A Case Report of Incidental Endotracheal Tube Firing in Operating Room during CO2 Laser-Assisted Laryngomicrosurgery

Abstract

Operating room fires are a rare but preventable danger in modern operating rooms. But sometimes accidental fires in operating room can be life threatening. Surgical fires require an ignition source, oxidizer, and fuel. Recently, laser as an ignition source in the presence of anesthetic gases has been associated with operating room fires in otorhinolaryngologic field. We describe a 30-year-old patient diagnosed with recurrent laryngeal papillomatosis treated by CO2 laser-assisted laryngomicrosurgery. In this case, we experienced endotracheal tube flaring during CO2 vaporization and then incidental endotracheal tube firing due to CO2 laser under high O2 circumference. Shortly after removal of firing endotracheal tube, the anesthesiologist considered careful re-intubation. To minimize the risk of operating room fires, surgeons must familiarize with the common possibilities where fire is known to occur. Furthermore, the prevention of operating room firing should be strongly considered during all operations using lasers.