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Table of Contents
LETTER TO EDITOR
Year : 2013  |  Volume : 29  |  Issue : 1  |  Page : 141

Fire in the operating room due to equipment failure


1 Department of Anaesthesiology, Command Hospital (Air Force), Bangalore, India
2 Department of Anaesthesiology, AJ Institute of Medical Sciences, Mangalore, Karnataka, India

Date of Web Publication10-Jan-2013

Correspondence Address:
Rajesh K Lalla
Department of Anaesthesiology, Command Hospital, Agaram Post, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.105836

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How to cite this article:
Lalla RK, Koteswara CM. Fire in the operating room due to equipment failure. J Anaesthesiol Clin Pharmacol 2013;29:141

How to cite this URL:
Lalla RK, Koteswara CM. Fire in the operating room due to equipment failure. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Nov 22];29:141. Available from: http://www.joacp.org/text.asp?2013/29/1/141/105836

Sir,

A 45-year-old woman, in American Society of Anesthesiologist physical status I, was scheduled for laparoscopic cholecystectomy at our hospital. After induction of anesthesia and neuromuscular blockade, the patient was mechanically ventilated. About 20 min after the start of the surgery, a burning smell was noted suggestive of burning of an electrical component. Suddenly, 1-ft-high flames were noted to emanate from the Datex Ohmeda Anesthesia Ventilator (7000, Datex-Ohmeda, Madison, WI, USA), mounted on Boyle Tec Anesthesia machine (Datex Ohmeda, Delhi, India). We immediately unhooked the anesthesia machine from the oxygen and nitrous oxide gas supply and disconnected the power cord. The patient's breathing circuit was disconnected from the machine and patient's lungs ventilated with help of a Bain's circuit connected to a wall-mounted oxygen bottle. The machine was wheeled out immediately and another machine from the opposite operating room, which fortunately was not in use, was wheeled in for anesthesia delivery. The fire was doused using carbon dioxide foam and dry sand. The surgery was continued and the patient had an uneventful recovery.

A hospital fire is a special situation because the patients in the hospitals are not capable of rescuing themselves unlike in other fire situations. Anesthesia workstations have been reported as sources of fire earlier. [1],[2],[3],[4],[5] Fumes emanating from an anesthesia ventilator, while it was undergoing checks, have been reported. [5] In our case, machine power was switched on and all check procedures had been performed on the morning of the event. The machine had been checked again prior to this particular case. Although the event happened during the surgery, fortunately the patient remained safe. The ventilator itself was damaged, but the anesthesia workstation was unharmed [Figure 1] and [Figure 2].
Figure 1: Datex-Ohmeda ventilator after the event

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Figure 2: A view of the Datex-Ohmeda ventilator after the event

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  References Top

1.Webb AI, Warren RG, Ackroyd RE. Anesthetic machine explosion. Anesthesiology 1982;57:343-5.  Back to cited text no. 1
[PUBMED]    
2.Rogers S, Davies MW. My Anesthesia machine's on fire. Anaesthesia 1997;52:505.  Back to cited text no. 2
[PUBMED]    
3.Usher AG, Cave DA, Finnegan BA. Critical incident with Narkomed 6000 Anesthesia System. Anesthesiology 2003;99:762.  Back to cited text no. 3
    
4.Eisenkraft JB. Hazards of the Anesthesia Workstation. ASA Refresh Courses Anesthesiol 2009:37:37-55.  Back to cited text no. 4
    
5.Schulte TE, Tinker JH. Narkomed 6400 anesthesia machine failure. Anesth Analg 2008;106:1018-9.  Back to cited text no. 5
[PUBMED]    


    Figures

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