Surgical Equipment - an overview (2022)

Surgical equipment like for instance an antimicrobial retractor could be fabricated by 3D printing the 3D object and subsequent deposition of a nanolayer of a specific antimicrobial agent.

From: 3D Printing: Applications in Medicine and Surgery Volume 2, 2022

Related terms:

  • Surgical Instrument
  • Endoscope
  • Operating Room
  • Surgical Technique
  • Anesthesia
  • Operation Duration
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Surgery for Proliferative Diabetic Retinopathy

Andrew P. Schachat MD, in Ryan's Retina, 2018

Surgical Equipment

Microscope and Lenses

As prerequisite, a modern binocular surgical (stereo-) microscope is required with coaxial illumination that should allow a magnification of 10–30-fold. It should be equipped with a motorized power zoom, power focusing, and X–Y-positioning via foot pedals. The microscope must be fitted with the corresponding laser filters to permit photocoagulation. A light-splitter is necessary for covisualization of the operating personnel and for the integration of a video system or other imaging features, as intraoperative OCT.105

For fundus visualization, different lens systems are available to neutralize the cornea's refractive power. The initial visualization of the central retina was performed using hand-held, planoconcave lenses or various contact lenses centered by the assistant or a sclera-fixated metal ring. For a better visualization of the fundus periphery, especially in gas-filled phakic eyes, biconcave lenses with 20–35° angle were developed.106,107

Today, 130° wide-angle viewing systems are available, and the inverted image is corrected through a stereoscopic diagonal inverter. Non-contact wide-angle systems (BIOM, EIBOS) are widely in use and can be managed by the surgeon alone.105,108 They offer a greater depth of field and better visualization through media opacities. Also, a lower incidence of postoperative epithelial defects or retinal detachments has been reported.109,110 To protect the corneal epithelium and guarantee for optimal fundus visualization, a corneal tear film must be maintained. The adjunctive use of carboxymethylcellulose gel or similar substances at surgery will promote corneal clarity.

Microinstruments and Illumination

Various types of surgical instruments have been developed and modified over the years. The instruments vary in the number of functions provided. Currently, a trend is towards single-use instruments or parts of them, providing maximal aseptic conditions. Twenty-gauge systems had become the long-time standard and are still used in rare situations, offering the greatest number of supplementary instruments with minimal flex.87,111

Small-Gauge Systems.

In more recent years, 23-, 25-, and 27-gauge instruments have been developed to provide nonsuturing vitrectomy, thereby minimizing inflammation and postoperative discomfort to the patient (Fig. 115.12).112–115 However, their efficiency in complex cases, such as advanced diabetic retinopathy, is still a matter of debate, as a higher rate of postoperative hypotony has been reported.116 In the recent literature, 23- and 25-gauge systems showed more stable and reproducible results even in severe proliferative diabetic retinopathy, compared with 27-gauge.112,117,118

3D printing and nanotechnology

Lazaros Tzounis PhD, Diploma Engineer, Petros Bangeas MSc, in 3D Printing: Applications in Medicine and Surgery Volume 2, 2022

Future perspectives: advancements beyond the state of the art

Surgical equipment like for instance an antimicrobial retractor could be fabricated by 3D printing the 3D object and subsequent deposition of a nanolayer of a specific antimicrobial agent. A lot of attention has been paid already to achieve planar surfaces, bulk materials, textiles, etc., with antimicrobial properties, especially in the health and hygienic field. More specific, the 3D objects could be produced at a specific use case and by design as well as patient specific. As PLA has been proven to be safe for surgical implantation, it can be selected for various future applications as it is a cost effective, safe, and environmentally suitable material for printing a surgical instrument. Ag NPs could be deposited in a wet deposition method via a versatile sonochemical protocol, yielding extremely reactive antimicrobial surfaces. The antimicrobial retractor must be strong enough to retract human tissue, must be hypoallergenic, and must tolerate repeat sterilization. Finally, it must be at least equivalent in cost, strength, and accessibility when compared with a standard stainless steel Army Navy retractor to be considered as a substitute.

