Carbon dioxide can eliminate operating room fires from alcohol-based surgical skin preps



Surgical fires are a rare event that still occur at a significant rate and can result in severe injury and death. Surgical fires are fueled by vapor from alcohol-based skin preparations in the presence of increased oxygen concentration and a spark from an energy device. Carbon dioxide (CO2) is used to extinguish electrical fires, and we sought to evaluate its effect on fire creation in the operating room. We hypothesize that CO2 delivered by the energy device will decrease the frequency of surgical fires fueled by alcohol-based skin preparations.


An ex vivo model with 15 × 15 cm section of clipped, porcine skin was used. A commercially available electrosurgical pencil with a smoke evacuation tip was connected to a laparoscopic CO2 insufflation system. The electrosurgical pencil was activated for 2 s at 30 watts coagulation mode immediately after application of alcohol-based surgical skin preparations: 70% isopropyl alcohol with 2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol with 0.7% iodine povacrylex (Iodine-IPA). CO2 was infused via the smoke evacuation pencil at flow rates from 0 to 8 L/min. The presence of a flame was determined visually and confirmed with a thermal camera (FLIR Systems, Boston, MA).


Carbon dioxide eliminated fire formation at a flow rate of 1 L/min with CHG-IPA skin prep (0% vs. 60% with no CO2, p < 0.0001). Carbon dioxide reduced fire formation at 1 L/min (25% vs. 47% with no CO2, p = 0.1) with Iodine-IPA skin prep and fires were eliminated at 2 L/min of flow with Iodine-IPA skin prep (p < 0.0001).


Carbon dioxide can eliminate surgical fires caused by energy devices in the presence of alcohol-based skin preps. Future studies should determine the optimal technique and flow rate of carbon dioxide in these settings.

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Correspondence to Edward L. Jones.

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Drs. Samuels, Carmichael, Wikiel, Robinson, Barnett, Jones, and Jones have no conflicts of interests or financial ties to disclose.

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Samuels, J.M., Carmichael, H., Wikiel, K.J. et al. Carbon dioxide can eliminate operating room fires from alcohol-based surgical skin preps. Surg Endosc (2019) doi:10.1007/s00464-019-06939-z

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  • Surgical fire
  • Carbon dioxide
  • Smoke evacuation
  • OR safety