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19 “Don’t Yell at Me!” Disruptive Behavior intheOR
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disruptive behavior in the OR.In 2008, the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) announced that disruptive behaviors would be
considered “sentinel events” and included any “intimidation and disruptive acts that
might foster errors, contribute to poor patient care, increase costs, and discourage
teamwork” [5]. JCAHO also recommends that “disruptive” physicians be nonpunitively educated and rehabilitated. This announcement has catalyzed professional societies, including the American College of Surgeons, to update and publish
professional standards and competencies, including interpersonal and communication skills and professionalism [60]. The result of these recommendations from
leadership is a call to hospitals to teach operative staff about how to identify and be
accountable for addressing disruptive behavior, as well as create accessible, nonpunitive processes for reporting disruptive behavior. After reports have been investigated, the institution should be obligated to have a transparent, consistent system in
place for dealing with and addressing these behaviors from surgeons. This can be
done with an intentional, organized OR and team structure, with clear expectations
of behavior and roles, multidisciplinary process improvement teams, bilateral active
feedback of team members, team-building initiatives, informal leaders, and rapidly
and consistently addressing disruptive behavior [61]. Villafranca and colleagues,
who have researched disruptive behavior and its effects on surgeons, surgical staff,
and patients, report that the key to mitigating disruptive behavior is prevention by
setting behavioral standards, helping clinicians to meet those standards, and selectively recruiting and hiring employees who are less likely to act disruptively [2].
This can be in the form of macro-level (institutional, cultural) solutions like monitoring compliance and enforcing standards, to microlevel solutions (individual,
team based) that support witnesses and those affected by disruptive behavior with
support to respond appropriately.
323
Conclusion: Call toLeadership forSurgeons
Disruptive behavior in the operating room can manifest in many forms and is the
product of individual, team, and cultural environment. The downstream effects of
disruptive behavior have implications for surgeons, teams, learners, surgical culture
at large, perioperative safety, and patient outcomes. As leaders of the operating
team, it is essential that surgeons do not contribute to disruptive behavior, either in
individual conduct or in perpetuation of a complicit culture. Understanding how to
recognize, address, manage, and ultimately prevent disruptive behavior in the operating room is of great importance, given that disruptive behavior has negative effects
on the surgeon, surgical teams, learners, and most importantly patients.
Preventing and addressing disruptive behavior in the operating room mandate a
multitiered approach. With a combination of systemic, institutional changes and
team-based approaches to promote a culture of open communication and teamwork,
a cultural shift can be instigated and perpetuated. Ultimately, interventions to effectively prevent and manage operating room conicts are successful when the focus
remains on improved patient care and outcomes [62]. As champions of patients and
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J. R. Coleman and R. Schulick
team leaders, surgeons must have an integral role in leading a culture of respect and
safety, void of disruptive behavior both in the operating room and within surgical teams.
References
1. American Medical Association. Report of the Council on Ethical and Judicial Affairs: physicians with disruptive behavior. https://www.ama- assn.org/delivering- care/ethics/physicians-
disruptive- behavior. Accessed 6 June 2019.
2. Villafranca A, Hamlin C, Enns S, Jacobsohn E.Disruptive behaviour in the perioperative setting: a contemporary review. Can J Anaesth. 2017;64(2):128–40.
3. Weber DO.Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician
Exec. 2004;30(5):6–14.
4. Tibble HM, Broughton NS, Studdert DM, Spittal MJ, Hill N, Morris JM, etal. Why do surgeons receive more complaints than their physician peers? ANZ J Surg. 2018;88(4):269–73.
5. Halverson AL, Neumayer L, Dagi TF.Leadership skills in the OR: part II: recognizing disruptive behavior. Bull Am Coll Surg. 2012;97(6):17–23.
6. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J
Surg. 2015;209(1):65–70.
7. Villafranca A, Fast I, Jacobsohn E.Disruptive behavior in the operating room: prevalence,
consequences, prevention, and management. Curr Opin Anaesthesiol. 2018;31(3):366–74.
8. Healey AN, Primus CP, Koutantji M.Quantifying distraction and interruption in urological
surgery. Qual Saf Health Care. 2007;16(2):135–9.
