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• W2023784391 abstract "DEMOGRAPHICS Case Title: Management of Intraoperative Airway Fire. Patient Name: Mr. Daniel Reiner. Scenario Name: Airway Fire Management. Date of Development: September 23, 2008. Learning Groups: Anesthesiologists and Nurse Anesthetists, Intensive Care Team Members, and Surgeons. CURRICULAR INFORMATION Educational Rationale Airway fires are rare but potentially catastrophic events that can result in major patient morbidity and mortality. The presence of a fuel, an oxidizing agent, and an ignition source comprise the “fire triangle” and increase the risk for a fire.1 Historically, airway fires were associated with the use of flammable anesthetic agents, and although these agents are no longer used, airway fires continue to occur, particularly with the use of lasers and electrocautery in head and neck surgeries.2–4 This case was designed specifically for anesthesiology residents, but it can be applied more broadly to practitioners working in settings where airway fire can occur such as the intensive care unit (ICU) where tracheostomies are often performed. Learning Objectives Learners will be assessed based on the Accreditation Council for Graduate Medical Education Competencies (ACGME Core Competencies): Medical Knowledge Describe the signs of an airway fire and components necessary for fire to occur. Describe management of airway fires including disconnection of the anesthetic circuit/discontinuation of oxygen/nitrous oxide (N2O) flow, removal of the endotracheal tube (ETT), flooding the surgical field with water or soaked gauze, ventilation with 100% oxygen, and eventual reestablishment of a definitive airway. Once the airway is reestablished, expectant management of pulmonary complications should commence. Describe this management strategy. Patient Care Recognize and manage an airway fire in the simulated operating room (OR) setting. Arrange an appropriate postoperative management plan for a patient who has suffered an airway burn. Practice-Based Learning and Improvement Assess personal performance through an interactive debriefing and video tape review to make suggested improvements in future management of the event. Assess the appropriateness of the hand-off received and institute changes in current practice to ensure proper patient hand-offs in the future. Interpersonal and Communication Skills Demonstrate appropriate and efficient communication skills with OR personnel during an airway fire. This includes constant communication with the surgeon and circulating nurse before, during, and after the fire. Demonstrate appropriate communication when receiving a patient from a colleague while a surgical case is ongoing. Demonstrate timely communication with the surgeon that the FiO2 has been appropriately lowered, the patient is maintaining an appropriate oxygen saturation, and nitrous oxide is not being used before entering the airway. Professionalism Display professionalism with the surgical team, with other colleagues, and with the OR staff during a crisis. Systems-Based Practice Review evidence-based and systems-based standards of care for the appropriate avoidance and management of airway fire. Didactics No prescenario didactics. Standardized debriefing using video tape review and a predefined learning objectives (as outlined above). Participant Assessment Participant assessment is based on scenario facilitator review of the following: Recognition of risk factors for airway fire. Management of airway fire. Appropriate display of communication and team leadership during crisis. Oral explanation of the scenario by participant after the debriefing. PREPARATION Supplies Mannequin simulator in which airway can be entered surgically. Full environment-simulated OR with anesthesia machine, operating table, and surgical drapes. Portable smoke machine (fire alarm test: the smoke machine was first tested in the laboratory with a fire marshal present to determine whether the steam would set off alarms. In our laboratory, the smoke machine does not trigger the fire alarm, so it is left fully enabled.) Strobe light (optional). 7.5 ETT, blackened at tip with indelible marker to appear charred. Audio clip of smoke/fire alarm (optional). Surgical kit: 6.0 reinforced ETT, 6.0 Shiley-style tracheostomy kit, monopolar electrocautery pen, scissors, Yankauer suction, surgical instrument (Mayo) stand, standard ETT, 60 mL syringe, and umbilical tape (or commercial ETT securing device). Supporting Files Patient's written preoperative assessment and laboratory results. Electrocardiogram. Chest x-ray with report showing basilar atelectasis or consolidation. Roles Surgeon and surgical resident. Anesthesiology resident. Active Monitors Noninvasive blood pressure cuff. Five-lead electrocardiogram. Pulse oximeter. Temperature probe. Capnograph. Intra-arterial catheter. Other Equipment Required Anesthesia machine that has passed full check out. Airway equipment: Macintosh and Miller blades, 7.5 ETT, stylette, and empty 10-mL syringe. Scissors. Two prepared 1000-mL intravenous (IV) fluid bags on blood infusion lines. Pharmacologic agents: propofol, succinylcholine, vecuronium, fentanyl, atropine, ephedrine, etc. Yankauer suction. Record keeping material (computerized