taken to the OR
for a tracheostomy.
The patient had an oral endotracheal tube and her lungs
were ventilated with 40% fraction of inspired oxygen during
the anesthetic. The surgical site was prepared according to
institutional protocol with a one-step povidone iodine/
isopropyl alcohol solution covering the face, neck, shoul-
ders, and upper chest. Shortly after application of the anti-
septic and placement of the surgical drapes, the surgeon
used the electrosurgical unit on the incision. He immediately
noted smoke around the incision site. The anesthesiologist
then noted a flame on the right side of the patient’s face. The
fire was rapidly extinguished after the drapes were re-
moved. Plastic surgeons evaluated the patient’s lips, right
facial, temporal, and shoulder region that sustained third-
degree burns. The endotracheal tube was not affected or
damaged by the fire, and otorhinolaryngologists determined
that there was no evidence of airway burns. The tracheos-
tomy was performed after the patient was draped again and
the surgical site bathed with povidone iodine/isopropyl
Ten days after the original burn, the patient underwent
debridement of the right ear, nose, upper and lower eyelids,
cheek, and shoulder. The right shoulder burn was 85 mm ?
57 mm in size. TransCyte, a human fibroblast-derived tem-
porary skin substitute, was applied to the right side of the
face and ear.
The patient’s postoperative course was complicated by
prolonged respiratory failure, hemodynamic instability, en-
terococcal bacteremia, and acute respiratory distress syn-
drome thought to be related to her third-degree burns. She
died 80 days after her coronary artery bypass graft and
aortic valve replacement surgery.
Fires in the patient care setting can seriously injure a
patient or the surgical staff, damage equipment, and
even cause deaths. Despite all efforts from health care
organizations to prevent such events (2), approxi-
mately 50–100 or more surgical fires are reported in
Accepted for publication July 29, 2005.
Address correspondence and reprint requests to Naomi P.
O’Grady, MD, Medical Director, Procedures, Vascular Access, and
Conscious Sedation Services, Critical Care Medicine Department,
National Institutes of Health, Building 10, Room 7D43, 10 Center
Dr., MSC 1662, Bethesda, MD 20892. Address e-mail to nogrady@
©2006 by the International Anesthesia Research Society
Anesth Analg 2006;102:172–40003-2999/06
the in the United States each year (3). The circum-
stances that lead to the onset of fires vary, but three
elements are required to initiate and maintain a fire:
an oxidizer, a combustible substance, and an ignition
In the case presented here, the use of povidone
iodine/isopropyl alcohol solution was a critical factor
and likely the fuel in this surgical fire. Some key
observations support this conclusion. First, the initial
site of fire corresponded to the distribution of povi-
done iodine/isopropyl alcohol solution used to pre-
pare the surgical site. Second, the short time between
the preparation of the surgical site with the alcohol-
based solution and the use of the electrosurgical unit
(the ignition source) might suggest that the solution in
some areas of the surgical field was not yet entirely
dry and that the amount of alcohol vapor was sub-
stantial. Third, the distribution of the burned area on
the patient corresponded to the distribution of the
antiseptic solution. Therefore, these observations
strongly suggest that the ignition source (electrosurgi-
cal unit) initiated the fire, which was fueled by and
spread according to the distribution of the flammable
alcohol-based solution on the patient’s skin.
The fact that alcohol-based antiseptic solution can
provide fuel for surgical fires has been demonstrated
both by reports of surgical fires in ORs and in a
laboratory study (5). In that study, alcohol vapors
from surgical preparation solutions combined with a
large concentration of oxygen delivered by face mask
afforded the fuel and oxidizer components of a surgi-
cal fire triggered by the use of an electrosurgical unit.
Further, even before the CDC recommendation for the
use of alcohol-based antiseptic, the flammability of
these products has been a major safety concern.
Briscoe et al. (6) in 1976 investigated the role of flam-
mable antiseptics in OR fires. The antiseptics (mainly
chlorhexidine) based in 70 percent alcohol ignited at
900°C. In a 100% oxygen environment, the ignition
point was 30°C–70°C lower. Decreasing the alcohol
concentration of the solution to as small as 20% still
led to ignition in room air at 940°C and 890°C in 100%
oxygen environment. These temperatures are easily
reached with the use of typical electrosurgical units
(6). In our patient, the overwhelming physical evi-
dence of the case and the pattern of burn observed,
strongly suggest that the use of povidone iodine/
isopropyl alcohol solution was an important factor
and the fuel for the surgical fire.
ECRI (formerly the Emergency Care Research Insti-
tute), an independent nonprofit health services re-
search agency, reports that most surgical fires occur in
the airway (34%) and head or face (28%), and that in
74% of all cases of surgical fires, an oxygen-enriched
environment is a contributing factor (3). In fact, a
common contributor as the oxidizer in many surgical
fires during head and neck surgery is the delivery of
large concentrations of oxygen via a face mask (4).
