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20 “Code Red!” Preventing andManaging Fire andSmoke Hazards intheOR
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3. Allow ammable liquids to dry fully before draping: Most solutions have a mini-
mum drying time of 3min for hairless skin, but this time increases when the
solution is applied to unclipped skin. Prep dry time must be monitored and
adhered to, and follow the manufacturer’s IFU.
333
Drape Management
1. Remove any solution-soaked materials from the operating room prior to draping
or use of the ignition source [12].
2. Draping should be done to avoid accumulation of oxidizers under the drape. If
available, use an adherent incise drape to isolate the head, face, and neck incisions from oxidizer-enriched atmosphere.
3. Coat head and facial hair within the surgical eld with water-soluble surgical
lubricating jelly [9].
A large part of reducing the re risk in the OR relies on minimizing the interaction between each side of the re triangle. Assessing the risk of the procedure at the
beginning of the procedure allows each member of the OR team to understand and
communicate re risks [9].
Prevention ofOperating Room Fires: Education
In addition to safely managing oxidizers, ignition sources, and fuel, an effective
response to OR re includes education and practice. Every member of the OR
team should receive training on OR re prevention and management and should
be familiar with their institutional re safety protocols [4]. Another tool to
enhance the OR team response to OR res is OR re drills and team simulation,
which have been shown to improve staff response to a re [4]. These OR drills
allow each member of the OR to be familiar with their pre-assigned role in managing a re and enhance communication amongst OR team members and with
the local authorities [9]. In high-risk cases, having a brief discussion during surgical time-out might be useful to review/assign roles in the case of a re. Finally,
it is useful to understand the different types of re extinguishers and uses during
OR res. Fire extinguishers should not be the rst choice during surgical res but
might be needed in cases where the re engulfs a patient, has migrated off the
patient, involves material that continues to burn after being removed from the
patient, or involves equipment in the OR [2]. Fire extinguishers are classied
according to the agent used (Table20.2).
The ECRI and APSF recommend CO2 extinguishers as they are nontoxic, readily
dissipate, and are not likely to result in thermal injury.
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Table 20.2 Fire extinguisher chart.
W. C. Levine and Y. Tameze
Management ofOperating Room Fires
In nonoperating room res, the RACE acronym (rescue, alarm, conne, and extinguish) is commonly used. In the operating room, this sequence may not be appropriate, depending on the type of re. Operating room res can be divided into res
occurring on the patients, in the patient (i.e., airway res), and in the operating room
environment.
20 “Code Red!” Preventing andManaging Fire andSmoke Hazards intheOR
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335
Fires Occurring onthePatient
About 44% of the res occurring on the patient occur on the head, neck, or upper
chest [2]. Managing the res that happen on the patient needs a team effort, with
each performing their pre-assigned re management tasks, which include [4]:
1. Calling for help.
2. Stopping the procedure.
3. Stopping the ow of all airway gases: removing the oxidizer can allow for the
re to subside.
4. Removing all drapes and burning material from the patient—even if the re
appears to be extinguished—to assess for lingering ames or re elements hidden underneath the ames.
5. Extinguishing all burning materials in, on, and surrounding the patient with
saline or water, or smothering with wet towels or sponges.
If the re is not extinguished by these measures:
1. Use a carbon dioxide re extinguisher, if no success.
2. Initiate the RACE re protocol:
(a) Rescue: move the patient from the burning source to a safe location.
(b) Activate the re alarm system.
(c) Conne: close the door to the room after evacuation and turn off medical gas
supply to the room. The medical gas zone valves should be shut off to prevent piped gas and vacuum systems from sustaining the re damage or prevent potential explosion.
(d) Extinguish: if possible, use a re extinguisher as you retreat from the area.
Do not pour saline or water on an electric re.
