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The Hazards of Surgical Smoke
Are dangerous particles lurking in the air of your OR?
Kendal Gapinski
Publish Date: February 4, 2015   |  Tags:   Staff Safety
surgical smoke ERGONOMICS Many of today's evacuator options will remove smoke and please your surgeons.

The coughing. The wheezing. Watery eyes and a runny nose. Those are just a few of the ailments that many surgical facility leaders describe when you ask how they felt after being exposed to surgical smoke.

"I dislike the odor — it reminds me of charcoal-broiled meat — and I am a vegetarian," says one manager who responded to an Outpatient Surgery Magazine survey on surgical smoke.

The acrid smell, though, shouldn't be your only concern. Kay Ball, PhD, RN, CNOR, FAAN, surgical smoke expert and an associate professor at Otterbein University in Westerville, Ohio, notes that her research has shown that nurses have twice the incidence of many respiratory problems — including sinus infections, allergies and asthma — compared to the general population. It's the contents of the plume that could be to blame, she says, which range from toxic chemical byproducts to viable bacteria and virus particles.

"We need to make this a priority," says Dr. Ball. "We have a sign on every door that says 'No Smoking,' but we allow smoking in the OR every day."

Smoke-filled air leads to problems
About one-third (32%) of the 76 facility leaders we surveyed say they or a staff member have felt the flu-like symptoms of surgical smoke exposure.

"Wheezing, sneezing, headache, nausea, watery eyes," says Ken Warnock, CST, a surgical tech from Clinton Township, Mich. One nurse says that one of her scrubs "became nauseated and had to leave during the case" after working in an OR without a working smoke evacuator.

Ever hear of reactive airway disease? Bonnie Weinberg, MSN, RN, CNOR, clinical practice specialist for the operating room at The Valley Hospital in Ridgewood, N.J., says that a couple years ago, a surgeon at her hospital complained of wheezing and some respiratory difficulty. He visited a pulmonologist, who told him that he had reactive airway disease caused by something in his environment — which the surgeon attributed to surgical smoke — and put him on an inhaler. Other nurses also told Ms. Weinberg that they dreaded scrubbing in because of the headaches and nasal congestion they would get after breathing in the smoke. The hospital decided to make the move to smoke-free ORs, spearheaded by the affected surgeon. "I said, 'Our campus is a smoke-free environment, so why aren't our ORs smoke-free?'" says Ms. Weinberg.

The surgeon worked with the other doctors in the facility to get them on board, and the hospital trialed several different plume evacuation pens. Ms. Weinberg says she also sat down with staff to explain the implications of surgical smoke and worked with the vendor of the pens to place posters around the facility reminding staff and surgeons about the importance of evacuating surgical smoke. A year has passed since the hospital began using the evacuators, and the surgeon tells Ms. Weinberg that he now "rarely has to use his inhaler."

What's in it?
Researchers are still working to find a direct link between surgical smoke and long-term health effects, but that doesn't mean facility leaders are any less concerned. One survey respondent says she's concerned about "the potential for long-term effects that may be insidious in nature." "I'm sure it can't be healthy to be inhaling the plume of smoke coming from using the cautery," adds another.

"I am concerned about the toxins, viruses and bacteria that can be present in surgical smoke and the long-term effects that staff can develop with repeated exposure," says Imelda Kelly, RN, CNOR, director of regulatory compliance at the ASC at Barnet Dulaney Perkins Eye Center in Phoenix, Ariz.

While many respondents are concerned about surgical smoke, several say they don't have a good grip on what exactly makes it such a problem. As one facility leader puts it, "What is aerosolized in the smoke that is harmful?"

Surgical smoke is made up of 95% water and 5% other matter, studies say, but it's that 5% that is worrying. Several studies have shown that there are toxic chemicals like benzene — which has been identified as a trigger for leukemia — as well as hydrogen cyanide, toluene, perchloroethylene, formaldehyde, acrylonitrile and ethylbenzene. Many of these components are carcinogenic and linked to respiratory problems, says Dr. Ball.

Surgical smoke is also made up of the vaporized blood, fluids and tissue of the patient. According to Dr. Ball, studies have shown that HPV, HIV and hepatitis pathogens capable of transmitting the diseases can be found in the smoke.

One director of perioperative services says that before her hospital began evacuating smoke, she had a staff member who believed she had contracted oral warts from laser plume. The manager also says that staff would frequently say they felt nauseous after working on procedures that produce a lot of smoke, like abdominoplasties and breast cases. Many of the nurses who worked extensively on these types of cases now complain of a chronic cough, she says. Although she is careful to stress that she can't prove that the smoke was the cause, she says it's easy to see how breathing in the contaminated material and toxic chemicals could contribute to the lasting health effects.

Many managers say they wish that workers would take the risks more seriously. "Staff and surgeons are not as concerned about it as they should be," says Susan Knerr, RN, MSN, CNOR, educator and manager of perioperative services at St. Rita's Medical Center in Lima, Ohio. "The more that staff are exposed to the surgical smoke, the more likely they'll increase their chance of having issues."

Getting everyone on board
About 40% of those who responded to the survey say they don't evacuate smoke for all procedures where it's produced, with many saying the biggest hurdle is getting staff and surgeons on board. "The hospital has introduced the surgical field smoke evacuators, but surgeon resistance is an issue," says a manager. There are plenty of evacuator options that will both remove smoke and please your surgeons, from freestanding devices to electrosurgery instruments with integrated evacuators, says Dr. Ball. She says no matter which style you choose, it's important to look for one that uses an ultra-low penetration air (ULPA) filter with 0.1 micron filtration capability, which is nearly 100% effective in capturing smoke particulate matter. Manufacturers have also been working to address ergonomic and noise problems to make evacuators more pleasant to use, she says.

"I've presented the facts to our staff, but there seems to be some resistance to using the smoke evacuator," says DeAnn Wittrock, RN, BSN, CNOR, nurse educator at Alaska Native Medical Center in Anchorage. "The supplies are available, so it is just a change in culture to start making it a priority."

Several say that the best way to increase compliance is to explain the dangers of the smoke, and to find a physician champion who can work with other surgeons. Ms. Weinberg says that the key to her hospital's success was educating staff and having surgeons actively involved in the purchasing decisions to find an evacuator everyone would use.

Dr. Ball adds that surgical smoke is a workplace safety issue, meaning OSHA could potentially cite you for it. Still, many respondents say that for the future, they hope for stricter rules making it mandatory to have smoke-free ORs. "Exposure to surgical smoke is easily managed with the appropriate smoke evacuators, so why should we expose staff to this?" asks Ms. Kelly. "The use of smoke evacuators should be mandatory and not left to physician discretion."