Electrocautery–Induced Fire during Adenoidectomy:
Anesthetic and Surgical Contributions
John Aker, CRNA, MS
Abstract
Flash fires, mucosal burns, and endotracheal tube ignition are known to occur
with the use of electrocautery during otolaryngology procedures. Anesthetic and
surgical factors are contributory. Leaks around uncuffed endotracheal tubes, the
use of increased inspired oxygen, long periods of current flow to the electrocautery
tip, and failure to clear accumulated debris from the electrocautery tip increase the
risk of an airway fire. This case report outlines the anesthetic and surgical factors
that precipitated the development of an electrocautery‐induced fire during
adenoidectomy in an 8 year‐old female. With the use of a current literature review
precautions and recommendations are provided for the practitioner in an attempt
to understand the risk of electrocautery‐induced fire during otolaryngology
procedures.
Introduction
An 8‐year old, 28 kg white female was scheduled for elective adenoidectomy for
sleep obstructive breathing. She was not allergic to any environmental or
pharmaceutical agents. Her current medical history was indicative of sleep
disordered breathing with snoring during sleep, and witnessed periods of breathing
cessation. The parents sought consultation with their pediatrician concerning
behavioral changes (irritability) and accompanying daytime drowsiness.
Anesthetic induction was accomplished by mask in the sitting position with
nitrous oxide in 30% oxygen, with incremental increases in sevoflurane reaching an
end‐tidal concentration of 6%. Following a loss of consciousness she was positioned
supine, and a #22 intravenous catheter was placed in the left upper extremity using
Plasmalyte 148. With the loss of consciousness airway obstruction was
unmistakable, requiring a jaw‐thrust and 5‐10 cm H20 continuous airway pressure
which successfully ensured a patent airway. During the period of airway
obstruction nitrous oxide was discontinued and 100% oxygen was administered
with an inspired sevoflurane concentration of 5%. Endotracheal intubation was
facilitated with the intravenous administration of 2 mg of morphine sulfate and 40
mg of propofol. The trachea was intubated with an oral 6.0 uncuffed Ring, Adair,
and Ewlyn (RAE; Mallinckrodt, St. Louis, Mo) endotracheal tube (ET). A leak‐test
immediately following intubation revealed a leak at 18 cm H20.1
The operating table was turned 90°, and a Crow‐Davis mouth gag was placed.
Breath sounds were equal and bilateral, and spontaneous respirations resumed.
With assisted ventilation, (peak inspiratory pressure less than 15 cm H20),
sevoflurane was administered with a blended concentration of air (2 liters) and
oxygen (0.5 liters) to attain an inspired oxygen concentration less than 35%. Prior
to reaching the target inspired oxygen concentration the surgeon began the
adenoidectomy using electrocautery (Valley Lab, Boulder, CO) in the coagulation
mode at 15 watts with an inspired oxygen concentration of 60%. The power to the
electrocautery was continuous (> 45 seconds) during the initial adenoid
cauterization without periodic cleaning of debris from the electrocautery tip.
Approximately 90 seconds after the procedure began the surgeon suddenly yelled
“fire” witnessing a flame at the tip of the electrocautery despite the cessation of
electrocautery current. Oxygen administration was immediately discontinued,
normal saline was flushed into the oral pharynx extinguishing the flame, and the
electrocautery was immediately removed from the mouth. During withdrawal the
electrocautery tip came in contact with the left corner of the lower lip producing a
blister injury to the mucosa. The electrocautery electrode tip was noted to contain a
large build‐up of eschar. An immediate airway examination found no damage to the
ET or surrounding oral, pharyngeal, and nasopharyngeal mucosal surfaces.
Adenoidectomy was resumed with sevoflurane in 21% oxygen (air 2 liters/minute).
At the conclusion of the procedure the patient was awakened in the operating
theater, extubated, and transported to the recovery room with a patent airway and
spontaneous respiration. She had minimal complaints of the oral mucosal blister.
She was observed in the post‐anesthesia recovery area for an additional 2 hours and
then discharged to the care of her parents.
Review of the Literature
A Pubmed literature search was conducted from 1970 through 2008 using the
search terms oral, tonsil, adenoid, burn, electrosurgical, electrocautery, pharyngeal,
tonsillectomy, adenoidectomy, otolaryngology, and airway fire. Table I lists the case
reports that specifically address electrosurgical injuries occurring during
pharyngeal, or adenotonsillectomy surgical procedures.
