Airway fire during tracheostomy

Inflammatory Myofibroblastic Tumor: A Rare Case Report

Inflammatory myofibroblastic tumors (IMTs) are rare benign tumors that can occur anywhere in the body, most commonly in the pediatric and young adult populations. The gold standard treatment is surgical resection, possibly along with chemotherapy and/or radiotherapy. IMTs have a high recurrence rate and may present with secondary symptoms, such as hemoptysis, fever, and stridor. We present a 13-year-old male patient with hemoptysis for one month who was subsequently diagnosed with an obstructing IMT of the trachea. The preoperative assessment showed the patient was not in acute distress and could protect his airway, even when lying flat. The treatment plan was discussed with the otolaryngologist, to keep the patient spontaneously breathing throughout the case. Anesthesia was induced with boluses of midazolam, remifentanil, propofol, and dexmedetomidine. Doses were adjusted as needed. Glycopyrrolate was also given to limit the patient's secretions before initiating the surgical procedure. The FiO₂ was kept under 30% as tolerated to reduce the risk of airway fire. During surgical resection, the patient was kept spontaneously breathing, and paralytics were avoided. Due to high tumor vascularity and inability to obtain hemostasis, the patient was kept intubated and on ventilation post-operatively until definitive treatment could be performed. On postoperative day 3, the patient returned to the operating room due to a worsening condition. He was found to have a partial obstruction of the right mainstem bronchus by the tumor. More of the tumor was debulked, and he remained intubated above the level of the debulked mass. The patient was then transferred to a higher acuity institution for advanced care. After the transfer, the patient underwent a carinal resection on cardiopulmonary bypass. This case provides insight into successfully sharing the airway during tracheal tumor resection, emphasizing minimizing the risk of airway fire and constant communication with the surgeon.

Advances and safe use of energy devices in lung cancer surgery

Objectives

A clear understanding of energy devices would help achieve high effectiveness and safety and guide the selection of devices. The present review aimed to elucidate the efficacy and adverse events of energy devices in lung cancer to guide the selection of appropriate devices depending on the situation.

Methods

Four major databases were searched electronically for relevant articles published until 16 April 2021. The reference lists of the identified papers were examined. We excluded (1) irrelevant studies, (2) manuscripts published in languages other than English and Japanese, (3) duplicates, and (4) studies for which the full text was not available in the databases. The results and key information obtained were summarized by means of a narrative approach.

Results

A total of 78 papers were included in the review and these were categorized according to the main topic of investigation as follows: (1) electrosurgery-related injuries, (2) fundamentals of electrosurgery, (3) monopolar devices, (4) bipolar electrosurgical devices, (5) ultrasonic energy devices, (6) energy devices in lung cancer surgery, (7) operating room fire risks, and (8) basic principles of surgery.

Conclusions

Understanding energy devices could help us use them in a more effective and safer manner. Knowledge of their selection criteria (suitability), merits, risks, and safety precautions relevant to each process of lung cancer surgery could guide appropriate selection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11748-022-01775-w.

Electrosurgical unit: Iatrogenic injuries and medico-legal aspect. Italian legal rules, experience and article review

BACKGROUND

The use of the electrosurgical unit (ESU) is well-established in the surgical practice. The Authors, to better understand the genesis of injuries connected to the use of electrosurgical instruments, conducted an in-depth literature review pertaining to this topic.

MATERIALS AND METHOD

Using the most important medical databases, a research of experimental studies in the last 20 years was conducted.

RESULTS

The analysis of the mechanisms responsible for the lesions showed that high energy devices remain as the most common cause of injury. Adverse events are mainly given by thermal injuries; cases of electromagnetic interference are also described in patients with pacemakers or sacral nerve stimulator and spinal stimulators as well as cases of fire of the endotracheal tube in the course of tracheostomy for the use of the electrosurgical unit in an environment with a high concentration of oxygen or anesthetic gases. Also reported in the literature are individual cases of fires caused by sparks from the electrosurgical handpiece also for the use of disinfectants and/or in relation to surgical drapes.

CONCLUSION

In order to clearly define the medical-legal aspects, focusing on the professional responsibility of the surgical and nursing staff, the authors' attention was brought to the need for an effective prevention plan that highlights not only the importance of an accurate procedural knowledge in order to safety use the electrosurgical instruments, but also the need for a system that monitors any complications or adverse events resulting from the use of such instruments.

Immediate Postoperative Complications in Adult Tracheostomy

Objective

Tracheostomy is one of the oldest operations for the management of airway obstruction. With time, indications expanded to prolonged mechanical ventilation, and currently, the majority of tracheostomies are done for this reason. There are several techniques used in a tracheostomy procedure, depending on surgeon preference. Immediate complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal wall perforation with esophageal injury are rare, although they do occur, and must be managed accordingly. This study aimed to assess differences in types and rates of immediate postoperative complications in patients undergoing tracheostomy when performed under general anesthesia and local anesthesia (awake tracheostomies) at a large academic institution. This is a continuing ongoing literature reporting tracheostomy adverse events.

