A narrative review on surgical fire—where are we now?

Introduction

Surgical fires, though infrequent, present a significant hazard to patients and staff, carrying the potential for severe injury or even fatality. These types of fires pertain to all surgical subspecialities (urology, orthopedic surgery, general surgery) since all surgeons use different forms of energy-based devices. In the United States, these incidents are classified as ’sentinel events’ by The Joint Commission, akin to wrong-site surgeries or retained surgical items (1). While the annual incidence of surgical fires has decreased over the past decade, statistics indicate that there are between 200–240 isolated events and 2–5 deaths annually due to surgical fires in the U.S. (2). Despite their rarity relative to the volume of surgeries performed, many physicians and staff remain unaware of the intraoperative risk of surgical fires and lack proper management protocols. Managing fires in the operating room demands meticulous attention and swift action to ensure the safety of both patients and staff. By understanding the etiology, risk factors, mitigation strategies, and management protocols associated with surgical fires, healthcare professionals can collaborate effectively to eliminate surgical fires. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-22/rc).

Methods

A PubMed literature search was utilized to identify articles pertaining to surgical fires from the years 2004–2024. A total of 374 articles resulted using the following search terms: “surgical fires” OR “prevention and management of surgical fires” OR “fire triangle”. However, with further filters, 28 articles were selected to review for this review. This article aims to comprehensively address surgical fires, covering their causes, risk factors, prevention strategies, and management protocols; empowering healthcare teams to create a secure operating room environment. A summary of the search strategy is provided in Table 1.

Discussion

The fire triangle

Surgical fires occur when three elements—an ignition source, a fuel source, and an oxidizer (oxygen)—converge, forming what is known as the fire triangle (Figure 1) (3). The fire triangle illustrates the foundation of fire science, offering a straightforward framework to grasp the conditions essential for fire initiation. This concept finds application within the controlled yet volatile environment of the operating room.

Figure 1 The fire triangle and commonly used flammable materials found in the operating room (3).

Each component of the fire triangle is unfortunately ubiquitous in surgical environments. It is important that hospital staff know each element of the fire triangle to mitigate fire risk. Oxygen, the primary component of the triangle, plays a crucial role in sustaining life and fostering tissue healing. However, its abundance within operating rooms heightens the fire hazard as an oxidizer. Both oxygen and nitrous oxide are effective oxidizers and can significantly increase the chance of ignition of fuel sources. While many items in the operating room are labeled as flame resistant, they still have the potential to catch fire and cause harm. It has been shown that common surgical material, such as gowns, laparotomy pads, and drapes, which are labeled as flame resistant, can become flammable with small elevations in oxygen content (Figure 2) (4). In addition, a slight increase in oxygen content can decrease the time to ignition and significantly increase the intensity of the surgical fire. The other two parts of the fire triangle, fuel sources and ignition sources, are also critical to recognize in the operating room to minimize the risk of a surgical fire. Ignition sources are often present in the operating room in the form of electrosurgical equipment, lasers, and fiberoptic light sources (5). The use of electrosurgical devices is the etiology of many surgical fires in the United States, the most common being a monopolar electrosurgical device (6). Lastly, surgical drapes, alcohol-based preparations, and even the patient can serve as fuel sources in the operating room, completing the fire triangle.

Figure 2 Common materials that are fuel sources for surgical fires in the operating room separated based on patient dependent and independent factors.

Understanding the fire triangle reveals its interdependent nature—fires only arise when each component of the triangle is present. Effective fire safety strategies necessitate addressing all three elements, whether through preventative measures like material handling protocols or suppression tactics such as utilizing extinguishing agents. Staff awareness of the fire triangle empowers hospitals and staff to mitigate fire risks, fortify safety protocols, and respond adeptly to fire emergencies. Through formalized fire safety plans, hospitals can minimize the potential harm to patients and staff, underscoring the vital role of this foundational concept in safeguarding healthcare environments.

Surgical fires and energy-based devices

The popularity of minimally invasive surgeries has steadily increased in recent years, with over fifteen million laparoscopic procedures performed annually across the globe (7). While laparoscopic surgery presents distinct advantages over open surgery for certain procedures, it is not without unique risks. These include issues such as pain from gas distension, patient burns caused by laparoscopic instruments, and even surgical fires from the laparoscopic equipment. Most of these injuries stem from stray energy released by electrosurgical currents from the electrosurgical devices. While surgical burns from laparoscopic equipment are more common, fires can also result from laparoscopic equipment, such as the camera and light cord used to illuminate the surgical field. This equipment can reach temperatures well over the point of ignition and can cause devastating surgical fires.