Table I Literature Review of Electrosurgical Injuries during Otolaryngology
Surgical Procedures
Author
Year
Procedure
Outcome
Etiology
Gupte, SR 2
1972
Oral excision
Oral mucosal burn
Ignite gauze
Simpson and
1986
Pharyngeal
ETT Fire
ETT leak, High O2
Keller, et, al. 4
1992
Tonsillectomy
ETT fire
ETT leak, High O2
Trent, CS 5
1993
Tonsillectomy
Oral mucosal burn
Stray cautery
Wolf 3
3 ‐cases
Zinder, et al. 6
1996
Tonsillectomy
Oral commissure
Non‐insulated bipolar
burn
MacDonald et
1994
Tonsillectomy
Flash fire‐ bismuth
ETT leak, High O2
Tsuchida et al.8
1997
Tonsillectomy
Flash‐fire oral burn
Dry gauze/sevoflurane
Tschopp, K.9
2002
Adenoidectomy
Grisel syndrome
Monopolar
Guzman et al.10
2005
Tonsillectomy
ETT Fire
ETT leak, High O2
Reilly et al.11
2006
Tonsillectomy
Oral/lip burn
ETT leak, High O2
al.7
Kaddoum et
2006
Tonsillectomy
Flash‐no burn
ETT leak, High O2
2008
Adenotonsillectomy
Perioral burn
ETT leak, High O2
al.12
Nuara et al.
The survey of published case reports demonstrates that flash fire or mucosal injury
from electrocautery is most frequently reported during tonsillectomy. In 7 of the
twelve reviewed case reports, electrocautery ignition was presumed to occur as a
result of the use of a high‐inspired oxygen concentrations with an accompanying
leak from the ET resulting in intraoral burn injury.3,4,7,10‐13 Additionally, the use of
dry gauze packing to occlude an ET leak was etiologic in two of the case reports.2,8
Discussion
Based upon data from the Food and Drug Administration (FDA) and ERCI it is
estimated that there are approximately 100 surgical fires each year, producing 20
serious injuries and two patient deaths.14 These figures may reflect underreporting
as 200 surgical fires alone are reported yearly to the America Association of Nurse
Anesthetist (personal communication Chuck Biddle, CRNA, PhD).
The fire triangle requires a fuel source, an oxygen source, and a mechanism for
ignition. (See Figure I) There are abundant fuel sources within the operating
theater including alcohol‐based prep solutions, linens, surgical drapes, dressings,
gowns and masks. Ignition sources include electrosurgical units, lasers, fiberoptic
light sources, and fiberoptic cables. When examining root causes of intraoperative
fires, the most common ignition source is the electrosurgical unit, while the most
common site of fire is within the airway, or about the head or face.2,14,15,16
Since its introduction in the 1960’s, electrocautery is the most commonly
employed technique for pediatric adenotonsillectomy. The electrocautery cutting
mode is used for dissection and separation of tissue planes, while the coagulation
mode is selected for control of surgical bleeding. Despite the presence of the
needed ingredients for the fire triangle, adenoid tissue and a polyvinyl chloride ET,
(fuel source), increased inspired oxygen, (oxidizer) and the electrocautery (ignition
source), adenotonsillectomy has not been considered to be a high‐risk procedure for
the development of an airway fire.18 In a prospective study of 25 children
undergoing adenotonsillectomy, Mattucci and Militana intubated children ages 4‐11
years of age, with an uncuffed ET that was selected utilizing the formula [age+14]
/4. Controlled ventilation with a peak airway pressure of 20 cm H20 employing
50% oxygen in nitrous oxide with 3% sevoflurane was administered in each case
without the development of an airway fire.18 However, from the literature search, it
is apparent that the risk of fire is increased in the presence of an inspiratory leak
around the ET as the oxygen level at the vocal cords approximates the inspired
oxygen concentration.19 The introduction of gauze packing to halt the ET leak
serves as an additional fuel source that may be ignited.2,8
In this case report the fuel source was adenoid tissue that accumulated on the tip
of the electrocautery tip. In the AORN Recommended Practices for Electrosurgery,19
it is recommended that the electrocautery tip be cleaned frequently to remove the
buildup of eschar. Eschar buildup on the electrode tip serves, as a fuel source that
can lead to fire.20 An abrasive electrode‐cleaning pad should frequently be used to
remove the accumulated eschar.20
With the use of an ignition source (electrocautery), and the presence of a fuel
source (adenoid tissue, ET) that cannot be controlled, the anesthetist must take care
to minimize the leak of inspired oxygen from an uncuffed ET. Following intubation
there was an identifiable leak at 18 cmH20. Despite the attempt to minimize peak
inspiratory pressures below 15 cm H20, and the use of spontaneous ventilation, it is
likely that this leak increased following neck extension and placement of the mouth
gag. The addition of air to the inspired oxygen mixture was chosen (rather than
nitrous oxide which supports combustion) to dilute the oxygen concentration at the
vocal cords prior to the beginning of the adenoidectomy. In addition, a return to
spontaneous ventilation was allowed to further minimize the leak around the ET.