Fig.2.11A shows the process for printing a PLA surgical retractor, as well as the method for sonochemically immobilizing Ag NPs, while the chemicals and the protocol followed to achieve high-quality monodispersed Ag NPs immobilized onto the retractor surface are illustrated in Fig.2.11B.

The optimization of 3D FDM AM processes via online monitoring and modeling approaches has the potential to provide high-quality components with built-in functionalities for multiple applications in various fields such as health, automotive, aeronautics and aerospace, consumer goods and electronics, industrial equipment and tooling, construction, and energy. Additionally, Three dimensional (3D) fused deposition modelling (FDM) additive manufacturing (AM) further developments at process and process optimization and process monitoring control level, as well as at materials level will improve the reliability, the quality and the accuracy as well as the multi-material capabilities through printed processes of nanocomposite filaments as fast as standard materials by avoiding process related issues.

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Endoscopic Endonasal Pituitary and Skull Base Surgery

Alfredo Quiñones-Hinojosa MD, in Schmidek and Sweet: Operative Neurosurgical Techniques, 2022

Surgical Equipment

Surgical equipment includes endoscopes with 0-, 30-, and 70-degree lenses (Fig. 15.4A) plus associated video-imaging system and light source connections, an endoscope lens-cleansing device, a rigid endoscope holder, and surgical instruments specifically customized or designed for endoscopic pituitary surgery. The length of the endoscope should be 18 cm, with shorter lengths having inadequate reach and much longer lengths being potentially awkward to maneuver. An endoscopic lens-cleansing device is recommended so that the surgeon can achieve better operating continuity (Fig. 15.4B). This device consists of a disposable irrigation tube, which has a loop of tubing passed through a battery-powered rotary device. The irrigation tube is connected into a warmed saline bag (the temperature prevents lens fogging), which is hung on a pole, and the motor-powered irrigation device is controlled by a foot pedal to flush saline forward. When the foot pedal is released, the motor reverses its rotary direction and draws the saline back for 1 to 2 seconds.

Endoscope holders provide stability of the visual image and bimanual instrument use without requiring a surgical assistant, during portions of the case such as drilling and tumor removal (Fig. 15.5). There are portions of surgery during which dynamic visualization is important, such as the initial approach to the sphenoid sinus rostrum and final visualization of any tumor remnants at anatomic corners of the sella, but endoscope holders provide camera stability akin to a video camera tripod during appropriate segments of surgery. Having a surgical trainee hold and drive the endoscope can help for the trainee’s education, but the stability and localization of views during surgery may be variable depending on the level of the trainee or assistant. The endoscope holder should provide rigid fixation of the endoscope while allowing simple transition between stable fixation and manual dynamic steering. The holding terminal should be compact and slender so as to render adequate operating space around the endoscope shaft for the surgeon to maneuver surgical instruments. We routinely use a customized manual endoscope holder specifically designed for EE-TS, in contrast to a nitrogen-powered holder called the Mitaka Point Setter (Mitaka USA; Park City, Utah) for our endoscopic transcranial approaches and a nitrogen-powered holder called Unitrac (Aesculap; Tuttlingen, Germany) forour endoscopic spine surgery. The EE-TS manual holder has multiple hand-tightened joints, but only a single joint has to be loosened during a case to transition between endoscope fixation and manual driving.

