title: Thermal damage of the humidified ventilator circuit in the operating room: an analysis of plausible causes.
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.
authors.affiliation: Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce St, Dulles 6, Philadelphia, PA 19104, USA. klaudanski@gmail.com
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Laudanski
authors.forename: Wilhelm K
authors.initials: WK
authors.lastname: Schwab
authors.forename: Craig W
authors.initials: CW
authors.lastname: Bakuzonis
authors.forename: David A
authors.initials: DA
authors.lastname: Paulus
mesh_terms: D000368:Aged; D000776:Anesthesiology / Q000295:instrumentation*; D004867:Equipment Design; D004868:Equipment Failure; D019544:Equipment Failure Analysis; D004869:Equipment Safety; D005260:Female; D005390:Fires; D006801:Humans; D009873:Operating Rooms; D017751:Safety Management; D012122:Ventilators, Mechanical