Fires Occurring inthePatient: Airway Fires
About 21% of the res occurring in the patient are airway res (Fig.20.2) [2]. As
soon as an airway re is suspected:
1. Remove the tracheal tube at the same time as disconnecting the breathing circuit
from the tracheal tube (Fig.20.3).
Fig. 20.2 Location of
surgical res (yellow: res
in patient; red: re on the
patient)From Health
Devices.
2009;38(10):314–32. Used
with permission from
ECRI Institute; www.
ecri.org
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Fig. 20.3 Tracheal tube
with oxygen owing
through it. Note the re
coming out of the tube as
well as the re progressing
inside the tube against the
ow of oxygen. Used with
permission from
Anesthesia Patient Safety
Foundation; www.apsf.org
W. C. Levine and Y. Tameze
2. Stop the ow of all airway gases.
3. Remove all ammable and burning materials from the airway. Pour saline into
the patient’s airway.
Once the re is extinguished:
1. Reestablish ventilation by mask, avoiding supplemental oxygen and nitrous oxide.
2. Examine the endotracheal tube to assess if fragments were left in the airway—
consider rigid bronchoscopy to further evaluate the airway.
3. Consider referral to burn center, based on the extent of the injury.
4. Assess for smoke inhalation injury in non-intubated patients, including OR team
members.
Fires intheOperating Room, But Not onor inthePatient
In res that occur in the operating room but do not involve the patient, electrical
equipment is often involved. The equipment at fault should be unplugged safely and
removed from the OR.If not possible, the same steps followed in res on the patient
(but not the airway) should be followed, and a re extinguisher might be needed to
extinguish the device in the room. The entire operating suite should be evacuated, as
the possibility of reball explosions from bottled alcohol or gas cylinders still
exists [13].
Conclusion
Operating room res are rare but can have tragic consequences for both the injured
patient and healthcare workers. In recent years, there has been an initiative from
professional societies (Anesthesia Patient Safety Foundation (APSF), American
Society of Anesthesiologists (ASA) ECRI, and Joint Commission), to raise awareness and prevent this “never event.” This effort has been echoed by hospital-based
initiatives to heighten clinicians’ awareness of surgical res by including surgical
re assessment scores to their surgical time-out, in addition to conducting yearly
OR re drills with mandatory attendance by surgeons, anesthesia providers, nurses,
and technicians. Fostering communications between surgical team members, in
addition to continued education about the three basic elements of surgical res and
management of OR res, is key in reducing the incidence of this “never event.”
20 “Code Red!” Preventing andManaging Fire andSmoke Hazards intheOR
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337
References
1. Smith LP, Roy S.Operating room res in otolaryngology: risk factors and prevention. Am J
Otolaryngol. 2011;32(2):109–14.
2. Emergency Care Research Institute. New clinical guide to surgical re prevention. Patients can
catch re—here’s how to keep them safer. Health Devices. 2009;38(10):314–32.
3. Clarications and expectations. Preventing surgical res. Making re safety a top priority in
the OR.Jt Comm Perspect. 2013;33(4):8–9, 11, 12.
4. Apfelbaum JL, Caplan RA, Barker SJ, Connis RT, Cowles C, Ehrenwerth J, et al. Practice
advisory for the prevention and management of operating room res: an updated report by the
American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology.
2013;118(2):271–90.
5. Anesthesia Patient Safety Foundation. Prevention and management of operating room res;
2010. https://www.apsf.org/videos/or- re- safety- video/. Accessed 31 May 2019.
6. Rinder CS.Fire safety in the operating room. Curr Opin Anaesthesiol. 2008;21(6):790–5.
7. Mehta SP, Bhananker SM, Posner KL, Domino KB.Operating room res: a closed claims
analysis. Anesthesiology. 2013;118(5):1133–9.
8. Jones TS, Black IH, Robinson TN, Jones EL. Operating room res. Anesthesiology.
2019;130(3):492–501.
