1. Management of Surgical Smoke in the Perioperative Setting
AORN Smoke Tool Kit 2013
Management of Surgical Smoke in the Perioperative Setting
Presenter Notes: Let’s begin with the definition of surgical smoke and the potential hazards of surgical smoke.

2. Service/Surgeon Compliance

3. Barriers to Compliance
AORN Smoke Tool Kit 2013
Barriers to Compliance
Equipment not available
Physician
Equipment is Noisy
Complacent staff
-- Ball, 2010
Surgeons' resistance or refusal
Cost
Bulkiness
Excessive noise
--Edwards & Reiman, 2012
Noise
Distraction
Ergonomic difficulty of equipment
--Watson, 2010
Again, as mentioned previously, barriers to smoke evacuation practices must be identified and addressed. As you see on the slide, several authors have reported various reasons for non-compliance of smoke evacuation practices.

4. Compliance Model Individual Innovativeness Characteristics
(Perioperative staff characteristics)
Perceptions of Attributes
(Staff perceptions of smoke evacuation recommendations)
Organization Innovativeness Characteristics
(Organization’s characteristics)
Age
Education level
Experience
Knowledge
Training
Presence of respiratory problems
Relative Advantage
Compatibility
Complexity
Trialability
Observability
Barriers to practice
Descriptors (locale, type)
Size
Complexity
Formalization
Interconnectedness
Leadership support
Barriers to practice
This compliance model was designed by researcher Kay Ball based on Roger’s Diffusion of Innovations model, which explores how innovations are accepted into practice. This compliance model explored how smoke evacuation recommendations are accepted into practice. This model involves the individual nurse’s characteristics, his or her perceptions of the smoke evacuation recommendations, and the organization’s characteristics. All of these attributes and characteristics were analyzed against compliance with smoke evacuation recommendations.
No compliance
Full compliance
Compliance with research-based smoke evacuation recommendations
* Based on Roger’s Diffusion of Innovations model. Reprinted with permission from Kay Ball, PhD, RN, CNOR, FAAN.

5. Smoke Evacuation Compliance Study
AORN Smoke Tool Kit 2013
Smoke Evacuation Compliance Study
Key indicators of compliance:
Education
Leadership support
Easy to follow policies
Regular internal collaboration
(Ball, K )
Dr. Ball found the most significant key indicator of compliance was education. In other words, if nurses were educated about the hazards of surgical smoke exposure, then they would be more apt to comply with smoke evacuation recommendations. Also significant to compliance was having strong leadership support that supported smoke evacuation practices, having easy to follow policies on smoke evacuation, and promoting regular internal collaboration (physicians and nurses working together to ensure all smoke is evacuated).

6. Composition of Surgical Smoke
AORN Smoke Tool Kit 2013
Composition of Surgical Smoke
150 different chemicals identified in surgical smoke (Pierce, et al. 2011)
Surgical smoke produced by the CO 2 laser is consistent with other energy-producing devices that generate surgical smoke. This smoke is comprised of 95% water and 5% of particulate, gases, and microorganisms. Roughly 150 different chemicals including benzene, toluene, formaldehyde, cyanide, and aerolin have been identified in surgical smoke.

7. Water Vapor Smoke plume and aerosols contain 95% water vapor
AORN Smoke Tool Kit 2013
Water Vapor
Smoke plume and aerosols contain 95% water vapor
Water vapor is itself not harmful, but acts as a carrier
We know water vapor is not in itself harmful, yet it can act as a carrier for particulates of surgical smoke.

8. Content of Surgical Smoke
AORN Smoke Tool Kit 2013
Content of Surgical Smoke
Gaseous toxic compounds
Bio-aerosols
Dead and live cellular material (including blood fragments)
Viruses
Carbonized tissue
Bacteria
As you see on the slide, surgical smoke can contain gaseous toxic compounds, bio-aerosols, live and dead cellular material including virus and bacteria.

