Infection Control Today - 07/2003: Dangers of Surgical Smoke

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Dangers of Surgical Smoke Still Persist Despite Awareness Campaign

By John Roark

During surgical procedures using a laser or electrosurgical unit (ESU), the thermal destruction of tissue creates a smoke byproduct. Research studies have confirmed that this smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses. At high concentrations, the smoke causes ocular and upper respiratory tract irritation in healthcare workers (HCWs), and creates visual problems for the surgeon. The smoke has unpleasant odors and has been shown to have mutagenic potential.1

The National Institute for Occupational Safety and Health (NIOSH) hazard-control statement listing the components of surgical smoke plume, its noxious effects, and the pros and cons of ventilation techniques and smoke-control work practices was last updated on March 2, 1998. Yet in spite of this report and their awareness of the potential hazards, perioperative team members continue to breathe surgical smoke.

Why should cumbersome or noisy practices change when we have been working without smoke evacuators for years? asks Brenda S. Gregory Dawes, RN, MSN, CNOR, in her article, Stop Smoke Campaign Begins With You, published in the November 2000 issue of AORN Journal. More importantly, if we realize the need, why is smoke plume evacuation a continuing concern rather than a problem solved?

A few years prior to my writing (the article), we had one legislator who was very supportive, but it just never did get anywhere. We needed other legislators to get the smoke initiative on the plate so that there could be protection, says Dawes. Since then we have not had a lot of luck legislatively mandating any type of smoke evacuation. We have the recommendations out there with OSHA, but its not anything that anyone is consistently practicing.

Part of the difficulty, she says, is proving surgical smokes hazardous effects. Its not the easiest hazard to prove because its one of those long-term effects. They feel that there are carcinogens in smoke. We know that in procedures where theres an actual virus involved, the virus could be transmitted. They feel like there is some carcinogenic effect. Its very similar to the smoke hazards you would associate with cigarette smoking.

As early as the 1980s, research indicated that smoke plume particles were too small to be filtered effectively by a standard surgical mask, and that laser plume causes pathological changes. The advent of laser technology resulted in recognizing the dangers of surgical plume and in efforts requiring HCWs to protect themselves during laser use.

Although electrosurgical devices have been in use for more years than lasers, the similarities in the smoke contents have not been recognized or regulated equally.

Control of Smoke From Laser/Electric Surgical Procedures recommends the following two means of controlling the risks posed by electrosurgical smoke:

Ventilation

Recommended ventilation techniques include a combination of general room and local exhaust ventilation (LEV). General room ventilation is not by itself sufficient to capture contaminants generated at the source. The two major LEV approaches used to reduce surgical smoke levels for healthcare personnel are portable smoke evacuators and room suction systems.

Smoke evacuators contain a suction unit (vacuum pump), filter, hose and an inlet nozzle. The smoke evacuator should have high efficiency in airborne particle reduction and should be used in accordance with the manufacturers recommendations to achieve maximum efficiency.

A capture velocity of about 100 to 150 feet per minute at the inlet nozzle is generally recommended. It is also important to choose a filter that is effective in collecting the contaminants.

A High Efficiency Particulate Air (HEPA) filter or equivalent is recommended for trapping particulates.

Various filtering and cleaning processes also exist which remove or inactivate airborne gases and vapors. The various filters and absorbers used in smoke evacuators require monitoring and replacement on a regular basis and are considered a possible biohazard requiring proper disposal.

Room suction systems can pull at a much lower rate, and were designed primarily to capture liquids rather than particulate or gases. If these systems are used to capture generated smoke, users must install appropriate filters in the line, insure that the line is cleared, and that filters are properly disposed of. Generally speaking, the use of smoke evacuators are more effective than room suction systems to control the generated smoke from nonendoscopic laser/electric surgical procedures.

Work Practices

The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site to effectively capture airborne contaminants generated by these surgical devices. The smoke evacuator should be on (activated) at all times when airborne particles are produced during all surgical or other procedures. At the completion of the procedure all tubing, filters, and absorbers must be considered infectious waste and be disposed appropriately. New filters and tubing should be installed on the smoke evacuator for each procedure. While there are many commercially available smoke evacuator systems to select from, all of these LEV systems must be regularly inspected and maintained to prevent possible leaks.

