Management of Surgical Smoke

in the Perioperative

Setting

44-year old surgeon developed laryngeal papillomatosis

Biopsy identified the same virus type as anogenital condyloma

Hallmo, et al (1991)

Total Cases: 951

Key indicators of compliance:EducationLeadership supportEasy to follow policiesRegular internal collaboration

(Ball, K . 2010)

To know the risks of surgical smoke

To understand the rationale for smoke management

To feel empowered to advocate for smoke evacuation in your OR.

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Gaseous toxic compoundsBio-aerosolsDead and live cellular material (including

blood fragments)Viruses Carbonized tissueBacteria

Acrolein BenzeneCarbon MonoxideFormaldehydeHydrogen cyanideMethaneToluenePolycyclic aromatic hydrocarbons (PAH)

Smoke plume and aerosols contain 95% water vapor

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

Human Immunodeficiency Virus = 0.15 micronHuman Papilloma Virus = 0.055 micronHepatitis B = 0.042 micron

Surgical Smoke = 0.1-5.0 micron

Concentration: over 1 million particles/cubic feetIt takes 20 min after the activation of the ESU

for the concentration to return to the baseline level (Nicola, et al. 2002).

Travel at 40 mph

Evenly distributed throughout the operating room

“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)

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)

Eye, nose, throat irritation

HeadachesNausea, dizzinessRunny noseCoughingRespiratory irritantsFatigueSkin irritationAllergies

Perioperative staff have

twice the incidence

of many respiratory problems as compared to the general

population. (Ball, 2010)

Soft contact lenses can absorb toxic gases produced by surgical smoke.

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)

AORNANSIECRI

NIOSH/CDCOSHA

Joint Commission

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

Airborne Contaminants:Shall be controlled by the use of ventilation

(ie., smoke evacuator). Respiratory protection required for any residual plume escaping

capture.

Recommends the evacuation of surgical smoke

The content of laser and ESU smoke is very similar

https://www.ecri.org/

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

General Duty Clause:

Employer MUST provide a safe workplace

environment!

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

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.

Strategies for Success

Communication with Surgeon and Perioperative Team members

Plan for Smoke Evacuation

Equipment availability

Relevant information about smoke evacuation and equipment used

EducationChart AuditsEquipment Service Reports

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Smoke Evacuation Methodsin the Perioperative Setting

In-line filtersSmoke evacuator systems

Laparoscopic filtering devices