Proper illumination of the body cavity during laparoscopic surgery is essential for visualization, achieved through a combination of light sources and cables. Different light sources offer varying qualities of light and temperatures, with most equipped with safety mechanisms to mitigate heat production. Laparoscopic light cables, commonly fiberoptic, transmit light via reflections through small glass fibers. However, the distal end of these cables can reach temperatures that exceed the ignition threshold of surgical drapes (8). Consequently, mishandling of laparoscopic light cords poses a risk of operating room fires and patient burns during these procedures.

Ignition sources, often controlled by surgeons, include electrosurgical units and lasers. Improper use of these devices, particularly in oxygen-rich environments or near flammable materials, can lead to fires. Electrosurgery is the use of high frequency electrical current to cut, coagulate, or desiccate tissue and can be performed in several modes, including monopolar and bipolar energy. Electrosurgical units, accounting for most operating room fires, require careful handling to prevent sparks. Monopolar energy allows current to pass from the probe electrode, into human tissue, and to a return pad on the patient to complete the electrical circuit. In contrast, bipolar energy utilizes a current that passes the human tissue between the two distal ends of the forceps electrode (9). Bipolar uses less voltage so less energy is required to achieve the desired effect. However, since it has limited ability to assist in the cessation of bleeding, it is more utilized for procedures where tissue can be grabbed with the forceps electrode. Monopolar energy can be used to cut, blend, desiccate, and fulgurate tissue. Monopolar devices are shaped like a pencil instrument and the active electrode is placed onto tissue to achieve the desired effect. The return electrode is a gel pad attached to the patient so that the current flows from the generator through patient tissue, and to the return pad. Monopolar energy is most used in surgery because of its versatility and its ability to stop bleeding (10). The current in bipolar mode is restricted to the tissue between the arms of the forceps, giving better control over the area being targeted and preventing damage to other tissues, significantly reducing the risk of burns compared to that of monopolar mode. All electrosurgical units can cause burn injuries to patients; however, only monopolar devices cause a spark resulting in ignition and the potential to cause a surgical fire. Proper care of these devices should be standardized to limit risk including placing the instrument in a nonconductive holster when not in use, using the lowest generator setting to achieve the desired tissue effect, cleaning the electrode tip frequently. It is recommended for surgeries that are high risk (airway procedures or head and neck surgeries) to use bipolar or ultrasonic devices due to the inability to create a spark, therefore, minimizing the risk of a fire. It is also recommended that these devices should not be used in the presence of flammable agents, the cables should not be wrapped around the instrument, and that users should avoid any towel clips or additional metal instruments on the surgical field (11).

Regarding the camera and light source in laparoscopic surgery, experts have recognized this risk of fires and patient burns during laparoscopic procedures and have offered several suggestions on how to minimize this risk (12).

• The laparoscopic light source should not be illuminated before the cable is connected to the laparoscopic camera to minimize the distal end igniting.
• If the light cable is disconnected from the camera during the operation for any reason, then the distal end should be held away from the drapes, placed in a moist towel, or turned off.
• Illuminated cords should be kept away from surgical drapes, patient skin, operating room staff, or any other flammable materials.

All laparoscopic surgeons should adhere to these guidelines to minimize fire risk. It is also imperative that residents receive comprehensive education on the correct handling of laparoscopic equipment and become acquainted with the common pitfalls associated with these instruments. Hospital institutions can play a crucial role by implementing protocols for the proper handling of laparoscopic equipment. For instance, labeling all light sources with warning labels can effectively alert users to potential risks. These labels should emphasize the risk of igniting drapes and other materials, stress the importance of ensuring proper fiberoptic cable connections before activating light sources, and recommend holstering devices when not in use to minimize fire hazards.

By taking these simple measures and prioritizing education for operating room staff, the occurrence of complications in laparoscopic surgery can be significantly reduced. Returning to the concept of the fire triangle, maintaining a safe distance between the ignition source (such as a laparoscopic light cable or laparoscope) and the fuel (represented by surgical drapes or the patient) in an oxygen-rich environment is essential for mitigating the risk of fires and burns.

Prevention strategies

Surgical fires pose a significant risk in operating rooms, with communication playing a pivotal role in their prevention. Each year in the United States, numerous lawsuits arise from surgical fires, often due to lapses in communication among team members. The American Society of Anesthesiologists (ASA) task force emphasizes the importance of proactive communication between surgeons and anesthesiology staff regarding potential ignition sources and oxygen-rich environments (13).