Users shall also utilize control measures such as universal precautions, as required by the Occupational Safety and Health Administration (OSHA)s Bloodborne Pathogen standard.2

OSHA issued guidelines for electrical smoke in March 1998. The document recommends that surgical smoke be removed and properly filtered by a smoke evacuation system as close to the surgical site as possible. It further is noted that personal protective equipment should be worn where engineering controls are not used or are inadequate.

Traditional surgical masks are not adequate to protect workers, and all HCWs exposed to laser or ESU smoke should wear respirators. The document states that HCWs should be educated about the known and potential dangers of ESU and laser smoke, Warnings that lasers reflect beams and should be used only by trained, qualified personnel are implied in the document.3

The Association of periOperative Registered Nurses (AORN) hosted two national conferences in January 1996 and February 1997 on the hazards of surgical smoke and concerns about air quality in ORs in which surgical procedures expose patients and personnel to possible danger from smoke associated with lasers, ESUs and powered instruments.

The 1996 meeting resulted in a consensus that smoke from ESUs should be treated the same as smoke from lasers, and that government agencies should apply the same regulations to smoke from ESUs as applied to laser smoke, and further investigations should be conducted on the hazards of surgical smoke.

The research that helped NIOSH decide to release a document was thought to be significant enough to support the need to develop regulations to control electrosurgical smoke. Unfortunately, says Dawes, OSHA did not agree.

Weve heard rumors for years about OSHA coming out with some type of mandate regarding evacuation of smoke, but nothings really happened, says Wayne Chappell, product manager for Megadyne Medical, a surgical electrode manufacturer. In fact, we saw the latest AORN guidelines that will be coming out in 2004, and their statement was pretty much the same as it was in 1998.

All surgical settings do not require or make protective measures available, and HCWs are not taking the initiative to stand up for their own health. Since the release of the document in 1996, however, many individuals have been working to improve conditions through a smoke initiative. Until spring 2000, it was believed that education and communication efforts would result in regulations to protect HCWs who use devices that create smoke. In April, AORN officials were alerted that OSHA would not produce a document until empirical evidence is available. Former AORN president Brenda C. Ulmer, RN, MN, CNOR, appointed a task force to continue the arduous process of convincing regulatory agencies and Congress that smoke is a hazard in the healthcare environment. 4

If given a choice, perioperative nurses would not volunteer to inhale air with known high levels of hazardous materials (e.g., benzene, hydrocarbons, cyanide) that are found in electrosurgical smoke samples, says Dawes. Protecting ourselves is a responsibility that we must take seriously. Perioperative nurses should not wait for regulations to be enforced. We have been breathing surgical smoke for years now is the time to stop.

The hazards from exposure to surgical smoke have not decreased. This is a huge issue for nurses. The question is, has their level of commitment to making a change decreased? They need to maintain a high level of commitment to their safety issues, electrosurgical smoke being one of them. And I preach that every day.


Product Showcase

Megadyne

E-Z Clean Non-stick Electrodes are coated with patented and proprietary PTFE coating which reduces eschar build-up. Less eschar means there is less smoke in the operative field, since there is little tissue adhered to the electrode which can continue to heat, burn, and smoke. The PTFE coating creates a durable, malleable tip providing a smooth feel across a variety of tissue. (800) 747-6110 or www.megadyne.com

Niche Medical

Niche Medical offers the SmartVac Smoke Evacuation System as a quiet, powerful, userfriendly, low cost per procedure, solution to the hazards of surgical smoke (i.e., acrolein, benzene, formaldehyde, hydrogen cyanide, toluene, HIV, HPV, hepatitis B and C, etc). Niche also offers filters, tubing and accessories for many other smokeevacuation systems. (800) 633-1055 or www.nichemedical.com

Utah Medical Products

The Filtresse Smoke Filtration System is a costeffective portable system for minor procedures. A three-stage disposable filter system features a HEPA prefilter with odor-absorbing activated charcoal, plus an ULPA main filter designed to minimize operational costs. Filtration efficiency is greater than 99.999 percent on 0.1 µm particles.

(800) 533-4984 or www.utahmed.com

Viasys Healthcare

The VitalVac harnesses advanced technology to simplify surgical plume evacuation. Incorporating laparoscopic, remote and footswitch modes, the VitalVac delivers customized plume removal during any procedure. The microchip filter capacity sensor simplifies filter changes, saving time and money. The VitalVac and VersaVac utilize a three-stage filter: a prefilter, an odor absorbing carbon element and an ULPA media component, rated 99.9997 percent efficient at 0.12 micron.

(800) 323-6305 or www.viasyshealthcare.com

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