Management of Surgical Smoke

in the Perioperative Setting

This Tool Kit was funded through the

AORN Foundation and supported by

ConMed Electrosurgery

Thank You

• Surgical smoke is hazardous and can negatively affect the health of surgical patients and the perioperative team members. The purpose of this activity is to discuss perioperative nursing care and recommended practices for operative and/or invasive procedures that have a potential to expose patients and the perioperative team to surgical smoke.

• The goal of this activity is to educate perioperative RNs about the hazards of surgical smoke and the associated nursing care to promote patient and worker safety.

Overview and Goal

After completion of this continuing nursing education activity, the participant will be able to:

• Identify the hazardous contents of surgical smoke.

• Discuss recommendations for surgical smoke evacuation and control.

• Describe perioperative nursing care to minimize the hazards of surgical smoke.

Objectives

Management of Surgical Smoke

in the Perioperative Setting

• Smoke Plume or Smoke Aerosol is the vaporization of substances (i.e. tissue, fluid, blood) into a gaseous form and are the by-products of surgical instruments used to destroy tissue.

• Instruments: Lasers, Electrosurgery, Orthopedic, and Ultrasonics Devices.

• Chemical Mixes - may produce plume or aerosols

What is Surgical Smoke/Plume?

– Laser

– Powered Surgical Equipment

– ESU unit

– Ultrasonic equipment

What generates Surgical Smoke/Plume?

• Gaseous toxic compounds

• Bio-aerosols

• Dead and live cellular material (including blood fragments)

• Viruses

• Carbonized tissue

• Bacteria

Content of Surgical Smoke

150 different chemicals identified in surgical smoke (Pierce, et al. 2011)

Composition of Surgical Smoke

• Smoke plume and aerosols contain 95% water vapor

• Water vapor is itself not harmful, but acts as a carrier

Water Vapor

Past Misconceptions:

“Surgical Smoke is not Hazardous”

“Surgical Smoke is Sterile”

Surgical Smoke is Hazardous!

So.. is Surgical Smoke Harmful?

• Patients• Perioperative Staff Members• Others (anyone in the procedure)

Inhalation and Exposure Potential to Harm

• Odor• Particulate Matter• Viable/non-viable virus or

bacteria

Hazards

• Using the CO2 laser on one gram of tissue is like inhaling the smoke from three cigarettes in 15 minutes.

• Using ESU on one gram of tissue is like inhaling smoke from six cigarettes in 15 minutes.

• (Tomita et al., 1989)

Inhaling Surgical Smoke

• 150 Chemical constituents of plume

Toxic Gases

Chemical Constituents

Acrolein BenzeneCarbon MonoxideFormaldehydeHydrogen cyanideMethaneToluenePolycyclic aromatic hydrocarbons (PAH)

Some Are Carcinogenic!

(Pierce, 2011)

Soft contact lenses can absorb toxic gases

produced by surgical smoke.Recommendation made by an OSHA safety violation not related to plume, 1990

Chemical Effect

• Carbonized tissue• Blood• Intact virus and bacteria (HIV, HPV,

Hepatitis)

Particulate Matter

Size of Particulate Matter

77% of Surgical Smoke Particles are

less than1.1 microns

Human Immunodeficiency Virus = 0.15 micronHuman Pappillomavirus = 0.055 micronHepatitis B = 0.042 micronOthers

• Tobacco Smoke = 0.1-3.0 micron• Surgical Smoke = 0.1-5.0 micron• Bacteria = 0.3-15.0 micron• Lung Damaging Dust = 0.5-5.0 micron• Smallest Visible Particle = 20 micron

Virus Sizes

• Smoke is evenly distributed throughout the operating room

• Smoke particles can travel about 40 mph

• When ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet– It takes 20 min after the activation of the ESU for the

concentration will return to the baseline level.

Particle Distribution (Nicola, et al. 2002)

Results: Long time exposure to fine particulate air pollution associated with incidence of CV disease & death among postmenopausal women.

