Airway Management II: Lecture 7 - Laser Airway

Question 1

For fire prevention, what member of the perioperative team is most in control of the fuel sources?

Answer 1

Surgeon
Anesthesia Care Provider
Nurse

Question 2

Which of the following supports combustion greater?

Answer 2

A. 100% O2
B. 50% O2/50% N2O
C. 35% O2/ 65% N2O
D. All of the above support combustion equally

Question 3

What does the fire acronym RACE stand for?

Answer 3

Rescue, alarm, confine, extinguish

Question 4

Airway Fires Youtube

Answer 4

https://www.youtube.com/watch?v=FjA3dEyutt4

Question 5

Case Report #1

Answer 5

A well-known surgical colleague was performing endoscopic sinus surgery on a patient under local anesthesia with MAC when he encountered a bleeder at the base of the septum. Since electrocautery was connected and pinned to the drape, he picked up the hand piece with the needle point attached, put his suction device on the source of bleeding, placed the needle point on the spot, and pressed the cautery button. Instantly, there was a dull “poof,” a red- orange flare, and smoke filled the patient’s nasal cavity. What the surgeon did not realize was that the anesthesia practitioner, who was administering the heavy IV sedation, had inserted narrow-gauge plastic tubing into the opposite nostril as a precaution against over- sedation and was administering O2 at the time.

When the smoke cleared and the nasal cavity was suctioned out, it was apparent that the patient had sustained severe burns of the septal mucosa, turbinates, and nasopharynx that evolved into disastrous consequences and an indefensible lawsuit.

Question 6

Laser Surgery

Answer 6

Light
Amplification by
Stimulated
Emission of
Radiation

Advantages:
Dry field
Good hemostasis
Rapid healing and minimal scarring
Surgical accuracy
Preservation of normal tissue
High degree of sterility
Decreased post op edema and pain
Shorter surgical time/recovery

Question 7

Characteristics of Lasers Commonly Used in the OR

Answer 7

Question 8

Type of Laser Determined By?

Answer 8

Procedure
Type of Surgery
Location
Requirement of the Physician

Question 9

Laser Protection

Answer 9

Personnel:
Laser specific protective eyewear (goggles) w/ sideguards

Patient:
Protective goggles (not always used unless the procedure is up near the airway)
Moist eye patches
Moist towels
Laser protected ETT (if working in the airway)

Question 10

Operating Room Hazards

Answer 10

Retinal or corneal damage

Laser plume of smoke can lead to lung problems:
Interstitial pneumonia
Bronchiolitis
↓ mucociliary clearance
Inflammation
Emphysema
Vector for certain viruses

Airway fires/OR fires

Question 11

OR Fire Statistics

Answer 11

Incidence 100 per year – Reported

27 million OR cases per year

Experts in the field estimate that the number of reported fires represents from 1% to 10% of the total number of fires

Ignores “near misses”…
…fiberoptic cable scorching a “bullet” hole in the drapes without any flames, and virtually no smoke

If you assume reported fires represent 10% of actual fires and there are 3 “near misses” for every actual fire, then there are roughly 1,000 OR fires per year and 3,000 near misses for a total of 4,000 incidents/year. This works out to about one incident per every 6,750 procedures. If your institution performs 10,000 procedures/year, then your facility could easily encounter one incident per year.

Question 12

What are the two categories of fire in the operating room?

Answer 12

External fires
Involving drapes, dressings, gauze sponges, or objects such as tubing or petroleum-based ointments, etc., in which immediate action by the surgeon (and surgical team) can limit injury.

Internal airway fires
Involving the endotracheal tube in which immediate action by the anesthesiologist (and/or anesthetist) and surgeon is critical.

Each category requires different response strategies to mitigate injury.

Question 13

What Makes a Fire?

Answer 13

Question 14

What is the ESU?

Answer 14

Electrosurgical units (ESU)
… also known as a Bovie

Provide electrical energy that is used to cut and coagulate tissue

The energy is delivered to the tissue through an active electrode controlled by the surgeon

These sources can create sparks and lead to fires.

Question 15

What is an Oxidizer Enriched Atmosphere (OEA)?

Answer 15

Oxygen rich environment
Highly combustible

An OEA can significantly increase the risk of fire during surgical procedures.

Question 16

Fire Requirements

Answer 16

Two major ignition sources:
Electrosurgical units (ESU)
Lasers

Virtually any piece of electrical equipment can short out and lead to sparks and arcing

Question 17

More Ignition Source Visuals

Answer 17

Question 18

What are the sources of fuel in the OR?

Answer 18

Fuel
There are several sources of fuel in the OR including some that are subtle

Linens: gown, drapes, blankets, and paper goods.

