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Making The Case For Smoke Evacuation
Educate your staff on the risks to reap a safer OR environment.
Kay Ball
Publish Date: October 10, 2007   |  Tags:   Staff Safety

The mechanical evacuation of surgical smoke is still not a standard practice in many ORs, even though it poses a similar hazard as secondhand cigarette smoke. Here's a look at the risks of surgical smoke and some compelling reasons to make smoke evacuation routine.

The primary health risk of surgical smoke is its inhalation by OR staff, since the particulate matter, chemicals and microorganisms carried by a plume present a potential infection and carcinogen risk to those breathing them in. Surgical smoke is:

  • Surgical smoke contains toxic gases. The plumes of vaporized tissue, blood and fluid have been found to contain carbon monoxide, formaldehyde, hydrogen cyanide, benzene, toluene and many other hazardous chemicals. Surgical smoke also contains many of the same elements that have been identified in cigarette smoke - which studies have long shown to be a carcinogenic mix - making the comparison to secondhand smoke more apt.
  • Microscopic. Surgical smoke particles are very small. At 1.1 microns in size or smaller, the particulate can be pulled into standard wall or ceiling suction equipment, clogging up the lines like a coronary artery building up with plaque, and reduce the ventilation's effectiveness. Surgical smoke can also slip through a standard surgical mask, settling in your lungs' alveoli and leading to irritation and emphysematic reactions.
  • Biohazardous. Surgical smoke may be a biohazard. Researchers have identified bacterial DNA in surgical smoke, raising the very real possibility that disease could be viably transmitted through a plume. While the toxic gases and the small particulate size have been proven conclusively, surgical smoke's potential for disease transmission is based on anecdotal evidence and limited studies conducted only on bovine tissue. But it's a caution worth keeping in mind.
  • Malodorous. Surgical smoke smells bad. You don't have to survey too many OR nurses, scrubs or techs to conclude that the noxious plume nauseates surgical team members, irritates their eyes and respiratory systems, and can even permeate soft contact lenses.

Patient's in harm's way, too
Surgical smoke can also have detrimental effects on the patient undergoing surgery as well as the process of surgery.

When plumes of smoke accumulate in a patient's abdomen during laparoscopic or endoscopic procedures and aren't properly evacuated, the patient will absorb the smoke. As a result of this absorption, his methemoglobin and carboxyhemoglobin levels will rise and he'll likely suffer from post-op nausea and headaches in PACU. For a long time, we clinicians may have blamed those increased levels and their effects on the anesthesia, but they can be actually caused by the absorption of the smoke's byproducts.

Surgical smoke can impede the progress of surgery itself. In minimally invasive procedures where a lot of tissue ablation takes place, plume in the abdomen can create visibility problems by obscuring the view of laparoscopic instruments or causing build-up on their lenses. Not only does this lengthen the time to completion, it also stands to increase the risk for missteps, errors and post-op complications if the surgeon has difficulty visualizing the procedure.

Authorities advise
In the face of these hazards, regulatory agencies and professional organizations have acknowledged the danger of surgical smoke and encouraged its evacuation from the operating theater, but their statements have been largely recommendations and not enforced requirements.

AORN has issued perhaps the strongest statements on the issue. More than a decade ago, its Recommended Practice included exhortations that "patients and perioperative personnel should be protected from inhaling smoke generated during electrosurgery" and that "an evacuation system should be used to remove surgical smoke ' as close to the source of the smoke as possible." Such recommendations have also appeared in later editions of AORN's guidelines as well as the organization's Position Statement on Workplace Safety.

The National Institute for Occupational Safety and Health advises facilities to employ proper ventilation to "minimize the acute health effects and reduce the potential for long range chronic disorders" resulting from inhalation. The American National Standards Institute similarly notes that "local exhaust ventilation ' used to capture airborne contaminants as near as practical to the point of evolution without altering surgical effectiveness [can] produce an effective removal rate."

OSHA has not codified a standard addressing the workplace hazard of surgical smoke. It's understood, however, that the issue is covered by the agency's General Duty Clause, which mandates that "each employer shall furnish to each of his employees employment and a place of employment that are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees." Not providing smoke evacuation can be interpreted as not providing a safe workplace, and an OR nurse could contact OSHA to report her facility in violation of this clause.