Among various surgical instruments, a monopolar suction coagulator (No. 8- or 9-French cannula), a bipolar suction coagulator (No. 8- or 9-French cannula), and a single-bladed bipolar coagulator are used for hemostasis. These are all disposable, and the monopolar suction coagulator is malleable and insulated. The malleable monopolar is useful during the endonasal stage when preparing the nasal cavity for anterior sphenoidotomy. The single-bladed bipolar has one electrode at the core and the other at the shell. Suction cannulas with curved or malleable tips (No. 5- and 7-French cannulas) are typically used. Dural suturing at the sella is typically not needed, but titanium microclips and nitinol U-clips are commercially available. In addition, standard surgical sutures may be used in conjunction with specialized tying techniques if needed.25 Other instruments used include a micropituitary rongeur, a pituitary rongeur, ethmoid rongeurs, a high-speed drill, micro-Kerrison rongeurs, pituitary ring curettes, Jannetta 45-degree microdissector, single-bladed Kurze scissors, and a specially-designed septal opener. A slender high-speed drill is useful when the sphenoid sinus is small or has limited pneumatization.

Regulatory requirements and Good Manufacturing Practices (GMP)

Tim Sandle, in Sterility, Sterilisation and Sterility Assurance for Pharmaceuticals, 2013

Abstract:

The proper sterilisation of medical devices, surgical instruments, supplies and equipment utilised in direct patient care and surgery, together with the preparation of medicinal products that are required to be filled aseptically, is a critical aspect of the modern health care delivery system and directly impacts patient safety. To ensure this, international standards together with an overarching regulatory framework are essential. The various sources and types of standards and guidance applicable to sterilisation and to the manufacture of sterile products are introduced. The regulatory approach, with a focus on European regulatory and the US FDA, is outlined. Many of the standards have the objective of describing or advancing Good Manufacturing Practice (GMP) and the centrality of GMP to quality systems is emphasised. In order to place current standards in context, the origin of GMP in the wake of infamous medical incidents are discussed.

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Endoscopic Third Ventriculostomy, Cerebral Aqueductoplasty, and Septum Pellucidotomy

Alfredo Quiñones-Hinojosa MD, in Schmidek and Sweet: Operative Neurosurgical Techniques, 2022

Surgical Equipment

There are several components to a functioning endoscopic setup: the endoscope itself, a light source, a video unit, and irrigation source. Familiarization with each piece of equipment by the entire surgical team is critical to ensure an efficient, safe, and effective procedure.

There are three basic types of endoscopes: rigid, flexible, and semiflexible (Fig. 83.1). Rigid scopes offer the best optics (a wide-angled view), allow magnification without loss of resolution, and can have a wide array of instruments passed through them. Flexible scopes allow a wide degree of bending, which allows the operator to look around corners. However, their resolution diminishes with magnification, and they may not allow many instruments to be passed through them. Semiflexible scopes have better resolution and less flexibility compared with flexible scopes but do not have the resolution or wide-angled view seen with rigid scopes.41 We prefer rigid scopes with a 0- or 12-degree angle of view for ETV.

The light source provides bright, cold illumination and typically comes from a halogen, xenon, or metal-halide lamp. In particular, the color of the picture seen under illumination with xenon most closely resembles the color in natural sunlight.11,41 The video unit is composed of a video camera, a camera control unit, video monitor, and a video documentation system (Fig. 83.2).

The irrigation source can either be manual or mechanical. Manual irrigation requires an assistant to continuously irrigate and intermittently change syringes. The pressure of irrigation can be adjusted, which can be helpful in achieving hemostasis and to subjectively examine the pulsatility through the opening once the ventriculostomy is made. Mechanical irrigation is automated, precluding the need for an assistant to continuously irrigate. Some systems allow for variations in flow speed, whereas in others, the pressure of irrigation is constant and cannot be adjusted. Another option is continuous irrigation with the solution suspended 20 to 30 cm above the head, which protects from the danger of continuous infusion of irrigation, leading to elevated ICP when the outlet of the endoscope is blocked. The solution used for irrigation should be slightly warmed normal saline or Ringer solution at a flow rate of less than 15 mL/min.

