Did you know that perioperative nurses have twice the incidence of some respiratory problems as compared to the general population? This information surprised me too when the data from my doctoral research revealed this startling and unsettling fact.

"Prevalence Comparison of Respiratory Conditions" below represents the alarming prevalence of specific respiratory conditions as reported by the nurses participating in my research survey on surgical smoke compliance. This information is compared to the prevalence of respiratory conditions reported by the general U.S. population.

Surgeons are not immune to this workplace hazard either. There have been reports of surgeons contracting diseases potentially caused from pathogens transmitted within surgical smoke. One surgeon, who was known to vaporize condyloma without using a smoke evacuator, developed laryngeal papillomatosis. When his throat lesions were biopsied, the same DNA strains were found in his throat lesions that are normally found in anogenital warts. Other physicians have informally reported conjunctival lesions, nasal growths and respiratory problems probably caused from surgical smoke exposure. Even ophthalmologists have complained about the odor of surgical smoke during LASIK procedures when visible smoke is not even observed.

These reports only lead to the question, "What are we breathing in the OR?" We must control surgical smoke to minimize and even eliminate respiratory hazards.

The culprit: electrosurgery smoke
The key to controlling the hazards of surgical smoke is to employ proper smoke evacuation practices when "hot" tools are used to cut and coagulate tissue. Laser plume appears to be evacuated appropriately in most facilities (Edwards & Reiman, 2008), but electrosurgery smoke is still being ignored and is allowed to infiltrate our surgical suites. Electrosurgery pencils are now available with a smoke tube surrounding the electrosurgery blade. This design lets you evacuate smoke at the site of production, causing a vortex movement of the plume. These ESU pencils have been ergonomically constructed to provide operator comfort, increased visibility and effective smoke evacuation.

Yet even though devices and equipment are available, compliance with smoke evacuation recommendations is still lacking in most facilities. My PhD research to identify key indicators of compliance with surgical smoke recommendations reported the vast inconsistencies in surgical smoke evacuation practices. Indicators of compliance include strong leadership support and easy-to-follow and use smoke evacuation policies and equipment.

One of the most powerful factors of whether the nurse is compliant with smoke evacuation recommendations is if the nurse received training and education about surgical smoke hazards and evacuation practices.

The results of compliance research also highlight 4 major barriers to proper smoke evacuation that the nurse participants identified. The most common obstacles that keep nurses from complying with smoke evacuation recommendations are:

• Smoke evacuation equipment is not available.
• The surgeon says smoke evacuation is not needed.
• The noise smoke evacuators produce.
• Staff is complacent (and just can't be bothered with smoke evacuation).

These findings are based on a survey of 777 nurses I conducted as part of my dissertation. Interestingly, I found that freestanding ambulatory surgery centers are more likely to evacuate smoke than hospitals, as are larger or urban facilities.

Attacking the problem
By recognizing the major barriers to compliance, surgical team members can begin to address each one of them individually to initiate a 100% smoke-free surgical environment. Some ideas for you to consider:

• Perioperative nurses and physicians can discuss the need to have a smoke evacuator in every operating room so that smoke evacuation devices are always available.
• Surgeons can be educated on the importance of appropriate smoke evacuation practices, while their procedure cards must reflect smoke evacuation equipment and supplies for all surgical procedures that generate plume.
• Many facilities may have outdated smoke evacuators that are very noisy when activated. Consider replacing these systems with the newer, quieter models to minimize this bothersome noise in the OR.
• Staff complacency is the most difficult barrier to tackle.
• The nurses who want to practice in an environment without air contamination must promote their passion for clean air, serve as mentors to others who want to follow smoke-evacuation guidelines, and educate their colleagues about the hazards of inhaling surgical smoke.
• Since the presence of surgical smoke is a workplace hazard, administrators must mandate smoke-evacuation practices to provide a safe environment, or someday OSHA may be knocking at the door.

How are you doing?
So are your smoke evacuation practices effective in removing all of the surgical smoke created in your operating room? Or are you continually breathing in the toxic gases, tiny particles and potentially disease-forming contaminants found in surgical smoke? Research articles have documented the many hazards of surgical smoke.

Organizations and agencies have published detailed recommendations to guide practitioners in the proper evacuation of surgical smoke. AORN's smoke evacuation tool kit can be acc-essed easily by all AORN members (www.aorn.org) to provide guidance on taking that first step toward a smoke-free surgical environment (tool kit includes a PowerPoint presentation, sample policy, competency checklist, bibliography of smoke articles, links to smoke evacuation vendors and creative signs to post throughout the OR to promote smoke evacuation).

The references are abundant, the solutions are easy. Smoke evacuation must be used to provide clean air in the OR. Don't let surgical smoke invade your lungs. Be the leader in your OR in achieving a 100% smoke-free environment.

References:
Edwards, B.E. & Reiman, R.E. (2008). Results of survey on current surgical smoke control practices. AORN Journal. 87(4):739-749.
Hallmo, P., & Naess, O. (1991). Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. European Archives of Oto-Rhino-Laryngology. 248(7):425-7.