or paper). Duration Setup/preparation: 10 minutes. Simulation: 10 to 15 minutes. Debriefing: 15 minutes. CASE The participant is told that he/she will be relieving an anesthesiologist colleague who is doing an elective tracheostomy in the OR. The case is underway. The anesthesia resident (sitting in a chair in the OR) gives the following presentation: Dan Reiner is a 74-year-old man currently an inpatient in the ICU status after a hemicolectomy for mesenteric ischemia 10 days ago. He has remained intubated and ventilated because of respiratory failure and intermittent hemodynamic instability requiring vasopressor support (which he is no longer receiving). His ventilator settings in the ICU were FiO2 of 0.6, with 8 cm H2O positive end-expiratory pressure. The patient now presents for elective surgical tracheostomy. Anesthesia is being maintained with sevoflurane, fentanyl, and vecuronium. Patient Data Background and Baseline Status Patient history: Dan Reiner is a 74-year-old male ICU patient with the recent history presented above. Pertinent history is as follows: Medical and surgical history: hypertension, no surgeries before current admission. Allergies: none known. Social history: 40 pack-year history of smoking. Review of systems: patient anesthetized and unable to supply. Current medications and allergies: Fentanyl infusion titrated to sedation, midazolam infusion titrated to sedation, and heparin subcutaneous injection 5000 units twice daily. Physical examination: General: obese, anesthetized, intubated, and ventilated. Weight: 98 kg; height: 169 cm. Vital signs: blood pressure, 115/56 mm Hg; heart rate, 84 bpm; respiratory rate, 12; temperature, 36.5°C; SpO2, 96%. Intraoperative ventilator settings: mode, volume control; tidal volume, 750 mL; positive end-expiratory pressure, 8 cm H2O; FiO2, 1.0. Airway: 7.5 ETT in situ, tied in place with umbilical tape. Lungs: bilateral breath sounds, rhonchi bilaterally. Heart: regular rate and rhythm, no murmurs, gallops, or rubs. Background and briefing information for facilitator/coordinator. Airway Fire Background Although the true incidence of OR fires is hard to determine, it is estimated that as many as 200 of these serious events may occur each year.5,6 All OR staff should be aware of situations in which airway fire may occur based on surgical site (ie, head and neck procedures), surgical tools (ie, electrocautery, lasers, and fiberoptic light sources), and anesthetic factors (ie, high FiO2, use of N2O). Three elements must be present for an airway fire to start: (1) fuel, (2) an oxidizing agent, and (3) an ignition source.1 During head and neck surgeries, there is a confluence of these elements and hence, the risk of fire is greater. Oxygen and N2O support combustion as oxidizing agents (N2O functions equally well as oxygen in supporting combustion). ETTs, which are often made of flammable material (eg, Polyvinylchloride), provide the fuel source.7 Finally, lasers or electrocautery can provide an ignition source. By understanding the elements required to start a fire, surgeons and anesthesiologists can implement preventive maneuvers such as decreasing FiO2 and avoiding electrocautery use during tracheostomy placement and airway surgeries in general. When a fire does occur, the patient must be immediately disconnected from the circuit and the gas flow discontinued. The fire can be extinguished using wet gauze and/or saline from the field or from cut IV solution bags. The ETT should be removed and drapes should be removed and thrown to the floor as they may be flammable and impede efforts to extinguish fire from the field. Ventilation must be quickly reestablished once the fire is extinguished. Immediate removal of the burnt tube and placement of a new ETT should be performed because a smoldering tube will continue to damage tissue if left in place, even in the absence of ongoing fire. However, reintubation may be more difficult after the injury and may have been difficult a priori given the likelihood of airway edema and secretions in many ICU patients. Ventilation is eventually supported by the new tracheostomy in this scenario, but establishment of a tracheostomy should be considered in any scenario if subsequent attempts at reintubation are unsuccessful. Once a fire has been recognized and extinguished, patients may develop severe pulmonary sequelae as a result of the fire itself, from debris and from smoke inhalation, requiring further care. Inhalation injury can result in airway edema, inflammation, mucosal necrosis, and charring.1 Fiberoptic bronchoscopy, laryngoscopy, and esophagoscopy are recommended to visualize the extent of the damage to the airway and surrounding structures.8 Loss of airway is a possibility if edema and debris make intubation or mask ventilation difficult. Destruction to the normal mucociliary function promotes increased secretions, atelectasis, pneumonia, and barotraumas from increased airway fragility after the injury. These can be fatal and indeed up to 20% of patients involved in an OR-based fire die or suffer serious injury.9 Steroids have not been definitively proven as helpful in reducing sequelae after airway fires or inhalational injuries.10 Administration of antibiotics may be prudent if signs and symptoms of infection develop