Ophthalmology ethics

Alex V Levin, in The Ophthalmic Assistant (Ninth Edition), 2013

Medical industry

Medical industry provides us with our therapeutic agents, diagnostic agents, medical technology, and surgical equipment. It is a necessary and integral part of medicine. In addition to the use of these products, physicians will have direct interaction with representatives of medical industry in the form of sales representatives wanting to give information about new products, opportunities to try new products, invitations to participate or lead industry-sponsored educational events with or without social components, invitations to become a spokesperson for industry products, invitations to write papers / conduct research / write monographs sponsored by industry, offers of grants to support research activities or program development, gifts of free samples of medications or gifts ranging from items of nominal value for medical use (e.g., note pads with the drug company name on each page), to more significant gifts such as sporting event tickets, free meals, and even all-expenses-paid trips to lovely locations with or without a sometimes nominal educational component.

As the reasonable patient would likely expect that the medical decisions of their ophthalmologist are free from influence and conflict of interest, it is not difficult to see why multiple studies have shown that patients generally object to such relationships between physicians and medical industry. Research also indicates that, despite the often-heard claims of physicians to the contrary, these practices do affect our prescribing patterns. It is then not surprising to learn that medical industry spends billions of dollars on advertising and such contacts with physicians, presumably not out of purely altruistic motives but rather in recognition of the positive effect such expenditures have on company profit.

Most ophthalmic and other medical professional societies, as well as the institutions in which physicians work, now have policies regarding interaction with medical industry. These policies grew out of the recognition of the potential for influence on the decision making of medical personnel if they stand to benefit from the largesse of industry in a personal way. Some physicians have rejected restrictions out of a feeling of entitlement, especially in times when physician fees are dropping and other restrictions on practice are increasing. Physicians may assert that their own autonomy to conduct their lives as they see fit is no less important than that of the patient. This conflict rages on and is most apparent at large meetings, where companies present enormous and elaborate displays and every conference participant may be given a tote bag and a neck strap for their identification badge emblazoned with drug company logos.

The pharmaceutical industry has also recognized the ethical dilemmas these relationships and activities engender. As a result they have implemented voluntary restrictions. Companies may contribute much in the way of information and financial support for medical meetings and claim that they have not influenced the scientific content (although there are many drug company-sponsored talks on exhibit floors in addition to the official scientific program). The risk of the public perception of impropriety and the potential for adverse manifestations of conflict of interest in direct patient care remain to be resolved.

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Laparoscopic Cholecystectomy and Choledocholithotomy

A. NAGLE, N.J. SOPER, in Surgery of the Liver, Biliary Tract and Pancreas (Fourth Edition), 2007

CONTRAINDICATIONS

Absolute and relative contraindications to performing laparoscopic cholecystectomy have decreased since the 1990s as minimally invasive surgical equipment and skills have improved (Table 35.2). Absolute contraindications include the inability to tolerate general anesthesia or laparotomy, refractory coagulopathy, diffuse peritonitis with hemodynamic compromise, cholangitis, and potentially curable gallbladder cancer. Diffuse peritonitis with hemodynamic compromise represents a surgical urgency in which attempted laparoscopic cholecystectomy is not prudent because the cause is unclear or uncertain. Standard open laparotomy allows rapid determination of the cause and more expeditious management of the disorder. Suspicion of gallbladder malignancy (e.g., porcelain gallbladder) generally mandates that standard open resection be undertaken because of persistent concerns with adequacy of resection and reports of port site metastases associated with the use of minimally invasive surgical techniques for the treatment of intra-abdominal malignancies. Relative contraindications are dictated primarily by the surgeon's philosophy and experience. These include previous upper abdominal surgery with extensive adhesions, cirrhosis, portal hypertension, severe cardiopulmonary disease, morbid obesity, and pregnancy.

Intra-abdominal adhesions secondary to previous abdominal surgery can tether underlying viscera and consequently increase the risk of hollow organ injury during placement of laparoscopic trocars (Wolfe et al, 1991). This risk can be reduced, however, by using alternative initial access sites distant from the previous surgery and placement of initial trocars under direct vision using a direct cutdown technique on the peritoneum. The adhesions can be taken down to allow optimal port placement.