9. 150 Chemical constituents of plume include:
AORN Smoke Tool Kit 2013
Toxic Gases
150 Chemical constituents of plume include:
Acrolein
Benzene
Carbon Monoxide
Formaldehyde
Hydrogen cyanide
Methane
Toluene
Polycyclic aromatic hydrocarbons (PAH)
Toxic substances have been identified in surgical smoke. Some of these substances are carcinogenic.
When tissue is pyrolyzed (pyrolysis: a chemical change brought about by the action of heat)
with energy devices (such as electrosurgery or laser), toxic gases are produced that produce an offensive odor. Over 150 different chemical constituents have been identified in surgical smoke. Some of these gases are carcinogenic. These gases exist in trace amounts in surgical smoke but we inhale them everyday which can create an accumulative effect. There’s a need to determine the impact of cumulative effects of the toxic gases in surgical smoke. There is a lot of research about the inhalation of different individual chemicals. Benezene, for example, has been shown to be a possible trigger for leukemia. Many of these chemicals are very toxic effects on the human body.

10. Particulate Matter Carbonized tissue Blood
AORN Smoke Tool Kit 2013
Particulate Matter
Carbonized tissue
Blood
Intact virus and bacteria (HIV, HPV, Hepatitis)
Along with the toxic gases that create the surgical smoke odor, tiny particles are generated within surgical smoke that can easily be inhaled. These particles can consist of carbonized tissue, blood fragments, and possibly intact virus or bacteria.

11. Size of Particulate Matter
AORN Smoke Tool Kit 2013
Size of Particulate Matter
77% of Surgical Smoke Particles are
less than
1.1 microns
In a classic study in 1975, Dr. Mihashi and his colleagues noted that 77% of the particles within surgical smoke are less than 1.1 microns in size. Inhaling particles of this size can easily be deposited in the alveoli, the gas exchange regions of the lungs, which can lead to respiratory problems. Also the circulating blood will pick up whatever is in the alveoli and circulate it randomly throughout the body.

12. Virus Sizes Tobacco Smoke = 0.1-3.0 micron
AORN Smoke Tool Kit 2013
Virus Sizes
Human Immunodeficiency Virus = 0.15 micron
Human Papilloma Virus = micron
Hepatitis B = micron
Others
Tobacco Smoke = micron
Surgical Smoke = micron
Bacteria = micron
Lung Damaging Dust = micron
Smallest Visible Particle = 20 micron
The particulate matter within surgical smoke have the potential to carry minute viral particles. Typical virus particles and the comparison to other particles are listed above. Lung damaging dust is among the largest particles—with virus and bacteria particles being much smaller. Remember Dr. Mihashi study noted that 77% of the particles in surgical smoke are 1.1 microns in size and smaller. A standard surgical mask filters 5 micron in size particles and are ineffective when used during procedures not employing proper smoke evacuation practices.

13. Particle Distribution
AORN Smoke Tool Kit 2013
Particle Distribution
Smoke is evenly distributed throughout the operating room
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, et al. 2002).
A study reported by Nicola, et al. in 2002 found that surgical smoke is evenly distributed throughout the operating room. Smoke particles can travel about 40 mph. This research demonstrated that when the ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet. After activating the ESU and generating surgical smoke, the concentration of particles returns to the baseline level after about 20 minutes. Adding to this concern is the fact that every surgical suite must have an air exchange of at least 15 times per hour; therefore, surgical smoke particles get caught up on these air currents and evenly distribute them throughout the OR.

14. Worker Safety: Exposures to Smoke/Plume
AORN Smoke Tool Kit 2013
Worker Safety: Exposures to Smoke/Plume
“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)
OSHA which is part of the US Department of Labor keeps statistics on worker exposures to laser and surgical smoke.

