Preventing and Managing Operating Room Fires in Otolaryngology—Head and Neck Surgery

Development of an Improved LASER-Resistant Endotracheal Tube

OBJECTIVES

Surgical fires, particularly within Otolaryngology, remain a surprisingly frequent and devastating complication of laser-related surgery in the oropharynx and airway; Current estimates suggest anywhere from 200 to 600 surgical fires per year in the United States, with 20%-30% of these occurring as a complication of laser surgery and 90%-95% of these occurring in the head and neck region. Unfortunately, the complications of laser surgery in the airway may include respiratory failure, airway burns with stenosis, and may result in mortality. The most commonly utilized endotracheal tube for protection against inadvertent laser strikes, the Laser-Shield II tube (Medtronic), was removed from the commercial marketplace in 2016 after cases of airway fires were reported as a result of feature deficiencies in the product (FDA MAUDE Database review). Since the demise of the Laser-Shield II tube, alternatives such as the Mallinckrodt laser tube and handmade reinforced tubes have been utilized, although shortcomings in design and features have made these options less appealing to practicing Otolaryngologists. Creating a laser-safe endotracheal tube is critical for safe upper airway surgery. This paper evaluates new technologies, materials, and technical innovations in endotracheal tubes that may advance patient safety in laser-assisted Otolaryngology procedures.

STUDY TYPE

This paper evaluates new technologies, materials, and technical innovations in endotracheal tubes that may advance patient safety in laser-assisted Otolaryngology procedures.

METHODS

First, this article reviews the background of laser surgery in Otolaryngology and the consequent risk of surgical fire with resultant development of laser-resistant endotracheal tubes and commercial availability. Next, a review of claims and national database review of product failures related to previous laser-resistant endotracheal tubes is performed through the FDA MAUDE database. This includes an evaluation of cases: review of techniques in laser airway surgery including spontaneous ventilation, decreased O2 concentration, currently available endotracheal tubes including "handmade" fixes for perceived safety risks, and determination of failure points for previous laser-resistant endotracheal tubes. Third, the paper reviews the requested features of an "ideal" laser-resistant endotracheal tube. Finally, the paper reviews failure testing from an initial, unsuccessful attempt at material development and the consequent development of alternative technologies that address failure points from previous endotracheal tubes and addresses requested features with a detailed analysis of FDA-approval required testing. Extensive lab testing of the new tube predicts a significant reduction of risk in vivo with inability to perforate the shaft or cuff of the tubes under standard working conditions.

RESULTS

While no iteration of a laser-resistant endotracheal tube is entirely laser safe, advances in technology can improve the safety profile of these devices. The new tube contains a double cuff, a soft and flexible shaft to minimize laryngeal insertion trauma, a smooth external surface, a tight-to-shaft balloon, and methylene blue dye in the cuff to alert the user to inadvertent penetration. These characteristics were the most requested by laryngologists in the development of a new laser-resistant tube. The newest endotracheal tube brings the features most requested by Otolaryngologists in a laser-resistant tube, and improves the safety profile over previous tubes.

CONCLUSION

Development of a new endotracheal tube represents an advancement in safety for the Otolaryngologist in laser airway surgery. Understanding the previous history and the science behind surgical fire formation is essential in advancing safety for patients in the future.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:S1-S12, 2024.

Airway fires in otolaryngologic surgery: A database review

PURPOSE

An estimated 34 % of reported operating room fires involve the airway. Despite the inherent risks in otolaryngologic surgery, education regarding prevention and management of airway fires is limited in graduate medical training. One contributing factor is a lack of reporting of such rare events in our literature.

METHODS

The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to fires occurring during surgical procedures of the airway from January 1, 2010, to March 31, 2020.

RESULTS

3687 reports were identified and 49 unique reports of airway fire were included. Sustained fires were described in 16 (32.7 %) reports and 33 (67.3 %) described transient flares. 2 fires extended beyond the airway and 9 (18.4 %) were noted to have occurred at the start of the case. Fires were reported most commonly during tonsillectomy (n = 22 [44.9 %]), vocal fold excision (n = 5 [10.2 %]), and adenoidectomy (n = 4 [8.2 %]). 46 reports attributed flare initiation to a specific element of the fire triangle. 16 patient and 2 operator injuries were reported. Saline washing was utilized in 7 (14.3 %) cases overall. Patients were extubated immediately in 2 (12.5 %) of the 16 reports of sustained fires. 0 mortalities were reported.

CONCLUSION

Airway fires were reported in a variety of upper airway procedures performed regularly by otolaryngologists. The triggering factor that led to fire was identified as a spark or char in about half of the reported cases, and only 2 reports described immediate removal of the endotracheal tube.