Cirrhosis results in a brittle, friable, heavy liver that may be difficult to retract in the cephalad direction, limiting exposure of the porta hepatis and gallbladder. Cirrhosis also may be accompanied by decreased synthetic function of the liver resulting in coagulopathy and portal hypertension. Coagulopathies must be reversed before performance of laparoscopic cholecystectomy. The ability to achieve effective hemostasis laparoscopically is significantly compromised compared with that of open exposure. Portal hypertension and aberrant portosystemic venous collateralization may lead to exsanguinating hemorrhage from small veins in the liver bed and porta hepatis or large veins in the abdominal wall (e.g., a recanalized umbilical vein) at risk for laceration during trocar puncture. Laparoscopic cholecystectomy may be attempted with care in these patients by experienced surgeons; however, prompt conversion to an open procedure is recommended in the face of unusual bleeding, regardless of the stage of the operation (Soper NJ, 1993).

Preexisting cardiac conditions mandate vigilant intraoperative observation for significant arrhythmias known to be associated with establishment of a carbon dioxide pneumoperitoneum, including bradycardia and ventricular ectopy. Also, in patients with cardiac pacemakers, alternative energy sources, such as bipolar electrosurgery or ultrasonic coagulation, should be used because of known interference problems caused by monopolar electrosurgical devices.

Most patients undergoing laparoscopic cholecystectomy exhibit mildly elevated Pco2 (Liu et al, 1991). Chronic obstructive pulmonary disease may predispose patients to carbon dioxide retention disproportionate to the measured end-tidal value during laparoscopic cholecystectomy (Wittgen et al, 1991). Prudent measures in these patients include obtaining preoperative pulmonary function tests and arterial blood gas determinations and maximizing pulmonary function by smoking cessation and bronchodilator therapy. An intraoperative arterial catheter also should be placed to allow frequent measurement of Pco2 and pH. Hypercarbia may manifest as hypertension, tachycardia, or ventricular arrhythmias and should be addressed by immediate evacuation of the pneumoperitoneum and stabilization. Slow re-establishment of the pneumoperitoneum may be attempted, but the procedure should be terminated or converted to open if the hypercarbia recurs and is refractory to continued pneumoperitoneum.

Morbid obesity was initially a relative contraindication to laparoscopic cholecystectomy primarily because of thickness of the abdominal panniculus relative to the length of early trocar and sheath designs, making institution and maintenance of a pneumoperitoneum problematic if not impossible. Various instrument manufacturers have since developed longer port systems to obviate this problem. With pneumoperitoneum established, there is usually no additional risk with performance of laparoscopic cholecystectomy in an obese patient, unless the liver is diffusely infiltrated with fat, making it more friable and prone to injury during forceful retraction or by inadvertent instrument contact with the hepatic capsule (Schirmer et al, 1992). Retrospective and prospective studies have shown modestly increased operative times with performance of minimally invasive procedures in obese patient groups (Schirmer et al, 1992; Underwood et al, 1998). Today, laparoscopic cholecystectomy is commonly performed in morbidly obese patients and seems to offer the same advantages as in nonobese patients and may offer advantages more specific to obese patients, such as decreased wound infections, incisional hernias, and thrombotic complications (Miles et al, 1992; Talamini & Gadacz, 1992). Rather than being contraindicated in morbidly obese patients, laparoscopic cholecystectomy may become the preferred mode of therapy for these patients.

