Ambient Environmental Hazards in the OR Kay Ball, RN, MSA, CNOR, FAAN Lewis Center, OH Red Team – April 17, 2007

ObjectiveObjective Discuss control measures for inhalation hazards in the OR.

Inhalation Hazards  Transmissible diseases  Toxic fumes  Anesthesia gases  Glutaraldehyde  Surgical smoke

Spaulding’s Classifications Spaulding’s Classifications è Critical (Sterilize) è Semi-critical (Disinfect) è Non-critical (Clean)

GlutaraldehydeGlutaraldehyde

Glut History ä Tanning agent for leather ä Tissue fixative ä Preservative in cosmetics ä Therapeutic agent for warts & other infections ä X-ray processing solution & film emulsion

Glutaraldehyde Disinfection  Broad spectrum antimicrobial “cold” disinfectant  Glut action – bonds protein  Device preparation – thorough cleaning and rinsing  Efficacy monitoring  Soak time controversy

ControversyControversy FDA 45 min soak 25 degrees C. Prof. Org 20 min soak Room temp.

Glut Hazards  Skin & mucous membrane hazards  Ingestion hazards  Respiratory hazards  Chronic exposure hazards

Exposure Levels  0.04 ppm Detect odor  0.2 ppm Exposure level  0.3 ppm Irritant  0.4 ppm Pouring

VentilationVentilation Glut V ent Processing Area

Spill Procedure Ammonia

AAMI Document “Safe use and handling of glutaraldehyde-based products in health care facilities”

Glut Advantages  Effective for HLD  Highly compatible  Sterilization with long soak times  Low cost, convenient

Glut Limitations  Unstable - Effective life 2-4 weeks  Thorough rinsing - mandatory  Skin, respiratory hazards  Glut bonds proteins Options for alternatives: Other soaking solutions (Cidex OPA) or sterilization methods

Cidex - OPA ORTHO-PHTHALDEHYDE  HDL in 10 min at 20 degrees C  Ortho-phthaldehyde (.55%) + insert ingredents (99.45%)  No sterilant claims  Reuse 14 days (test strip)  Endorsed by many manufacturers  Stains skin, eye & resp irritant, causes headaches

Sterilization Options  Steam  Ethylene Oxide  Peracetic Acid  Gas Plasma  Ozone Sterilize

The Effects of

Miners – Air Problems OR Team Serving as the Biological Indicator for Poor Air Quality

AORN RP  Personnel working with an ESU or laser should avoid exposure to smoke plume generated during tissue cutting and coagulation. Surgical smoke causes headaches, watery eyes, respiratory problems in healthcare workers

NIOSHNIOSH ä 1988 ä “Smoke generated during laser surgery presents a potential health hazard.”

NIOSHNIOSH ä 1985 ä “There’s a potential hazard from smoke generated by electrosurgical knives.”

ResearchResearch Tomita et al, 1989 Laser: 1gm tissue 3 unfiltered cigarettes ESU: 1gm tissue 6 unfiltered cigarettes Laser and ESU smoke are very similar!

Hazards of Plume  Odor  Particulate Matter Size  Viability  Endoscopy concerns

Odor from Toxic Gases *Polycyclic aromatic hydrocarbons *Benzene *Toluene *Formaldehyde *Acrolein ODOR

Toxic Fumes and Vapors  Acrolein  Benzene  Formaldehyde Possible carcinogens!!!!

Particulate Matter  American College of Surgeons: 5 microns = bacterial colonization  Regular surgical mask: 5 micron filtration  Research - 77% of surgical smoke is 1.1 microns in size and smaller (Mihashi et al., 1975)  Particulate ends up in the alveoli of your lungs

ResearchResearch Baggish et al, 1988 Rats breathed unfiltered & filtered plume Unfiltered plume: Rats developed hypoxia, pulmonary problems Filtered plume: No changes

Viability Research Garden et al, 1988 Used CO2 laser on cow papillomavirus Used CO2 laser on cow papillomavirus Found intact viral DNA in plume Found intact viral DNA in plume Injected viral DNA from plume into cow Injected viral DNA from plume into cow Grew same viral lesion Grew same viral lesion Potential of transmission of viable viral contaminants Potential of transmission of viable viral contaminants

Transmission of virus to Dr. Hallmo et al, yo laser Dr developed laryngeal papillomatosis 44yo laser Dr developed laryngeal papillomatosis Lesions show same DNA type as anogenital condyloma from patients Lesions show same DNA type as anogenital condyloma from patients

EndoscopyEndoscopy Ott et al, 1993 Laparoscopy & plume Laparoscopy & plume Increase methemoglobin & carboxyhemoglobin Increase methemoglobin & carboxyhemoglobin (methemoglobin-  O 2 carrying (methemoglobin-  O 2 carrying capacity of RBCs) capacity of RBCs) Delay in healing? Delay in healing?

RecommendationsRecommendations  AORN  ANSI  NIOSH  CDC  OSHA  Global recommendations All say to evacuate surgical smoke!

SolutionsSolutions Appropriate smoke evacuation system

In-line Filter For small amounts of plume use in-line filter Correct positioning needed Patient Wall Suction AORN Pilot Survey: Most popular method

Wall Suction  Corrodes pipes  Contaminates building  Flow may not be high enough to capture surgical smoke Wall suction 2 cfm Evacuator cfm

Smoke Evacuator Needed when larger amounts of smoke created

Critical Features  Efficiency  Filtering capability  Charcoal filter – removes odor  ULPA filter – removes small particulate (.1 microns, % efficiency)  Suction power

Filter Changing Follow manufacturer’s recommendations when changing Occupational Hazard NOT Environmental Hazard

Solutions Position smoke tube close to the tissue impact site

Automatic On/Off System

Evacuation during endoscopy

Choices

SolutionsSolutions High Filtration Masks 0.1 micron filtration Not the first line of defense

Questions???Questions??? Nurses Advocating Smokefree Theatres Immediately