A cautionary tale for thoracic surgery teams: unexpected surgical fire during open-window thoracostomy: a case report

Introduction

Background

Surgical fires are recognized as a critical safety issue within operating rooms. These events, although infrequent, carry the risk of devastating consequences (1). Current literature indicates that heightened awareness and strict adherence to fire prevention protocols are pivotal in mitigating such risks. However, incidents continue to occur, suggesting gaps between knowledge and practice.

Rationale and knowledge gap

The fire risk is well recognized when the airway is exposed during surgery with high oxygen environments, such as tracheostomy or bronchial procedures (2-4). However, there is a paucity of literature regarding fire occurrence in procedures deemed to be at lower risk without direct airway exposure, as in open-window thoracostomy (OWT) for empyema due to bronchopleural fistula (BPF). The incident reported herein challenges this perception and highlights a knowledge gap in the understanding of fire risks during diverse thoracic surgical procedures.

Objective

The objective of this case report was to detail the unexpected occurrence of a surgical fire during an OWT and to dissect the contributing factors. This case study emphasizes the awareness of surgical fires beyond traditional high-risk scenarios, the importance of communication between surgical teams, and the universal application of fire safety protocols. We present this article in accordance with the CARE reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-24-7/rc).

Case presentation

A 72-year-old male, a former smoker, underwent a right upper lobectomy for squamous cell carcinoma. He developed severe respiratory failure due to aspiration pneumonia and acute respiratory distress syndrome. We performed a tracheostomy on postoperative day 7. Additionally, he suffered from empyema secondary to BPF (Figure 1). On postoperative day 69, we performed an OWT. The patient required two-lung ventilation with 70% oxygen due to hypoxemia at the beginning of the surgery. The oxygen concentration was increased to 100% due to escalating air leakage and respiratory failure. We packed gauze into the thoracic cavity to decrease air leakage and improve oxygenation.

Figure 1 Chest computed tomography scan pre-open-window thoracostomy. Chest computed tomography scan taken two months after the onset of acute respiratory distress syndrome following the primary lung resection (just before open-window thoracotomy) demonstrates bilateral diffuse patchy ground-glass opacities, fibrotic areas with honeycombing, and bronchiectasis. The bronchopleural fistula orifice (blue arrows) and the infected pleural cavity (yellow arrowheads) are also visible.

During the procedure, a surgical fire occurred when electrocautery was used for partial resection of the second rib outside the thoracic cavity (Figure 2). The fire was quickly extinguished by pouring saline and did not spread to the surgical drapes. Bronchoscopy showed no inhalation injury (Figure 3A), and only mild burn injuries were observed at the edge of the surgical wound (Figure 3B). The surgery was completed without further use of electrocautery (Video S1). The patient’s respiratory condition improved after OWT, and the burn injuries healed within a month. The BPF closed six months post-OWT, and the patient was discharged one year after lung resection.

Figure 2 Occurrence of surgical fire. The surgical fire occurred outside the thoracic cavity during the procedure.

Figure 3 Bronchus and skin findings post-surgical fire. Bronchoscopic image after surgery shows no significant burns in the bronchial mucosa surrounding the bronchopleural fistula orifice (arrow) (A). Only mild burns (arrowheads) in the skin surrounding the open-window thoracostomy incision (B) after surgical fire are shown.

At the time of discharge, the patient and his family mentioned that they felt well-informed about the procedures and trusted the expertise of the surgical team. Despite the unforeseen complications, they were satisfied with the care the patient received and the outcome of the procedures.

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration (as revised in 2013). 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 editorial office of this journal.

Discussion

Key findings

The key finding of this case report is that a surgical fire during a thoracic surgical procedure is not always associated with known high-fire-risk situations. It underscores the importance of recognizing fire hazards in a broader range of surgical environments and sharing them among surgical team members.

