No Smoking Allowed

October 1, 2004

No Smoking Allowed Addressing the Dangers of ESU/Laser Plume and Surgical Fires in the OR

No Smoking Allowed
Addressing the Dangers of ESU/Laser Plume and Surgical Fires in the OR

By Kris Ellis

Surgical smoke and laser plume arebyproducts that are created when tissue and cells are vaporized duringelectrosurgical and laser procedures. While these methods provide immeasurablebenefit for the patients they treat, they and the healthcare workers (HCWs) whoperform and facilitate the procedures in the operating room (OR) face possiblerisks to their own health from the smoke itself.

Over the last couple of decades, numerous studies haveexamined the possible hazards of surgical smoke. In addition to decreasingvisibility in the OR and irritating the eyes and respiratory tracts of HCWs inthe immediate vicinity, surgical smoke may contain toxic gases and harmful biological material such as blood fragments and viruses.1

Surgical smoke also contains a number of potentially harmfulchemicals such as acetonitrile, benzene, carbon monoxide, formaldehyde, methaneand phenol. The dangers of long-term contact with these and other toxins are asource of great concern for many HCWs and scientists.

In a review of the existing literature, authors recommendefforts to minimize exposure to surgical smoke and suggest that its minimaltoxic capacity is similar to that of cigarette smoke.2 However, studies alsowarn that more serious health threats may exist, particularly when laser comesin contact with tissue containing dangerous viruses.

In fact, one study has specifically demonstrated thetransmission of papillomavirus via laser plume.3 Authors of this study alsoadvise HCWs to take appropriate precautions in order to minimize health risks,specifically when viral disease is present.

Another study theorizes that the infection of a laser surgeonwith laryngeal papillomatosis was caused by exposure to laser plume during lasertreatment of patients with anogenital condylomas.4 In this case the surgeonspatients were the only known source of infection.

The presence and possible transmission of harmful material isenough to make laser plume and surgical smoke big concerns, especially for HCWswho are exposed to it on a regular basis. I think its a concern and a lotof other people do as well, says Carol Petersen, RN, BSN, MAOM, CNOR,perioperative nursing specialist at AORN. Whether people are really gettingsick from it is harder to prove because there are so many variables.

Although laser plume and surgical smoke are widelyacknowledged to be dangerous, a specific federal standard does not exist. TheOccupational Safety and Health Administration (OSHA) does recognize the threatsurrounding this issue, but some feel that a more comprehensive and focusedguideline is in order. OSHA has a general guideline that includes smokeplume, but its not as definitive as everyone would like, says Petersen.

OSHA does state that the general duty clause, Section 5(a)(1)of the Occupational Safety and Health Act of 1970 may be cited in cases where ahazard is not specifically addressed by an OSHA standard. OSHA also issued a Hazard Information Bulletin in 1988 thaturged its consultative and compliance personnel to alert HCWs of the potential hazards of laser plume when possible.5

Part of the reason that OSHA has not made a definitivestatement on surgical smoke and theyve lumped it in with some other things isthe research that has been done so far hasnt shown enough problems, Petersen continues. People havent been injured enough,although there have been reports that they have.

Given the amount of information available to the healthcommunity, Petersen thinks most OR nurses are aware of the threat surgical smokeposes. There has been a lot of press on it and a lot of information at our(AORN) Congress, she says. I dont think anyone thought much about itwhen they were in smoke from electrosurgical units (ESUs), even though that canbe equally dangerous. When lasers came around and when they were also doingcondyloma warts, people started to worry about viruses in those, whether theywere venereal type warts or whether they were papalomas that were on vocalchords.

Once concerns began to surface about potential harm from laserplume, methods of protection for HCWs and patients started to become available.Today, concerned HCWs and facilities have several options to pick from in orderto neutralize risks from smoke in the OR. One option is surgical masks. While standard masks do notoffer much in the way of protection from exposure to bacteria or viruses insurgical smoke, high performance masks are available that can block out most ofthese tiny contaminants if worn correctly. Although this may help, masks are notdesigned to trap and eliminate the smoke contaminants. Another drawback to this approach is the relative difficultyin breathing that users may experience.

Some facilities may choose to make use of the existing wallsuctions in their ORs as a method of smoke fi ltration. In this case, suctionswould be fitted with inline filters that protect the suction system and trapparticles in the smoke. While this may be adequate in some cases, it is notalways realistic. For example, open procedures may require HCWs to hold suctionhoses very close to the site at which the smoke originates.6 This can be a difficult and inefficient mechanism in circumstances such as these.

The use of a mechanical smoke evacuation systemwith a highly effi cient fi lter is widely recommended as a means of providingoptimal protection from surgical smoke. This type of system should also includea device to capture smoke at its source that does not impede a surgeonsability to perform the procedure and an effective vacuum source. Such a systemis endorsed by many agencies such as the Centers for Disease Control andPrevention (CDC), the National Institute for Occupational Safety and Health(NIOSH) and the American National Standards Institute (ANSI).

For facilities that have not yet enacted a method of smokeevacuation or fi ltration of any kind, Petersen recommends education and action.I would first of all do a literature search to fi nd information on exactlywhats in the smoke and the possible outcomes associated with it, she says.

