Answer: d
For surgeons to achieve hemostasis and tissue dissection during surgery, they often use heat-producing instruments, including electrosurgery wands, lasers, ultrasonic devices, and high-speed drills, burrs and saws. The heat from these devices causes fluid to release from tissue cells in steam form, spewing the cell contents into the air and into your lungs if you fail to protect yourself.

Answer: b
Benzene is just one of many harmful chemicals that have been identified in surgical smoke. Because of that, OSHA — along with several other organizations — sets permissible exposure limits to protect workers from the hazards associated with inhaling benzene. OSHA's exposure limit is 1 part per million (ppm) for an 8-hour workday.

Harmful chemicals in surgical smoke aren't just limited to benzene. Studies have confirmed that the smoke can contain toxic gases and vapors such as hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses. In one report, a surgeon who rarely evacuated the surgical smoke when using a laser to vaporize condyloma developed laryngeal papillomatosis. A biopsy showed the same type of virus found in anogenital warts, which are normally found in the throat.

Answer: a
If there's one document you should always have on hand, it's NIOSH's Control of Smoke From Laser/Electric Surgical Procedures (tinyurl.com/qb9uhv8). The organization's alert recommends that whenever smoke is produced, it needs to be evacuated and filtered.

A smoke evacuator contains a suction unit, filter, hose and inlet nozzle. It should have high efficiency in airborne particle reduction and is recommended to have a capture velocity of about 100 to 150 feet per minute. Room suction systems often pull at a much lower rate. It's generally agreed that smoke evacuators are more effective.

Answer: d
Failing to evacuate smoke during surgery is just as harmful to patients as it is to staff. For example, as smoke is produced inside the abdomen during laparoscopy, it's absorbed through the peritoneal membrane, which increases methemoglobin and carboxyhemoglobin concentrations in the patient's bloodstream. This increase reduces the oxygen-carrying capacity of red blood cells. Because pulse oximeter readings are compromised in the presence of these variants, it can cause falsely elevated readings, which means anesthesia providers might not notice when patients become hypoxic.

Answer: c
Standard surgical masks weren't made for keeping smoke out, so it's not surprising they don't always do a great job of it. Keep your staff safe. Let them know that standard surgical masks filter at various efficiencies, but most only filter particles up to about 5 micrometers in diameter. That means the majority of the smaller-particle surgical smoke — including harmful chemicals and viruses — are sneaking through. High-filtration masks, sometimes called "laser" masks, offer better protection, filtering particles up to 0.1 micrometer in diameter.

Answer: d
This is why surgical masks, even high-filtration ones, don't always offer enough protection. Approximately 77% of the particulate matter in smoke measures 1.1 micrometers or smaller. Viral particles can be even smaller than 0.1 micrometer. Although higher-filtration masks can offer some respiratory protection, there's ongoing controversy about how and how long you should wear a mask; one that's worn too loose or too long is less effective. Remember though, a mask should never be the only defense against smoke.

Answer: b
An evacuation system equipped with an ultra-low penetration air (ULPA) filter is the most effective way to remove smoke. ULPA filters are made up of a depth-media material that is capable of capturing particulate matter as small as 0.12 microns at an efficiency rate of 99.9999%. At that rate, only 1 in 1 million particles will escape capture.

Three-stage systems include a pre-filter that captures large particles, an ULPA filter that captures smaller particle components and a special charcoal filter that captures toxic chemicals. These systems normally have variable suction volume capacities to accommodate different levels of smoke production. An effective portable evacuation system should be able to pull 30 to 50 cubic feet of smoke per minute.

Answer: a
In order to be airborne, the particle has to be smaller than 100 micrometers in diameter. Particles larger than 5 micrometers are deposited on the walls of the nose, pharynx, trachea and bronchus. If they're smaller than 2 micrometers, they get deposited in the bronchioles and alveoli — the gas exchange region of the lungs.

Answer: b
While some facilities have stringent policies on evacuating smoke during laser procedures, research shows that far fewer are as strict when it comes to electrosurgery. However, research shows that there is virtually no difference in the smoke produced. Lasers and electrosurgery units both work by using high thermal energy, which scatters cell contents. A study done by the ECRI Institute, an independent research center in Plymouth Meeting, Pa., shows that when reviewed, the particles from both laser and electrosurgical smoke look very similar. You should have a smoke evacuation policy for both types of procedures. Bottom line: All surgical smoke, along with the chemicals and the bioaerosol it carries, should be considered harmful.

Answer: d
We all know surgical smoke smells bad, but did you know it could also cause lasting effects on staff in the OR? Nurses who've been exposed to surgical smoke often complain of eye, nose and throat irritation, headaches, nausea, dizziness, runny nose, coughing, respiratory irritants, fatigue, skin irritation and allergies. If it's hard to get staff and surgeons at your facility to follow smoke evacuation protocol, remind them that these damaging effects can be minimized or even eliminated by simply using a smoke evacuator effectively.