Yet, the adenoidectomy was initiated with a recorded inspired oxygen concentration
of 60%. This illustrates the importance of teamwork, and the responsibility of all
operating theater personnel (anesthetist and surgical team) to openly communicate
regarding the dangers of employing electrocautery in an increased oxygen
environment.
Although the ET did not ignite in this particular case, polyvinyl chloride ETs are
know to be flammable. The oxygen index of flammability of the polyvinyl chloride
ET is 0.25, e.g. the ET is flammable in an oxygen environment exceeding 25%.21
Accordingly, the inspired oxygen concentration should not be greater than 25%. Yet
many children presenting for adenotonsillectomy have a preoperative history of
sleep disordered breathing, that precipitates the preoperative development of
chronic hypoxemia and pulmonary hypertension and may require the
intraoperative administration of an inspired oxygen concentration in excess of
25%.22,23 The minimum desired inspired oxygen concentration must be selected
according to the patients co‐existing medical history. When a high‐inspired oxygen
concentration is required to maintain acceptable oxygen saturation, the surgeon
must be notified and an alternative surgical approach (elimination of
electrocautery) may be required.
The use of a cuffed ET would have controlled and prevented a leak of inspired
oxygen at the vocal cords (see Table II). However, the use of a cuffed ET in children
is controversial.24 It has been the professed understanding and traditional teaching
since the 1960’s that the use of a cuffed ET in children younger than 8 years of age
should be avoided.24 This teaching is not universally applied, and is empirical rather
than scientifically based. There is emerging evidence for the use of the cuffed ET in
the pediatric patient, and the application of a cuffed tube in this case may have
controlled the pharyngeal oxygen concentration, decreasing the risk of an
electrocautery‐induced fire.24
Table II. Advantages of Cuffed Endotracheal Tubes
Endotracheal tube sealing with cuff in trachea
Cuff volume easily adjustable
Use of low inspired gas flows
Precise determination of end‐tidal carbon dioxide
Decreased environmental pollution
Avoidance of repeat laryngoscopies
Reduced risk of aspiration
A recently published practice advisory for the prevention and management of
operating room fires outlines the importance of fire safety education, and the annual
review of institutional fire safety protocol.25 This advisory suggests that a cuffed ET
tube should be considered when an ignition source is in close proximity to an
oxygen‐enriched atmosphere.25 This case has resulted in a re‐examination of our
departmental practice of utilizing an uncuffed ET during adenotonsillectomy. The
adaptation of the currently manufactured cuffed ET for pediatric patients is
hampered by poor design (long cuff, Murphy eye, variable outside diameter,
inadequate depth markings).24 A newly designed, thin‐walled cuffed ET is currently
being developed specifically for use in the pediatric patient (Microcuff, Kimberly‐
Clark, Roswell, Georgia) and will be examined for future use in pediatric
adenotonsillectomy.
Summary
Adenoid tissue can serve as a fuel source and may be ignited by electrocautery in
the presence of an increased inspired oxygen concentration when a leak is present
around an uncuffed ET. The application of a cuffed ET allows the use of a lower
fresh gas flows, while providing a higher inspired oxygen concentration.
Furthermore, there must be collaboration and frank communication between all
members of the surgical team to minimize an oxidizer‐enriched atmosphere in the
proximity to an electrocautery ignition source.
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Figure I.
The Fire Triangle