Endotracheal tube fire during tracheostomy

Corresponding author: Eunju Lee, M.D., Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, 75, Nowon-gil (215-4 Gongneung-dong), Nowon-gu, Seoul 139-706, Korea. Tel: 82-2-970-2820, Fax: 82-2-970-2413, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Despite the reduced use of inflammable anesthetics, there are still a number of reported fire incidents. If an endotracheal tube ignites during anesthesia, it progresses rapidly and the patient experiences a mild to a heavy burn. A severe burn may even cause death [1]. A male patient (171 cm, 51 kg) with a chief complaint of odynophagia was diagnosed with tongue cancer from computed tomography (CT) scan and biopsy. A tracheostomy was scheduled before a radical excision. A brain tumor was discovered by chance from a preoperative magnetic resonance imaging (MRI) scan but it was decided that only observation of the progress would be made because of the very small size of the tumor. Upon arrival in the operating room patient’s oxygen saturation was 95%. Anesthesia induction was done and the anesthesiologist intubated the patient. Using direct curvedblade laryngoscopy, a 7.0 internal diameter reinforced polyvinyl chloride endotracheal tube (ETT; Safety-Flex with Murphy Eye; Mallinckrodt, Athlone) was intubated without difficulty. The tube cuff was filled with air. After intubation, the ETT was fixed at a depth of 22 cm from the teeth. A normal breathing sound was made from the auscultation of both lungs. Afterwards, anesthesia maintenance was done with sevoflurane (1-2 vol%, oxygen 2 L/min) and nitrous oxide (2 L/min). An experienced ear-nose-throat (ENT) surgeon who had performed 40 tracheostomies sterilized the surgical site with betadine and alcohol (83% ethanol). After 10 min, electrocautery in the monopolar cutting mode was used for skin incision at the 2-4 tracheal cartilage, at the midpoint between the cricoids cartilage and the sternal notch. Ten minutes into the surgery, the anesthesiologist discovered that the ETCO2 waves were irregular, so he switched respiration to the manual mode. When observing the surgical view, he discovered that the cuff of the ETT had burst. The ENT surgeon tried to stop the bleeding at the tracheal incision site using electrocautery in the bipolar coagulation mode (25 watt). At that moment, grey smoke coming from the tracheostoma was observed. The authors assessed that it was due to an ignition from the ETT. Manual ventilation and the supply of oxygen, nitrous oxide, and sevoflurane from the anesthesia machine were stopped. Smoke came from the tracheostoma for about 3 sec. The ENT surgeon twice poured 10 cc saline at the fire site and extinguished the fire. From the point of ignition to the point of fire extinguishment, the patient was maintained in the state of apnea to reduce the possibility of foreign-body aspiration. At the time of ignition, the tracheostomy had been almost