Fire in the operating room during tracheotomy: a case report.

We describe a patient who sustained facial burns during a tracheotomy. The electrosurgical unit indirectly started the fire during monitored anesthesia care when a high inspired oxygen concentration was being delivered to the patient by simple face mask. This case points out the need for prevention strategies, intraoperative vigilance, and quick intervention to prevent further patient injury any time the electrosurgical unit is used in an oxygen-enriched atmosphere.