Fires in the Operating Room: Does Clipping Hair Make a Difference?

Edward L Jones, MD, Douglas M Overbey, MD, Brandon C Chapman, MD, Sarah A Hilton, MD, Todd R Arcomano, MD, Teresa S Jones, MD, John T Moore, MD, Thomas N Robinson. University of Colorado

Background: Operating room fires are rare events that remain an under-reported source of devastating complications. Surgical fires are commonly a result of alcohol-based surgical skin preparations ignited by electrosurgical energy in the presence of oxygen. Manufacturer guidelines recommend waiting at least 60 minutes after application to hair-bearing areas in order to decrease the risk of fire. We could find no studies examining the flammability of common surgical preps with respect to hair. The PURPOSE of our study was to determine the relationships between surgical fires and hair when using alcohol-based skin preps.

Methods: A standardized, ex-vivo model was created with 4cm² pieces of porcine skin. A hand-held “Bovie” was activated for 2 seconds on 30W coag mode with room air oxygen (21%). Alcohol-based preps included: 70% isopropyl alcohol with 2% chlorhexidine gluconate (Chloroprep), and 74% isopropyl alcohol with 0.7% iodine (Duraprep). Non-alcohol based preps were: 4% chlorhexidine gluconate and 1% iodine paint. Preps were tested immediately after application (0 minutes) and after a 3-minute delay (per manufacturer recommendations when no hair is present). A visible flame was considered positive and was confirmed with thermal imaging. Experiments were repeated 20 times based upon a pre-test probability of 35%. Fisher's exact test was used to compare categorical variables with statistical significance set at p<0.05.

Results: Non-alcohol based skin preps (4% chlorhexidine and 1% iodine paint) caused no fires on immediate 0% (0/40) or 3-minute delayed testing 0% (0/40) [similar to saline control (0%, 0/20; p=1.0)]. Alcohol-based skin preps created fires both immediately and on delayed testing in 23% (36/160) of experiments. When comparing clipped vs. hairy skin, there was no difference in the incidence of fire with alcohol-based preps. (Table 1)

Conclusion: Alcohol-based skin prep causes surgical fires. The presence of hair did not alter the incidence of fire whether or not the surgeon waited 3 minutes for drying. Patients remain at risk for burn when alcohol-based skin prep is used regardless of the presence of hair.