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LETTER TO THE EDITOR

Fire During Thoracotomy: A Need to Control the Inspired Oxygen Concentration

Department of Anesthesia and Perioperative Care; University of California San Francisco; San Francisco, CA; katzj{at}anesthesia.ucsf.edu

To the Editor:

Fires in the operating suites, although considered rare events, are certainly one of the most frightening and potentially devastating experiences for those involved. Although exact numbers of operating room fire incidents are not known, it is estimated on the basis of data from the Food and Drug Administration and the ECRI that there are approximately 100 surgical fires each year in the United States, resulting in up to 20 serious injuries and one to two patient deaths (1).

We report a case of fire within the thoracic cavity during pleurectomy for mesothelioma. There are numerous case reports of surgical fires in the literature but only one case related to thoracic surgery (2). Recently, JCAHO issued a sentinel event alert regarding prevention of surgical fires (3). As with most surgical fires, the cause of the fire can be attributed to one or more arms of the fire triangle (4). The combination of a high-inspired oxygen fraction (Fio₂), dry gauze, and the electrocautery were all instrumental in producing the fire in our case.

A 66-yr-old 106-kg man was referred for right thoracotomy and radical pleurectomy and decortication for malignant mesothelioma. His past medical history included hypertension and diabetes mellitus. After placement of a right radial arterial cannula and a thoracic epidural catheter, anesthesia was induced with IV propofol 200 mg and fentanyl 250 µg, and neuromuscular blockade was achieved with rocuronium 80 mg. The trachea was intubated with a 39F left-sided double-lumen endobronchial tube (Bronchocath®), and anesthesia was maintained with desflurane, fentanyl, and oxygen. Double-lumen tube placement was checked by traditional inspection and auscultation, and correct positioning was confirmed using fiberoptic bronchoscopy. The patient was turned to the left lateral decubitus position for the planned right posteriolateral thoracotomy.

Initially, dependent one-lung ventilation was initiated to facilitate surgical exposure and define the extent of disease. To facilitate pleurectomy, the surgeon requested the right lung be re-expanded while countertraction was applied to the lung with a lap tape. The pleural plaque was peeled off the lung using electrocautery to seal the inevitable tearing of the visceral surface of lung controlling air leakage and bleeding. Suddenly an arc occurred, resulting in the dry lap tape catching on fire. The scrub nurse immediately doused the wound with water and the surgeon removed the lap tape, tossing it off the field onto the floor. The fire lasted only a few seconds.

Circumstances during thoracic procedures produce an environment favorable for producing a surgical fire. Typically, nearly 100% oxygen is used during a thoracotomy because of the increased intrapulmonary shunt during one-lung (dependent) ventilation. During this period of time, the ambient oxygen concentration in the thoracic cavity should be that of room air. However, with inflation of the operative lung, variable lung leaking may occur and if presented with a fuel source (e.g., a dry gauze lap pad) and a source of ignition (e.g., the electrocautery) the conditions are favorable to ignite a fire. To minimize the chance of fire within an oxygen-enriched environment, it is recommended to moisten the sponges with saline before putting them in the operative field. The intensity of the electrocautery should also be limited if possible.

Our case is somewhat different than what occurs during a typical lung resection surgery. During resection of the pleural plaque the surgeon requests an inflated lung rather than a collapsed lung. The pleurectomy nearly always results in visceral lung injury, resulting in gas leakage. It is here that the anesthesiologist can differentially control the oxygen concentration between the lungs. Nearly 100% oxygen should be delivered to the dependent (non-operative) lung while compressed air can be insufflated under continuous positive airway pressure to the operative lung. The surgeon has an inflated lung producing countertraction during pleurectomy, whereas the operative thoracic cavity will have an oxygen concentration of compressed air. One potential concern is that insufflating air with continuous positive airway pressure to the nondependent lung during one-lung ventilation might in fact lower the arterial oxygen partial pressure (Pao₂) by inhibiting hypoxic pulmonary vasoconstriction in the upper lung and thus increasing the intrapulmonary shunt. The insufflated air would raise the alveolar oxygen partial pressure to approximately 100 mm Hg, reversing hypoxic pulmonary vasoconstriction normally observed during one-lung ventilation. Counteracting the inhibition is uptake of oxygen from the nondependent lung even though the Fio₂ is only 0.21. We have employed this approach in several patients and our data indicate that Pao₂ is nearly unchanged when continuous positive airway pressure with compressed air is insufflated to the operative lung.

In conclusion, fire during thoracotomy can be a life-threatening emergency. The combination of a high Fio₂, a dry lap tape, and electrocautery increased the likelihood of an intraoperative fire. Although nearly 100% oxygen is recommended during thoracotomy and one-lung ventilation, differential lung ventilation and lowering the inspired oxygen fraction to the operative lung is indicated, especially when surgery is required on an inflated lung with concomitant air leaks.

References

1. ECRI. A guide to surgical fires: How they occur, how to prevent them, how to put them out. Health Devices 2003;32:5–24.[Medline]
2. Ortega R. A rare cause of fire in the operating room. Anesthesiology 1998;89:1608–9.[Web of Science][Medline]
3. Joint Commission on Accreditation of Healthcare Organizations. Preventing surgical fires. Sentinel Event Alert 29, June 24, 2003.
4. Barker SJ, Polson JS. Fire in the operating room: A case report and laboratory study. Anesth Analg 2001;93:960–5.[Abstract/Free Full Text]

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