Dear Q&A,

In the hospitals where I have practiced, there have always been eye ointments available, most of which are petroleum-based, for corneal protection along with eye tapes. In our practice, it is common for the surgeons to request the use of this lubricant without tapes or adhesive dressing to the eyes when performing procedures on the head and neck, most often in the presence of endotracheal anesthesia. These surgeries commonly involve electrocautery. I have seen literature recommending all petroleum-based products be restricted from the operating room. I have seen a number of hospital policies that ban use of petroleum products and strong warnings against use in other locations where oxygen is administered by nasal cannula, such as with home COPD users. Does the APSF have any position on the use of petroleum-based eye ointment in head and neck surgeries or on the use of petroleum-based products in the operating room in general? Does the eye ointment commonly used by anesthesia professionals present a fire risk? My understanding is that the ointment, as well as the glycerin-based substitute carry a flammability rating of one. I am assuming that the use of such ointment would be against recommendations in surgeries utilizing an open oxygen source. Is this the case?
The use of lubricant in this manner has never been implicated in an operating room fire here. Does the foundation have any reports implicating the lubricant in such a fire? Thank you for your time and your strong role in patient advocacy, lending support to the members of our profession against practices that could cause harm.

Rebekah L. Scotch, MD NorthStar Anesthesia Worchester, MA

Dear Dr. Scotch:

Thank you for your question and your interest in prevention of surgical fires. Here are some answers to the questions in your letter.

Does the APSF have any position on the use of petroleum-based eye ointment in head and neck surgeries or on the use of petroleum-based products in the operating room in general?

Specific to ointments, the APSF does not have a discrete position on the use of petroleum-based eye ointments. However, the APSF does take a leading role in efforts and education to prevent surgical fires. We focus mainly on reducing the fire risk by limiting the concentration of the open delivery of oxygen to less than 30% FiO₂ or to control the airway with an LMA or endotracheal tube if a higher oxygen concentration may be required.

Some debate exists if lubricant is needed, prevents harm, or even increases risk for ocular trauma. Some believe the best corneal protection is provided by taping the eye in a “lash to lid” fashion where the upper lash is approximated to lower lid and then the eye taped closed.

Does the eye ointment commonly used by anesthesia professionals present a fire risk?

Yes, of the 3 elements needed for a fire (fuel, an oxidizer, and ignition source) the anesthesia providers are usually responsible for controlling the oxidizer (oxygen and nitrous oxide) concentration. Application of petroleum based eye ointment is one of the few instances where anesthesia providers are responsible for the fuel source.

My understanding is that the ointment, as well as the glycerin-based substitute carry a flammability rating of one. I am assuming that the use of such ointment would be against recommendations in surgeries utilizing an open oxygen source, is this the case?

Petroleum/paraffin based ointments are flammable, as are most substances, in an oxygen-enriched environment. Flammability ratings are based upon room air concentration of oxygen and not an increased oxygen concentration. The proximity of the fuel, such as ointments, to open delivery of oxygen in concentrations greater than 30% and to an ignition source such as an electrosurgical unit (ESU) establishes the surgical fire risk. Another factor to consider is the amount of lube applied. A thin coat is more prone to ignite because of inability to dissipate heat over a large amount of ointment.

The use of lubricant in this manner has never been implicated in an operating room fire here. Does the foundation have any reports implicating the lubricant in such a fire?

Since reporting of surgical fires is not mandated uniformly across the US, incidence really cannot be calculated. One surgical fire case describes the open delivery of oxygen via cannula, petroleum-based lube in the eyes, and use of an ESU to remove skin lesions near the eye that resulted in second-degree facial burns. Again, a confluence of all 3 elements needed to create a fire. If the oxygen concentration is kept to less than 30%, especially in cases of an intubated patient, and the ignition source is distant, this greatly reduces the risk for fire. So when in doubt, limit the oxygen concentration!

Charles E. Cowles, MD, MBA Associate Professor Department of Anesthesiology and Perioperative Medicine The University of Texas MD Anderson Cancer Center Houston, TX

---

The APSF sometimes receives questions that are not suitable for the Dear SIRS column. This Q and A column allows the APSF to forward these questions to knowledgeable committee members or designated consultants. The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of the APSF. It is not the intention of the APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall the APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.