Waiting three minutes after application of alcohol-based skin preparation does not reduce operating room fires.

Peter M Einersen, MD¹, Jason M Samuels, MD¹, Krzysztof J Wikiel, MD², Heather Carmichael, MD¹, Douglas M Overbey, MD¹, John T Moore, MD², Carlton C Barnett, MD¹, Thomas N Robinson, MD, MS², Teresa S Jones, MD, MS², Edward L Jones, MD, MS². ¹University of Colorado – Denver, ²VA Eastern Colorado Healthcare System

Introduction: Operating room fires are “never events” that expose the patient to the risk of devastating complications. Our group has previously demonstrated that alcohol-based surgical skin preparations fuel operating room fires. Manufacturer guidelines recommend a three-minute delay after application of alcohol-based preps to decrease the risk of prep pooling and surgical fires. The purpose of this study was to evaluate the efficacy of the three-minute dry time in reducing the incidence of surgical fires.

Methods and Procedures: A standardized, ex vivo model was used with a 15x15cm section of clipped, porcine skin. Alcohol-based surgical skin preparations tested were 70% isopropyl alcohol (IPA) with 2% chlorhexidine gluconate (CHG) and 74% IPA with 0.7% iodine povacrylex (Iodine-IPA). Nonalcohol-based solutions included 2% chlorhexidine gluconate and 1% povidone-iodine “paint.” An electrosurgical "Bovie" pencil was activated for 3 seconds on 30 Watts coagulation mode in 21% oxygen, both immediately and 3 minutes after skin preparation application, with and without solution pooling.

Results: No fires occurred with immediate testing of nonalcohol-based preparations (0/40). Alcohol-based preps created flames on immediate testing in 83% (33/40) of cases when pooling was present. Without pooling, flames occurred in 40% (16/40) of cases on immediate testing. After a 3-minute delay, there was no difference in the incidence of fire when pooling was present (33/40 vs. 33/40, p > 1). Similarly, there was no difference when pooling was not present (16/40 vs. 14/40, p = 1). (Table 1)

Conclusions: Alcohol-based surgical skin preparations fuel surgical fires. Waiting 3 minutes for drying of the surgical skin prep did not change the incidence of surgical fire (regardless of whether there was pooling of the prep solution). The use of nonalcohol-based skin preps eliminated the risk of fire.