Methods

A retrospective chart review was performed to identify patients who underwent tracheostomy placement between January 1, 2013 and December 31, 2019 at the Detroit Medical Center, USA. Postoperative complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal perforation were collected along with gender, age, and revision tracheostomy status. IBM SPSS Statistics (IBM Inc., Armonk, USA) was used for statistical analysis with the statical significance defined as a p<0.05.

Results

A total of 1,469 patient charts were reviewed. Of these, 1,342 met the inclusion and exclusion criteria, of which, males were 57.2% (n=768), and females were 42.8% (n=574). The age range was 18 years to 96 years (mean=58.03; SD= 15.97), and BMI range was 12-83 (mean=28.77; SD=7.885).

Multinomial logistic regression was performed to determine whether age, BMI, sex, and revision tracheostomies were represented across both general and awake tracheostomy groups proportionally to their numbers in the total sample. It showed non-significant value for age (χ2=0.776, p=0.378), BMI (χ2=0.004, p=0.947), but significant value for sex (χ2=4.645, p=0.031), revision tracheostomy (χ2=18.282, p<0.001), indicating that males and revision tracheostomies over-represented in awake tracheostomies.

Next, Pearson correlation analysis was performed to determine any significant linear relationship between age, sex, and tracheostomy complications. It showed a significant positive correlation between age and tracheal stomal infection [r(1,340)=0.062, p=0.022].

An independent sample t-test showed a statistically significant difference between the mean pneumothorax and pneumomediastinum of general (n=1,277, mean=0.01, SD=0.088) and awake tracheostomies (n=65, mean=0.08, SD=0.269, t=2.069, p=0.043).

Pneumothorax pneumomediastinum complications between the general tracheostomy and awake tracheostomy odds ratio (OR)-6.22, indicates the chance of pneumothorax /pneumomediastinum complication is 6.22 times more in awake tracheostomy than general tracheostomy. Based on the above statistical analysis, we rejected the null hypothesis.

Conclusions

Tracheostomy is the procedure of choice to relieve the upper airway obstruction and treat patients requiring prolonged mechanical ventilation. A slightly higher number of Immediate postoperative complications in awake tracheostomy were noticed in patients with more surgically challenging revision tracheostomies.

Airway fire during awake tracheostomy using high-flow nasal oxygen

High-flow nasal oxygen is increasingly used in complex head and neck surgical procedures and difficult airway management. We describe a case where an operating room fire occurred while using high-flow nasal oxygen during an awake tracheostomy for an obese patient in airway extremis due to supraglottitis. Shortly after the operation began, and before incision of the trachea, electrical diathermy applied to bleeding sub-cutaneous vessels ignited a small flame. This was extinguished without harm to the patient and the procedure was completed without further complication. Fire requires three components: fuel; heat; and an oxidiser. We speculate that high-flow oxygen channelled under the drapes and acted as the oxidiser; either tissue eschar or vapourised fat were the fuel; and the diathermy supplied a source of ignition to complete the fire triad. When using high flows of concentrated oxygen, practitioners should aim to minimise all of these factors and be alert for the risk of fire at every stage of the operation.

Surgical fires: Still a burning issue in England and Wales

A significant number of surgical fires occur each year and can have devastating effects on patients. The National Reporting and Learning System database identified 37 reports of surgical fires in England and Wales between January 2012 and December 2018 - over 52% resulting in some degree of harm. Surgical fires remain preventable adverse events that can be avoided by adherence to effective preventative strategies and improved education. This article surveys the existing literature, addressing the fire triad and how to effectively manage and prevent a surgical fire.

Anesthesia-related Safety Profile of a High-energy Ultrasonic Scalpel in Oropharyngeal and Laryngeal Surgery: An Ex Vivo Model

Introduction

The aim of this study was to evaluate the fire risks associated with a harmonic scalpel, with an established avian model simulating oropharyngeal/laryngeal surgery. 

Methods

A standard polyvinyl-chloride (PVC) endotracheal tube (ETT) was inserted into a degutted, whole raw chicken through which 100% oxygen was piped at 10 L/min. The inflated cuff of the tube was grasped and sectioned with the jaws of a standard high-power ultrasonic dissection system Ultracision (Ethicon Endosurgery, Cincinnati, Ohio, USA). Then, the whole ETT was grasped and cut, leaving the device in contact with the ETT for two more minutes. In a second step under the same conditions, an electrosurgical device was placed into the chicken cavity and activated at the chicken tissue near the ETT at a setting of 20 W. All trials were repeated to ensure accuracy.

Results

No ignition could be produced with the harmonic scalpel under any operation mode settings. In all cases, the ETT was cut through with some fumes and brown discoloration at the site of contact. The electrosurgical device easily caused flash ignition within seconds.