Pregnancy is a controversial relative contraindication to laparoscopic cholecystectomy because of the unknown effects of prolonged carbon dioxide pneumoperitoneum on the fetus. It has been shown that laparoscopic cholecystectomy can be performed safely during pregnancy, but only with great care (Soper N et al, 1992a); the procedure should be restricted to the second trimester, after organogenesis is complete and before the size and height of the uterine fundus encroach on the operative field. Open insertion of the initial port or alternative location of the initial port in the right upper quadrant should be used to avoid injury to the gravid uterus, and the insufflation pressure should be limited to less than 12 mm Hg to avoid respiratory embarrassment and decreased vena caval return. Also, maternal hyperventilation with close monitoring of end-tidal carbon dioxide should be undertaken to prevent fetal acidosis. When visualization of the biliary tree is required, laparoscopic ultrasound is used in place of cholangiography to avoid fetal radiation exposure. Finally, perioperative consultation with an experienced obstetrician is advisable, as is perioperative monitoring of the fetal heart.

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Aldehydes, esters, ketones, ethers and amines

F. Testud, J. Descotes, in Human Toxicology, 1996

Glyoxal and glutaraldehyde

These two aliphatic dialdehydes are highly effective biocides widely used in the cold sterilization of medical, surgical and dental equipment. In France, they are often included together in commercial products [21]. Adverse effects occur mainly in hospital workers: headache, irritating symptoms of the eyes, skin and respiratory tract [22], even when ambient levels are below occupational limits (TLV = 0.2 ppm in most countries). Wiggins et al. [23] reported an unusual case of recurrent epistaxis associated with upper respiratory tract irritation and skin rash when handling a 50% glutaraldehyde solution. Inadequate rinsing of a Hoskin lens after soaking in 2% buffered glutaraldehyde resulted in keratopathy without long-term sequelae in a 88-year-old woman [24]. Glutaraldehyde and to a lesser extent glyoxal are also strong sensitizers: allergic contact dermatitis [25] and occupational asthma have been documented in health care workers [26] and radiographers [27]. Recently, systemic toxicity was suggested by 7 patients occupationally exposed to glutaraldehyde who experienced work-related tachycardia and palpitations; in 2 of them, ECG was obtained while they were symptomatic and showed supraventricular tachycardia [28].

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Mediastinal Mass and Superior Vena Cava Syndrome

Daniel Kalowitz, Menachem M. Weiner, in Cohen's Comprehensive Thoracic Anesthesia, 2022

Equipment Considerations

It is necessary to ensure that all possible necessary medications and equipment are present and easily accessible. This includes both anesthetic equipment, as well as surgical equipment. When complications from a mediastinal mass occur, the effects are quick and potentially life-threatening. Having to wait even moments for rescue medications or equipment can be life-threatening.

All possible medications that may be needed, including inotropes and vasopressors, should be drawn up and readily available. Multiple laryngoscopes and endotracheal tubes (ETTs) should be present in the operating room. This includes ETTs of different sizes, different lengths, such as microlaryngeal tubes, and different types, such as reinforced and double lumen tubes (DLTs). There are numerous reports of respiratory complications being relieved by laryngoscopy,58 advancing an ETT, passing a smaller diameter ETT, or passing a longer ETT beyond the area of compression.10,37,56,59 If necessary, using a DLT may provide a more stable patent airway than a standard polyvinyl chloride ETT because it is more rigid.45

Having a rigid bronchoscope in the room, with an experienced provider ready to use it, is another important piece of equipment that must be present and can be a life-saving device. A rigid bronchoscope, which is more solid and sturdy than an ETT, has a higher likelihood of being able to displace a mass that is causing airway compression. The rigid bronchoscope will also enable the surgeon to stent open the airway, thereby enabling patient oxygenation and ventilation through the rigid bronchoscope.56,59 The mode of ventilation to be used with the rigid bronchoscope, such as high-frequency jet ventilation, should be planned in advance, and the ventilator should be readily available and tested before the induction of anesthesia.