The current standard of care is to assign a surgical fire risk assessment score to each procedure and surgery that takes place in the hospital (Figure 3). The scale ranges from 0–3 with 3 being the highest risk operation. One point is given for each of the following: (I) surgical site above the xiphoid, (II) an open oxygen source is used, (III) and if an ignition source is present during the surgery (14). Most hospitals have a set of protocols to follow if a surgery is considered high risk. These pathways include utilizing high oxygen flow rate and a low fraction of inspired oxygen during the operation, replacing open oxygen circuits, such as nasal canula, with compressed air or discontinuing supplemental oxygen for a period (2–4 minutes) prior to use of electrocautery, and having sterile water available to douse fires if needed. It is also imperative that surgeons use the lowest energy setting for their electrocautery devices that still allow them to achieve the desired result and function. Many assessments also have areas to document time allowed to dry for skin preparation, ensuring that at least 3 minutes has passed since the last application of skin preparation until the start of surgery. By proactively addressing potential fire hazards before an operation and fostering a culture of safety within an operating room, staff can minimize the likelihood of fires.

Figure 3 An example of a fire risk assessment tool that hospitals utilize before all surgical procedures to minimize the risk of a surgical fire to improve safety for healthcare workers and patients. prep, preparation; N/A, not available.

Anesthesiology staff are primarily responsible for managing oxidizing compounds in the operating room, such as oxygen and nitrous gas. These compounds are found in most operation rooms and have been shown to drastically increase surgical fires especially involving monitored anesthesia care (MAC). MAC entails administering anesthesia while monitoring vital signs and patient consciousness during surgical procedures while utilizing masks or nasal cannulas to deliver supplemental oxygen. Unlike general anesthesia, where patients are completely unconscious, MAC allows patients to maintain partial consciousness. Despite its benefits, including quicker recovery times and reduced risks compared to general anesthesia, MAC has been associated with an increased risk of surgical fires compared to traditional anesthesia methods. Studies on operating room fires indicate that most fires caused by electrocautery occur during procedures involving MAC. Reported instances of fires during MAC increased from six percent in the period from 1985 to 1989 to one third of cases from 2000 to 2009. The majority of cases (99%) of fires during MAC occurred in conjunction with the use of supplemental oxygen, with 64% of incidents involving plastic surgery procedures on the head and neck (15). The concentration of oxygen delivered via mask or nasal cannula around the head and neck region can be particularly hazardous during such procedures. It has been shown that when oxygen is present in concentrations above 30%, it significantly increases the risk of a surgical fire. To mitigate these risks, the American Society of Anesthesiologists Practice Advisory Committee recommends several precautions. These include minimizing the use of supplemental oxygen during MAC procedures and maintaining the lowest feasible fraction of inspired oxygen to sustain adequate oxygen saturation. Additionally, the adoption of open draping techniques, which involve methods to prevent the accumulation of oxygen beneath surgical drapes, can further reduce the risk of fire.

Surgeons and surgical staff must control and minimize fuel sources within the operating room. Common fuel sources include surgical drapes, warming blankets, Bair huggers, and alcohol-based skin preparation solutions (3). Skin preparation before surgery is crucial to prevent post-operative wound infections. Three primary agents used in the operating room are chlorhexidine gluconate, iodophors, and alcohol. The widely used ChloraPrep contains 2% chlorhexidine gluconate and 70% isopropyl alcohol, known for its flammability (16). Most fires caused by preparation solutions stem from solution pooling, whether under the drapes or in the umbilicus or other crevices on the patient’s body. Fire risk assessment should guide skin preparation practices, adhering closely to manufacturer instructions to ensure patient safety. Although many hospitals advocate a 3-minute dry time, studies suggest little evidence supporting this duration, emphasizing instead the importance of monitoring for solution pooling and wet appearances, which are more indicative of fire risk (17,18).

In response to the ongoing threat of surgical fires, the Joint Commission issued a sentinel event alert in 2023, outlining preventive actions. These actions include comprehensive preoperative risk assessments, maintaining oxygen concentrations below thirty percent, managing electrosurgical devices during procedures, and providing staff training. Education and training programs, including simulation-based learning, play a crucial role in raising awareness and standardizing fire safety protocols across healthcare facilities.

