Surgical Smoke Evacuation in the Time of COVID-19
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Surgical Smoke Evacuation in the Time of COVID-19
Transcript of Surgical Smoke Evacuation in the Time of COVID-19
Surgical Smoke Evacuation in the Time of COVID-19
Surgical Smoke SafetyEmily Jones, MSN, RN, CNOR, NPD-BC
AORN Perioperative Practice Specialist
Outcomes• Review the hazards of surgical smoke and best
practices for preventing patient and healthcare worker
exposure
• Discuss the evidence-based guidelines for surgical
smoke evacuation and control
• Examine specific considerations and recommendations
related to surgical smoke during the COVID-19
pandemic
• Review the current surgical smoke evacuation public
policy landscape
What is Surgical Smoke?•malodorous
• visibleBy-product
• ESU, laser, ultrasonic devices
•High-powered toolsEnergy devices
• Plume, smoke plume
• Bio-aerosols, LGACAKA
Blood particles
VirusesBacteria
Benzene
Carbon monoxide
Hydrogen cyanide
Formaldehyde
Acetonitrile
Acrylonitrile
Pyrrole
Acetylene
Acroloin
Alkyl benzene
Benzaldehyde
BenzonitrileButadiene
Butene
3-Butenenitrile
Creosol
1-Decene
2,3-Dihydro indeneEthaneEthyl benzene
Ethylene
Furfural
Hexadecanoic acidIndole
Methane
3-Methyl butenal
6-Methyl indole
4-Methyl phenol
2-Methyl propanal
Methyl pyrazenePhenol
Propene
2-Propylene nitrile
Pyridine
Styrene
Toluene
1-Undecene
Xylene
Inhaling Surgical Smoke
Did you know?
Tomita et al., 1981
Health Effects• Respiratory issues
• Anxiety
• Carcinoma
• Skin and eye issues
• Headache, nausea, vomiting
• Lightheadedness
• Throat irritation
• Renal and hepatic issuesAlp et al., 2005Ball, 2010
Reprinted with permission from AORN. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
Benson et al., 2013
Patient Hazards
Reduced visibility Procedure delay Absorption
CarboxyhemoglobinemiaPort-site
metastasis
Virus Presence in Surgical Smoke
HPV
HIV
HBV
SARS-CoV-2 Virus
• Small particle size ~0.05-0.2 microns
• Presence in tissue and body fluids
• Easily transmissible
• Aerosolization and potential presence
in surgical smoke
Vourtzoumis et al., 2020Zakka et al., 2020
Provide a surgical smoke-free work environment
Evacuate all surgical smoke
Use smoke evacuators with ULPA filters
Dispose of filters and tubing appropriately
AORN Surgical Smoke Safety Guideline
Multidisciplinary team decision
Provide education and competency verification
Develop policies and procedures
Participate in QI activities
AORN Surgical Smoke Safety Guideline
https://www.cdc.gov/niosh/topics/hierarchy/default.html
Evaluating Smoke Evacuation Equipment
MULTIDISCIPLINARY TEAM
SAFETY, EFFICIENCY, AND COST
FLOW RATE
FUNCTIONALITY NOISE LEVEL COMPATIBILITY AND APPLICATION
FILTER TYPE
Guideline for a Surgical Smoke Safety, 2019ECRI, 2020
ULPA FiltersEducation and Misconceptions
Jason MucilliPrincipal R&D Engineer
Surgical Safety Portfolio R&D Lead
Medtronic, Surgical Innovations
Smoke Evacuation FiltersFilter Anatomy and International Standards
• Typical smoke evacuator filters will consist of four stages:
Prefilter, ULPA, Carbon and Expanded Foam
• ISO 165714 dictates that “the filtration system shall include an
ULPA filter in accordance with EN18225… with an overall
particulate efficiency of not less than 99.9995% (U15 Filter
Class)” tested at the most penetrating particle size
Smoke Evacuation Filters- ULPAEfficiency Ratings and Particle Capture Mechanisms
• What does it mean to be 99.9995% efficient?
