Assessing the impact of surgical smoke
By Carina Stanton, MA
News Editor/Writer
Many perioperative nurses are exposed to surgical smoke on a daily basis, yet there is still much to be learned about long-term hazards and the ways of mitigating the risks of exposure to surgical smoke.Guidance issued by various governmental, medical and industry organizations shows broad agreement on steps that should be taken to protect against this hazard, but the specified control measures are not being applied in all cases. That's why AORN's General Surgery/Gynecology Specialty Assembly (SA), AORN's Perioperative Environment of Care Committee and researchers from Duke University are partnering to gather information on the extent to which medical staff are using the recognized control measures to reduce exposure to surgical smoke.
"Everyone knows about the concerns associated with surgical smoke, but fewer (perioperative nurses) are exposed to current research and resources that would help them make informed decisions about how to best deal with this potentially harmful by-product of surgical procedures," said Wendy Winer, RN, BSN, CNOR, an endoscopic surgery specialist at the Center for Women's Care and Reproductive Surgery and Emory University School of Nursing in Atlanta and the chair of the General Surgery/Gynecology SA.
"AORN members need to have the latest information on surgical smoke and have a way to share their thoughts and experiences regarding this surgical hazard, especially members of this SA who are often exposed to smoke in the OR daily," Winer said.
Winer also serves on AORN's Perioperative Environment of Care Committee, which is working this year to promote education and action to make the perioperative work environment safer.
A silent threat
Surgical smoke is a term used to describe the aerosols, particulates and vapors released into the air when electrosurgical or laser energies are used in surgery to cut tissue. Evidence suggests that surgical smoke contains dangerous chemical and biological agents that can cause negative health effects for surgical staff, as well as patients.
"When exposed to electrocautery or surgical laser beams, tissues produce toxic gases, such as benzene, which research has shown to be carcinogenic. While gases and other harmful particulates in the smoke are in trace amounts, they accumulate over time, which puts surgical staff members at risk for developing long-term respiratory problems, such as asthma and emphysema-like conditions," explained Kay Ball, RN, MSA, CNOR, FAAN, chair of the Perioperative Environment of Care Committee.
Ball's current doctoral studies and research focus on industry compliance with recommended guidelines for evacuating surgical smoke. In addition to toxic gases, other hazards related to surgical smoke include inhaling the smoke particulates, transmission of disease from these particulates and patient hazards during laparoscopy when a plume is not sufficiently evacuated. Ball cited several studies linking viral DNA transmission from a surgical patient to the airway of a surgical staff member. The small size of the particulate matter in surgical smoke itself is a problem.
"Most common surgical masks filter particles that are 5 microns in diameter or larger, but most particulates from surgical smoke plume measure around 1.1 microns in diameter or smaller, so surgical smoke particles without the proper smoke evacuation method can settle in lungs or clog OR suction lines," Ball noted.
In the face of these workplace and patient safety hazards, Ball and other researchers investigating surgical smoke are finding inconsistent use of local exhaust ventilation (LEV), including smoke evacuators and wall vacuums, to remove smoke plume as they are created. She suggests that all members of the surgical team access educational resources on the hazards and proper evacuation of surgical smoke.
"I think once we teach people all the negative consequences of not evacuating surgical smoke created by a laser and how easy LEV is to use, we will have more consistent use. My goal is to have 100% compliance," she said. To learn more about surgical smoke hazards and compliance, Ball suggests accessing www.becomenasti.com, a Canadian-based Web site developed by Nurses Advocating Smokefree Theatres Immediately (NASTI).
Assessing compliance
In June AORN encouraged all members to take part in a Web-based benchmark survey, which was developed by researchers at Duke University Medical Center to measure the extent of LEV use during procedures that produce surgical smoke. "We want to determine people's current practice and compare and contrast this to the generally accepted guidance for controlling surgical smoke," said Ben Edwards, MS, CLSO, a health physicist in the Radiation Safety division at Duke University Medical Center who designed the survey with his colleague Robert Reiman, MSPH, MD, assistant clinical professor in the department of radiology at Duke University Medical Center. The survey findings will be published in 2008 in AORN Journal.
Edwards specializes in radiation safety, including laser safety and the associated nonbeam hazardous effects of lasers, one of which is surgical smoke. This work led Edwards and Reiman to the realization that no U.S. regulatory agencies, including the Labor Department's Occupational Safety and Health Administration (OSHA), explicitly mandate LEV use to control surgical smoke.
Many professional organizations have adopted recommendations supporting the use of LEV for surgical smoke, including AORN, the American Nurses Association and the American National Standards Institute.
Several U.S. government agencies, including the Centers for Disease Control and Prevention, the Federal Drug Administration and OSHA, have issued concurring statements supporting use of LEV, but those guidelines are not mandatory, Edwards explained. "OSHA can cite employers for not controlling recognized workplace hazards under (federal labor laws) "general duty clause," but historically OSHA inspectors may invoke this clause only if they find a situation that will result in serious injury or death.
"It's difficult for OSHA to demonstrate that surgical smoke falls in this category," Edwards added. "Therefore, healthcare providers confront a paradox on implementing use of LEV to remove surgical smoke because there are consistent recommendations but no clear regulations.
"The issue of surgical smoke in the workplace is about where second hand cigarette smoke was 20 years ago—it was tolerated," Edwards said. "People thought if they weren't smoking themselves they were not at risk. Today we know better. Evidence has driven regulation to provide smoke-free public places to protect people from the harmful effects of cigarette smoke exposure. Further research on the health effects of exposure to surgical smoke and the practice of its proper evacuation will hopefully lead to similar regulation to improve workplace safety in U.S. ORs."
Exposing the effects of surgical smoke
In addition to participating in the Duke University online survey, Winer of the General Surgery/Gynecology SA also hopes members will use the SA's online community of practice to learn more about surgical smoke and to share their personal experiences with this OR hazard.
"Our SA members need to share their personal experiences from surgical smoke exposure and the ways it is being dealt with in the OR. The only way we can protect ourselves from this potentially harmful hazard is by speaking out and contributing to further research," Winer said.
To access the General Surgery/Gynecology Specialty Assembly Online Community of Practice, SA members should go to the AORN Specialty Assemblies home page and access the Specialty Assembly Online Communities of Practice or e-mail Wendy Winer at wwiner@mindspring.com.
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