◙ HAZY UNDERSTANDING Many OR personnel fail to connect their respiratory problems to smoke exposure.

If you don't smoke, chances are you don't plan to start. That would be foolish. But if you're working in a perioperative setting that doesn't adequately evacuate surgical smoke, you may be facing the same dangers as a cigarette smoker. Studies show that inhaling the smoke generated by 1 gram of tissue during laser surgery is about the same as smoking 3 unfiltered cigarettes in 15 minutes. And inhaling the smoke from 1 gram of tissue during electrosurgery ups the ante to 6 cigarettes in 15 minutes. Do it several times in every shift and it's as though you have a 2-pack-a-day vice.

When it comes to failing to evacuate surgical smoke, it's time to kick the habit.

◙ Present the evidence
The list of chemicals found in surgical smoke, as detailed in an influential study (tinyurl.com/l3w6cdy) by William Barrett, MD, and Shawn Garber, MD, is eye-opening. Of these, say Drs. Barrett and Garber, carbon monoxide, acrylonitrile, hydrogen cyanide, formaldehyde and benzene are especially worrisome.

The most common misconception regarding surgical smoke is among perioperative team members who claim they've been exposed to surgical smoke for years and had no ill effects. They often fail to connect their respiratory problems to smoke exposure. But one study found that perioperative nurses are twice as likely as the general population to develop respiratory issues.

Patients face risks, too, including having malignant cells transplanted to other tissues during laparoscopic procedures and increased risk of methemoglobin and carboxyhemoglobin, which can lead to hypoxia and decreased oxygen perfusion of tissues.

Unfortunately, there's often a lack of multidisciplinary support for smoke-evacuation efforts — many surgical team members simply continue to resist using smoke evacuators. One reason is there's a learning curve with some products — ESU pencils that have integrated tubing to evacuate smoke, for example. They can be difficult to maneuver in small spaces and the profile is larger at the tip. The cost can also be hard to swallow. Surgical pencils with integrated tubing cost 8 to 10 times as much as standard ESU pencils. Surgeons and facility leaders typically prefer to use resources on other products.

For those reasons and others, the overall situation appears to be improving little, if at all. Ben Edwards and Robert Reiman, MD, surveyed a random sample of AORN members in 2007 and again in 2010. They found that while the use of wall suction as a control measure had increased for nearly all procedures, progress in other control measures was mixed, with improvement related to some procedures, no change for most, and a decrease in compliance for a few others. There's no recent data to suggest any dramatic changes have taken place since then.

◙ NASTY HABIT Every plume of surgical smoke is likely to contain numerous hazardous substances.

◙ Gain support
Though the research is clear and the dangers are real, finding the support you need to get the right smoke evacuation products in place can be as challenging as getting a smoker to quit, even if it's just as important.

The best recipe for real change is to make it as easy as possible and to involve key players. Persistence is key. Continually evaluating new products and offering options is important. In almost all instances, there's more than one way to evacuate surgical smoke. And every day we're seeing new products that are streamlined, lighter and smaller and, in the case of ESU pencils, that have tubing that's easier to control.

First, assess whether your current smoke evacuation practices are adequate. Are there gaps with equipment and practices? What equipment and supplies (for example, filters and tubing) are available to you? If your current approach isn't adequate, you need to enlist physician, administrative and staff support. Remember, education is key.

Since surgeons are likely to wield plenty of influence, it's important to include them in every step as you attack the problem. Show them the proof — the studies that spell out the risks associated with surgical smoke. Ideally, you'll implement a program of smoke evacuation on every surgery that produces smoke, so finding surgeon champions is key.

AORN provides plenty of ammunition with its Surgical Smoke Evacuation Tool Kit (aorn.org/smoketoolkit), which includes educational materials and tips on how to evaluate products and implement evacuation systems.

◙ Focus on a solution
The complaints about smoke evacuators are generally predictable: They're loud. They're distracting. They're too expensive. They're bulky. Surgeons don't like them or refuse to use them. Fortunately, as noted, technology is gaining ground, making the usual complaints easier to overcome. If you need to upgrade your smoke evacuation capabilities to keep staff and patients safe, there are several factors to consider, as spelled out by AORN guidelines.

A smoke evacuator is the best way to capture all surgical smoke. And efficiency is the primary consideration when evaluating options. The amount of smoke one can capture depends on its motor rating, the tubing size of the collection device, how close the collection tubing is to the site where smoke is generated, and the amount of smoke being created. Ideally the evacuator will

• be easy to use and quiet;
• have either a foot pedal to activate it or an automatic sensor that turns the unit on and off as smoke is created and evacuated;
• be easy to access and portable; and
• have an indicator (either a light or an alarm) that alerts you when the filter needs to be changed.

Ultra-low penetration air (ULPA) filters are much more effective than high-efficiency particulate air (HEPA) filters for capturing tiny smoke particles, allowing only 1 in a million particles to escape. A good triple-filter system includes a pre-filter to capture large particles and fluid, a ULPA filter to capture small particulate matter and a charcoal filter that absorbs toxic gases and odors. Coconut-based charcoal filters are the most absorptive.

If you're dealing with very small amounts of smoke, you may be able to get by with only a wall suction unit. They're simple to use, but they move air less than 5 cubic feet per minute (compared to 25 to 50 for smoke evacuators). Keep in mind, it's extremely important to use in-line filters with wall suction and to keep them from getting clogged with smoke particulate matter. They need to be changed according to manufacturer recommendations and carefully disposed of. An overused filter provides no protection.

Staff should also always wear appropriate PPE when there's any chance of being exposed to surgical smoke. A fit-tested surgical N95 filtering face piece respirator or a high-filtration mask is the best choice. But masks should never be the only layer of protection against the dangers of surgical smoke.