Infection Control Today - 07/2003: Dangers of Surgical Smoke

Dangers of Surgical Smoke Still PersistDespite Awareness Campaign

By John Roark

During surgical procedures using a laser orelectrosurgical unit (ESU), the thermal destruction of tissue creates a smokebyproduct. Research studies have confirmed that this smoke plume can containtoxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde,bioaerosols, dead and live cellular material (including blood fragments), andviruses. At high concentrations, the smoke causes ocular and upper respiratorytract irritation in healthcare workers (HCWs), and creates visual problems forthe surgeon. The smoke has unpleasant odors and has been shown to have mutagenicpotential.1

The National Institute for Occupational Safetyand Health (NIOSH) hazard-control statement listing the components of surgicalsmoke plume, its noxious effects, and the pros and cons of ventilationtechniques and smoke-control work practices was last updated on March 2, 1998.Yet in spite of this report and their awareness of the potential hazards,perioperative team members continue to breathe surgical smoke.

Why should cumbersome or noisy practiceschange when we have been working without smoke evacuators for years? asksBrenda S. Gregory Dawes, RN, MSN, CNOR, in her article, StopSmoke Campaign Begins With You, published in the November 2000 issue of AORNJournal. More importantly, if we realize the need, why is smoke plumeevacuation a continuing concern rather than a problem solved?

A few years prior to my writing (the article),we had one legislator who was very supportive, but it just never did getanywhere. We needed other legislators to get the smoke initiative on the plateso that there could be protection, says Dawes. Since then we have not hada lot of luck legislatively mandating any type of smoke evacuation. We have therecommendations out there with OSHA, but its not anything that anyone isconsistently practicing.

Part of the difficulty, she says, is provingsurgical smokes hazardous effects. Its not the easiest hazard to provebecause its one of those long-term effects. They feel that there arecarcinogens in smoke. We know that in procedures where theres an actual virusinvolved, the virus could be transmitted. They feel like there is somecarcinogenic effect. Its very similar to the smoke hazards you wouldassociate with cigarette smoking.

As early as the 1980s, research indicated thatsmoke plume particles were too small to be filtered effectively by a standardsurgical mask, and that laser plume causes pathological changes. The advent oflaser technology resulted in recognizing the dangers of surgical plume and inefforts requiring HCWs to protect themselves during laser use.

Although electrosurgical devices have been in usefor more years than lasers, the similarities in the smoke contents have not beenrecognized or regulated equally.

Control of Smoke From Laser/Electric SurgicalProcedures recommends the following two means of controlling the risks posedby electrosurgical smoke:

Ventilation

Recommended ventilation techniques include acombination of general room and local exhaust ventilation (LEV). General roomventilation is not by itself sufficient to capture contaminants generated at thesource. The two major LEV approaches used to reduce surgical smoke levels forhealthcare personnel are portable smoke evacuators and room suction systems.

Smoke evacuators contain a suction unit (vacuumpump), filter, hose and an inlet nozzle. The smoke evacuator should have highefficiency in airborne particle reduction and should be used in accordance withthe manufacturers recommendations to achieve maximum efficiency.

A capture velocity of about 100 to 150 feet perminute at the inlet nozzle is generally recommended. It is also important tochoose a filter that is effective in collecting the contaminants.

A High Efficiency Particulate Air (HEPA) filteror equivalent is recommended for trapping particulates.

Various filtering and cleaning processes alsoexist which remove or inactivate airborne gases and vapors. The various filtersand absorbers used in smoke evacuators require monitoring and replacement on aregular basis and are considered a possible biohazard requiring proper disposal.

Room suction systems can pull at a much lowerrate, and were designed primarily to capture liquids rather than particulate orgases. If these systems are used to capture generated smoke, users must installappropriate filters in the line, insure that the line is cleared, and thatfilters are properly disposed of. Generally speaking, the use of smokeevacuators are more effective than room suction systems to control the generatedsmoke from nonendoscopic laser/electric surgical procedures.

Work Practices

The smoke evacuator or room suction hose nozzleinlet must be kept within 2 inches of the surgical site to effectively captureairborne contaminants generated by these surgical devices. The smoke evacuatorshould be on (activated) at all times when airborne particles are producedduring all surgical or other procedures. At the completion of the procedure alltubing, filters, and absorbers must be considered infectious waste and bedisposed appropriately. New filters and tubing should be installed on the smokeevacuator for each procedure. While there are many commercially available smokeevacuator systems to select from, all of these LEV systems must be regularlyinspected and maintained to prevent possible leaks.