The exponential rise of energy-based devices in the operating room has revolutionized surgery, however, these new devices present a new set of risks and can lead to injury and harm to both the patient and user. The annual incidence of surgical fires caused by surgical devices continues to rise (Figure 4) (19). To combat this safety issue, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) created The Fundamental Use of Surgical Energy (FUSE) program. FUSE is an initiative to assist surgeons with the understanding behind electrosurgical devices to minimize risks (20). This program is offered to surgeons, other physicians, and residents to gain basic knowledge on how to safely use energy-based devices in the operating room. The FUSE curriculum offers three main sections: (I) a standardized curriculum that is online based and free to the user; (II) continuing medical education credits that can be obtained from the online curriculum for a small fee; and (III) an assessment consisting of 80 multiple choice questions to ensure the surgeon has the knowledge and tools to safely perform and react to situations in the operating room that may arise with electrosurgical instruments (21). FUSE courses are currently being taught worldwide and are a requirement of numerous certifications for general and minimally invasive surgeons. FUSE also provides hands-on courses for surgeons to simulate operating room fires in a controlled setting. FUSE continues to undergo development and stays up to date on emerging devices to continue to fill the gap in resident and physician curriculum to ensure that surgeons are competent and safe when using energy-based devices.

Figure 4 Annual incidence of surgical fires caused by electrosurgical devices from 2006–2016 from the U.S. Food and Drug Administration Manufacturer and User Device Experience Database. Data extrapolated from Overbey et al. (19).

Comprehensive preoperative risk assessments are essential in identifying potential fire hazards and risks. Continuous quality improvement efforts, including regular safety protocol reviews and staff feedback mechanisms, help enhance fire prevention measures. Training programs increase awareness among healthcare professionals about the causes and prevention strategies related to surgical fires. Simulation-based learning allows practitioners to practice responding to fire scenarios in a controlled environment, fostering essential skills in fire risk identification and mitigation. Effective communication, proactive risk assessment, and comprehensive training are vital components in preventing surgical fires. By implementing these preventive measures, healthcare facilities can ensure patient safety and minimize the occurrence of these preventable incidents.

Response strategies

Operating room fires can be categorized into those involving the patient directly (airway fires and fires on a patient) and those confined to the surgical environment. When a fire affects the patient, immediate extinguishment, and removal of burning material are paramount to prevent further harm. Simultaneously, discontinuing all anesthetic gases, especially oxygen, is essential for fire mitigation. Once the fire is under control, patient care resumes, with the surgical team discussing next steps. In cases where surgical drapes or other flammable materials ignite, caution is imperative due to their waterproof nature. Surgeons should use saline or moist surgical towels to smother the flames, avoiding actions that could agitate or spread the fire.

While rarely used for surgical fires, knowledge of the use of fire extinguishers is essential. The rating of a fire extinguisher depends on the type of fuel involved in the fire. Class A fuels, such as drapes, paper, and human tissue, are distinct from Class B fuels, which encompass flammable skin preparation agents like ChloraPrep (22). Fires involving electrical equipment fall under Class C. Carbon dioxide extinguishers are classified as Class A and B; however, they can also be used for Class C fires after the equipment is unplugged. Another type of extinguisher, the water mist extinguisher, employs distilled or ionized water. Though permitted in operating rooms, these extinguishers may harbor bacteria and are limited to Class A and C fires, providing no protection against Class B fires (23).

Clean agent fire extinguishers use either a chemical or inert gas to suppress a fire and are incredibly effective at covering Class A, B, and C fires but are heavier and more expensive compared to CO₂ extinguishers. Both Emergency Care Research Institute (ECRI) and ASA advocate for carbon dioxide extinguishers as the most suitable for operating rooms, particularly when patients are the fuel source, as they lack ammonium phosphate, reducing contamination and tissue damage (24). For enhanced safety measures in the event of a surgical fire, the current recommendation is to mount a 5-pound CO₂ extinguisher outside each operating room to ensure swift response. In case of a fire, immediate priority lies in protecting patients and staff from harm. When dealing with a fire on a patient, water, or saline in a nearby basin should be used first. If surgical drapes catch fire, they must be swiftly removed from the patient and extinguished on the floor using a fire extinguisher. It is crucial for all operating room staff to be familiar with the location and operation of fire extinguishers within the hospital. Operating room staff must be up to date on the PASS technique, an acronym for Pull, Aim, Squeeze, and Sweep, which is a fundamental method for effectively using a fire extinguisher. First, Pull the pin at the top of the extinguisher to break the tamper seal. Next, Aim the nozzle or hose at the base of the fire, ensuring a targeted approach. Then, Squeeze the handle to release the extinguishing agent, maintaining a steady grip throughout. Finally, Sweep the nozzle or hose from side to side, covering the entire base of the fire with the extinguishing agent until the flames are completely suppressed (25). This technique maximizes the efficiency of the extinguisher and enhances the safety of both individuals and property in the event of a fire emergency.

