Intrathoracic fire during preparation of the left internal thoracic artery for coronary artery bypass grafting
© Friedrich et al; licensee BioMed Central Ltd. 2010
Received: 16 November 2009
Accepted: 10 March 2010
Published: 10 March 2010
A surgical fire is a serious complication not previously described in the literature with regard to the thoracic cavity. We report a case in which an intrathoracic fire developed following an air leak combined with high pressure oxygen ventilation in a patient with severe chronic obstructive pulmonary disease. The patient presented to our institution with diffuse coronary artery disease and angina pectoris. He was treated with coronary artery bypass graft surgery, including left internal thoracic artery harvesting. Additionally to this rare presentation of an intrathoracic fire, a brief review of surgical fires is included to this paper.
While surgical fires are rare, they can potentially result in significant morbidity and mortality [1–3]. A comprehensive literature search revealed only a limited number of intraoperative fires. The vast majority of cases involved endotracheal ventilation and the use of electrocautery or laser. Surgical fires are created with an igniting source (an oxidizer and fuel). Igniting agents include electrocautery or laser, which combine with either oxygen or nitrous oxide as the oxidizer. The fuel for the fire may be the surgical drapes, prepping agents, or even human tissue itself [2, 4, 5]. We present an interesting case of an intrathoracic fire in a patient undergoing LIMA harvesting during CABG surgery.
Spirometry before surgery.
< 0.30 kPa/L
The consequences of a surgical fire can be fatal [6–8]. Surgical fires can potentially happen whenever an invasive procedure is performed [9, 10]. There are very few reported cases of fires caused by a leaking oxygen connection in operating room [1, 2]. In other cases surgical fires resulted next to the airways [6, 11]. Under special conditions in the surgical environment the combination of: 1) oxygen, 2) an ignition source and 3) inflammable material - three essential elements - may result in a surgical fire [1, 2, 7]. In critical situations oxygen-rich ventilation is often needed. The use of 100% oxygen during episodes of hypoxemia is a cornerstone of anesthetic management. Additionally, in cases of open airways (e.g., tracheal, carinal, and bronchial resections) continuous positive airway pressure is often applied with preferred air-mixture of 100% oxygen to improve oxygenation . In such cases we must understand that high oxygen concentrations in closed spaces could increase a risk of fire [8, 9, 12]. It is important to note that under normal circumstances, modern inhalation anesthetics are not ignitable .
In the present case sevoflurane was used. Electrocautery or laser may have led increased the temperature near or above the ignition temperature [14, 15]. Aly et al.  reported a fire caused by electrocautery when it entered in to trachea, probably due to the high pressure stream of oxygen passing over the hot electrocautery tip and hot charred tissue. Casey and collaborators  reported an intratracheal fire ignited by Nd-YAG laser during treatment of tracheal stenosis. In our case, a lightbow initiated by electrocautery resulted in the fire of a surgical gauze sponge and the space around it. An alternative to electrocautery may be ultrasonic scalpels [16, 17] - the harmonic scalpel which contains a transducer system using piezoelectric crystals. Markovicz and colleagues  found that bipolar electrosurgery produced ten times more tissue damage than ultrasonic energy. Their study also showed that the harmonic scalpel produced less than 1°C temperature increase in the area of the LITA.
We did not expect that harvesting the LITA would induce a fire in a surgical sponge, given the thorax was open. The case demonstrates that pulmonary leakage may result in a high oxygen saturation of the pleural space, which may result in combination with electrocautery in burning of surgical materials/tissue. To avoid another occurrence in a similar case during harvesting of the LITA with an air leak we recommend the use of a wet surgical sponge for compression of the left lung.
In conclusion, the combination of the three components: fuel, oxygen, and ignition can induce a fire in the surgical field. This case points out the importance of persistent vigilance and quick reaction to prevent injury in the operating theater.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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