Users shall also utilize control measures such asuniversal precautions, as required by the Occupational Safety and HealthAdministration (OSHA)s Bloodborne Pathogen standard.2

OSHA issued guidelines for electrical smoke inMarch 1998. The document recommends that surgical smoke be removed and properlyfiltered by a smoke evacuation system as close to the surgical site as possible.It further is noted that personal protective equipment should be worn whereengineering controls are not used or are inadequate.

Traditional surgical masks are not adequate toprotect workers, and all HCWs exposed to laser or ESU smoke should wearrespirators. The document states that HCWs should be educated about the knownand potential dangers of ESU and laser smoke, Warnings that lasers reflect beamsand should be used only by trained, qualified personnel are implied in thedocument.3

The Association of periOperative RegisteredNurses (AORN) hosted two national conferences in January 1996 and February 1997on the hazards of surgical smoke and concerns about air quality in ORs in whichsurgical procedures expose patients and personnel to possible danger from smokeassociated with lasers, ESUs and powered instruments.

The 1996 meeting resulted in a consensus thatsmoke from ESUs should be treated the same as smoke from lasers, and thatgovernment agencies should apply the same regulations to smoke from ESUs asapplied to laser smoke, and further investigations should be conducted on thehazards of surgical smoke.

The research that helped NIOSH decide to releasea document was thought to be significant enough to support the need to developregulations to control electrosurgical smoke. Unfortunately, says Dawes,OSHA did not agree.

Weve heard rumors for years about OSHAcoming out with some type of mandate regarding evacuation of smoke, but nothingsreally happened, says Wayne Chappell, product manager for Megadyne Medical, asurgical electrode manufacturer. In fact, we saw the latest AORN guidelinesthat will be coming out in 2004, and their statement was pretty much the same asit was in 1998.

All surgical settings do not require or makeprotective measures available, and HCWs are not taking the initiative to standup for their own health. Since the release of the document in 1996, however,many individuals have been working to improve conditions through a smokeinitiative. Until spring 2000, it was believed that education and communicationefforts would result in regulations to protect HCWs who use devices that createsmoke. In April, AORN officials were alerted that OSHA would not produce adocument until empirical evidence is available. Former AORN president Brenda C.Ulmer, RN, MN, CNOR, appointed a task force to continue the arduous process ofconvincing regulatory agencies and Congress that smoke is a hazard in thehealthcare environment. 4

If given a choice, perioperative nurses wouldnot volunteer to inhale air with known high levels of hazardous materials (e.g.,benzene, hydrocarbons, cyanide) that are found in electrosurgical smoke samples,says Dawes. Protecting ourselves is a responsibility that we must takeseriously. Perioperative nurses should not wait for regulations to be enforced.We have been breathing surgical smoke for years now is the time to stop.

The hazards from exposure to surgical smokehave not decreased. This is a huge issue for nurses. The question is, has theirlevel of commitment to making a change decreased? They need to maintain a highlevel of commitment to their safety issues, electrosurgical smoke being one ofthem. And I preach that every day.

Product Showcase

Megadyne

E-ZClean Non-stick Electrodes are coated with patented and proprietary PTFE coatingwhich reduces eschar build-up. Less eschar means there is less smoke in theoperative field, since there is little tissue adhered to the electrode which cancontinue to heat, burn, and smoke. The PTFE coating creates a durable, malleabletip providing a smooth feel across a variety of tissue. (800) 747-6110 or www.megadyne.com

NicheMedical

Niche Medical offers the SmartVac SmokeEvacuation System as a quiet, powerful, userfriendly, low cost per procedure,solution to the hazards of surgical smoke (i.e., acrolein, benzene,formaldehyde, hydrogen cyanide, toluene, HIV, HPV, hepatitis B and C, etc).Niche also offers filters, tubing and accessories for many other smokeevacuationsystems. (800) 633-1055 or www.nichemedical.com

Utah Medical Products

TheFiltresse Smoke Filtration System is a costeffective portable system for minorprocedures. A three-stage disposable filter system features a HEPA prefilterwith odor-absorbing activated charcoal, plus an ULPA main filter designed tominimize operational costs. Filtration efficiency is greater than 99.999 percenton 0.1 µm particles.

(800) 533-4984 or www.utahmed.com

Viasys Healthcare

The VitalVac harnesses advanced technology tosimplify surgical plume evacuation. Incorporating laparoscopic, remote andfootswitch modes, the VitalVac delivers customized plume removal during anyprocedure. The microchip filter capacity sensor simplifies filter changes,saving time and money. The VitalVac and VersaVac utilize a three-stage filter: aprefilter, an odor absorbing carbon element and an ULPA media component, rated99.9997 percent efficient at 0.12 micron.

(800) 323-6305 or www.viasyshealthcare.com