[A case in which the endotracheal tube was ignited by an electrocautery during tracheotomy]

Electrocautery is essential in the modern operation. But if we use it carelessly, a severe complication can occur. Tracheotomy was performed by surgeons after laparotomy and drainage in a patient with severe pancreatitis. Endotracheal tube was ignited during hyperoxidation immediately after trachea was incised by electrocautery. Trachea and bronchi was damaged by heat. After the tracheotomy we examined his trachea and bronchi with a bronchoscope periodically. Electrocautery should be used carefully during hyperoxidation.