Simulation training results in performance retention for the management of airway fires: A prospective observational study

Given the severity of the consequences of operating room fires, it is recommended that every anaesthesiologist master fire safety protocols and periodically participate in operating room fire drills. The aim of the present study was to evaluate skill retention one year after an airway fire training programme. Anaesthesiology residents were evaluated using an airway fire simulation-based scenario one year after an educational programme that included a one-h long problem-based learning session, a simulation-based airway fire drill with debriefing, and a formal group discussion. The same simulation scenario was used for both the initial training and the one-year assessment. Thirty-eight anaesthesiology residents participated as pairs in the initial training programme. Of these, 36 participated in the evaluation a year later. Performance after one year was better than performance during the initial simulation. Time to removal of tracheal tube was 7.0 (4.0-12.8) s (median (interquartile range)) at the one-year assessment compared with 22.0 (18.5-52.5) s at the time of initial training (P < 0.001). Performance improvement was also demonstrated by a higher incidence of performance of crucial action items (cessation of airway gases, removal of sponges and pouring of saline), as well as shorter duration of time necessary to perform these tasks. After controlling the fire, the time to re-establish ventilation by bag-mask ventilation or intubation was shorter at one year: 18.0 (11.0-29.0 ) s, compared with initial training 54.0 s (36.2-69.8) s (P = 0.001). We conclude that skills are effectively retained for a year after an airway fire management training session.

Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines

Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Fire safety study on high-flow nasal oxygen in shared-airway surgeries with diathermy and laser: simulation based on a physical model

High-flow nasal oxygen (HFNO) has been used in "tubeless" shared-airway surgeries but whether HFNO increased the fire hazard is yet to be examined. We used a physical model for simulation to explore fire safety through a series of ignition trials. An HFNO device was attached to a 3D-printed nose with nostrils connected to a degutted raw chicken. The HFNO device was set at twenty combinations of different oxygen concentration and gas flow rate. An electrocautery and diode laser were applied separately to a fat cube in the cavity of the chicken. Ten 30 s trials of continuous energy source application were conducted. An additional trial of continuous energy application was conducted if no ignition was observed for all the ten trials. A total of eight short flashes were observed in one hundred electrocautery tests; however, no continuous fire was observed among them. There were thirty-six events of ignition in one hundred trials with laser, twelve of which turned into violent self-sustained fires. The factors found to be related to a significantly increased chance of ignition included laser application, lower gas flow, and higher FiO₂. The native tissue and smoke can ignite and turn into violent self-sustained fires under HFNO and continuous laser strikes, even in the absence of combustible materials. The results suggest that airway surgeries must be performed safely with HFNO if only a short intermittent laser is used in low FiO₂.

Complications associated with PlasmaBlade TnA during tonsillectomy and adenoidectomy from 2010 to 2020: A MAUDE study

PURPOSE

The pulsed-electron avalanche knife (PEAK) PlasmaBlade TnA (Medtronic, n.d.) is a relatively new electrosurgical technology that is used widely in head and neck surgery (Medtronic Manuals, n.d.). This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to PEAK PlasmaBlade TnA during tonsillectomy and adenoidectomy.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacture and User Facility Device Experience database was queried for reports of PlasmaBlade TnA adverse events from June 6, 2009, to August 30, 2020. Data were extracted from reports pertaining to tonsillectomy with or without adenoidectomy.

RESULTS

128 reports were identified, from which 163 adverse events were extracted. Of these, 23 (14.6%) were related to patients, and 140 (85.4%) were related to device malfunction. The most frequently reported patient-related adverse event was a burn injury (17 [73.9%]). The most common device malfunctions were dislodgment of device component (39 [27.9%]), followed by tip ignition (32 [22.9%]), damaged tip or wire during operation (28 [20%]), and melted device (24 [17.1%]).

CONCLUSIONS

PEAK PlasmaBlade TnA have demonstrated utility in tonsillectomy with or without adenoidectomy but are associated with adverse events. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further study is needed to clarify optimal approaches to education.

Adverse Events Associated With Laser Use in the Upper Airway

OBJECTIVE

Surgical lasers are used extensively in head and neck surgery. Laser use in the upper airway offers many advantages but also presents risks to patients and operators that are not reported comprehensively. This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to laser use in the upper airway.

METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of surgical laser adverse events from January 2010 to March 2020. Data were extracted from reports pertaining to the upper airway.

RESULTS

Sixty-two reports involving upper airway laser use in an operating room were identified, from which 95 events were extracted. Of these, 40 (42.1%) were adverse events to patients, 2 (2.1%) adverse events to operators, and 53 (55.8%) device malfunctions. Dislodgement of laser fiber in the airway (23 [57.5%]), burn (8 [20%]), and scar (5 [12.5%]) were the most common adverse events to patients. Two incidents of eye exposure through unfiltered microscope lenses were the only adverse events to operators. Fiber break (26 [49.1%]) and flare (12 [22.6%]) were the most common device malfunctions.

DISCUSSION

Surgical lasers have demonstrated utility in head and neck surgery but are associated with risks. This study discusses adverse events and device malfunctions associated with airway laser surgery and emphasizes shortcomings in current reporting.

IMPLICATIONS FOR PRACTICE

Standardized reporting and multi-institutional research are needed to better understand adverse events related to surgical laser use and to allow accurate estimation of their prevalence.