Explanation of findings and comparison with similar research

Surgical fires have been reported during tracheostomy, oropharyngeal surgery, endoscopic laser surgery, and facial surgery (2-6). A study of fire incidents during surgery found that 97% of fires caused by electrocautery occurred above the xiphoid process, with 12% in the oral and tracheostomy areas (7). Surgical sites above the xiphoid process pose a high risk due to their proximity to oxygen sources and the frequent presence of an oxygen-enriched atmosphere (OEA). In thoracic surgery, surgical fires have been reported during bronchoplasty in lung transplantation and repair of broncho-esophageal fistula (7), both involving opened airways exposed in the surgical field.

During the surgery in our case, due to the presence of BPF and two-lung ventilation with high oxygen concentration, there was an occurrence of OEA both inside the thoracic cavity and on the patient’s body, which resulted in a fire outside the thoracic cavity. Unfortunately, the surgical team failed to recognize and communicate the potential risk for surgical fire based on OEA at the surgical site, which could have been caused by BPF and the potential need for intraoperative high oxygen concentration. This issue should have been discussed preoperatively to prevent such incidents.

To prevent surgical fires, surgical teams should be familiar with fire risks, communicate effectively, and implement preventive measures. In this case, if the team had adequately communicated and shared the risk factors associated with OEA at the surgical site due to BPF and the need for high oxygen concentration, they could have avoided using the electrosurgical devices or opted for devices at low risk for surgical fire, such as ultrasonic devices, thereby preventing the fire (8).

In this case, extracorporeal membrane oxygenation (ECMO) was considered a contingent plan to manage oxygenation. This decision focused on maintaining adequate oxygen levels rather than proactively addressing the potential fire risk due to airway exposure. This risk was not fully appreciated in our preoperative assessment. Recognizing the airway exposure in retrospect, ECMO would have been employed preemptively, thereby strictly limiting oxygen levels at the surgical site to mitigate the fire risk.

Current guidelines recommend keeping the oxygen concentration as low as necessary to maintain adequate tissue oxygenation, particularly in surgeries with a risk of airway exposure to open flames or ignition sources. Ideally, for surgeries with a high fire risk, the fraction of inspiratory oxygen (FiO₂) levels should be kept at or below 30% when possible (1,8). However, in our case, clinical circumstances required FiO₂ levels to exceed this preferred threshold, reaching up to 70%, which highlights the challenge of balancing optimal oxygenation against fire safety. These experiences underscore the importance of considering all potential risks, including those that are less apparent, in preoperative planning.

Strengths and limitations

A strength of this report is the detailed documentation of the incident, allowing for a thorough analysis. Lessons learned from this experience highlight the critical role of communication and risk factor sharing among surgical teams and the need for preventive measures for surgical fires. To reduce the risk of OEA at the surgical site, anesthesiologists should minimize the concentration of oxygen and consider one-lung ventilation whenever possible. Surgeons, on the other hand, should avoid using electrosurgical devices in cases where there is a risk of OEA.

The limitation of this case report includes the singular nature of the case, which may not provide a broad representation of such events.

Implications and actions needed

Effective communication about OEA risks, utilization of low-risk devices, and minimizing oxygen concentration by anesthesiologists are essential preventive measures. Our experience emphasizes the necessity of vigilance and adherence to fire safety protocols to avert such incidents in thoracic surgeries.

Conclusions

In conclusion, surgical fires can have catastrophic impacts on both patients and surgical teams. Therefore, surgical staff must remain vigilant of the potential risks, even when the airway is not exposed. Effective communication among team members is crucial to identify possible risk factors and implement appropriate preventive measures. Open communication, awareness, and adherence to best practices can significantly reduce the likelihood of surgical fires and their associated complications.

Acknowledgments

The authors thank Editage for the English language editing.

Funding: This study was partially supported by the financial support provided by the Japan Medical Education Foundation (JMEF) through the Research Grant for Medical Education (No. J2203).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-24-7/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-24-7/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-24-7/coif). T.E. serves as an unpaid editorial board member of Shanghai Chest from January 2023 to December 2024. 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. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration (as revised in 2013). 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 editorial office of this journal.

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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