15. Reported Health Effects
AORN Smoke Tool Kit 2013
Reported Health Effects
Eye, nose, throat irritation
Headaches
Nausea, dizziness
Runny nose
Coughing
Respiratory irritants
Fatigue
Skin irritation
Allergies
When surgical smoke is inhaled, there are definite symptoms such as nausea, dizziness, watery eyes, runny nose, headaches, fatigue, respiratory problems, skin irritation, and allergies. These symptoms can be minimized and even eliminated with proper smoke evacuation practices.

16. Inhaling Surgical Smoke
AORN Smoke Tool Kit 2013
Inhaling Surgical Smoke
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)
Dr. Tomita and his colleagues conducted a classic study in 1989 that is still being referenced today since it makes such a powerful point. This study compared the inhalation of smoke from vaporized human tissue to the smoke created by cigarettes. They determined that inhaling the plume produced when using the CO2 laser to vaporize one gram of tissue (which is not a lot of tissue) is like smoking three unfiltered cigarettes in 15 minutes.  Inhaling the smoke produced when using an electrosurgery device to vaporize one gram of tissue is like smoking six unfiltered cigarettes in 15 minutes. This study demonstrates that smoke generated by using an electrosurgery device may be more hazardous than that produced by a laser. Let’s just agree that these plumes are very similar and both need to be evacuated completely. When laser technology was first introduced, classes were conducted to educate healthcare providers on laser practices and hazards, such as surgical smoke. The laser went hand-in-hand with the smoke evacuator. Today, compliance with smoke evacuation using the laser is much greater than when electrosurgical energy is used. Therefore, we must focus on the realization that electrosurgical smoke can be just as hazardous as laser plume and must be evacuated consistently.

17. AORN Smoke Tool Kit 2013
Respiratory Problems
Perioperative staff have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010)
Allergies
Sinus infections/problems
Asthma
Bronchitis
Ball (2010) reports in her research on compliance with smoke evacuation recommendations; perioperative nurses report twice the incidence of many respiratory problems as compared to the general population.

18. Chemical Effect Soft contact lenses can absorb toxic gases
AORN Smoke Tool Kit 2013
Chemical Effect
Soft contact lenses can absorb toxic gases
produced by surgical smoke.
Recommendation made by an OSHA safety violation not related to plume, 1990
Soft contact lenses can absorb the toxic gases produced by surgical smoke. They can become cloudy and uncomfortable. OSHA made the recommendation that soft contact lenses should not be worn if surgical smoke isn’t evacuated appropriately during surgical procedures. OSHA made this recommendation after realizing this concern during a safety violation citation that wasn’t even related to compliance with surgical smoke evacuation recommendations.

19. Case Report 44-year old laser physician developed
AORN Smoke Tool Kit 2013
Case Report
44-year old laser physician developed
laryngeal papillomatosis
Biopsy identified the same virus type as
anogenital condyloma
Hallmo, et al (1991)
The potential for the transmission of viable organisms within surgical smoke is great. Since research that would purposely expose humans to the dangers of surgical smoke are unethical, we need to depend on anecdotal reports and animal studies about the potential for transmission of disease from surgical smoke inhalation. In a study by Hallmo, et al (1991) a 44-year old surgeon, who rarely evacuated the surgical smoke when using the laser to vaporize condyloma, developed laryngeal papillomatosis. When his lesions were biopsied, the same type of virus was identified that is found in anogenital warts, which is not normally found in the throat. This report, along with other anecdotal reports continue to support that best practice is to evacuate and filter surgical smoke.

20. Patient Safety: Laparoscopic Surgical Procedures
AORN Smoke Tool Kit 2013
Patient Safety: Laparoscopic Surgical Procedures
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)
As smoke builds up inside the abdomen during laparoscopy, the smoke is absorbed through the patient’s peritoneal membrane. When the smoke is absorbed by red blood cells, an increase in carboxyhemoglobin and methemoglobin occurs. Both of these substances reduce or deplete the oxygen-carrying capacity of the red blood cell, which remains within the patient’s body throughout the life of the red blood cell. Carbon monoxide levels increase as well exposing both the patient (during the procedure) and the perioperative team (when the insufflated gas is released into the OR at the end of the case) to higher than recommended exposure limits.