• If inlet air contains 1,000,000 𝑝𝑎𝑟𝑡𝑖𝑐𝑙𝑒𝑠
𝑐𝑚3 , the filtrate must contain less than 5 𝑝𝑎𝑟𝑡𝑖𝑐𝑙𝑒𝑠
𝑐𝑚3
Smoke Evacuation Filters- ULPAEfficiency Ratings and Particle Capture Mechanisms
• Particle Capture Mechanisms Explained:
• Straining3: particles larger than the average space
between fibers
• Inertial Impaction3: airflow may force larger particles with
sufficient inertia to impact the fibers and adhere
• Interception3: Similar to impaction - except no direct
impact - Entrapped by adhesion forces
• Diffusion2,3: Very small diameter particles are knocked off
path by other molecules - trapped particles Figure 1: Particle Capture Mechanisms3
Smoke Evacuation Filters- ULPAMost Penetrating Particle Size (MPPS)
• Three ‘micro-scale’ mechanisms have been combined in studies
using physics modeling of motion and airflow
• Figure 2 overlays these efficiency curves
• The minimum efficiency point is known as the most penetrating
particle size (MPPS)
• Key Takeaway: The MPPS does not equal the lower size limit!1,2,3
• MPPS can better be described as ‘the most difficult particle size to capture
• Particle sizes smaller and larger than this point are captured at an even
greater efficiency
• U15 rated ULPA filters have an MPPS of 0.1 – 0.2um; particles smaller and
larger than this are captured with 99.9995% efficiency or greaterFigure 2: Filter efficiency as a function of particle diameter3
Expert Opinion During COVID-19
• Minimize exposure to staff members
• Wear appropriate personal protection
• Use caution during aerosol-generating
procedures
• Minimize use of surgical energy
• Evacuate all surgical smoke
Laparoscopy and COVID-19
COVID-19 & Laparoscopy
Trocars
Insufflation
Respiratory PPE
Energy-generating
devices
Smoke evacuators
Filtration devices
Francis, N., Dort, J., Cho, E. et al., 2020
CLEARING THE AIR, TOGETHER
PROGRAM BENEFITSCREATING A SAFER ENVIRONMENT
PROGRAM OBJECTIVESCREATING A SAFER ENVIORNMENT
GETTING STARTEDPREREQUISITES
GAP ANALYSISEVALUATE EQUIPMENT NEEDS
*AORN does not support or endorse any particular solution.
ONLINE EDUCATIONPROGRAM CORNERSTONE
COMPLIANCE MONITORINGCONDUCT A CLEAR AUDIT
AWARD CRITERIACRITICAL FACTORS
AWARD CRITERIATHREE YEAR DESIGNATION
RECOGNITIONRECOGNIZING FACILITIES FOR THEIR COMMITMENT
Legislation and Advocacy
Jennifer Pennock, MS, AORN
Senior Manager, Government Affairs
Surgical Smoke Evacuation Legislation 2020 Status
2021 Predictions
What Can You Do?
• Go Clear Award
• Gather Stories from OR Staff
• AORN Advocacy Engagement
AORN ResourcesCOVID-19 and Surgical Smoke Safety
COVID-19 FAQs and Tool Kit
Care of the Perioperative COVID-19 Patient (eBook)
• Roadmap for Resuming Elective
Surgery after COVID-19
• Checklists and workflows
• Evidence-based
Preop OR Recovery
Management of Smoke Tool Kit• Guideline Essentials
• Case studies
• Key takeaways
• Policy & Procedure templates
• Customizable presentations
• Competency tools
• How-to videos
• Awareness posters
• Educational resources
Medtronic & AORNA Partnership
Will RiseleyU.S. Marketing Manager
Electrosurgery, Smoke Evacuation, Energy Hardware
Medtronic, Surgical Innovations
Medtronic & AORN
Partnership with a shared purpose
• Medtronic Mission: Alleviate pain, restore health, and extend life
• Co-Developers and sponsors of the Go Clear™ program since
development in 2015• > 1,000 facilities registered for the program• > 16,000 staff members enrolled in the education modules• 102 facilities have received the Go Clear Award
Valleylab™ commitment to innovation & safety
• Leaders for over 50 years
• Safety at the heart of everything
• Continued investment in Research & Development
References for Smoke Safety Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Surgical smoke and infection control. J Hosp Infect.