Conclusion

The harmonic scalpel appears to be a safer tool than electrosurgical devices in the setting of open cavity surgery in oxygen-enriched environments with respect to the presence of flammable medical PVC devices as ETT or catheters.

Emergency Response in the Ambulatory Surgery Center

As more surgeries are moving out of the hospital setting, effective emergency response in freestanding ambulatory surgery centers requires organized preparedness. Rapid, consistent emergency response can be challenged by their rarity of occurrence, fast-paced environment, and relative lack of resources. Anesthesiologists who practice in these settings must be aware of the differences between the management of an anesthetic emergency in the hospital with virtually unlimited resources and staff, versus an ambulatory surgery center with limited resources and slightly different goal: stabilization and transfer of care. Regular simulation-based training schedules are effective for ambulatory surgery center preparedness for emergency response.

Surgical Fires in Otolaryngology: A Systematic and Narrative Review

Objective

To bring attention to the epidemiology, prevention, management, and consequences of surgical fires in otolaryngology by reviewing the literature.

Data Sources

PubMed, EMBASE, Web of Science, and Scopus.

Review Methods

Comprehensive search terms were developed, and searches were performed from data source inception through August 2016. A total of 4506 articles were identified; 2351 duplicates were removed; and 2155 titles and abstracts were independently reviewed. Reference review was also performed. Eligible manuscripts described surgical fires involving patients undergoing otolaryngologic procedures.

Results

Seventy-two articles describing 87 otolaryngologic surgical fire cases were identified. These occurred during oral cavity or oropharyngeal procedures (11%), endoscopic laryngotracheal procedures (25%), tracheostomies (36%), “other” general anesthesia procedures (3%), and monitored anesthesia care or local procedures (24%). Oxidizing agents consisted of oxygen alone (n = 63 of 81, 78%), oxygen and nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81, 1%). The fractional inspired oxygen delivered was >30% in 97% of surgical fires in non–nitrous oxide general anesthesia cases (n = 35 of 36). Laser-safe tubes were used in only 12% of endoscopic laryngotracheal cases with endotracheal tube descriptions (n = 2 of 17). Eighty-six percent of patients experienced acute complications (n = 76 of 87), including 1 intraoperative death, and 22% of patients (n = 17 of 77) experienced long-term complications.

Conclusion

Surgical fires in otolaryngology persist despite aggressive multi-institutional efforts to curb their incidence. Guideline recommendations to minimize the concentration of delivered oxygen and use laser-safe tubes when indicated were not observed in many cases. Improved institutional fire safety practices are needed nationally and internationally.

Perioperative Management of an Airway Fire: A Case Report

Accidental fire can occur with upper airway injury and can be fatal if inappropriately managed. Effective communication between the anesthetic and the surgical teams can reduce the risk of such an adverse event. Understanding the interaction between fuel, oxidizer, and ignition source in an airway fire may also reduce the incidence. The literature on upper airway thermal injury has focused on prevention and intraoperative management, but few studies have described postburn management. In this report, we describe the intraoperative occurrence of an airway fire during a surgical tracheostomy and subsequent patient management.

Complications, Implications, and Prevention of Electrosurgical Injuries: Corner Stone of Diathermy Use for Junior Surgical Trainees

Diathermy is commonly used in modern-day surgery. The incidence of electrosurgical injuries related to diathermy is under reported, as it is difficult to ascertain the true impact on both patient and healthcare professionals. As junior surgical trainees, understanding of the mechanism and biophysics of the electrosurgical tools enables safer usage and contributes to improved outcome. Careful use of electrosurgical tools during operation and appropriate communication amongst staff members are pivotal to a safe surgical outcome. Here, we discuss the causes and risk factors regarding electrosurgical complications along with suggestions to ensure safe practice, focusing on commonly neglected areas.

A case of bilateral pneumothoraces resulting from tracheostomy for advanced laryngeal cancer

Pneumothorax is a possible complication of tracheostomy. We report a rare case of bilateral pneumothoraces resulting from tracheostomy in an advanced laryngeal cancer patient. A 59-year-old man was referred to our clinic for evaluation and treatment of laryngeal tumor. Laryngeal endoscopy showed limited movement of bilateral vocal cords, and computed tomography revealed a tumor lesion extending from the vocal cords to the subglottic area. Three days after the first visit, the patient developed respiratory difficulty, and we elected to perform emergency tracheostomy for airway management. Immediately after the start of the procedure, he began hyperventilating, and complained of respiratory discomfort and chest pain. We then recognized a mediastinal air leak, and we suspected pneumothorax resulting from the tracheostomy. Chest X-ray showed bilateral pneumothoraces; therefore, we inserted bilateral chest drainage tubes, which stabilized his respiratory condition. We speculated that the pathogenesis of the bilateral pneumothoraces was weakened alveolar walls secondary to long-term smoking, and a significant rise in airway pressure because of airway constriction by the neck-extended position and hyperventilation, during tracheostomy.