Cardiopulmonary bypass (CPB), as well as staff capable of initiating and maintaining CPB, must be considered for high-risk patients. This involves having a cardiac surgeon and perfusionist present. The use of CPB can maintain patient oxygenation, ventilation, and perfusion if any or all of these functions become compromised. If a mediastinal mass were to compress the airway, the CPB can be initiated to replace the role of the lungs.60 If the mass were to obstruct the inflow or outflow of the heart, CPB can maintain adequate perfusion.

The approaches that have been used with CPB range from having everything “standby” in the room to cannulating the patient and initiating CPB before induction of anesthesia. Although there are reports of unexpected cardiopulmonary collapse and the use of CPB as a rescue maneuver, cannulation and initiation of CPB using a femorofemoral approach takes approximately 20 minutes, even with the most experienced providers.29,42,55 Most reports seem to agree that CPB standby is not an acceptable rescue measure for symptomatic or high-risk patients, as the time it takes to initiate CPB increases the risk of neurologic injury and death.30,42,61,62 Some argue that placing wires into the femoral vessels is adequate, as this can save time and provide quicker cannulation.29 However, these wires may be lost, kinked, or dislocated during attempted emergency cannulation.42 Therefore when the need for cardiopulmonary collapse is likely, patients should have their femoral vessels cannulated awake, under local anesthesia, before induction of anesthesia. In severe cases, CPB may be initiated while the patient is awake and maintained until CPB is no longer needed.44,63–66 Alternative locations for the CPB cannulas can also be used depending on the nature of the situation. For example, a jugulosaphenous venovenous shunt can be used in cases of SVCS to relieve and avoid an increase in venous pressure and prevent complications because of respiratory compression.67

Having TEE present, with a provider who is able to obtain appropriate images and interpret them quickly, should be considered. TEE has been used in patients with mediastinal masses during moments of hemodynamic instability to help guide intraoperative management.29,42,68–70 TEE is a valuable tool to help monitor real-time cardiac function and as mentioned previously, can provide valuable information on the extent of the mass and possible cardiac or great vessels invasion.

Last, Linnaus et al.71 report using a sternal hook connected to a sternal elevator to lift the chest and temporarily reverse the respiratory complications seen with an anterior mediastinal mass.

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Operating Room Electrical, Fire, Laser, and Radiation Safety

Anuja K. Antony, ... William G. Austen, in The MGH Textbook of Anesthetic Equipment, 2011

Combustible Materials

Combustible material serves as the “fuel” in the fire triangle model. These are any materials that can be burned; they can be in gas, liquid, or solid state.

Endotracheal (ET) Tube

The specific material composition of an ET tube (PVC, red rubber, metallic) determines the risk and characteristics of a tracheal fire. ET tubes are usually penetrated by laser or surgical equipment before ignition. A characteristic of ET tube fire is that the fire usually starts in the inner rim of the penetrated area then spreads along the direction of oxidizing gas.

Polyvinylchloride Tube (PVC Tube)

PVC tubes are products of petroleum-based extractions. They are combustible in an oxidizer-rich environment, usually with an ignition by a laser. Once ignited, PVC tubes can produce a torchlike fire. Increasing positive end-expiratory pressure (PEEP) is thought to decrease the risk of PVC tube fire during laser surgery.22 Blood, saliva, and mucus covered PVC tubes have a higher risk for fire. Furthermore, rubber-based ET tube may have an advantage over PVC tubes during extubation. Other components of the fire triangle should be avoided when possible (i.e., nitrous oxide or high concentration of oxygen gas). Saline-filled cuff ET tubes may further reduce the risk for fire in the airways.23-27 Metallic tapes such as aluminum-foil tape and copper-foil tape have been developed to protect combustible endotracheal tubes from the CO2 laser. Comparatively, the Laser-Guard-wrapped PVC tracheal tube and the Tyco Healthcare/Nellcor Laser-Flex tracheal tube are less reflective of incident CO2 or KTP laser surgery laser radiation than the copper- or aluminum foil-wrapped red rubber tracheal tubes.25,28 Laser-Guard helps protect the shafts of combustible PVC endotracheal tubes from direct, high power, continuous CO2 laser radiation.25,29