2006;62(1):1–5
Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A. Presence of human immunodeficiency virus DNA in
laser smoke. Lasers Surg Med. 1991;11(3):197–203
Ball K. Surgical smoke evacuation guidelines: compliance among perioperative nurses. AORN J. 2010;92(2):e1–
e23.
Benson S.M., Maskrey J.R., Nembhard M.D., Unice K.M., Shirley M.A. and Panko J.M. Evaluation of personal
exposure to surgical smoke generated from electrocautery instruments: A pilot study. Annals of Work Exposures
and Health, 2019;63(9)
Benson SM, Novak DA, Ogg MJ. Proper use of surgical N95 respirators and surgical masks in the OR. AORN J.
2013;97(4):457–467.
Clinical questions about COVID-19: Questions and answers. Centers for Disease Control and Prevention (CDC).
2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
References for Smoke Safety COVID-19: Considerations for optimum surgeon protection before, during, and after operation. American College
of Surgeons (ACS). 2020. https://www.facs.org/covid-19/clinical-guidance/surgeon-protection
Dobrogowski M, Wesolowski W, Kucharska M, Sapota A, Pomorski LS. Chemical composition of surgical
smoke formed in the abdominal cavity during laparoscopic cholecystectomy—assessment of the risk to the
patient. Int J Occup Med Environ Health. 2014;27(2):314–325
ECRI. [COVID-19] Considerations for smoke evacuation during non-deferrable surgery [ECRI Exclusive Hazard
Report]. 2020
Fox-Lewis A, Allum C, Bokes D, and Roberts S. Human papillomavirus and surgical smoke: a systematic review.
Occupational & Environmental Medicine. 2020.
Francis, N., Dort, J., Cho, E. et al. SAGES and EAES recommendations for minimally invasive surgery during
COVID-19 pandemic. Surg Endosc 2020;34, 2327–2331. https://doi.org/10.1007/s00464-020-07565-w
Guideline for a Surgical Smoke Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.;
2019:1029-1060.
References for Smoke Safety Kwak H.D., Kim S.-H., Seo Y.S. and Song K.-J. Detecting hepatitis B virus in surgical smoke emitted during
laparoscopic surgery. Occup Environ Med 2016Dec;73(12):857-863. doi: 10.1136/oemed-2016-103724.
Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and
electrocauterization. Mutat Res. 1981;89(2): 145-149.
Vourtzoumis P., Alkhamesi N., Elnahas A., Hawel J.E. and Schlachta C. Operating during COVID-19: Is there a
risk of viral transmission from surgical smoke during surgery? Can J Surg. 2020;63(3)
Zakka K., Erridge S., Chidambaram S., Kynoch M., Kinross J. and Purkayastha S. Electrocautery, Diathermy, and
Surgical Energy Devices: Are Surgical Teams at Risk During the COVID-19 Pandemic? Ann Surg. 2020 Jun
9;272(3):e257–62. doi: 10.1097/SLA.0000000000004112. Epub ahead of print. PMID: 32541232; PMCID:
PMC7467049.
Zhou Q., Hu X., Zhou J., Zhao M. and Zhu X. Human papillomavirus DNA in surgical smoke during cervical loop
electrosurgical excision procedures and its impact on the surgeon. Cancer Management and Research 2019:11
3643–36542019
References for ULPA Filters Medtronic1. Japuntich, D. A. (2007). A comparison of two nano-sized particle air filtration tests in the
diameter. Journal of Nanoparticle Research, 9:93–107.
2. Kim, S. C. (2007). Experimental study of nanoparticles penetration through commercial
filter media. Journal of Nanoparticle Research, 9:117–125.
3. Perry, J. (2016). Submicron and Nanoparticulate Matter Removal by HEPA-Rated Media
Filters and Packed Beds of Granular Materials. NASA Technical Memo, 218-224.
4. ISO 16571:2014, 3.28, 8.3.2
5. EN1822-1
Questions
