Surgical smoke evacuation recommendations

Kay Ball, PhD, RN, CNOR, FAAN

Perioperative consultant/educator, associate professor, Otterbein University, Westerville, Ohio, USA  

Safety in the operating room environment has been an issue that has deservedly received much interest and recognition over the years. Most of the attention has been on patient safety, but growing concerns have begun to highlight workplace safety for healthcare professionals.  

Research has demonstrated that over 500,000 healthcare workers are exposed to the hazards of surgical smoke each year in the USA.1 Surgical smoke has been an inhalation hazard for healthcare professionals since the electrosurgery device was first used in the early 1920s. Since then, other cutting and coagulating energies have been introduced that produce a plume when interacting with tissue. Even though these energies differ, the surgical smoke created is very similar. All surgical smoke contains toxic gases and particulate matter that may transmit disease.

Complying with evidence-based smoke evacuation recommendations has become an area of concern, as smoke evacuation practices continue to vary widely among different surgical arenas throughout the world. Not only do smoke evacuation practices vary from country to country and city to city, but they vary from facility to facility, and even from department to department within the same facility. Attention to proper smoke evacuation methods has become recognized by the nursing community. Many nursing leaders are passionate about changing current practices so that clean air is provided within surgical and other environments where plume is created.

Hazards of surgical smoke
Surgical smoke is an inhalation hazard to healthcare workers, as it creates an offensive odor and produces very small particles that could potentially transmit disease. Inhalation of plume has been known to be the cause of acute and chronic inflammatory respiratory problems, such as emphysema, asthma and chronic bronchitis.

Surgical smoke inhalation has also been directly linked to conditions such as:

• Anemia
• Anxiety
• Cancer
• Cardiovascular problems
• Hypoxia
• Headaches
• Eye irritation
• Nasopharyngeal lesions
• Nausea
• Vomiting
• Throat irritation
• Fatigue.2

When surgical smoke is generated within a body cavity during an endoscopic procedure, the smoke byproducts can be absorbed by the patient, thus becoming a hazard for the patient.3

When tissue is coagulated or cut with different surgical energies, such as electrosurgery or laser, toxic gases are formed that create an unpleasant odor. Many of these toxic gases are the same contaminants that are found in cigarette smoke. Some of these toxic gases, such as acrolein, benzene, and formaldehyde are known carcinogens.4,5

Even though these gases are found in trace amounts in surgical smoke, many healthcare providers, such as perioperative nurses and technologists, are exposed to these air contaminants on a regular basis. No definitive studies have been conducted to determine the cumulative effects of inhaling these toxic gases.

Surgical smoke contains very small particles with the average size of 0.3 microns. Research has shown that over 77% of the plume contents are approximately 1.1 microns in size and smaller.6 When these small particles are inhaled, they can end up in the alveoli of the lungs of healthcare workers which can lead to acute or chronic respiratory problems.  

Research conducted by Dr Baggish on laboratory mice demonstrates that when surgical smoke is inhaled, hypoxia, pulmonary congestion and bronchial hyperplasia or hypertrophy can occur.7 Other research notes that even when an excimer laser is used during corneal sculpting procedures, respirable particles exist in the plume.8

Standard surgical masks filter 0.5 micron in size particles and should never be considered as the first line of defence for protection against surgical smoke inhalation. If the plume particulate is suctioned into a wall or ceiling suction line, then the particulate can begin to accumulate and potentially occlude the suction line.  

Since operating rooms are required to have increased air movement and exchanges of air, the small particles within surgical smoke can travel long distances from the surgical site. Distribution studies reveal that smoke particle concentration levels can remain high throughout the operating room as the particles can spread quickly while being suspended within the air.9 Therefore, a circulating nurse can be exposed to as much dangerous particulate from smoke as compared to the surgical team positioned at the sterile field.

Research has demonstrated that surgical smoke can contain viable particles that can potentially transmit disease. Dr Jerome Garden’s research notes that intact DNA from bovine papillomavirus can be extracted from surgical smoke. When the intact viral DNA is injected into another area of the cow, the same papilloma lesions appear.10,11 Since the growth of this papillomavirus was not the result of the cow inhaling surgical smoke, transmission through inhalation has not been demonstrated.

Further studies are needed to validate the transmission of viral and bacterial contamination through inhalation. However, many anecdotal reports have raised the concerns about the transmission of pathogenic organisms within surgical smoke.1,4 For example, a surgeon in Norway developed laryngeal papillomatosis after he consistently vaporized condyloma without using smoke evacuation methods.12

Another report notes the presence of verrucae in unusual sites, such as in the anterior nares, of laser operators.13 These and other reports strongly suggest the high potential for transmission of viral DNA within surgical smoke.1

When plume is not evacuated during endoscopic procedures (such as laparoscopy), the patient can absorb the byproducts of combustion, which can cause problems. Dr Ott conducted research that notes when surgical smoke is not evacuated during laparoscopic procedures, patients are more inclined to be nauseated or complain of headaches in the post-anesthesia care unit.3

Blood test findings show that these patients have increased levels of methemoglobin and carboxyhemoglobin that leads to a decrease in the oxygen-carrying capabilities of the red blood cells. This, in turn, causes the symptoms of headache, nausea and even blurred vision for patients.  

When surgical smoke is properly evacuated during laparoscopic procedures, increased levels of methemoglobin and carboxyhemoglobin are not found. This study supports that smoke evacuation during endoscopic procedures needs to be performed to ensure patient safety.

