Crisis in the operating room: Fires, explosions and electrical accidents

Journal of Artificial Organs

Volumn 13, Issue 3, 2010, Pages 129-133

  Nishiyama, Keiko ^a   Komori, Makiko ^a   Kodaka, Mitsuharu ^a   Tomizawa, Yasuko ^b  

^a TOKYO WOMEN'S MEDICAL UNIVERSITY   (Japan)

^b TOKYO WOMEN'S MEDICAL UNIVERSITY   (Japan)

Author keywords

Electrical breakdown; Explosion; Fire; Heart lung machine; Operating room

Indexed keywords

ALCOHOL; ANTIINFECTIVE AGENT; CHLORHEXIDINE GLUCONATE; METHANOL; POVIDONE IODINE; THIOMERSAL;

BURN; CARDIOPULMONARY BYPASS; DEATH; ELECTRIC ACCIDENT; EXPLOSION; FIRE; HEAD AND NECK SURGERY; HEART LUNG MACHINE; HUMAN; LAPAROTOMY; OPERATING ROOM; PNEUMATOSIS INTESTINALIS; PRIORITY JOURNAL; SHORT SURVEY; SURGICAL EQUIPMENT; TRACHEA INJURY; TRACHEA OBSTRUCTION;

ACCIDENTS; ELECTRICITY; EQUIPMENT FAILURE; EXPLOSIONS; FIRES; HUMANS; OPERATING ROOMS; SMOKE INHALATION INJURY;

EID: 78149406726     PISSN: 14347229     EISSN: None     Source Type: Journal    
DOI: 10.1007/s10047-010-0513-0     Document Type: Short Survey

References (41)