9. Arora S, Hull L, Sevdalis N, Tierney T, Nestel D, Woloshynowych M, etal. Factors compromising safety in surgery: stressful events in the operating room. Am J Surg. 2010;199(1):60–5.
10. Berguer R, Smith WD, Chung YH. Performing laparoscopic surgery is signicantly more
stressful for the surgeon than open surgery. Surg Endosc. 2001;15(10):1204–7.
11. Hassan I, Weyers P, Maschuw K, Dick B, Gerdes B, Rothmund M, etal. Negative stresscoping strategies among novices in surgery correlate with poor virtual laparoscopic performance. Br J Surg. 2006;93(12):1554–9.
12. Weber J, Catchpole K, Becker AJ, Schlenker B, Weigl M. Effects of ow disruptions
on mental workload and surgical performance in robotic-assisted surgery. World J Surg.
2018;42(11):3599–607.
13. Sevdalis N, Undre S, McDermott J, Giddie J, Diner L, Smith G.Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World
J Surg. 2014;38(4):751–8.
14. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, etal. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159–73.
15. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, etal. Communication failures
in the operating room: an observational classication of recurrent types and effects. Qual Saf
Health Care. 2004;13(5):330–4.
16. Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand.
2005;49(7):898–901.
17. Rogers D, Lingard L, Boehler ML, Espin S, Klingensmith M, Mellinger JD, etal. Teaching
operating room conict management to surgeons: clarifying the optimal approach. Med Educ.
2011;45(9):939–45.
18. Vessey JA, Demarco RF, Gaffney DA, Budin WC.Bullying of staff registered nurses in the
workplace: a preliminary study for developing personal and organizational strategies for the
transformation of hostile to healthy workplace environments. J Prof Nurs. 2009;25(5):299–306.
19. Walinder R, Runeson-Broberg R, Arakelian E, Nordqvist T, Runeson A, Rask-Andersen A.A
supportive climate and low strain promote Well-being and sustainable working life in the operation theatre. Ups J Med Sci. 2018;123(3):183–90.
19 “Don’t Yell at Me!” Disruptive Behavior intheOR
https://t.me/med1917
20. Laschinger HK, Grau AL, Finegan J, Wilk P. New graduate nurses’ experiences of bullying
and burnout in hospital settings. J Adv Nurs. 2010;66(12):2732–42.
21. Pfferling JH.The disruptive physician. A quality of professional life factor. Physician Exec.
1999;25(2):56–61.
22. Kulaylat AN, Qin D, Sun SX, Hollenbeak CS, Schubart JR, Aboud AJ, etal. Perceptions of
mistreatment among trainees vary at different stages of clinical training. BMC Med Educ.
2017;17(1):14.
23. Richardson DA, Becker M, Frank RR, Sokol RJ.Assessing medical students’ perceptions of
mistreatment in their second and third years. Acad Med. 1997;72(8):728–30.
24. Lebenthal A, Kaiserman I, Lernau O.Student abuse in medical school: a comparison of students’ and faculty’s perceptions. Isr J Med Sci. 1996;32(3–4):229–38.
25. Fitzgerald CA, Smith RN, Luo-Owen X, Turay D, Ferrada P, Han J, etal. Screening for harassment, abuse, and discrimination among surgery residents: an EAST multicenter trial. Am Surg.
2019;85(5):456–61.
26. Fagan A, Parker V, Jackson D.A concept analysis of undergraduate nursing students speaking
up for patient safety in the patient care environment. J Adv Nurs. 2016;72(10):2346–57.
27. Dwyer J, Faber-Langendoen K. Speaking up: an ethical action exercise. Acad Med.
2018;93(4):602–5.
28. Arora S, Sevdalis N, Nestel D, Tierney T, Woloshynowych M, Kneebone R. Managing
intraoperative stress: what do surgeons want from a crisis training program? Am J Surg.
2009;197(4):537–43.
29. Musselman LJ, MacRae HM, Reznick RK, Lingard LA. ‘You learn better under the gun’:
intimidation and harassment in surgical education. Med Educ. 2005;39(9):926–34.
30. Moawad GN, Tyan P, Kumar D, Krapf J, Marfori C, Abi Khalil ED, etal. Determining the
effect of external stressors on laparoscopic skills and performance between obstetrics and
gynecology residents. J Surg Educ. 2017;74(5):862–6.