Air Pollution and Women

44-year old laser physician developed

laryngeal papillomatosis

Biopsy identified the same virus type as

anogenital condyloma

Hallmo, et al (1991)

Case Report

Surgical smoke evacuation guidelines: Compliance among perioperative nurses. (Ball, 2010)

Chemical composition of gases surgeons are exposed to during endoscopic urological resections. (Weston et al. 2009)

Surgical smoke: a concern for infection control practitioners. (Ortolano, 2009)

Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of

smoke extractor systems in UK plastic surgery units. (Hill et al. 2012)

Occupational hazards facing orthopedic surgeons. (Lester et al. 2012),

Becker’s ASC Review reprint of Understanding and Controlling the Hazards of Surgical Smoke (Novak et al March 28, 2011)

Surgical smoke and the dermatologist. (Lewin et al Sept 2011)

Surgical Smoke: It’s a Universal Concern

• Surgical smoke compliance study 2009• To identify key indicators of compliance

with surgical smoke evacuation recommendations

Ball, K. (2010).

Smoke Evacuation Compliance Study

Individual Innovativeness Characteristics

(Perioperative nurse characteristics)

Perceptions of Attributes

(Nurses’ perceptions of smoke evacuation recommendations)

Organization Innovativeness Characteristics

(Organization’s characteristics)

No compliance

Full compliance

Age

Education level

Experience

Knowledge

Training

Presence of respiratory problems

Relative Advantage

Compatibility

Complexity

Trialability

Observability

Barriers to practice

Descriptors (locale, type)

Size

Complexity

Formalization

Interconnectedness

Leadership support

Barriers to practice

Compliance with research-based smoke evacuation recommendations

Compliance Model*

* Based on Roger’s Diffusion of Innovations model. Reprinted with permission from Kay Ball, PhD, RN, CNOR, FAAN.

Key indicators of compliance:

• Education

• Leadership support

• Easy to follow policies

• Regular internal collaboration

(Ball, K . 2010)

Smoke Evacuation Compliance Study

• November 2010

• Survey e-mailed to current, active members of AORN

• North American health care facilities

• 1,356 responses /10,000 email requests

• Compared findings from 2007 similar studyEdwards & Reiman 2012

Perioperative RN Survey

• Use of the wall suction during laser procedures (excepting laser hair removal and LASIK) is similar to that for electrosurgery, electrocautery, diathermy (ES/EC/D), or ultrasonic scalpel procedures.

• Lower incidence of smoke evacuator use than wall suction use

• Smoke evacuator use rates have not changed significantly from 2007 to 2010

• Indicate that few facilities routinely used effective respiratory protection for surgical smoke (Edwards & Reiman 2012)

Study Results Indicate:

How can the patient be protected from surgical smoke?

Laparoscopic procedures present unique exposures to smoke to the patient.

Patient Safety: Exposures to Surgical

Smoke

Minimally Invasive Surgery (MIS)

• Levels of carboxyhemoglobin of patients who underwent laparoscopic procedures using laser were significantly elevated. (Ott, 1998)

• Carbon monoxide levels increase in the peritoneal cavity and exceed recommended exposure limits. (Beebe et al 1993)

Laparoscopic Surgical Procedures

• Loss of Visibility of Surgical Field– Potential to delay the procedure

• Health effects to Patient

• Health effects to Perioperative Staff– When pneumoperitoneum is released into the OR without

filtration

• Important to use a filtering device or a closed evacuation system

MIS and Smoke

“Each year, an estimated 500,000 workers, including surgeons, nurses, anesthesiologists, and surgical technologists, are exposed to laser or electrosurgical smoke.”

Laser/Electrosurgery Plume. Occupational Safety and Health Administration (OSHA) Quick Takes. United States Department of Labor

http://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed Dec 5, 2012)

Worker Safety:Exposures to Smoke/Plume

• Eye, nose, throat irritation

• Headaches

• Nausea, dizziness

• Runny nose

• Coughing

• Respiratory irritants

• Fatigue

• Skin irritation

• Allergies

Health Effects Reported by Healthcare Workers

Respiratory Problems

Perioperative nurses have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010)

– Allergies

– Sinus infections/problems

– Asthma

– Bronchitis

• AORN

• ANSI

• ECRI

• International Federation of Perioperative Nurses

• Joint Commission

• NIOSH/CDC

• OSHA

Healthcare and Regulatory Standards and Recommendations

Airborne Contaminants:

Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any

residual plume escaping capture.

Note: ESU produces the same type of airborne contaminants as lasers.

ANSI Standard 7.4 of Z136.3 - 2011

(Safe Use of Lasers in Healthcare)

Ventilation combination of general room and local exhaust ventilation (LEV).

• portable smoke evacuators • room suction systems.

NIOSH/CDC: Ventilation

• The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site

• The smoke evacuator should be ON (activated) at all times when airborne particles are produced

• Follow Standard Precautions

NIOSH/CDC: Work Practices

• All smoke evacuator tubing, filters, and absorbers

-considered infectious waste

-disposed appropriately.