but antibiotics are not mandatory. The patient should be examined for external burns that may require treatment as well. Some degree of acute respiratory distress syndrome should be expected and therefore patients are best managed in an ICU setting. Simulation Scenario Background State 1 The simulator is being mechanically ventilated with stable vital signs and an oxygen saturation greater than 97%. Anesthesia monitor waveforms (ie, arterial line tracing, capnography, ECG, and pulse oximetry) are being displayed and appear normal. The patient is being maintained on a volatile anesthetic and oxygen at FiO2 of 1.0. The blackened ETT is already in place and secured with umbilical tape (multiple knots are made, assuring that tube removal is challenging). IV access is in place. The simulator is draped in the standard fashion for tracheostomy with only the neck exposed. Two gowned “surgeons” are positioned on each side of the OR table with instruments in hand and “working” on the airway. The smoke machine is positioned on the simulator's chest, under the Mayo stand and concealed by a drape or blue towel so that when activated, smoke will fill the entire area from Mayo stand to head drape. The participant enters the simulated environment to find the case underway. A cursory patient hand-off is provided endorsing the history described above by the anesthesia resident who is sitting in a chair filling in the anesthetic record. He states, “I just need to grab a quick lunch and I'll be right back. It's just plug-and-play in here.” State 2 The surgeon announces he will be entering the airway “soon” and will need the participant to pull the ETT back a few centimeters and let the cuff down. Participants should ideally proceed to decrease the FiO2 to <50% (ideally, <30%)9,11 at this point and determine if the surgeons are using electrocautery around the surgical site. When the participant goes under the drapes to manipulate the ETT, he/she will find it difficult to move given the umbilical tape being knotted tightly and can use the available scissors to cut the umbilical tie. To ensure that the participant does not see the scenario confederate activating the smoke machine, the tube should be tied extremely tight so that it is not quickly undone, which would allow the participant to look over the drapes before a large plume of smoke is created. When the main surgeon is convinced, the participant is sufficiently distracted, he states he is entering the airway (using the electrocautery pen) and he activates the smoke machine. The other surgeon rapidly inflates the cuff on a standard ETT hidden beneath the drapes with the 60-mL syringe and a loud “pop” is heard as the cuff breaks. The main surgeon screams, “Whoa guys, he's on fire!” State 3 A fire alarm clip is played and a strobe light turned on to simulate an OR fire alarm. The simulator begins to desaturate to approximately 75% over 2 to 3 minutes and mild tachycardia develops. The surgeons continue to scream that the fire is in the airway and they cannot continue with the tracheostomy until it is put out. The participant should quickly recognize the airway fire after the “pop” in state 2, which uniformly leads them to look over the drapes, finding a large plume of smoke. Gas flow should be turned off and the circuit disconnected. The ETT should be pulled out and examined. Fire should be extinguished as previously discussed, and the participant should instruct the surgeons to flood the field with saline and state that they would do the same down the ETT. The participant should also communicate with surgeon as to the length of time required to complete the surgical airway and reintubation should be considered. If reintubation is attempted, the airway occluder and tongue-swelling functions are enabled making direct laryngoscopy unsuccessful, mask ventilation difficult, and necessitating completion of the tracheostomy by the surgeons to establish a definitive airway. State 4 The surgeon completes the tracheostomy. The circuit is attached to the Shiley or ETT placed in the airway. The oxygen saturation slowly improves to approximately 88% but maintains this level for the duration of the scenario. The participant should discuss their plan for the patient at this point as discussed above, including ICU admission, steroid administration, and the need for bronchoscopic examination of the airway. Debriefing The participants review the video of their performance with the simulation facilitator and discuss the points regarding risk of airway fire, components needed for fire, management of acute intraoperative airway fire, and postoperative care. Their performance is framed in terms of compliance with the ASA's recommendations regarding OR fires.12 The appropriateness of the patient hand-off is also discussed with the participant with emphasis on not only a thorough presentation of the patient's history but also a review of the ongoing anesthetic plan as a way of preventing such a scenario from occurring. Participants are asked finally to summarize the salient points regarding risk and management of airway fires and referred to the Anesthesia Patient Safety Foundation's video regarding OR fires11 before the scenario concludes." @default.
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