31. Coats RD, Burd RS.Intraoperative communication of residents with faculty: perception versus
reality. J Surg Res. 2002;104(1):40–5.
32. Spruce L.Back to basics: speak up. AORN J. 2014;99(3):407–12; quiz 13–5.
33. Ludwig B, Turk B, Seitz T, Klaus I, Lofer-Stastka H. The search for attitude—a hidden curriculum assessment from a central European perspective. Wien Klin Wochenschr.
2018;130(3–4):134–40.
34. Stratton TD, McLaughlin MA, Witte FM, Fosson SE, Nora LM.Does students’ exposure to
gender discrimination and sexual harassment in medical school affect specialty choice and
residency program selection? Acad Med. 2005;80(4):400–8.
35. Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW, Epel ES. Burnout and
stress among US surgery residents: psychological distress and resilience. J Am Coll Surg.
2018;226(1):80–90.
36. Schiff L, Tsafrir Z, Aoun J, Taylor A, Theoharis E, Eisenstein D.Quality of communication in
robotic surgery and surgical outcomes. JSLS. 2016;20(3):e2016.00026.
37. Catron TF, Guillamondegui OD, Karrass J, Cooper WO, Martin BJ, Dmochowski RR, etal.
Patient complaints and adverse surgical outcomes. Am J Med Qual. 2016;31(5):415–22.
38. Bates DW, Singh H. Two decades since To Err Is Human: an assessment of progress and
emerging priorities in patient safety. Health Aff (Millwood). 2018;37(11):1736–43.
39. Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, et al.
Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery.
2006;140(1):25–33.
40. Catchpole K, Mishra A, Handa A, McCulloch P.Teamwork and error in the operating room:
analysis of skills and roles. Ann Surg. 2008;247(4):699–706.
41. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, etal. Surgical team
behaviors and patient outcomes. Am J Surg. 2009;197(5):678–85.
42. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, et al.
Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg.
2007;204(4):533–40.
325
326
https://t.me/med1917
43. Rosenstein AH, O’Daniel M.Invited article: managing disruptive physician behavior: impact
on staff relationships and patient care. Neurology. 2008;70(17):1564–70.
44. Maddineshat M, Hashemi M, Tabatabaeichehr M. Evaluation of the disruptive behaviors
among treatment teams and its reection on the therapy process of patients in the operating
room: the impact of personal conicts. J Educ Health Promot. 2017;6:69.
45. Minhas MS, Muzzammil M, Effendi J. Assessment of safety levels in operation rooms at
two major tertiary care public hospitals of Karachi. Safe surgery saves life. J Ayub Med Coll
Abbottabad. 2017;29(4):580–6.
46. Smetzer JL, Cohen MR.Intimidation: practitioners speak up about this unresolved problem. Jt
Comm J Qual Patient Saf. 2005;31(10):594–9.
47. Rydenfalt C, Johansson G, Larsson PA, Akerman K, Odenrick P. Social structures in
the operating theatre: how contradicting rationalities and trust affect work. J Adv Nurs.
2012;68(4):783–95.
48. Hasty BN, Miller SE, Bereknyei Merrell S, Lin DT, Shipper ES, Lau JN.Medical student perceptions of a mistreatment program during the surgery clerkship. Am J Surg. 2018;215(4):761–6.
49. Hultman CS, Connolly A, Halvorson EG, Rowland P, Meyers MO, Mayer DC, etal. Get on
your boots: preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism. J Surg Res. 2012;177(2):217–23.
50. Graaand M, Bemelman WA, Schijven MP.Appraisal of face and content validity of a serious
game improving situational awareness in surgical training. J Laparoendosc Adv Surg Tech.
2015;25(1):43–9.
51. Naguib S, Meyr AJ. Reliability, surgeon preferences, and eye-tracking assessment of
the stress examination of the tarsometatarsal (Lisfranc) joint complex. J Foot Ankle Surg.
2019;58(1):93–6.
52. Anton NE, Beane J, Yurco AM, Howley LD, Bean E, Myers EM, etal. Mental skills training
effectively minimizes operative performance deterioration under stressful conditions: results
of a randomized controlled study. Am J Surg. 2018;215(2):214–21.
