Incidental operating room fire from a breathing circuit warmer system: a case report

Area of Science:

• Anesthesiology
• Medical Device Safety
• Patient Safety

Background:

• Breathing circuit warmers (BCWs) are essential for maintaining patient temperature during anesthesia.
• Airway fires in operating rooms pose severe risks.
• This report details a unique case of a BCW-related airway fire.

Observation:

• An electrical short in a BCW initiated a fire within the breathing circuit.
• The fire was rapidly extinguished, and the patient disconnected, with exposure under 10 seconds.
• Initial bronchoscopy revealed soot but no immediate edema or airway narrowing.

Findings:

• The patient sustained tracheal and bronchial burns from the inhalation injury.
• Inflammatory response worsened over two weeks before gradual recovery.
• Complete mucosal healing and return to normal respiratory tract function occurred within four weeks.

Implications:

• This is the first reported case of a fire originating from a BCW.
• Effective emergency response and subsequent medical management are crucial for patient outcomes.
• Emphasizes the critical need for extreme caution with all electrical medical devices used in proximity to patient airways.