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Surgical tracheostomy and airway fire - a case report

ABSTRACT Background: Airway fire is rare but potentially hazardous event. It may occur during tracheotomy surgery, laser surgery of the airway, and elsewhere. For a fire to occur, the triad of fuel, oxygen, and an ignition source is needed. We want to present a case of airway fire due to inadvertent cuff damage during tracheotomy before total laryngectomy. Case report: A 64-year old male patient, 85 kg of weight was scheduled for laryngectomy and selective neck dissection. Beside hypertension he had no other health problems. After standard preoperative preparation anesthesia was induced by propofol, sufentanyl, and rocuronium. Airway was secured with 6 mm cuffed armored endotracheal tube. Anesthesia was maintained with sevoflurane in 50% mixture of oxygen and air. Preliminary tracheotomy was planned first, and 3 minutes of preoxygenation with 100% oxygen was applied. Just before the opening of the trachea, sevoflurane was shut down and ventilation stopped. After the incision of the trachea with surgical scalpel, a surgeon used electrocautery to stop the bleeding and we experienced a little explosion in a surgical field, without visible fire. A cuff of the tube was inflamed. Saline was added to surgical field. Inflamed tube has been removed for inspection, and replaced with a “U” tube No 9 through the tracheostomy. The ventilation was then continued. Additional 8 mg of dexamethasone was added and anesthesia was maintained with 63 sevoflurane in mixture of oxygen/air 50%/50%. The surgeon did the inspection of the distal part of the trachea and it was without evident damage. The rest of the planned procedure was without unexpected events. The patient was placed in the ICU postoperatively, spontaneously breathing and awake. 7 days after the operation the surgeon did the tracheoscopy and confirmed no thermal damages. The patient was discharged home in a good condition. Discussion: According to the ASA closed claims analyses of airway fires published in 2013. (1): 103 OR fires were reported since 1985 ; with the electrocautery as the ignition source in 90% cases and 85% occurred during head, neck, or upper chest procedures. Since there is growing trend in last decades of electrocution use during surgical procedures prevention strategies for surgeons and anesthethist is mandatory during these procedures in order to avoid devastating complications (2, 3). The ASA published an Operating Room Fires Algorithm (4) with detail instructions, but still there is a debate whether to remove the tube or not in cases of difficult or edematous airway, since this can result in permanent airway loss (3- 4). References: 1. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 05 2013, Vol.118, 1133-1139. doi:10.1097/ ALN.0b013e31828afa7b 2. Current Opinion in Anaesthesiology. 21(6):790– 795, DEC 2008 ; DOI: 10.1097/ ACO.0b013e328318693a, Fire safety in the operating room 3. Caplan RA, Barker SJ, Connis RT, et al: Practice advisory for the prevention and management of operating room fires, Anesthesiology 108:786-801, 2008. 4. Rogers ML, Nickalls RW, Brackenbury ET, Salama FD, Beattie MG, Perks AG. Airway fire during tracheostomy: prevention strategies for surgeons and anaesthetists. Annals of The Royal College of Surgeons of England. 2001 ; 83(6):376-380.

airway fir ; tracheostomy

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