9. Association of Perioperative Registered Nurses. Fire risk safety tool kit; 2019. https://test.
aorn.org/guidelines/clinical- resources/tool- kits/re- safety- tool- kit.
10. Mathias JM.Scoring re risk for surgical patients. OR Manager. 2006;22(1):19–20.
11. Akhtar N, Ansar F, Baig MS, Abbas A.Airway res during surgery: management and prevention. J Anaesthesiol Clin Pharmacol. 2016;32(1):109–11.
12. NFPA 99: health care facilities code. Quincy, MA: National Fire Protection Association; 2015.
13. A clinician's guide to surgical res. How they occur, how to prevent them, how to put them out.
Health Devices. 2003;32(1):5–24.
“I Got Stuck!” Blood Exposure intheOR:
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Prevention andManagement ofSharp
21
Injuries andInfectious Disease Exposure
TalaBallouz, CarineSakr, andNesrineA.Rizk
Background
The rst report of occupational exposure to human immunodeciency virus (HIV)
through a needlestick prick was reported in 1984in the United Kingdom [1]. Since
then, several strategies, such as the Occupational Safety and Health Administration
(OSHA) Bloodborne Pathogens Standard [2], have been implemented to provide
guidance for the prevention of such incidents. Yet, needlesticks and other types of
injuries continue to occur in healthcare settings. It is estimated that 600,000–800,000
needlestick and other percutaneous injuries occur among healthcare workers
(HCWs) in the United States annually [3]. Elseviers etal. calculated a rate of 3.7
sharp injures per 100 healthcare workers per year, based on data from Australia,
Europe, Africa, and North America [4]. Surgical personnel carry an increased risk
because of potential injuries caused by sharp surgical instruments [5]. In a recent
study, Makary etal. reported that 83% of surgery residents reported a needlestick
injury during their training [6]. These injuries are typically associated with substantial nancial costs related to the testing, prophylaxis, and counseling needed, as well
T. Ballouz · N. A. Rizk (*)
Department of Internal Medicine, Division of Infectious Diseases, American University of
Beirut, Beirut, Lebanon
e-mail: nr00@aub.edu.lb
C. Sakr
Department of Employee Health, American University of Beirut Medical Center,
Beirut, Lebanon
© 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_21
339
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as lost productivity [7, 8]. In addition, most HCWs experience psychological distress after such injuries, affecting their productivity and work time and thus leading
to more economic costs [8–11].
In this chapter, we will discuss the risks and management of occupational
exposure to the three most commonly reported blood-borne pathogens (BBPs):
hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV.We will also mention
the standards of prevention of exposure including the standard issued by
OSHA.Throughout the chapter, as our focus is exposure to blood-borne pathogens in the healthcare setting, we will follow the Centers for Disease Control and
Prevention (CDC) nomenclature and use the term “source” to refer to the source
patient (SP) [12]. We will refer to the exposed healthcare worker as “exposed
employee” (EE).
T. Ballouz et al.
Definitions
According to OSHA, blood-borne pathogens are “pathogenic microorganisms
that are present in human blood and can cause disease in humans” [3]. They are
transmitted through contact with contaminated blood and result in an infection in
the exposed individual. The most frequently described pathogens are HBV, HCV,
and HIV.Other less frequently reported pathogens include Brucella, syphilis, varicella zoster virus, Ebola virus, and malaria [13].
The most signicant means of transmission in healthcare settings is intravenous
exposure to contaminated blood. According to OSHA, blood is dened as human
blood and any blood components or products made from human blood. Other potentially infectious products include (1) human body uids, including, but not limited
to, semen, vaginal secretions, and cerebrospinal, pleural, or pericardial uids; (2)
any unxed tissue or organ from a living or dead human; and (3) HIV-containing
cell or tissue or organ cultures, HIV- or hepatitis virus-containing culture medium,
or blood, organs, or other tissues from experimental animals infected with HIV,
HBV, or HCV.Fluids that do not transmit HIV unless they contain blood include
tears, nasal secretions, saliva, sputum, gastric secretions, feces, and urine [3, 12].