Clearing the air: What's in your policy?
The most effective efforts are being implemented on a facility-by-facility basis. Your surgical smoke evacuation policy should:

  • cover the chemical, particulate and biological hazards that plumes present;
  • require that mechanical smoke evacuators be available for every case producing significant amounts of smoke and be adamant about the evacuators' use during these procedures;
  • explain that their proper use involves holding the nozzle of the evacuator close to the impact site for the maximum capture of smoke;
  • distinguish when an evacuator is needed, as opposed to smaller plumes that may be safely handled by in-line suction devices; and
  • recommend the use of high-filtration surgical masks, which can block particles as small as 0.1 microns, as opposed to standard masks, which filter only particles larger than 5 microns.

Any policy is predicated on the idea that the facility will buy the appropriate surgical smoke evacuators. Pay attention to the type of filter used since an ultra-low penetration air filter (also known as an ULPA filter) is 99.99 percent effective at capturing particulate matter down to 0.1 microns in size. High-efficiency penetration air filters (HEPA filters) are designed to catch 99.97 percent of particles down to 0.3 microns, which can still miss some smoke particles. In terms of the composition of charcoal filters, coconut-based charcoal has been found to be more absorbent than wood charcoal.

The evacuator's air displacement or "pull" is another factor you'll want to see demonstrated, as is the amount of noise it makes when it is put to work. As always, ease of use is a critical benefit for the OR staff assisting a surgeon. Some smoke evacuators are operated by a foot pedal and some automatically turn on when a plume of surgical smoke is created, then turn off once the smoke is removed. Portable equipment will make it easy for staff to move an evacuator from OR to OR, but affordable equipment may help to ensure that every OR has an evacuator on hand.

To evacuate smoke generated during laparoscopic procedures, consider equipment that features low-pressure suction valves, which remove the plume through gentle air movement without deflating the pneumoperitoneum that your high-flow insufflator has introduced into the patient's abdomen. A closed system de-insufflator function may also provide a safeguard against the spewing of trace amounts of blood and DNA into the air along with the smoke when laparoscopic ports are removed at the end of a procedure.

If surgeons and staff still won't evacuate surgical smoke after you've implemented policies and installed equipment, determine the barriers to evacuator use. Perhaps the surgeons resist on account of the equipment's noise. Perhaps they're unaware of the extent to which their nurses and techs are exposed to the smoke, since they spend fewer hours or days a week in the OR. Perhaps surgical team members don't take the time to set up the evacuation equipment before a case.

What does it take to create a change in practices? Primarily, it's education. Provide your staff with adequate information on the consequences of surgical smoke, the recommendations based on strong evidence and your facility's requirements. In the final analysis, the benefits of smoke evacuation may be incalculable, but they'll pay off. Safer, healthier employees may be just the beginning. One Toronto hospital found that having smoke evacuators in every surgical suite, in its implications for workplace safety, proved to be a valuable staff recruiting and retention tool.

Another story: An OR director submitted a budget request for smoke evacuators for surgery, but the request was denied. So she instructed the surgical staff to notify the employee health office the next time they felt compromised by the effects of surgical smoke. After the employee health office's records showed more than 10 smoke-related complaints in a short time, the hospital president dropped by surgery to find out what was going on. He wondered why there wasn't any smoke evacuation equipment. The director said the budget request had been denied. Evacuators were immediately purchased. Lesson learned: The more we educate surgical team members on the true hazards of surgical smoke, the more compliance we're going to see.

On the Web

  • OSHA's "Safety and Health Topics: Laser/Electrosurgery Plume": writeOutLink("www.osha.gov/SLTC/laserelectrosurgeryplume/index.html",1)
  • NIOSH's "Control of Smoke from Laser/Electric Surgical Procedures": writeOutLink("www.cdc.gov/niosh/hc11.html",1)
  • Become NASTI, the Web site of the Canadian-based advocacy group Nurses Advocating Smoke-free Theatres Immediately: writeOutLink("www.becomenasti.com",1)
  • AORN's "Position Statement on Workplace Safety": writeOutLink("www.aorn.org/PracticeResources/AORNPositionStatements/Position_WorkplaceSafety",1)