53. Gettman MT, Pereira CW, Lipsky K, Wilson T, Arnold JJ, Leibovich BC, etal. Use of high
delity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: initial experience. J Urol. 2009;181(3):1289–96.
54. Goldberg MB, Mazzei M, Maher Z, Fish JH, Milner R, Yu D, et al. Optimizing performance through stress training—an educational strategy for surgical residents. Am J Surg.
2018;216(3):618–23.
55. Kleiner C, Link T, Maynard MT, Halverson CK.Coaching to improve the quality of communication during briengs and debriengs. AORN J. 2014;100(4):358–68.
56. Armour Forse R, Bramble JD, McQuillan R.Team training can improve operating room performance. Surgery. 2011;150(4):771–8.
57. Wolf FA, Way LW, Stewart L.The efcacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg.
2010;252(3):477–83.
58. Larson BA, Martinson DJ.Words can hurt. Dealing with verbal abuse in the operating room.
AORN J. 1990;52(6):1238–41.
59. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting
professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med.
2007;82(11):1040–8.
60. American College of Surgeons. Statements on principles; 2016. https://www.facs.org/about-
acs/statements/stonprin#anchor1256362016. Accessed 6 June 2019.
61. Sax HC. Building high-performance teams in the operating room. Surg Clin N Am.
2012;92(1):15–9.
62. Rogers DA, Lingard L, Boehler ML, Espin S, Schindler N, Klingensmith M, etal. Foundations
for teaching surgeons to address the contributions of systems to operating room team conict.
Am J Surg. 2013;206(3):428–32.
J. R. Coleman and R. Schulick
“Code Red!” Preventing andManaging
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Fire andSmoke Hazards intheOR
WiltonC.Levine andYasmineTameze
Introduction
An estimated 550–650 surgical res occur in the United States per year, leading to
devastating repercussions to patients, in addition to signicant legal and economic
consequences for the surgical team and the facility involved [1, 2]. Together with
retained sponges and wrong-site surgery, patient safety groups consider surgical
res as “never events”—events that can be avoided entirely with organizational
checks and balances [3]. Fire risk can be minimized when the operating room team
understands re hazards presented by each side of the re triangle, and appropriate
steps are taken to minimize these risks. This chapter describes the risks, prevention,
response, and impact of res in the operating room and procedural areas.
20
The Risks: TheFire Triad
A re requires three components: (1) an oxidizer, (2) an ignition source, and (3) a
fuel. This is also known as the “re triangle” (Fig.20.1).
W. C. Levine (*) · Y. Tameze
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital,
Boston, MA, USA
e-mail: wlevine@mgh.harvard.edu
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_20
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W. C. Levine and Y. Tameze
Fig. 20.1 The classic “re triangle” and examples of components found in the operating room.
Used with permission from Anesthesia Patient Safety Foundation; www.apsf.org
Oxidizers
In surgical res, oxidizers typically include oxygen and/or nitrous oxide. In the OR,
oxygen is provided to the patient via tracheal tubes, laryngeal mask airways, face
masks, or nasal cannulas. These are especially hazardous when contributing to an
oxidizer-enriched atmosphere (i.e., any oxygen concentration of more than 21%, or
the presence of any concentration of nitrous oxide). Such environments are also created when the conguration of draping and oxygen sources promote the trapping or
pooling of an oxidizer-rich atmosphere [4]. Redraping such that no “tent” covers the
eld helps decrease the possibility of an oxygen-rich environment [5]. It is recommended that an open draping technique (where the face is partially covered or not
covered at all) be used to reduce the risk of accumulated oxygen under the drape
when surgery is required in proximity to the oxygen source [6]. These oxidizerenriched environments increase the likelihood and intensity of combustion in the
surgical eld.
20 “Code Red!” Preventing andManaging Fire andSmoke Hazards intheOR
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329
Ignition Sources
In OR res, the ignition source may encompass any source of energy in the operating
room that can start a re in the presence of fuel and oxidizer. These include, but are
not limited to, electrocautery (ECU) or electrosurgery (ESU) units, lasers, ber- optic
light cords, and cable connections. Of the reported surgical res, between 70% and
90% had ESU equipment as their ignition source, 10% were caused by lasers, and the
rest were caused by a variety of other ignition sources [2, 7]. One of these other ignition sources worth mentioning is the ber-optic light cord. As the frequency of cases
done robotically and laparoscopically increases, the ber-optic light is emerging as an
important ignition source, as it can burn quickly through the drapes and cause thermal
injury to patients. In appropriate settings, these lights can ignite an operating room
re; therefore, it is important that they are on “standby” mode when not in use [8].