• New filters and tubing should be installed on the smoke evacuator for each procedure.

• Local Exhaust Ventilation systems

-regularly inspected and maintained

Follow Standard Precautions at the completion of the

Procedure

General Duty Clause:

Employer MUST provide a safe workplace environment!

OSHA

Recognizes: Lasers and electrosurgical plume contains toxic,

mutagenic, and carcinogenic elements

Mandates and Identifies:Removal of atmospheric contaminants with acceptable engineering controls, local ventilation, including smoke evacuation systems

OSHA Respiratory Protection

• Independent, nonprofit organization

• Researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care

• Electrosurgery smoke is overlooked

• The spectral content of laser and ESU smoke is very similar https://www.ecri.org/ accessed 12/13/12

ECRI

• The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.

• Note: Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide.

Environment of care. In Comprehensive Accreditation Manual: CAMH for Hospitals. The Official Handbook. Oakbrook Terrace, IL Joint Commission; 2009: EC-6-EC-6.

Joint Commission

Position Statement Includes:•Recognition of blood borne pathogens and potential for viral transmission

•Identification of smoke as a workplace safety hazard and requirement for compliance with IEC

•Face masks of 0.1 micron filtration worn according to infection control policy and procedure

•Use of standard precautions

•Use of LEV with ULPA filter

•Collection of smoke not > 2cm from evolution point

•Use of in-line filters when LEV not available

International Federation of Perioperative Nurses

Surgical Plume Scavenging for Health Care • The First Dedicated Standard World Wide - MODEL• Covers all plume from surgical & therapeutic devices• Addresses all systems:

• dedicated, central, in-line, free standing• “Will seek IEC and ISO for endorsement”• Affects all provinces and practice settings• Published early 2009

Canadian Standards

• Electrosurgery Safety• Laser• Minimally Invasive Surgery (MIS)• AORN Position Statement Surgical

Smoke and Bio-Aerosols

AORN

“Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.”

Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141.

Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156.

Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184.

AORN Recommended Practices

• “Evacuate smoke with a smoke evacuation system in open and laparoscopic procedures

• Use standard precautions and dispose of smoke evacuator filters, tubing and wands (considered as potentially infectious waste)

• Used smoke evacuator filters, tubing, and wands should be disposed of as potentially infectious waste following standard precautions”

Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141.

AORN Electrosurgery RP X

RP. V “Potential hazards associated with surgical smoke generated in the laser practice setting should be identified and safe practices established.”

Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156.

AORN Recommendations: Laser

“IV.j.1. Surgical smoke should be removed by use of a smoke evacuation system in both open and laparoscopic procedures.

IV.j.2. Surgical smoke should be evacuated and filtered during the laparoscopic procedure and at the end of the procedure when the pneumoperitoneum is released.”

Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184.

AORN RecommendationsMinimally Invasive Surgery (MIS)

Recommends

• Wear appropriate PPE

• Remove smoke with an evacuation system for open procedures and MIS procedures

• Place capture device close to the source of the smoke

• Use evacuation system according to manufacturer’s written instructions for use

AORN Recognizes Surgical Smoke is

Hazardous

Smoke Evacuation in the Perioperative Setting

Smoke evacuator systems: Larger amounts of plume

In-line filters: Smaller amounts of plume

Laparoscopic filtering devices

Smoke Evacuators-First Line of Defense

• Many products

• Evaluate the features and benefits

• Selection

Evaluating Smoke Evacuators

• Ease of use

• Quiet

• Foot pedal activation/automatic on-off

• Portability and access

• Indicators for filter changes

• Efficiency

• Cost

Characteristics Smoke Evacuation Systems

Efficiency -Filtering capability -Suction power

Critical Features of Smoke Evacuators

Motor Rating

Tubing Size

Site Proximity

Amount of Smoke Generated

Smoke Capture Depends on

• Pre filter (captures large particles)

• ULPA filter (captures small particles)

• Charcoal filter (captures toxic gases and odors)

Triple Filter System

Only one in a million particles will escape capture

Ultra-low Penetration Air Filtration (ULPA)

• Simple

• Evacuate less than five cubic feet per minute (CFMs)

• Effective for small amounts of smoke

• Use an In-line filter!

• Use and change as recommended by the manufacturer’s instructions

• Use standard precautions when changing and disposing of in-line filters

Wall Suction: Use an In-Line Filter!