Airway fires, while rare, can have catastrophic consequences. Immediate action is crucial in such scenarios. First, all anesthetic gases must be halted, and the endotracheal tube should be removed. Injecting saline into the airway can help extinguish the fire. Following this, reintubation and ventilation are often needed to reestablish patient oxygenation (26). During surgeries involving the airway, electrocautery units or lasers, commonly used for tissue coagulation or cutting, pose significant risks. Gases like oxygen and nitrous oxide, which are highly combustible, make non-flammable drapes and patient tissue, inherently flammable. Even when intubated, surgeons and anesthesiologists should not assume the cuff is intact. Leaks around the endotracheal tube can occur, resulting in the accumulation of gases in the oropharynx and creating an oxygen-rich environment prone to ignition. Flammable materials, including endotracheal tubes, surgical sponges, and patient tissue, further heighten the risk. Managing an airway fire requires a specialized approach and many clinicians are surprised at the recommendation to remove the ETT after disconnecting the circuit. This key step should not be missed as trapped oxygen with the lungs and airway results in persistence of the fire and more extensive damage. The duration of time the patient is without oxygenation is often well within tolerance as, in practice, these maneuvers can be done in 60 seconds or less by experienced and trained surgical teams. Once the airway is re-established, common practices such as inhaled bronchodilators and humidification can aid in reducing bronchospasm and alleviate mucous plugging or airway dryness following a fire. In all cases of airway fire, immediate cessation of the case and transfer to a burn center is essential to optimizing outcomes (27). Airway edema can develop rapidly following a fire and maximal support may be required and should not be underestimated.

Regular, annual, emergency drills are essential for preparing the surgical team to respond efficiently to fires. These drills should simulate various scenarios, allowing team members to practice their roles effectively. Additionally, conducting thorough analyses of fire incidents helps identify root causes and areas for improvement, informing protocol refinement, equipment updates, and training program enhancements.

One of the most effective methods for training surgical staff in fire prevention and management is the use of simulations and augmented reality. Simulations provide a controlled, risk-free environment where surgical teams can practice identifying potential fire hazards, executing fire prevention strategies, and responding effectively in the event of a fire. Through repeated, hands-on experience, healthcare professionals can build muscle memory and increase their confidence in handling these critical situations. Simulations can be tailored to replicate a variety of surgical scenarios, thereby broadening the scope of training and enhancing the versatility of the surgical team’s response capabilities. Augmented reality further enhances simulation-based training by overlaying digital information onto a physical environment. This technology can be used to create realistic fire scenarios that incorporate dynamic visual and auditory cues, providing an immersive experience that closely mirrors real-life situations. Augmented reality can highlight potential ignition sources and flammable materials, offering real-time feedback and guidance on best practices for fire prevention and control. By integrating augmented reality into surgical training, teams can benefit from an engaging and interactive learning experience that reinforces key safety concepts and promotes a deeper understanding of the complexities involved in preventing surgical fires. By implementing these preventative measures above and maintaining a culture of safety within the surgical team, the risk of surgical fires can be significantly reduced, ensuring the well-being of patients and staff alike.

Conclusions

In conclusion, the importance of implementing robust surgical fire prevention measures cannot be overstated. While surgical fires remain rare, their potential for catastrophic consequences demands unwavering attention from all healthcare professionals involved in surgical procedures. By addressing the components of the fire triangle and implementing stringent protocols for risk assessment, material selection, and oxygen administration, healthcare facilities can significantly reduce the likelihood of surgical fires. Moreover, the identification and elimination of potential ignition sources, coupled with comprehensive training programs and regular equipment maintenance, are indispensable in safeguarding patient safety.

Education emerges as a cornerstone of effective fire prevention strategies, necessitating continuous learning and collaboration among multidisciplinary teams. By fostering a culture of vigilance and open communication, healthcare institutions can ensure that every member of the surgical team remains prepared to confront potential fire hazards swiftly and effectively. Looking ahead, ongoing research and innovation in fire prevention technology and training methods offer promising avenues for further enhancing patient safety in surgical settings. By embracing a comprehensive approach grounded in collaboration, education, and unwavering commitment to excellence, we can minimize the risk of surgical fires and ensure that every procedure unfolds safely, preserving both patient well-being and the integrity of the healthcare profession.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-22/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-22/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-22/coif). E.J. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from September 2023 to August 2025, and receives consulting fees from Boston Scientific for providing training in Laparoscopic Common Bile Duct exploration. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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