When a mucous membrane (including eye, mouth, nose) or non-intact skin
comes in contact with blood, bloody uids contaminated with blood, or any of the
previously mentioned infectious material, it is known as an exposure incident.
When this exposure occurs in the setting of a person’s work duties, it is known as an
occupational exposure [3]. The main mode of exposure in healthcare personnel is
percutaneous injury through a contaminated sharp object such as a hollow-bore
needle, suture needle, scalpel, or glass. However, other modes of exposure have
been reported and include mucous membrane exposure, non-intact skin exposure,
and bites. Potential exposures to blood and body uids could also occur through
large-volume spills.
In the healthcare setting, most signicant exposures occur within the context of
surgery and surgical procedures, as those are usually associated with exposure to a
large volume of blood and deep injuries.
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Table 21.1 Risk of acquisition of blood-borne pathogens by mode of exposure
Mode of exposure
Percutaneous 6–30% 1.8% 0.3%
Mucous membrane Unknown Unknown 0.09%
Non-intact skin Unknown Unknown <0.1%, incomplete
Bite Unknown Unknown Unknown
HBV Hepatitis B virus, HCV Hepatitis, HIV Human immunodeciency virus
HBV HCV
HIV
341
Risk ofAcquisition After Occupational Exposure toHBV,
HCV, or HIV
The risk of transmission of HBV, HCV, and HIV depends on several factors and
varies across settings. These factors include the baseline prevalence of these pathogens within both the general and healthcare facility populations, the type of injury
(deep or shallow), the nature of the body uid involved (with blood being the most
infectious), the concentration of the virus in the uid, and the availability of postexposure prophylaxis [12, 14]. Table21.1 summarizes the risk of acquisition of bloodborne pathogens by mode of exposure in the healthcare setting.
Risk ofTransmission ofHBV
The highest titers of hepatitis B have been found to be in blood, blood products, and
serous exudates [12]. It is present in moderate titers in saliva, semen, and vaginal
secretions [15, 16]. The lowest titers can be found in urine, tears, and feces [15, 17,
18]. Outside of the body, HBV is relatively stable and can survive up to 7days on
surfaces at room temperature [19]. HBV transmission depends on the hepatitis B
status of the source and the immunity of the exposed individual. The hepatitis B
surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) of the source determine
infectivity. In a nonimmune healthcare worker, the risk of transmission after a
needlestick prick ranges from 30% to 62% if the source is HBsAg and HBeAg positive, and 6% to 30% if the source is HBsAg positive and HBeAg negative. The risk
of infection is tremendously reduced in the immune EE [12, 20].
Risk ofTransmission ofHCV
Similar to HBV, HCV circulates at the highest titers in blood. In addition, studies
have shown that HCV can be detected in different human body uids including
saliva, semen, urine, sweat, and tears [21–24]. However, only serum has been
proven infectious in human and experimental models. HCV can also survive for
long periods of time on surfaces and inside needles, with one study recovering viable HCV for up to 6weeks from dried spots of blood [25]. The most common way
of occupational HCV acquisition is through percutaneous exposure through sharp
and needlestick injuries. Studies estimate the average incidence of anti-HCV
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seroconversion from percutaneous injuries from a known HCV-positive source to be
1.8% (range: 0–7%) [12]. The risk of infection with other modes of exposure is less
well dened, with two case reports describing HCV transmission after blood splash
to the conjunctiva [26, 27].
T. Ballouz et al.
Risk ofTransmission ofHIV
HIV is the most reported and studied blood-borne pathogen. Studies have estimated
the average risk of HIV acquisition in HCWs after percutaneous injury with inoculation of blood from an HIV-positive source to be around 0.3% (95% condence
interval: 0.2–0.5%). This risk is lower after a mucous membrane exposure to HIVinfected blood and is almost 0.09% (95% condence interval: 0.006–0.5%) [28].
