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: Education Leadership support Easy to follow policies Regular 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. 6

Gaseous toxic compounds Bio-aerosols Dead and live cellular material (including blood fragments) Viruses Carbonized tissue Bacteria

Acrolein Benzene Carbon Monoxide Formaldehyde Hydrogen cyanide Methane Toluene Polycyclic 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 micron Human Papilloma Virus = micron Hepatitis B = micron Surgical Smoke = micron

Concentration: over 1 million particles/cubic feet It 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 (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 Headaches Nausea, dizziness Runny nose Coughing Respiratory irritants Fatigue Skin irritation Allergies

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)

AORN ANSI ECRI NIOSH/CDC OSHA 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

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

Education Chart Audits Equipment Service Reports

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Smoke Evacuation Methods in the Perioperative Setting In-line filters Smoke evacuator systems Laparoscopic filtering devices