Once awareness of the potential threat has been established,HCWs will often be more likely to embrace procedural changes designed to protectthemselves and patients. The transition is not much of an issue if you knowits something that you should be extremely concerned about, says Petersen. I would make sure that everybody on the teamwas willing to move forward with a plan of action.

Only You Can Prevent OR Fires

In addition to creating dangerous smoke, lasers and ESUs havethe potential to ignite fires in the OR. Although this scenario is relativelyrare, with about 100 OR fires occurring each year in the United States, theresults can be devastating for patients and surgical staff.7 Facilities musttake measures to ensure that HCWs are properly equipped and informed to preventfires from occurring. HCWs must also be educated and prepared to takeappropriate action if they do occur.

When theyre doing lasers, if its anywhere around theface or on the trachea, the patient will be intubated and they need to have aspecial protective layer on them, otherwise the laser will go right through,says Petersen. The environment is oxygen-rich and it doesnt take much tostart a fi re.

In A Clinicians Guide to Surgical Fires: How They Occur,How to Prevent Them, How to Put Them Out, several specifi c recommendationsare given in regard to both ESUs and lasers. For ESUs, they include:

  • Place the electrosurgical pencil in a holster when not inactive use.

  • Allow the pencil to be activated only by the personwielding it.

  • Deactivate the pencil before removing it from the surgicalsite.

  • If open oxygen sources are employed, use bipolar electrosurgery whenever possible and clinically appropriate (bipolarelectrosurgery creates little or no sparking or arcing).

For lasers:

  • Place the laser in standby mode whenever it is not inactive use.

  • Activate the laser only when the tip is under the surgeonsdirect vision.

  • When performing laser surgery through an endoscope, pass the laser fiber through the endoscope before introducing the scope into the patient (this will minimize the risk of fiber damage). Before inserting the scope, verify the fibers functionality.

  • Use appropriate laser-resistant tracheal tubes duringupper-airway surgery and follow product directions.

If a fire should break out, an immediate and decisiveresponse is vital.

Small fires on the patient can usually be extinguished bysmothering with a towel or gloved hand. Larger fires on the patient requiremore steps such as stopping the flow of oxygen to the patient, removing andextinguishing the burning materials and swiftly caring for any injuries to thepatient.

A fire in the OR can be a sudden and confusing event. Forthis reason, many facilities decide to institute a fire safety plan.Identifying and resolving potential issues such as evacuation routes and thelogistics of evacuating anesthetized patients, for example, can give HCWs theability to react quickly and efficiently in an actual fire emergency. As withlaser and surgical plume, preparation and knowledge are the keys to safety.

Smoke Evacuation Systems
Clearing the Air in the OR

By Kris Ellis

As evidence continues to mount on the potential health threatsof surgical smoke and laser plume, many facilities are moving to protect theirsurgical staff and patients by instituting surgical smoke evacuation systems inthe operating room (OR). Some believe a shift in initiative is necessary to makethis effort most effective. There have been documented concerns regardingsurgical smoke for well over 20 years, says Daniel Palmerton, vice presidentof sales and marketing at Buffalo Filter. This type of workplace safety issueneeds to be shifted from a clinical responsibility to infection control and riskmanagement responsibility to assure compliance with a growing number of federal,professional and state regulations and standards.

Smoke evacuation can provide protection to patients andhealthcare workers (HCWs) in many ways. During laparoscopic and endoscopicprocedures, patients can be protected from their own autologous plume, says Palmerton. Although more work needs to be done toinvestigate long-term patient outcomes, the absorption of smoke plume in theperitoneal cavity, regardless of how it is generated, has been shown to becytotoxic, carcinogenic and mutagenic.

Effective smoke evacuation can prevent exposure to possiblecontaminants in smoke. HCWs are protected from inhaling fugitive particulatematterdead and live cellular matter, blood fragments, viruses, toxic gases,vapors and bio aerosols, Palmerton explains. Most of these particles are of respirable particulate size(0.3-0.5 microns).

Filtration is an important component of protection. Theproperties of the filter itself provide excellent protection, says RandyTomaszewski, RN, BSN, MBA, vice president of marketing at Skytron. Skytronuses a combination of HEPA and ULPA filter. HEPA filters provide an efficiency of 99.97 percent when tested with 0.3 micron dioctylphthalate (DOP)aerosol, ULPA filters have 99.999 percent efficiency with 0.12 micron latexspheres.

Tomaszewski says this highly efficient filtration is able tocapture and neutralize bacterial, viral and fungal infectious agents as well assmoke plume, glues, bone dust and other surgically generated by-products. Otherbenefits include enhanced vision at the surgical site and elimination of odorswithin the OR.

Systems may be incorporated into existing ORs in differentways, depending on the manufacturer. Todays stand-alone smoke evacuationsystems can be easily incorporated into existing ORs because they are smaller,quieter and more portable, says Palmerton.

Many smoke evacuators can be used with ESU carts, or can bebuilt into surgical booms or service heads.

While there is still much to be learned about the specificdangers of surgical smoke and laser plume, prevention of exposure via smokeevacuation remains the method of choice for many. Unanimity may not yet exist,but, as Palmerton says, To the best of my knowledge, there is no regulatorybody or agency in the world that believes it is a good idea to breathe ablatedhuman tissue.