Surgical Smoke Transmits Infectious Diseases; Here's How to Stop It

April 3, 2017

By Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC

When it comes to preventing infection in the perioperative environment, infection preventionists and perioperative nurses are strong allies. We collaborate to share our unique perspectives on patient safety and uncover little known dangers or risks that put our patients at increased risk for exposure to infectious disease. However, there is a dangerous vehicle for infection transmission in the OR that is lurking right under our noses, literally—that danger is surgical smoke.

Did you know that bacteria and viruses, along with a host of chemicals and other toxins, are released every time any energy-generating device is used on patient tissue? This means the daily practice of using electrosurgery devices, lasers, ultrasonic scalpels and other energy-generating tools that ablate tissue are releasing microscopic particles into OR air that harbor potentially infectious pathogens.

If surgical smoke evacuation is not used, or not used correctly, these particles that are small enough to be inhaled by anyone nearby, can carry viable bacterial and viral pathogens directly into the respiratory system.

Occupational Transmission of Viruses and Bacteria
An infection preventionist should be interested in surgical smoke safety because of this potential transmission of disease through aerosols in surgical smoke.

This is especially relevant in the transmission of human papillomavirus (HPV), which has been epidemiologically linked to transmission through surgical smoke. For example, several case studies discuss perioperative professionals who work with lasers and electrosurgery devices who have presented with cancerous masses along the airway that are positive for HPV.
- A 44-year-old laser surgeon who had used a laser in therapeutic procedures involving anogenital condyloma acuminate presented with a large, confluent papillomatous mass in the anterior commissure and along the right vocal cord and four smaller, discrete, smooth papillomas on the left vocal cord. Biopsy results from these laryngeal lesions showed squamous papillomas with HPV-6 and HPV-11 DNA identified, the same HPV types found in anogenital condyloma.1
- A 28-year-old perioperative nurse who assisted on electrosurgical and laser surgical excisions of anogenital condylomas developed recurrent and histologically proven laryngeal papillomatosis. After a virological institute investigated her condition, it was confirmed there was a high probability of correlation between the occupational exposure and laryngeal papillomatosis. The nurse’s condition was accepted as an occupational disease.2

There is also evidence confirming the transmission of viable bacteria through surgical smoke. For example, perioperative bacterial exposure from the laser smoke plume generated by CO2 laser resurfacing was found to be positive for Staphylococcus, Corynebacterium, and Neisseria.3

Smoke Evacuation: A Tool for Infection Prevention
While the research identifies these infectious risks tied to surgical smoke exposure, studies also point to the effectiveness of implementing surgical smoke evacuation to capture the surgical plume generated during surgery, thereby capturing any infectious pathogens the smoke may contain. In fact, requirements from agencies such as the National Institute for Occupational Safety and Health (NIOSH) and guidance from professional organizations, including AORN, identify local exhaust ventilation as the first line of protection against the hazards of surgical smoke.

Infection preventionists play a key role in advocating for surgical smoke evacuation, and they play an equally critical role in ensuring that policies, procedures and daily practices in the OR that require surgical smoke evacuation also require extremely careful handling of smoke evacuation tools and accessories because this technology becomes a collection location for the viruses, bacteria and other toxins in surgical smoke. 

In fact, it is a regulatory requirement that smoke evacuator filters, tubing, and wands that have been used must be handled using standard precautions, and disposed of as biohazardous waste, as discussed in AORN’s new Guideline for Surgical Smoke Safety, which is published in the 2017 edition of Guidelines for Perioperative Practice.

A Team Approach to Advocating for Surgical Smoke Safety
In addition to spreading infectious diseases, surgical smoke also exposes perioperative team members and patients to at least 150 hazardous chemicals that can cause a number of adverse health effects, including: eye, nose and throat irritation; asthma; emphysema; chronic bronchitis; hypoxia or dizziness; nasopharyngeal lesions; and even life-threatening conditions such as carcinoma, leukemia, and cardiovascular dysfunction.

These are some of the factors why AORN launched the Go Clear program with Medtronic in conjunction with the AORN Foundation to create the AORN Go Clear Award™.

This comprehensive Surgical Smoke-Free Recognition Program is designed to educate and guide facilities toward providing a healthy, smoke-free OR for their perioperative teams and patients.

AORN encourages our infection prevention colleagues to join our effort in raising awareness of the dangers of surgical smoke to ensure surgical smoke safety and address this largely unknown cause for spreading infectious disease. With our shared focus on preventing the spread of infectious pathogens, including antibiotic-resistant bacteria, infection preventionists have a shared responsibility with their nurse colleagues to advocate for a smoke-free OR.

Many of us can remember a time when cigarette smoke was allowed in public. Today we breathe in the benefits of cigarette smoke-free spaces—the same can be done with creating a smoke-free OR, but it will take a team effort to help hospital administration, perioperative team members and even patients to take a stand against the harmful effects of surgical smoke. We each have a choice in whether we accept our work to prevent this workplace hazard.

I choose to take a stand for clean air in the OR and I hope you will, too—for our patients, for our colleagues, and for our collective promise as healthcare professionals to promote health and healthy environments.

Take a stand with AORN. Talk to perioperative team members about their personal experiences with surgical smoke and encourage a collaboration to implement AORN’s Go Clear Award™ to promote surgical smoke safety in your facility. Learn more about the Go Clear Award™ by visiting

Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC, AORN president, has been a perioperative nurse for over 30 years and has been in surgical services management positions for more than 20 years. Stratton is currently the vice president of perioperative services at Doctors Hospital in Augusta, Ga.

1. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol. 1991;248(7):425-427.
2. Calero L, Brusis T. Laryngeal papillomatosis— first recognition in Germany as an occupational dis- ease in an operating room nurse. Laryngorhinootologie. 2003;82(11):790-793.
3. Capizzi PJ, Clay RP, Battey MJ. Microbiologic activity in laser resurfacing plume and debris. Lasers Surg Med. 1998;23(3):172-174.