1. AG Macdonald 1994 A brief historical review of non-anaesthetic causes of fires and explosions in the operating room Br J Anaesth 73 847 856 1:STN:280:DyaK2M7os1eisQ%3D%3D 10.1093/bja/73.6.847 7880680
2. ECRI. Fires from oxygen use during head and neck surgery. Health Devices. 1995;24:155-6.
3. ECRI. A clinician's guide to surgical fires. Health Devices. 2003;32:5-24.
4. ML Rogers RW Nickalls ET Brackenbury FD Salama MG Beattie AG Perks 2001 Airway fire during tracheostomy: prevention strategies for surgeons and anaesthetists Ann R Coll Surg Engl 83 376 380 1:STN:280:DC%2BD38%2FkvFKrtw%3D%3D 11777128
5. M Niskanen S Purhonen V Koljonen A Ronkainen E Hirvonen 2007 Fatal inhalation injury caused by airway fire during tracheostomy Acta Anaesthesiol Scand 51 509 513 1:STN:280:DC%2BD2s7nslyitA%3D%3D 10.1111/j.1399-6576.2007. 01280.x 17378792 (Pubitemid 46425738)
6. HM Wang KW Lee CJ Tsai IC Lu WR Kuo 2006 Tracheostomy tube ignition during microlaryngeal surgery using diode laser: a case report Kaohsiung J Med Sci 22 199 202 10.1016/S1607-551X(09)70308-0 16679303
7. DH Paugh KW White 2005 Fire in the operating room during tracheotomy: a case report AANA J 73 97 100 15835828
8. RN Kaddoum EJ Chidiac MM Zestos Z Ahmed 2006 Electrocautery-induced fire during adenotonsillectomy: report of two cases J Clin Anesth 18 129 131 10.1016/j.jclinane.2005.09.032 16563331
9. CC Wu CH Shen WM Ho 2002 Endotracheal tube fire induced by electrocautery during tracheostomy: a case report Acta Anaesthesiol Sin 40 209 213 12596621
10. SA Rogers KG Mills Z Tufail 2001 Airway fire due to diathermy during tracheostomy in an intensive care patient Anaesthesia 56 441 443 1:STN:280:DC%2BD3M3lt1WntA%3D%3D 10.1046/j.1365-2044.2001.1317/az1174.x 11350329 (Pubitemid 32447522)
11. DA Baur RC Butler 1999 Electrocautery-ignited endotracheal tube fire: case report Br J Oral Maxillofac Surg 37 142 143 1:STN:280:DyaK1M3pslOgsQ%3D%3D 10.1054/bjom.1997.0095 10371323 (Pubitemid 29213498)
12. AK Chou PH Tan LC Yang GC Sun SW Hsieh 2001 Carbon dioxide laser induced airway fire during larynx surgery: case report Chang Gung Med J 24 393 398 1:STN:280:DC%2BD3MvmvVCgsQ%3D%3D 11512372
13. JI Simpson GL Wolf 1986 Endotracheal tube fire ignited by pharyngeal electrocautery Anesthesiology 65 76 77 1:STN:280:DyaL283ms1Kgsg%3D%3D 10.1097/00000542-198607000-00012 3729060
14. A Aly M McIlwain JA Duncavage 1991 Electrosurgery-induced endotracheal tube ignition during tracheotomy Ann Otol Rhinol Laryngol 100 31 33 1:STN:280:DyaK3M%2FptVentA%3D%3D 1985525
15. AM Ho S Wan MK Karmakar 2007 Flooding with carbon dioxide prevents airway fire induced by diathermy during open tracheostomy J Trauma 63 228 231 10.1097/TA.0b013e31805f7011 17622897 (Pubitemid 47057602)
16. JI Simpson GL Wolf A Rosen Y Krespi GA Schiff 1991 The oxygen and nitrous oxide indices of flammability of endotracheal tubes determined by laser ignition Laryngoscope 101 981 984 1:STN:280:DyaK3MzlvFOqug%3D%3D 10.1288/00005537-199109000-00009 1886447
17. A Avgerinos N Kalantzis G Rekoumis G Pallikaris G Arapakis T Kanaghinis 1984 Preparation and the risk of explosion during colonoscopic polypectomy Gut 25 361 364 1:STN:280:DyaL2c7lvFOisg%3D%3D 10.1136/gut.25.4.361 6423457
18. EW Taylor S Bentley D Youngs MR Keighley 1981 Bowel preparation and the safety of colonoscopic polypectomy Gastroenterology 81 1 4 1:STN:280: DyaL3M3htlensg%3D%3D 6786947
19. MF Barrkman 1965 Intestinal explosion after opening a caecostomy with diathermy Br Med J 1 1594 1595 1:STN:280:DyaF2M%2Fpt1OisQ%3D%3D 10.1136/bmj.1.5450.1594 14288130
20. JM Branday 1982 Jejunal gas explosion resulting from use of diathermy Br J Surg 69 728 1:STN:280:DyaL3s%2Fns1ajuw%3D%3D 10.1002/bjs.1800691214 7171974 (Pubitemid 13201865)
21. HW De Wilt RIH Borel KJ Brouwer 1996 Gas explosion during colonic surgery J R Coll Surg Edinb 41 419 8997036