Fuels
Fuels include any ammable sources including alcohol preps, surgical drapes, linens, sponges, towels, surgical drapes, and the patient (see Fig.20.1). When using
alcohol-based surgical prep solutions, it is critical to use the smallest possible solution preparation and to follow the manufacturer’s instructions for use (IFU).
Typically, alcohol-based surgical prep is required to dry for a minimum of 3min
before placing the surgical drapes. This is to allow drying and evaporation of any
remaining liquid prep.
The Risks: Assessing thePreoperative Surgical Fire Risk
A key element to re prevention in the OR is the communication amongst each of
the OR team members regarding re risk assessment and the plan to minimize the
risk [5, 7]. Ideally, this should be done at the beginning of the case and included in
the surgical “time-out” [3, 4]. Several professional organizations have highlighted
the importance of a surgical time-out at the beginning of the case that includes the
re risk assessment [9]. One tool to assess re safety risk is the Silverstein Fire Risk
Assessment [10], where each case is given a score from 0 to 3 (Table 20.1). The
Table 20.1 Silverstein Fire
Risk Assessment Tool
Risk factor
Surgery above the xiphoid 1 0
Open oxygen source 1 0
Available ignition source 1 0
Total score – –
From Scoring re risk for surgical patients. OR Manager.
2006;22(1):19–20. Used with permission from Access
Intelligence
Yes
No
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scoring is based on the surgical location, oxygen source, and presence of a source of
ignition. Based on the score, the surgery is considered high risk (3 points), intermediate risk (2 points), or low risk (0–1 point) [2, 10]. The plan for surgical re preven-
tion will be based on the level of risk. As the patient’s re risk score increases, the
OR team should follow the guidelines listed for the patient’s highest score along
with the standard re safety precautions of the lower scores [9]. For example, if a
patient has a re risk score of 3 (high re risk), the OR team should implement all
of the recommended guidelines listed under “high risk” along with the standard re
safety recommendations.
W. C. Levine and Y. Tameze
Prevention Measures Based onRisk Assessment
For all procedures (score 0–3), the following standard prevention measures should
be taken [4]:
– Surgical drapes should minimize the accumulation of oxidizer under
the drapes.
– Before placing the surgical drapes, ammable skin solutions must be allowed to
dry for at least 3min or according to the package insert, before draping.
– Gauze and sponges should be moistened before use in proximity to igni-
tion source.
– Protect heat sources (i.e., keep the active electrode tip in holster when not
in use).
For intermediate-risk procedures (2 points):
These procedures have the potential to convert to being high risk. The OR staff
should follow the prevention measures described above, but be prepared to initiate
high-risk precautions if necessary.
For high-risk procedures (3 points) such as procedures above xyphoid requiring
the use of an open oxygen source in the presence of an ignition source (i.e., ENT
surgery, dermatology/plastic procedures), the key to prevention is altering one or
more of these components to avoid combustion. This implies (a) minimizing or
avoiding an oxidizer-rich atmosphere near the surgical site, (b) safely managing
ignition sources, and (c) safely managing fuels [2].
Minimizing or Avoiding anOxidizer-Rich Atmosphere Near
theSurgical Site
The open delivery of oxygen from a direct source, such as through nasal cannula or
face mask, is the predominant oxidizer cause in OR res, accounting for about 85%
of operating room res reviewed by a closed claim analysis [7]. In fact, many materials that will not burn or sustain a ame in ambient air do burn in an oxygen-rich
environment: for example, polyvinyl chloride (PVC) plastic, a component of endotracheal tubes, requires 26% oxygen to maintain burning [2].
20 “Code Red!” Preventing andManaging Fire andSmoke Hazards intheOR
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For high-risk procedures:
– Delivery of supplemental oxygen (i.e., via nasal cannula or face mask) should be
avoided.
