耳鼻喉科中的手术大火

August 12, 2009

Ronda Alexander, MD
Assistant Professor

TheWall Street Journalreported recently that approximately 650 surgical fires are reported in U.S. hospitals each year, and another three to four times as many are “near misses” or unreported events.1对于外科医生，麻醉医生和 /或员工而言，手术大火的风险是非常真实和合理的关注。当考虑未报告的手术火灾数量时，风险变得更加重要。

Ignition Source + Fuel + Oxidizer = Fire

手术火灾需要发生“经典三合会”元素：创建火花，燃料（要燃烧）和氧化剂的点火源。电外科单元，激光器和光线都是手术火灾的点火源。手术室大火中“燃料”的常见来源包括气管管，手术室窗帘或毛巾，海绵和酒精准备解决方案。2The presence of an oxidizing agent, such as oxygen or nitrous oxide, is the final key factor in the triad. All three of these elements must be present in order to ignite a fire in an operating room.

Higher Risk in ENT Procedures

Intraoperative fires are a well-described and potentially devastating complication of surgery; head and neck or ENT surgical procedures are at the highest risk of operating room fire, due to the presence of exposed supplemental oxygen around flammable materials. Fires have been reported during tracheostomy, adenotonsillectomy, and skin surgery of the head and neck.3–5My colleague Lee Smith, MD, (of Schneider Children’s Hospital in Long Island, New York) and I recently surveyed members of the American Academy of Otolaryngology-Head and Neck Surgery on their experience with surgical fires. We were surprised to learn that 25 percent of respondents had personally witnessed a fire in the operating room. The complete survey responses are currently being presented at an upcoming national meeting.6

消除点火源

Our research team has conducted a series of scientific experiments to determine the risk factors of various surgical modalities, including electrocautery (Bovie), CO2在过去两年中，激光和双极射频消融（共振成）。我们检查了内窥镜手术中使用卤素灯源，电外科手术（2）的内窥镜手术中发生火灾和烧伤的风险，并创建了机械模型，以研究口咽和气道手术中的火灾风险。7

为了在机械模型中复制口咽手术，将6.0个气管管插入了整个Raw鸡的颅端，通过该鸡肉以每分钟10升的方式将100％的氧气管道。之所以使用生鸡，是因为有机组织对于电孔设备进行电力是必要的，而鸡肉腔的体积和大小近似于人类口腔和口咽。机械模型模拟了在常规扁桃体切除术中可以看到的口咽中的游离氧的设置。然后，我们在腔室中的鸡肉组织上测试了电动机设备（Bovie），并在相同情况下测试了双极射频等离子体消融装置（共振子）。

虽然我们能够使用电动器设备非常快速地点燃火灾（在大多数试验中30秒钟（图1和图2）中，我们都无法在我们的任何机械模型中使用Coblator造成火灾。

我们的研究表明，虽然电外科设备和CO2lasers (Figure 3 and Figure 4) present a significant risk of fire during open cavity surgery in oxygen-enriched environments, that risk appears to be eliminated with bipolar radiofrequency plasma ablation.7

我们推测，共镀技术不会产生点燃火的必要的“火花”，从而阻止了火灾的点火。此外，共振兴会导致较少的热能耗散，而周围温度较低，从而进一步降低了点火风险。通过消除点火源，即使在100％富含氧气的环境中，在我们的机械模型中消除了口腔和口咽火的风险。

Awareness is Key to Reducing Risk

As with any potential hazard, awareness is the first step to prevention. Last May, the American Society of Anesthesiologists (ASA) issued a practice advisory for the prevention and management of operating room fires. The advisory detailed several precautions for the OR team to follow to help avoid surgical fires.8

在每个手术病例之前，或团队应确定手术火灾的高风险。如果存在高风险的情况（即存在三合会），则团队应决定防止和管理火灾的计划和角色。护理人员，麻醉师和外科医生之间的沟通至关重要。

The role of oxygen and nitrous oxide are important factors to consider. The anesthesiologist should collaborate with all surgical team members throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source. One of our recent studies evaluating the minimum oxygen requirements to obtain a fire in our mechanical model suggests that a fraction of inspired oxygen (FiO2）低于50％的人可能会消除点火的风险，9and we are currently performing additional studies to quantify these risks.

限制“火三合会”的任何手臂都降低了手术火灾的风险。电动机和CO2当三合会的其他臂存在时，激光都可以用作点火源。即使在存在100％纯氧的情况下，在“最高风险”情况下，共晶棒也不具有点燃的能力，因此不被视为点火源。这表明，即使存在氧气和燃料源，双极射频等离子体消融也消除了开放腔手术期间火灾的风险。

What to do if a Surgical Fire Occurs

医疗专业人士同意，在手术火灾的情况下，最重要的是消除火灾并保护患者。当发生手术大火时，请停止手术，清除着火的一切，然后立即减少氧气。这些必须同时同时发生，以最大程度地减少患者受伤的风险。

In June 2003, The Joint Commission, a nonprofit group that accredits and certifies more than 15,000 healthcare organizations and programs in the United States, issued a Sentinel Event Alert on reducing surgical fires. In the alert, the group recommends that healthcare organizations help prevent surgical fires by:

  • 通过遵循激光和ESU安全实践，通知工作人员（包括外科医生和麻醉师）有关控制热源的重要性
  • 通过允许足够的时间使患者准备蒸发来管理燃料；并建立指南，以最大程度地减少窗帘下的氧气浓度
  • developing, implementing, and testing procedures to ensure appropriate response by all members of the surgical team to fires in the OR

Organizations are strongly encouraged to report any instances of surgical fires as a means of raising awareness and ultimately preventing the occurrence of fires in the future. Reports can be made to Joint Commission, ECRI, the Food and Drug Administration (FDA), and state agencies, among other organizations.10Airway fires are a significant risk in the OR, but with awareness, the proper tools, and preventive measures, they can be easily avoided.

References

  1. Landro, L. In Just a Flash, Simple Surgery Can Turn Deadly. Wall Street Journal, Informed Patient. February 18, 2009
  2. Smith LP，Roy S.Fire/burn risk with electrosurgical devices and endoscopy fiber optic cables.Am J Otolaryngol. 2008 May-Jun;29(3):171-6.
  3. Niskanen M, Purhonen S, Koljonen V, et al.Fatal inhalation injury caused by airway fire during tracheostomy.Acta Anaesthesiol Scand. 2007; 51(4): 509-13.
  4. Prasad R, Quezado Z, St. Andre A, et al.Fires in the operating room and intensive care unit: awareness is the key to prevention.Anesth肛门。2006;102（1）：172-4。
  5. Varcoe RL, MacGowan KM, Cass AJ.Airway fire during tracheostomy.ANZ J Surg. 2004; 74(6): 50.
  6. 史密斯LP,罗伊美国耳鼻喉科专家的经验智慧h Operating Room Fires. Survey of the membership of the American Academy of Otolaryngology–Head and Neck Surgery, 2008. To be presented at AAO-HNS annual meeting, October 2009
  7. Roy S, Smith LP. “Device-Related Risk of Airway Fire in Oropharyngeal Surgery” Abstracts of the AAO-HNS Annual Meeting, 2008; in press, American Journal of Otolaryngology
  8. 练习预防和管理手术室火灾的咨询。麻醉学。2008年5月； 108（5）：786-801。
  9. Roy S, Smith LP: What does it take to start an Oropharyngeal Fire? Abstracts of the Society for Ear, Nose and Throat Advances in Children, 2008 meeting
  10. 防止手术大火。联合委员会。Sentinel事件警报；第29期 - 2003年6月24日。[阅读更多]
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