21. Healthcare and Regulatory Standards and Recommendations
AORN Smoke Tool Kit 2013
Healthcare and Regulatory Standards and Recommendations
AORN
ANSI
ECRI
NIOSH/CDC
OSHA
Joint Commission
There are several international and national organizations that address standards affecting patients and health care workers on the topic of exposure to hazardous materials and surgical smoke.

22. AORN Recommended Practices
AORN Smoke Tool Kit 2013
AORN Recommended Practices
“Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.”
Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:
Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:
Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::
As you see, the AORN recommended practices are consistent in the wording of the recommendations.
These recommendations state, “Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.”

23. ANSI Standard 7.4 of Z136.3 - 2011 (Safe Use of Lasers in Healthcare)
AORN Smoke Tool Kit 2013
ANSI Standard 7.4 of Z (Safe Use of Lasers in Healthcare)
Airborne Contaminants: Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any residual plume escaping capture.
The most recent version of the American National Standards Institute Z136.3 (2011) state that airborne contaminants from laser surgery SHALL be controlled. Also they note that the electrosurgical device produces the same type of airborne contaminants as lasers do. Many organizations and agencies are making their recommendations more powerful with changing the verb from “should” to “shall.” This is a more powerful word to help encourage compliance.

24. ECRI Independent, nonprofit organization
AORN Smoke Tool Kit 2013
ECRI
Independent, nonprofit organization
Researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care
Electrosurgery smoke is overlooked
The spectral content of laser and ESU smoke is very similar accessed 12/13/12
ECRI, formerly the Emergency Care Research Institute, a nonprofit agency in Plymouth Meeting, PA, recommends that it is prudent to evacuate surgical smoke, and that there is no difference between smoke produced by lasers and smoke produced by electrosurgery units. ECRI Health Devices: Laser Smoke Evacuators, 1990.

25. NIOSH/CDC: Work Practices
AORN Smoke Tool Kit 2013
NIOSH/CDC: Work Practices
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
Follow Standard Precautions
NIOSH/CDC recommend that:
*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 plume is present
*Follow Standard Precautions

26. Employer MUST provide a safe workplace environment!
AORN Smoke Tool Kit 2013
OSHA
General Duty Clause:
Employer MUST provide a safe workplace environment!
The Occupational Safety and Health Administration (OSHA), General Duty clause states the employer must provide a safe work environment. Since employers must provide a safe work place environment, it’s logical that smoke evacuation devices must be provided and used so that staff members are not exposed to surgical smoke.

27. AORN Smoke Tool Kit 2013
Joint Commission
The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.
Note: 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.
Environment of care. In Comprehensive Accreditation Manual: CAMH for Hospitals. The Official Handbook. Oakbrook Terrace, IL Joint Commission; 2009: EC-6-EC-6.
The Joint Commission also addresses standards about minimizing risks associated with exposure to vapors and hazardous gases and they include ESU and laser. The Joint Commission also works collaboratively with OSHA to ensure a safe workplace environment is maintained for workers.

28. Smoke Evacuation Methods in the Perioperative Setting
AORN Smoke Tool Kit 2013
Smoke Evacuation Methods in the Perioperative Setting
In-line filters
Smoke evacuator systems
Laparoscopic filtering devices
Let’ s now discuss smoke evacuation and best practices to decrease patient and worker exposure to surgical smoke in the perioperative setting.