Red Rubber (RR) Endotracheal Tubes

Sterile disposable PVC ET tubes are now routinely used in surgery. Previously, red rubber (Rusch-Germany) tracheal tubes were used. These tubes were sterilized for reuse, which carried a small a risk of infection. Similar to PVC tubing, RR tubes also pose a risk for operating room fires if penetrated by laser energy in an oxidizer-rich environment. Use of a rubber ET tube may have an advantage over plastic PVC ET tube, with a potentially more rapid extubation in the case of an ET tube fire.24

Laser-Resistant Tubes30

An appropriate laser-resistant tracheal tube should be used for the procedure (e.g., carbon dioxide [CO2], neodymium-doped yttrium aluminium garnet [Nd:YAG], Ar, erbium-doped yttrium aluminium garnet [Er:YAG], potassium titanyl phosphate [KTP]). Laser-resistant tubes provide improved safety; PVC and RR tubes can readily ignite in an oxygen-rich environment with continuous laser energy supported by nitrous oxide combustion.31,32

The tracheal cuff of the laser tube should be filled with saline and colored with an indicator dye such as methylene blue. Before laser activation, the surgeon should indicate to the anesthesiologist that laser activation is about to occur so that delivered oxygen content can be reduced to the minimum acceptable, nitrous oxide use can be terminated, and ample time can transpire (a few minutes) for reduction of the oxidizer-rich atmosphere. Adding PEEP during CO2 laser operations on the airway in which laser-resistant tracheal tubes with PVC components are used may decrease the incidence of fire.33

Prep Agents34

Many prepping agents and certain ointments are flammable. In particular, alcohol-based prepping agents are extremely flammable and vapors from these agents can ignite from a laser or ESU. One should avoid dripping or pooling of residual alcohol-based preps, especially at the umbilicus and suprasternal notch of the patient because vapors trapped under drapes or residual wet draping may ignite with heat or sparks. When prepping with alcohol-based prep, proper technique should be employed to ensure proper drying time and limited exposure of any volatile solution in the operating room. Also, surgical petroleum-based ointment, especially if applied in thin layers, can absorb considerable heat and vaporize. These vapors, after mixing with oxygen, serve as a potential ignitable source. To the contrary, water-based lubricants (K-Y jelly) do not burn and can be used to coat hair as a fire retardant. Similarly, water-based prepping agents (Betadine, Pharmaseal) should be used when possible.

Patients

A patient’s body hair, eyelashes, mustache, and eyebrows are all combustible. Water-based lubricant can reduce the fire hazards.

Intestinal Gas

Methane, hydrogen sulfide, and sulfur gas in the GI tract have all been reported sources for combustible gas within the patient’s body.34,35 Care should be taken to reduce the intestinal gases as much as possible by proper preoperative bowel preparation. Oxygen may also diffuse into the GI tract and become a combustible firehazard.

Surgical Products

Surgical drapes, gowns, masks, shoe covers, mattresses, pillows, and blankets can serve as fuels for operating room fires. An oxygen-rich environment may override the fire-resistant properties of surgical products.36 Sponges, gauze, and ace bandages can also be fuels for operating room fires. However, moistening sponges and gauze with saline reduces the chance for fire. Disposable drapes may be troublesome when caught on fire because they are water repellant. One should consider that fire-resistant drapes are not fireproof.

Gauze, especially with blood, can be very combustible under an oxygen-rich environment.37,38

Equipment/Supplies

Other equipment that may become fuel in the operating room include anesthesia components, flexible endoscopes, coverings of fiberoptic cables, gloves, blood pressure and tourniquet cuffs, stethoscope tubing, smoke evacuator hoses, instrument cabinets, disposable packaging material (plastics), and warming blankets (Bair Huggers).

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