Thermal damage of the humidified ventilator circuit in the operating room: an analysis of plausible causes.

Laudanski, Krzysztof; Schwab, Wilhelm K; Bakuzonis, Craig W; Paulus, David A · Anesth Analg · 2010

case_report · Level V

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Abstract

Fire in the operating room is a rare but potentially devastating event. In this case report, we describe 2 separate fires of a Westmed heated humidification circuit. We conducted a detailed analysis of potential causes of the fires, including a simulation and series of experiments. Our conclusions were (1) a combination of factors led to the fires; and (2) substantial changes in the design could decrease, but may not completely eliminate, the risk of operating room fire.

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