ABSTRACT

Fire in the operating theater is a potential source of important morbidity for the patient. Laser surgery of the head and neck district presents a particularly high risk of fire due to the presence of all three elements of the ‘fire triad,’ necessary to cause combustive or explosive events: an oxidiser, a fuel, and a heat source. The aim of the present study is to emphasise the need of new prevention tools and greater adherence to the recommendations available in the literature.

The sudden occurrence of combustion within the airway of an infant undergoing laryngeal laser surgery was presented along with his management.

An infant underwent CO2 laser surgery for the treatment of the laryngeal stenosis. Unfortunately, the endoscopic procedure was complicated by a fire of the tracheal tube. The tube was immediately removed, the saline was flushed down the trachea and the ventilation was maintained through a face mask. Subsequently, a fiberoscopy was performed and showed a vocal cord burn.

Since operating room fires are still an underreported occurrence, we believe that this present work might raise awareness about this potential complication and give useful suggestions for the management of airway fires in paediatric anaesthesia.

Keywords: Airway fire, perioperative complications, paediatric anaesthesia, laser surgery, airways management, safety