Prep Agents: Alcohol, aerosols, tinctures, and degreasers such as acetone

Dressings: Stockinet, tape, sponges, and gauze

Ointments: Wax, benzoin, petroleum, aeroplast

Equipment/Supplies: anesthesia components, insulation material around cables and wires, gloves, cuffs, and hoses

Patient: Hair, particularly around the face, and GI tract gases such as methane

Understanding these fuel sources helps in fire prevention strategies.

Question 19

Fuel Source: Drapes

Answer 19

Hang vertically from the operative field to the floor

Vertical alignment of the drapes allows flames to rapidly
spread

Can obscure flames, smoke, and heat

The flame retardant feature can increase the risk that a fire underneath the drapes will go undetected for a longer period of time

The upside-down U configuration of the drapes presents the worst of four scenarios - fires beneath drapes are often difficult to detect, but once they involve the bottom edge of the drapes they spread explosively

Question 20

Body Hair

Answer 20

Body hair is extremely flammable, particularly when saturated with oxygen

Fine hair covering most body surfaces and found predominately on the face easily ignites

After ignition, the fire can spread at two to ten feet per second

Question 21

Oxygen Sources

Answer 21

The OR is an Oxidizer Enriched Atmosphere (OEA)

OEA can transform a flame into an instantaneous flash or explosion

What is not generally appreciated is that even a relatively modest increase in the 02 level such as from 21% to 25% can accelerate the spread of fire

Another source of oxygen is nitrous oxide which is sometimes used in general anesthetics (mainly dental offices)

Question 22

Oxygen Sources from Anesthesia

Answer 22

Airway surgeries frequently use oxygen and nitrous oxide to ventilate and anesthetize patients:

Support combustion

Reduce the amount of energy (e.g., current, heat, friction) needed to ignite flammable substances

During airway surgery, these gases leak around the tracheal tube, its cuff, or packing, creating an OEA in the oropharynx

Some fuels that will not burn in the 21% concentration of oxygen found in room air will burn vigorously in an OEA.

Question 23

Created Gases

Answer 23

During surgery a portion of the tissue heated by an ESU turns to gas, some of which – especially gas evolved from fatty tissue – will burn, if made hot enough or if mixed with sufficient oxygen

Reinforces the need to evacuate smoke as close to the surgical site as possible

Question 24

Recommendations to Avoid Airway Fires

Answer 24

Surgeons and anesthesiologists should be aware of the hazards of using ESUs in the OEAs commonly present in the oropharynx and trachea

Only commercially available insulated probes should be used
Do not use red rubber catheter or other materials to sheathe probes

Surgeon should not use ESUs to cut tracheal rings and enter the airway
Using scissors or a scalpel instead will avoid the risk of fire

Be sure that any sponge, gauze, or pledget used in the airway is applied wet and kept wet

Use laser appropriate ETT

Fill cuff with methylene blue tinted NS

Question 25

True or False: Body hair is extremely flammable, particularly when saturated with oxygen.

Answer 25

True ## Footnote Fine hair can easily ignite and spread fire quickly.

Question 26

Communication

Answer 26

Awareness of the risk of fire and communication between the surgeon and the anesthesiologist can allow for turning the oxygen off at these times or switching to air. Oxygen tends to pool under the drapes and may take some time to disperse when switched off.

Question 27

Protocol for Airway Fires

Answer 27

Question 28

ASA Operating Room Algorithm

Answer 28

1 Ignition sources include but are not limited to electrosurgery or electrocautery units and lasers. 2 An oxidizer-enriched atmosphere occurs when there is any increase in oxygen concentration above room air level, and/or the presence of any concentration of nitrous oxide. 3 After minimizing delivered oxygen, wait a period of time (e.g., 1-3 min) before using an ignition source. For oxygen dependent patients, reduce supplemental oxygen delivery to the minimum required to avoid hypoxia. Monitor oxygenation with pulse oximetry, and if feasible, inspired, exhaled, and/or delivered oxygen concentration. 4 After stopping the delivery of nitrous oxide, wait a period of time (e.g., 1-3 min) before using an ignition source. 5 Unexpected flash, flame, smoke or heat, unusual sounds (e.g., a “pop,” snap or “foomp”) or odors, unexpected movement of drapes, discoloration of drapes or breathing circuit, unexpected patient movement or complaint. 6 In this algorithm, airway fire refers to a fire in the airway or breathing circuit. 7 A CO2 fire extinguisher may be used on the patient if necessary.

