Operating Room Fires and Surgical Skin Preparation

BACKGROUND: Operating room fires are "never events" that remain an under-reported source of devastating complications. One common set-up that promotes fires is the use of surgical skin preparations combined with electrosurgery and oxygen. Limited data exist examining the incidence of fires and surgical skin preparations. STUDY DESIGN: A standardized, ex vivo model was created with a 15 x 15 cm section of clipped porcine skin. An electrosurgical "Bovie" pencil was activated for 2 seconds on 30 Watts coagulation mode in 21% oxygen (room air), both immediately and 3 minutes after skin preparation application. Skin preparations with and without alcohol were tested, and were applied with and without pooling. Alcohol-based skin preparations included 70% isopropyl alcohol (IPA) with 2% chlorhexidine gluconate, 74% IPA with 0.7% iodine povacrylex, and plain 70% IPA. RESULTS: No fires occurred with nonalcohol-based preparations (p < 0.001 vs alcohol-based preparations). Alcohol-based preparations caused flash flames at 0 minutes in 22% (13 of 60) and at 3 minutes in 10% (6 of 60) of tests. When examining pooling of alcohol-based preparations, fires occurred in 38% (23 of 60) at 0 minutes and 27% (16 of 60) at 3 minutes. CONCLUSIONS: Alcohol-based skin preparations fuel operating room fires in common clinical scenarios. Following manufacturer guidelines and allowing 3 minutes for drying, surgical fires were still created in 1 in 10 cases without pooling and more than one-quarter of cases with pooling. Surgeons can decrease the risk of an operating room fire by using nonalcohol-based skin preparations or avoiding pooling of the preparation solution.