In-Line Filters with Wall Suction

From the patient>

To wall suction >

Example of an ULPA filter

Evacuator Filters for MIS Procedures

• Irrigation/Aspiration System

• Active System

• Passive System

• When there is no in-line filters:– Damage to healthcare facility air exchange– Less suction

• 3.5 – 5 CFM Wall Suction• 25-50 CFM Smoke Evacuators

CFM is a measure of air flow rate

Wall Suction Problems

• It’s an occupational hazard• Wear PPE• Dispose of used smoke evacuation filters per

manufacturer’s instructions and your facility’s procedures

Disposal and Changing Smoke Evacuation Filters

Perioperative Nursing Care

• Patient assessment– Will your patient be exposed or potentially exposed to

surgical smoke?

• Diagnosis

• Planning care

• Interventions and evaluation of outcomes

• Patient outcomes

Perioperative Nursing Care

Wear appropriate PPE

Surgical Attire

Remember, local exhaust ventilation is the first line of protection from surgical smoke.

A Surgical Mask • prevents release of potential contaminants into the

environment • protects the wearer from large droplets , ie greater than 5

microns, when the mask is fluid resistant• does not seal the face and may allow contaminants to enter

the wearer’s breathing zone

A High Filtration Mask has a filtering capacity of particulate matter at 0.3 to 0.1 microns in size

Surgical Masks

Wear a fit-tested surgical N95 filtering face piece respirator or a high-filtration mask during procedures that generate surgical smoke

High-filtration mask (0.3 microns to 0.1 microns) This mask does not seal the face and may allow contaminants to enter the wearer’s breathing zone

Wear Respiratory Protection

Wear a fit-tested surgical N95 filtering face piece respirator for

• Disease transmissible cases (HPV)• Aerosol transmissible diseases (TB, Varicella,

Rubeola)• Aerosol generating procedures (e.g.,

bronchoscopy)

Wear Respiratory Protection

• Communication with Surgeon and Perioperative Team members

• Plan for Smoke Evacuation

• Equipment and Optimal placement of equipment

• Patient and Team member Smoke Protection Methods

Team Briefing

• Discuss PPE and Respiratory Protection/Masks Options

• Type of Smoke Evacuation Method

Hand off Communication

• Use standard precautions when disposing of used smoke filter devices and other used smoke equipment.

Safe Handling

Documentation

Relevant information about smoke evacuation and equipment used

Smoke Evacuation Program

• Increase awareness of the hazards of surgical smoke

• Promote and implement safe practices

• Interdisciplinary Team– Include Perioperative RNs, Anesthesia providers,

Surgeons, Administration, Infection Preventionist, Employee Health, Safety Officer, Risk Managers

Smoke Evacuation Program

• Must have data and analyses: – Scientific research data

– Financial analysis

• Must have support from:– Administrative Safety Committee

– Infection Control

– Risk Management

Implementing Smoke Evacuation

Practices

•Equipment not available

•Physician

•Equipment is Noisy

•Complacent staff-- Ball, 2010

•Surgeons' resistance or refusal

•Cost

•Bulkiness

•Excessive noise--Edwards & Reiman, 2012

•Noise

•Distraction

•Ergonomic difficulty of equipment--Watson, 2010

Barriers to Compliance for Smoke Evacuation Practices

Policies and Procedures

• Address best practices for the patient and the perioperative team

• National Regulatory and Professional Standards

• Credentials, Competency and Training

• Equipment

• Operational Guidelines

• Patient and health care worker incidents

• Aware of surgical smoke hazards for the patient and the perioperative team members?

• Aware of the PPE required for perioperative team members?

• Know how and when to use filtering devices and smoke evacuators?

• Able to set up the smoke evacuators available in the work setting?

• Know about cleaning, decontamination, and maintenance of smoke evacuation equipment and accessories?

Staff Education and Competency

• Quality and Safety Committee Reports

• Educational programs

– perioperative nursing care

– research on hazards

• Equipment, Device, Supply Inservices

• Reminder signs

• AORN Posters

• Checklists

• Monitor practices

Use a Variety of Educational Activities

• Education and Competency

• Equipment Service Reports

Quality Monitoring

• Thousands of hospitals make that claim• Let’s advocate to make the

Perioperative Setting Smoke-free as well.

Protect our Patient-Our Colleagues-Ourselves from

the Hazards of Surgical Smoke

Are Hospitals ReallySmoke Free?

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