Question 29

Fire Prevention General

Answer 29

Turn off O2 at the end of the case... Room air ~ 21% O2 Typical OR room air ~22% Leaving the O2 on in an OR all weekend will greatly increase the O2 concentration leads to increased risk of OR fire Know how to use a fire extinguisher PASS (Pull, Aim, Squeeze, Sweep)

Question 30

Fire Prevention for AA

Answer 30

The ESU deserves special attention since so many risks involve the ESU During MAC cases discontinue O2 use during ESU or laser use... ...This reduces the ambient O2 level. Stop O2 at least one minute prior to ESU usage and wait at least one minute after ESU usage before resuming O2

Question 31

Fire Prevention for Surgeon

Answer 31

Keep the ESU in a non-conductive holster... ...Protects drapes from inadvertent discharge of the ESU ESU, Light Cables and Laser Use... ...Activate only when the tip of the unit is in view and deactivate before the unit is removed from the surgical site ...Place in “stand-by” mode when not in use Bowel Procedures... ...Be aware that methane may be present in bowel and use caution with the ESU ...Similar care must be exercised with body cavities containing O2 or nitrous oxide Clean ESU Electrodes Often... ...Carbonized tissue can contribute to arcing. It also increases resistance, makes the unit less effective, and may result in a request to "increase the bovie" Use Care with ESU Wires... ...Avoid coiling and kinking of ESU wires which can lead to induction currents or shorts Use Hand Activated-ESU's and Avoid Foot-Activated Units... ...Lowers the risk of inadvertent discharge of the ESU Avoid the ESU When Cutting Tracheal Rings... ...Reduces the risk of airway fire ESU Power Settings... ...Use the lowest power setting possible with the ESU, and activate for short periods of time. Avoid long periods of use with high power settings Evacuate Gaseous Products of ESU... ...Reduces one potential source of fuel or ignition ESU Return Pad... ...Place the pad over a wide area over a large muscle mass close to the surgical site

Question 32

What should be done to avoid airway fires during surgery?

Answer 32

* Use commercially available insulated probes * Do not use red rubber catheter * Keep sponges and gauze wet * Use laser appropriate ETT * Fill cuff with methylene blue tinted NS ## Footnote These measures are critical to prevent fires in the airway during surgeries.

Question 33

What is the communication protocol for airway fires?

Answer 33

Reestablish the airway and resume ventilating with air until certain that nothing is left burning in the airway ## Footnote Then switch to 100% oxygen and examine the airway via FOB.

Question 34

Important Acronyms

Answer 34

When responding to a fire (RACE): Rescue Alarm Confine Extinguish To effectively use a fire extinguisher (PASS): Pull Aim Squeeze Sweep

Question 35

What are the three main classes of fire extinguishers encountered in the OR?

Answer 35

* Class A: Used on paper, cloth, and plastic * Class B: Used when liquids or grease are involved * Class C: Used for energized electrical equipment ## Footnote Understanding the appropriate extinguisher type is crucial for effective fire management.

Question 36

What is the responsibility of the surgical team regarding fire prevention?

Answer 36

Fire prevention is a shared responsibility of the entire surgical team ## Footnote Each member must be vigilant and proactive in managing fire risks.

Question 37

What should be done at the end of the case regarding oxygen?

Answer 37

Turn off O2 at the end of the case ## Footnote Leaving O2 on increases the risk of OR fire.

Question 38

What is recommended to clean ESU electrodes?

Answer 38

Clean ESU Electrodes Often ## Footnote Carbonized tissue can contribute to arcing and decrease the effectiveness of the unit.

Question 39

What are always present during surgery?

Answer 39

Factors of a fire. ## Footnote This includes elements like heat, fuel, and oxygen, which together form the fire triangle.

Question 40

What is the best defense against an ignition incident during surgery?

Answer 40

Vigilance of the surgical team in controlling the fire triangle. ## Footnote This emphasizes the importance of teamwork and awareness in preventing fires.

Question 41

Who is responsible for fire prevention during surgery?

Answer 41

The entire surgical team. ## Footnote Fire prevention is a collective responsibility, not just limited to specific individuals.

Question 42

Fire Extinguishers

Answer 42

Three main classes encountered in OR: A, B, C Class A Used on paper, cloth, and plastic materials Class B Used when liquids or grease are involved Class C Used for energized electrical equipment

Question 43

Leadership and Prevention

Answer 43

Fire prevention is a shared responsibility of the entire surgical team... ...As a shared responsibility the surgical team needs to help each individual member of the team carry out her or his responsibility Nursing Staff: The nursing staff has most control of fuel sources and can take the lead in managing fuel sources Surgeons: Surgeons have most control over the sources of ignition and can take the lead in managing the sources of ignition Anesthesiologists: Anesthesiologists have most control of the sources of 02 and can take the lead in managing the sources of oxygen OR Manager: The OR Manager, with the support of the surgical team, should take the lead in designing procedures, providing resources, and implementing training sessions for all OR personnel

Question 44

Take Home Message

Answer 44

Fires are preventable in most cases Cases involving OR fires can be virtually indefensible and can result in substantial losses The most critical element in preventing OR fires is preoperative communication among the OR team: Surgeons should inform the anesthesiologist of the plan to use electrocautery Anesthesiologists should warn surgeons of the plan to use oxygen by cannula or any agent that supports combustion close to the surgical site. The basic elements of a fire are always present during surgery Vigilance of the surgical team in controlling the fire triangle is the best defense against an ignition incident Fire prevention is the responsibility of the entire team!!