Drapes covering a patient then result in accumulation
of concentrated oxygen under them (tenting). There-
fore, in an oxygen-rich environment, application of an
ignition source such as an electrosurgical unit, a defi-
brillator, a hot fiberoptic light source, or surgical laser
can readily initiate a fire (7–8). In fact, a laboratory
simulation of an operating room fire demonstrated
that without the closed space formed by a tent of
surgical drapes, the fire could not be initiated (5).
However, unlike most reports of surgical fire, in our
patient, it is unlikely that an oxygen-rich environment
contributed to the surgical fire, because the delivery of
a large concentration of oxygen (40% fractional in-
spired oxygen) was confined to a closed breathing
circuit. In addition, the circumstances of this surgical
fire suggest that a large oxygen concentration did not
contribute to the initiation and maintenance of the fire.
First, the fire occurred in the setting where the patient
had an endotracheal tube in place, which was attached
to a closed breathing circuit. Therefore, a large oxygen
concentration was not delivered openly in spaces sur-
rounding the surgical site as is often seen in patients
undergoing monitored anesthesia care when tenting
can occur. Second, the lack of fire in the airway would
suggest that high oxygen concentration was confined
to the breathing circuit and was not in continuity with
the area exposed to the electrosurgical unit.
Our report along with that of others (5) brings to
light the fact that with increased use of alcohol-based
skin antiseptics for hand hygiene and preparation of
the site of invasive procedures, the potential for fire
may increase in the hospital setting. Recognition that
these flammable agents are associated with fire haz-
ards warrants implementation of measures to increase
awareness and to prevent fires in the OR. Chlorhexi-
dine and povidone-iodine solutions are the most fre-
quently used skin antiseptics. Both solutions contain
isopropyl alcohol, a combustible substance. Although
there is no available documentation describing fires
involving chlorhexidine solutions, one can infer that
because chlorhexidine is only available in an alcohol-
based solution, it poses a potential risk for fires.
Povidone-iodine solution is also flammable, and sim-
ilar caution needs to be taken during its use. The
potential for fire is augmented when the alcohol-based
skin antiseptic is applied in ways that allow the solu-
tion to run off and wick into the patient’s hair, pool on
the skin, or wick into the surrounding linens. Atten-
tion to these details demands prolongation of the re-
quired drying time. If the patient is draped before the
solution is completely dry, alcohol vapors can be
trapped and channeled to the surgical site, where a
heat source could ignite the vapors (3).
The use of ignition sources coupled with the in-
creased use of alcohol-based antiseptics also calls for
increasing awareness of the increased fire hazard.
Electrosurgical units, surgical lasers, and fiberoptic Download full-text
light sources are very frequently used in the OR and
have substantial heating power that can ignite a fire in
an oxygen-enriched environment. Fiberoptic light
sources can transmit enough heat to cause charring of
surgical drapes that may lead to its ignition and fire in
the presence of high oxygen or nitrous oxide concen-
trations (4,8–10). Once again, awareness that using
more alcohol based substances in proximity to ignition
sources increases the risk of surgical fire is pivotal for
its prevention. Further, the use of alcohol-based anti-
septics calls for strict adherence to the proper use of
these substances, including observation of required
drying time. This may take a few minutes or more
until the field is completely dry (11).
In summary, with the new CDC recommendations
to use alcohol-based gel solutions for hand hygiene
and alcohol-based chlorhexidine solutions for skin an-
tisepsis before procedures, new risks are introduced.
In June 2003, the Joint Commission on Accreditation of
Healthcare Organizations issued a Sentinel Event
Alert on fires, calling on health care organizations to
educate their staff in preventing them. The report
underscores that education emphasizing how and
why fires start is the first and most important step to
take to reduce the risk of fires in the patient care
1. Guideline for hand hygiene in healthcare settings. J Am Coll
2. Joint Commission on Accreditation of Healthcare Organizations.
Organizations. Sentinel Event Alert. Issue 29, June 24, 2003.
3. ECRI. A clinician’s guide to surgical fires. Health Devices 2003;
4. ECRI. Fires from oxygen use during head and neck surgery.
Health Devices 1995;24:155–6.
5. Barker SJ, Polson JS. Fire in the operating room: a case report
and laboratory study. Anesth Analg 2001;93:960–5.
6. Briscoe CE, Hill DW, Payne JP. Inflammable antiseptics and
theatre fires. Br J Surg 1976;63:981–3.
7. Bruley ME, de Richemond AL. Supplemental oxygen versus
latent alcohol vapors as surgical fire precursors. Anesth Analg
8. Wolf GL, Sidebotham GW, Lazard JL, Charchaflieh JG. Laser
ignition of surgical drape materials in air, 50% oxygen, and 95%
oxygen. Anesthesiology 2004;100:1167–71.
9. Aly A, McIlwain M, Duncavage JA. Electrosurgery-induced
endotracheal tube ignition during tracheotomy. Ann Otol Rhi-
nol Laryngol 1991;100:31–3.
10. Macdonald AG. A brief historical review of non-anaesthetic
causes of fires and explosions in the operating room. Br J An-
11. ECRI. Improper use of alcohol-based skin preps can cause sur-
gical fires. Health Devices 2003;32:441–3.
CASE REPORT ANESTH ANALG