The risk of transmission of HIV through intact skin is not well quantied, with most
experts reporting the risk to be less than that of mucous membrane exposure. Risk
factors that increase occupational HIV acquisition are well described in epidemiological studies. Some of those factors relate to the type of equipment, with the highest risk occurring after deep-wound injuries, as well as percutaneous injuries with
hollow-bore blood-lled needles, blood-contaminated devices, and devices or needles recently used in an artery or vein [29]. A high viral burden in the source is
another important determinant of infectivity, with a greater risk associated with a
source patient with terminal acquired immunodeciency syndrome (AIDS), or with
a detectable high HIV viral load.
Management: Initial andSpecific
Although prevention remains the best strategy for protecting healthcare workers
from blood-borne pathogens, there is still a risk that exposure might occur during
invasive procedures and surgical interventions. In such cases, institutions should
have a clear system in place that guides incident reporting, evaluation, initial management, counseling, and follow-up of exposed cases, while ensuring condentiality
and privacy of the source and exposed individuals. Additionally, healthcare personnel should be adequately educated and trained in the prevention of occupational
exposure. It is crucial that clinicians who provide postexposure care be accessible at
all times of the day and night. Similarly, postexposure prophylaxis (PEP), hepatitis B
immunoglobulin (HBIG), and hepatitis B vaccine should always be available.
Appropriate management of blood exposure in the healthcare setting, including
the operating room, includes some key elements. These include initial management
of the wound, exposure reporting and assessment, and providing postexposure prophylaxis and appropriate counseling.
Those exposures cause stress and result in disruption of the workow and interruption of a procedure and lead to emotional distress and fear. This may disrupt
daily life and incur in several ways, especially if pharmacologic interventions are
recommended, in addition to the cost to the healthcare system (for testing and retesting, treatment, and appropriate medical follow-up).
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The Initial Management oftheWound andExposed Surface
If a healthcare worker has been exposed to blood or a bloody body uid, the rst
step in the management is cleaning of the exposed wound or punctured skin with
soap and water. There is no solid evidence behind this practice; however, it is recommended by OSHA, CDC, and WHO [2, 30–32]. Additionally, for exposures
involving mucous membranes (eyes, nose, mouth, or skin), the recommendation is
to vigorously ush the surface with water. The use of topical antiseptics (e.g., 2–4%
chlorhexidine) has not been shown to be benecial, although their use is not contraindicated. Similarly, squeezing or rubbing the injury site has been shown to be nonbenecial. The use of caustic agents such as iodine, bleach, and others should be
avoided. After the wound has been cleaned, a thorough assessment of the exposure
needs to be done by a trained practitioner to assess the risk of infection and appropriately manage the situation [12, 30, 32].
The Reporting oftheIncident
When an exposure occurs, prompt and condential reporting is essential. The Health
Insurance Portability and Accountability Act (HIPAA) privacy rules guarantee the
respect of the medical information of the source as well as the exposed personnel.
The incident is usually reported immediately to a senior practitioner or a supervisor.
It is important to document all the following details:
• Details on exposure
– Date and time
– Location
• Type of procedure
– The type of devices involved
– Description of the injury (depth of wound, type of body uid, duration and
volume of exposure, condition of skin)
• Details on the source of exposure
– Serologic status for HIV, HBV, or HCV (history of antiviral treatment, viral
load if applicable)
– History of HBV vaccination
• Details on the exposed HCW
– Serologic status for HIV, HCV, HIV
– HBV vaccination history
– Medical history
– Pregnancy or lactation
Finally, the report should mention what the management steps are and what follow- up will be recommended. This report not only serves as documentation for a
particular incident, but also aims at identifying effective preventive strategies and
any future risks or hazards. To ensure that this report is being correctly and promptly
done, education of healthcare workers on blood-borne exposure risks and
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