– If not able to maintain adequate delivery with oxygen concentration of ≤30%
with an open source, secure the airway with an endotracheal tube or a supraglot-
tic device
Airway Surgery
– Patients are usually intubated; therefore, monitoring both the fraction of inspired
oxygen concentration (FiO2) and fraction of expired oxygen (FeO2) is possible.
Both FiO2 and FeO2 should be ≤30% before activation of any ignition source.
– If using laser in the airway, the airway should be secured using a cuffed laser-
resistant endotracheal tube, and the cuff should be lled with saline and colored
with an indicator dye. The dye serves as a marker, to rapidly demonstrate inad-
vertent cuff perforation by the laser.
Exceptional cases exist when procedures above the xyphoid require conscious
sedation, and oxygen delivery via nasal cannula or mask is necessary to maintain
adequate oxygen saturation. These include (awake) carotid artery surgery, awake
craniotomies, and some pacemaker implantations. In such high-risk procedures,
where eliminating the use of an open oxygen source by securing the airway is not
an option, the recommendations are as follows [2, 4]:
331
– Use an oxygen blender or adaptor to use the lowest concentration of oxygen required
to maintain adequate hemoglobin saturations as monitored via pulse oximetry
(≥92%). If an oxygen blender or common gas outlet is not available, oxygen con-
centration adjustment can be made using a standard wye breathing circuit [5].
– The surgeon must communicate with the anesthetist or sedation nurse when
about to use an ignition source to allow for further reduction of fraction of
inspired oxygen concentration (≤30%) or discontinue nitrous oxide. There
should be a delay of 3–5min before using an ignition source to allow for dissipa-
tion of oxygen on the surgical eld. To further minimize the oxygen buildup, the
anesthetist or sedation nurse can “ush” with high-ow medical air or scavenge
the operating eld with suction.
Safely Managing Ignition Sources
Electrosurgical units (ESUs) are the most common ignition source in surgical res
[7]. It is recommended to avoid using any ESU devices in high-risk procedures. If
an ESU is necessary, avoiding the use of monopolar ESU and instead using a bipolar
tip or harmonic scalpel at the lowest effective energy setting are the best way to
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reduce any chances of combustion. Bipolar ESU uses low power across the forceps
tips and little to no sparking, which might be the reason why there has not been as
many reported cases of OR res with bipolar ESU [2, 11].
Surgical lasers are the second most frequent cause of ignition in surgical res
[2]. While less common than the res caused by ESUs, their res are more serious, as they deliver power as high as 120W focused in a small area. Laser energy
can penetrate drapes and ignite towels and linens that may burn for some time
before being noticed. As mentioned earlier, it is essential that the surgeon communicates clearly to the team prior to the use of ignition to make sure that there is
enough time for the nitrous oxide and oxygen to have dissipated from the surgical
eld. The recommendations to minimize ignition source risk include the following [2]:
– Place the electrosurgical active electrode in a holster when not in active use.
– The surgeon should activate the unit or laser only when the active electrode tip is
in direct view.
– If open oxygen sources are employed, use bipolar ESU, a scalpel, or har-
monic scalpel whenever possible. If not replaceable, use ESU with extreme
caution.
– During a tracheostomy, do not use ESU or ECU to cut into the trachea; use a
scalpel instead.
– Give the anesthetist or sedation nurse adequate notice of 3–5min before activat-
ing the ESU, to allow enough time for oxygen concentration ≤30% and NO2
discontinued, and the anesthetist or sedation nurse and surgeon should together
conrm the current oxygen concentration before use of the ESU.
– Use the lowest effective setting once ESU is activated.
W. C. Levine and Y. Tameze
Safely Managing Fuels
The nurses and OR staff typically handle the fuels, which include most of the materials that come in contact with the patient (including the patient), such as alcoholbased skin preparation solutions, sponges, drapes, and towels. Alcohol res can be
difcult to detect because they are able to burn in room air, and their ames are hard
to visualize with the naked eye. The recommendations to minimize fuel risks include
the following [2]:
Prep Solution
1. Avoid pooling or spilling of ammable liquid preps and apply alcohol-based
prep solutions using an appropriately sized applicator.
2. Avoid re-prepping any area. Re-prepping the area may lead to pooling of the
alcohol-based prep and a fuel reservoir.
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