22. N Shinagawa H Mizuno Y Shibata J Yura K Katsumi M Ito T Takeuchi 1985 Gas explosion during diathermy colotomy Br J Surg 72 306 1:STN:280: DyaL2M7nsFOrug%3D%3D 10.1002/bjs.1800720420 3986483 (Pubitemid 15090964)
23. PR Freund HM Radke 1981 Intraoperative explosion: methane gas and diet Anesthesiology 55 700 701 1:STN:280:DyaL38%2Fms1arug%3D%3D 10.1097/00000542- 198155060-00021 6795975
24. AR Dhebri SE Afify 2002 Free gas in the peritoneal cavity: the final hazard of diathermy Postgrad Med J 78 496 497 1:STN:280:DC%2BD38vivVyktg%3D%3D 10.1136/pmj.78.922.496 12185229 (Pubitemid 34948162)
25. R Tooher GJ Maddern J Simpson 2004 Surgical fires and alcohol-based skin preparations ANZ J Surg 74 382 385 10.1111/j.1445-1433.2004.02997.x 15144262 (Pubitemid 38703731)
26. EP Fong WT Tan LT Chye 2000 Diathermy and alcohol skin preparations-a potential disastrous mix Burns 26 673 675 1:STN:280:DC%2BD3M%2FgvFejtA%3D%3D 10.1016/S0305-4179(00)00020-6 10925195 (Pubitemid 30488068)
27. ME Bruley AL de Richemond 2002 Supplemental oxygen versus latent alcohol vapors as surgical fire precursors Anesth Analg 95 1464 10.1097/00000539- 200211000-00080 12401653
28. M Hargrove BC Ramish A O'Donnell T Aherne 2002 Electrical failure during cardiopulmonary bypass: an evaluation of incidence, causes, management and guidelines for preventative measures Perfusion 17 369 372 1:STN:280: DC%2BD38votFGgsg%3D%3D 10.1191/0267659102pf592oa 12243442
29. M Hargrove T Aherne 2007 Possible fire hazard caused by mismatching electrical chargers with the incorrect device within the operating room J Extra Corpor Technol 39 199 200 17972456
30. Uetera Y, Saitoh H, Matsumoto T. Intraoperative emergency situation: countermeasures for electrical failures in operating rooms at the University of Tokyo. Syujutsuigaku. 1999;20:386-9 (in Japanese).
31. Kawatani Y, Iwahana M, Sugahara S. A problem in extended operating room design resulted in power failure during surgery: a case report. J Jpn Assoc Oper Room Technol. 2003;24:63-6 (in Japanese).
32. Takado S. An electric supply stopped suddenly due to the power failure etc. Clin Eng. 2005;16:24-8 (in Japanese).
33. GL Wolf GW Sidebotham JL Lazard JG Charchaflieh 2004 Laser ignition of surgical drape materials in air, 50% oxygen, and 95% oxygen Anesthesiology 100 1167 1171 1:CAS:528:DC%2BD2cXktlKnsr8%3D 10.1097/00000542-200405000-00019 15114214 (Pubitemid 38541972)
34. Aoyagi S, Tayama E, Isamoto Y. Heart-lung machine suspended without electricity break down. Clin Eng. 2002;13:815-6 (in Japanese).
35. Kudo K. Human errors during heart-lung procedures: a suddenly stopped centrifugal pomp. Clin Eng. 2004;16:29-33 (in Japanese).
36. Kato M, Tamura H, Yamaguchi M, Shimada T, Hasegawa T, Ito T, Kawaharada S, Higami T. Testing of motion of a centrifugal blood pump in a cold environment. Jpn J Artif Organs. 2009;38:S-81 (in Japanese).
37. Kobayashi Y, Soyama Y, Hashimoto T, Hutae M, Yoshida H. Performance evaluation of a hand crank for a centrifugal pump. J Extra Corpor Technol. 2005;32:420-2 (in Japanese).
38. Y Tomizawa A Tokumine S Ninomiya N Momose T Matayoshi 2008 Quantitative evaluation of hand cranking a roller pump in a crisis management drill J Artif Organs 11 117 122 10.1007/s10047-008-0418-3 18836871
39. N Momose Y Tomizawa 2008 Incident-simulating device with wireless control for extracorporeal circulation crisis management drills Perfusion 23 17 21 1:STN:280:DC%2BD1cngtF2kug%3D%3D 10.1177/0267659108093874 18788213
40. Tomizawa Y, Yozu R, Momose N, Anno M, Matayoshi T, Minami S, Kenmoku K, Kamiya K. Troubleshooting simulations during extracorporeal circulation in a wet-lab. Jpn J Artif Organs. 2006;35:233-6 (in Japanese).
41. Kawata S, Yamaguchi K, Sawasaki H, Dohno T, Kubota S, Takahashi H, Kuroda H, Ookubo Y, Adachi A, Yoshimoto K, Miyatake T, Ooba J, Aoki H. Examination of a trouble simulation - the result of having carried out the wet lab in the hospital. J Extra Corpor Technol. 2009;36:38-43 (in Japanese).