Thermal damage of the humidified ventilator circuit in the operating room: An analysis of plausible causes
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. Copyright © 2010 International Anesthesia Research Society.