29. AORN Smoke Tool Kit 2013
In-Line Filter
Simple
Evacuate less than five cubic feet per minute (CFMs)
Effective for small amounts of smoke
Use and change as recommended by the manufacturer’s instructions
Use standard precautions when changing and disposing of in-line filters
Note Cubic feet per minute = CFM
The OR wall suction is often used to evacuate very small amounts of plume – for example, smoke that may be generated during a microlaryngoscopy vaporization of a vocal cord polyp. Using the wall suction is very simple but this system only moves air less than five cubic feet per minute (CFM). An inline filter is mandatory to protect the wall suction line from getting clogged with surgical smoke particulate matter. The inline filter should be used and changed as recommended by the manufacturer. Standard precautions must be used when changing and disposing of contaminated inline filters.

30. In-Line Filters with Wall Suction
AORN Smoke Tool Kit 2013
In-Line Filters with Wall Suction
To wall suction >
From the patient>
Again, it is extremely important that an in-line filter must be used when wall suction is chosen to evacuate small amounts of surgical smoke.
If there is no inline filter, then the particulate matter from smoke can build up inside the suction lines. For a suction to be effective, the suction lines and filters extending outside the operating room must also be clear. Inline filters must be used according to the manufacturer’s instructions, and changed as recommended while using standard precautions. An overused filter affords absolutely no protection for the suction line.
Example of an ULPA filter

31. Smoke Evacuator System
(add picture)

32. Laparoscopic Filtering Systems
AORN Smoke Tool Kit 2013
Laparoscopic Filtering Systems
Irrigation/Aspiration System
Active System
Passive System
There are several smoke evacuation devices available for laparoscopic procedures. A irrigation/aspiration system that does not interfere with the physician’s operative area can eliminate or decrease surgical smoke by continuous removal of plume throughout the entire procedure. There are passive and active systems for laparoscopic smoke removal. The passive systems are connected to a trocar sleeve and provide ventilation for air movement to disperse the surgical smoke. The active systems (such as a smoke evacuator for laparoscopic procedures) provide active movement of the insufflation gas with surgical smoke to remove the plume.

33. Strategies for Success
AORN Smoke Tool Kit 2013
Strategies for Success
Let’ s now discuss smoke evacuation and best practices to decrease patient and worker exposure to surgical smoke in the perioperative setting.

34. AORN Smoke Tool Kit 2013
Team Briefing
Communication with Surgeon and Perioperative Team members
Plan for Smoke Evacuation
Equipment and Optimal placement of equipment
Patient and Team member Smoke Protection Methods
A good time to discuss the required smoke evacuation methods is when you are planning and preparing for the procedure, as well as during the team briefing. Discussion can include the plan for smoke evacuation, the type of equipment and optimal placement of the smoke evacuation device, patient and team member protection methods, including what type of respiratory protection is recommended. A smoke evacuation program is much more successful when there is collaboration and communication among the surgeons and perioperative team members.

35. AORN Smoke Tool Kit 2013
Documentation
Relevant information about smoke evacuation and equipment used
It’s important to document relevant information about smoke evacuation and the type of smoke evacuation equipment used in the patient’s medical record.

36. Quality Monitoring Education and Competency Equipment Service Reports
AORN Smoke Tool Kit 2013
Quality Monitoring
Education and Competency
Equipment Service Reports
A quality monitoring program can include the dates of educational sessions involving surgical smoke hazards and smoke evacuation practices. Regular competency checks can determine if smoke evacuation recommendations are being followed consistently. All smoke evacuation equipment must comply with routine maintenance recommendations to ensure proper functioning.

37. We claim to be a “smoke-free” campus… …so why aren’t we?
AORN Smoke Tool Kit 2013
We claim to be a “smoke-free” campus… …so why aren’t we?
In summary, the message to healthcare workers is make sure that our surgical environments are smoke-free today! On the front door of a hospital, there’s a sign that says “No Smoking.” But what about the surgical smoke in the OR? We must protect our patients, our colleagues, and ourselves by making sure that our operative and invasive procedure areas are also smoke-free. We have the knowledge, technology, and passion, so let’s ensure all surgical smoke is evacuated.