1. Management of Surgical Smoke Tool Kit Part II: The Hazards of Surgical Smoke

2. There are five slide decks related to the management of surgical smoke in the perioperative setting. It is recommended to review the slide decks in order. This is Part II. Part I: Introduction to Surgical Smoke Part II: The Hazards of Surgical Smoke Part III: An Overview of Health Care Regulations, Standards, and Guidelines Related to Surgical Smoke Part IV: Smoke Evacuation in the Perioperative Setting Part V: Additional Perioperative Nursing Care Instructions to the Learner

3. The Hazards of Surgical Smoke Part II

4. Patients Perioperative Team Members Others (anyone in the procedure room) Inhalation and Exposure Potential to Harm

5. Odor Particulate Matter Viable/non-viable virus or bacteria Hazards

6. 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 Y, et al. 1981 Inhaling Surgical Smoke

7. Acetaldehyde*** Acrolein Acrylonitrile** Benzene** Butadiene*** Carbon monoxide Cyanide Ethanol Formaldehyde** Hydrogen cyanide Methane Phenol Polycyclic aromatic hydrocarbons* Toluene *** Carcinogen ** Potential Carcinogen * Increased risk of certain cancers Pierce JS, et al. 2011 Examples of Toxic Substances found in Surgical Smoke

8. Carbonized tissue Blood Intact virus and bacteria human immunodeficiency virus (HIV) human papilloma virus (HPV) hepatitis Particulate Matter

9. Particle Sizes Figure 2. Particle sizes and associated type of protection against pathogens and atmospheric hazards commonly found in hospital environments. The boxes with the dotted background are airborne- transmissible diseases. Reprinted with permission from the AORN Journal. Copyright © 2013, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved. Citation: 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.

10. Smoke is evenly distributed throughout the OR 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. Nicola JH, et al. 2002 Particle Distribution

11. Chemical composition of gases surgeons are exposed to during endoscopic urological resections. (Weston et al. 2009) Occupational hazards facing orthopedic surgeons. ( Lester et al. 2012) 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) Surgical smoke evacuation guidelines: Compliance among perioperative nurses. ( Ball, 2010) Surgical smoke and the dermatologist. (Lewin et al Sept 2011) Surgical Smoke: It’s a Universal Concern

12. Patient Safety

13. Laparoscopic procedures present unique exposures to smoke to the patient. Patient Safety: Exposures to Surgical Smoke

14. Minimally Invasive Surgery (MIS) Levels of carboxyhemoglobin of patients who underwent laparoscopic procedures using laser were significantly elevated

15. Pulse oximeter readings may be falsely elevated and could result in unrecognized patient hypoxia Laparoscopic Surgical Procedures

16. Carbon monoxide levels increase in the peritoneal cavity and exceed recommended exposure limits Laparoscopic Surgical Procedures

17. Exposure to carbon monoxide Increased levels of carboxyhemoglobin Occurrence of methemoglobin Loss of visibility in the surgical field or potential delay of the procedure Port site metastasis Exposure to Surgical Smoke during MIS: Risks to Patients

18. Exposure to carbon monoxide Increased levels of carboxyhemoglobin Occurrence of methemoglobin Loss of visibility in the surgical field or potential delay of the procedure Port-site metastasis Exposure to Surgical Smoke during MIS: Risks to Patients

19. Health Care Worker Safety

20. “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 https://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed July 22, 2015)https://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html Worker Safety: Exposures to Smoke/Plume

21. Long time exposure to fine particulate air pollution is associated with incidence of cardiovascular disease and death among postmenopausal women Miller KA, et al. 2007 Air Pollution and Women

22. Eye, nose, throat irritation Headaches Nausea, dizziness Runny nose Coughing Respiratory irritants Fatigue Skin irritation Allergies Health Effects Reported by Healthcare Workers

23. Respiratory Problems Perioperative nurses have twice the incidence of many respiratory problems as compared to the general population. Allergies – Sinus infections/problems – Asthma – Bronchitis Ball, 2010

24. 44-year old laser physician developed laryngeal papillomatosis Biopsy identified the same virus type as anogenital condyloma Hallmo P, et al. 1991 Case Report

25. Health effects to the perioperative team When pneumoperitoneum is released into the OR without filtration Important to use a filtering device or a closed evacuation system Exposure to Surgical Smoke during MIS: Perioperative Team Members

26. Surgical smoke is a hazard to patients and the health care providers Particulate matter in surgical smoke can contain carbonized tissue, blood, and intact virus and bacteria (e.g. HIV, HPV, Hepatitis) Patients and health care providers are also at unique risks during minimally invasive surgical procedures related surgical smoke Summary Part II

27. Please continue to the next slide deck: Part III Part I: Introduction to Surgical Smoke Part II: The Hazards of Surgical Smoke Part III: An Overview of Health Care Regulations, Standards, and Guidelines Related to Surgical Smoke Part IV: Smoke Evacuation in the Perioperative Setting Part V: Additional Perioperative Nursing Care End of Part II