CLEAR THE AIR Widespread use of smoke evacuation devices is lacking, even though surgical teams are aware of the dangers.

The smell of surgical plume is unmistakable, and so are the potential risks of inhaling it. As soon as particulate wafts into the OR air, your surgeons and staff are at increased risk of relatively minor skin and eye irritations, serious long-term respiratory issues or, worse, contracting a debilitating viral disease. Take ownership in your personal safety by understanding the true dangers of surgical plume and protecting yourself from the risk of exposure.

Airborne threats
There are several potential hazards associated with surgical smoke: blood fragments, viable bloodborne pathogens, bacteria and viruses, gases and vapors, and lung-damaging dust. Some of the gases have demonstrated carcinogenic and mutagenic potential.^1,2

Particulate matter generated during surgical procedures is dependent upon instrumentation and can range in size from 0.07 to 6.5 micrometers.^3,4 Acute and chronic respiratory conditions, like asthma, bronchitis and emphysema, are associated with the inhalation of particles smaller than 5 micrometers.³ Surgical smoke can also have strong odors that can lead to headaches and irritation of the eyes, nose and throat.

It has been demonstrated that 1 gram of tissue irradiated with a CO₂ laser releases smoke that has the mutagenic potential of 3 unfiltered cigarettes.⁵ This statistic gets cited often, but has not been replicated. It would be beneficial if studies were conducted to see if the same level of mutagenicity is measured in smoke generated with devices used in the OR today.

Research experiments have shown that HIV and hepatitis can remain viable in surgical smoke.^3,6 Case studies have demonstrated viral transmission of HPV from patients with anogenital condylomas to surgical team members in the OR. The impacted healthcare workers developed laryngeal papillomatosis.^7,8

Smoke evacuation is also a patient safety issue. It's been shown that carbon monoxide is produced during laparoscopic procedures. The carbon monoxide that's absorbed by patients increases post-operative peripheral blood carboxyhemoglobin levels and intra-abdominal carbon monoxide concentrations. Elevated carboxyhemoglobin at sufficient levels can result in nausea, headaches, dizziness and weakness.⁹ The same research demonstrating the viability of HIV in surgical plume also demonstrated that the virus remained viable for up to 2 weeks.⁶ Implementing smoke evacuation devices limits the amount of smoke that settles into the body cavity during surgical procedures and reduces the risk of disease transmission.

BLOWING SMOKE Don't listen to surgeons or nurses who aren't concerned about the dangers of airborne particulate.

Promoting personal protection
Improvements have been made to the overall awareness of the dangers of surgical smoke, but smoke evacuation devices still aren't used in all facilities. A 2010 survey of AORN members evaluated differences in rates of wall suction and smoke evacuator use over time. According to the survey's results, there was no change in the implementation of smoke evacuators between 2007 and 2010. Depending upon the procedure being performed, usage rates were as high as 85%, but also as low as 11%.

Even though rates for smoke evacuator usage did not change and the prevalence of usage was low for some procedures, over the same time period wall suction use, a much less efficient smoke evacuation option, increased significantly. However, neither device resulted in 100% compliance with these engineering controls, regardless of the procedure.¹⁰ It's important to note that the results of this survey are more than 5 years old, and significant improvements in compliance might have occurred.

There are several factors related to the lack of full compliance. Surgeons and surgical team members may be unaware of the potential hazards associated with surgical smoke. Surgeons may not be comfortable using evacuation devices or changing their operative protocols.

InstaPoll
We use a smoke evacuation device in every case that's appropriate.

• Strongly agree42%
• Agree14%
• Unsure17%
• Disagree17%
• Strongly disagree10%

SOURCE: Outpatient Surgery Magazine InstaPoll, n=229

I've spoken with surgical professionals at conferences and have received plenty of feedback from OR nurses. They're required to spend more time in the OR than surgeons, are more impacted by surgical smoke and are therefore more aware of the potential dangers associated with inhaling smoke. Nurses have indicated that smoke evacuators are only used in the OR if the surgeon agrees to use them.

The best way to influence change in the OR depends on the culture found at specific facilities. Although awareness of the dangers of surgical smoke is improving, collectively all facilities need to work on communicating those dangers to the frontline staff. All members of your surgical team need to be educated about the potential hazards associated with surgical smoke, as well as the measures they can take to improve the quality of their own working environment.

It's important to note that smoke evacuation devices are just the first line of defense. There are additional steps you can take to minimize exposure to potential hazards in the OR. Anyone working in the surgical suite during smoke-generating procedures can protect themselves from particulate matter, dust and bloodborne pathogens emitted into the air by wearing a surgical N95 respirator.

Surgical masks and laser masks may or may not be made with high filtration media. However, regardless of media used, these types of masks do not seal to the face. This allows particulate matter and gases to enter the wearers' breathing zone along the edges of the mask, avoiding the filtration media completely. Instead of choosing to wear surgical masks, or laser masks, you can choose to wear a surgical N95 respirator.

Unlike surgical or laser masks, surgical N95 respirators require a fit test, which ensures that the user is wearing a respirator that provides an adequate face seal, fits properly and offers the highest level of protection. A properly fitted surgical N95 respirator prevents at least 95% of airborne particles from entering the breathing zone of the wearer. However, surgical N95 respirators do not protect the wearer from gases and vapors found in surgical smoke, highlighting the need to still insist upon the use of smoke evacuators in the OR.

BREATHE EASY Educational efforts will improve compliance with smoke evacuation protocols.

More research needed
A primary obstacle in the use of smoke evacuation devices is the lack of quantifiable evidence showing exposure concentrations and the associated disease risk. If we want working conditions in the OR to be treated as an occupational setting, we need more research published in occupational health peer-reviewed literature. Many articles have been published identifying potential airborne hazards, but few have quantified those exposures or compared exposure levels with and without the use of smoke evacuation devices. No studies to date have evaluated the impact of those airborne hazards on the health of workers exposed to them.

Surgical staff members know how they feel physically after spending a day in the OR when smoke evacuator devices are not used. However, key decision-makers may need to review quantifiable evidence that demonstrates specific hazards and risks to healthcare workers and their patients.

The best way to improve smoke evacuation compliance is to ensure that hospital administrators, surgeons and surgical team members work together. All parties need to be educated on the hazards associated with surgical smoke and how the use of smoke evacuators can minimize potential exposures. They also need to work with the hospital's health and safety staff to ensure evacuation devices are properly used. It's also important to monitor the latest research associated with surgical smoke and smoke evacuator devices. Regular training needs to be conducted to inform all stakeholders of the research developments in this field. Simple-to-follow protocols need to be drafted and maintained.

While waiting for the scientific evidence to build, take all the precautionary steps necessary to avoid the inhalation of surgical smoke and to ensure the protection of healthcare workers and their patients.