Smoke evacuation methods
Methods to remove surgical smoke have been varied within surgical and treatment areas. 
The most popular device used to evacuate surgical smoke is the suction line designed to eliminate fluids from the surgical field.14,15 
This method of smoke evacuation is ineffective because the suction line within the wall or ceiling becomes contaminated with smoke particulate and the suction pull is usually not adequate to remove all of the smoke contaminants from the air.

If very small amounts of plume are created, then the fluid suction line can be used, but an inline filter must be positioned between the suction canister and the outlet connection to protect the line from particulate accumulation and contamination. The inline filter must never be placed within the suction line between the patient and the suction canister, because any moisture drawn into the tubing will destroy the effectiveness of the inline filter. 
Therefore, proper positioning of the inline filter is mandatory.

If larger amounts of plume are created, then an individual smoke evacuation system is required. A smoke evacuator may have a moisture filter to capture any moisture evacuated with the surgical smoke.  

A smoke evacuator must provide charcoal filtration and ULPA (ultra-low penetration air) filtration. The charcoal filter usually consists of activated virgin coconut-based charcoal to neutralize the toxic gases that produce the offensive odor of surgical smoke. An ULPA filter removes particulate matter that is 0.3 microns in size and larger at 99.9999% efficiency which provides effective smoke evacuation, if used appropriately.4  

Some desired features of a smoke evacuator include:

• Adequate suction power and pull
• 
Effective smoke filtration using a charcoal and ULPA filter
• A quiet system
• Easy to use and transport
• Cost-effective smoke evacuation supplies,
• 
An indicator alarm to notify the staff when the filter(s) need changed
• 
Automatic activation and deactivation 
controls
• Easy-to-change filters.

Some surgical environments have placed the individual smoke evacuator within the room column or on the electrosurgery cart for ready access and use. Other facilities have designed a centralized system that provides a smoke evacuation outlet in several rooms that link with a large smoke evacuation system designed to provide suction power for multiple sites. Care must be taken to purge and clean the suction lines on a routine basis so that particles will not accumulate, contaminate or obstruct 
the lumens.

Manufacturers have expanded the capabilities of their self-contained fluid evacuation systems to include smoke evacuation capabilities. 
To ensure that the filtration is adequate for smoke evacuation, an ULPA filter must be present within the smoke evacuation unit. Also, the suction pump must be powerful enough to evacuate the surgical smoke adequately.  

The technology used to evacuate fluids is different than what is needed to evacuate surgical smoke. Manufacturers have realized that smoke evacuation requires specific technology and has incorporated this in the design of their fluid evacuation systems.

Recommendations for smoke evacuation
Many agencies and professional groups have written guidelines based on research for the proper and effective evacuation of surgical smoke. Countries usually have a type of occupational safety and health administration that oversees safe work practices.

In the USA, the Occupational Safety and Health Administration (OSHA), as part of its general duty clause, requires that all employers provide a safe workplace environment for the employees. Nurses who have repeatedly been denied smoke evacuation equipment and supplies have reported to the OSHA that their own facilities have not provided safe work environments. This leads to surprise inspections by OSHA along with penalties and fines imposed for unsafe working conditions.

The American National Standards Institute’s Z136.3 guidelines on Safe Use of Lasers in Health Care Facilities (2005) highly recommends that all laser plume be evacuated properly.16 They also note that electrosurgery smoke is just as hazardous and must be appropriately eliminated.

The Canadian Standards Association published a powerful standard in 2009 that describes practices to be implemented to evacuate all surgical smoke. Professional surgical organizations throughout the world have written position statements and recommended practices addressing the need to provide consistent and efficient smoke evacuation practices.  

The Association of periOperative Registered Nurses (AORN) published an official statement about surgical smoke being hazardous in 2008 and then, in 2009, the AORN Surgical Smoke Evacuation Toolkit was introduced to help perioperative nurses achieve compliance with surgical smoke evacuation recommendations. 
The toolkit contains a Powerpoint presentation on the hazards and control of surgical smoke, a sample competency check-list for smoke evacuation skills, a model policy on surgical smoke evacuation, links to vendors selling smoke evacuation equipment and supplies, a bibliography of surgical smoke research and information, and creative reminder signs to download, print and put up throughout the operating room department. This toolkit can be accessed by AORN members at www.aorn.org.

Compliance with smoke evacuation recommendations    
Even though many explicit recommendations, standards and guidelines have been published, perioperative professionals are still reluctant to employ proper smoke evacuation practices. Attempts to create smoke-free operating rooms have failed because adherence to recommended smoke evacuation guidelines is lacking. The key indicators of comformity to smoke evacuation recommendations were studied so that educational and incentive programs can be developed to promote compliance with smoke evacuation recommendations.14

Since the perioperative nurse plays a powerful role in whether smoke evacuation practices are used during plume-producing procedures, a random sample of 4,000 AORN members, who are staff nurses and who are involved with electrosurgery, were chosen from a universe of 20,272 
nurses. A descriptive explanatory/exploratory study14 was conducted using a validated and piloted web-based online survey that consisted of both expert-generated questions and adaptations of previously 
proven measures.

The Diffusion of Innovations theory by Rogers17 served as the model for the survey questions, since it describes the key indicators for the adoption of an innovation, including individual innovativeness characteristics, perceptions of the innovation attributes, and the organization’s innovativeness characteristics (Figure 1). A total of 777 survey responses were gathered over a two-month period, representing a 19.4% response rate.

The SPSS statistical computer package was employed to analyze the data using frequency/descriptive statistical techniques and bivariate analyses to examine the relationship between the key indicators and compliance with smoke evacuation recommendations. Major findings reveal that specific key indicators positively influence compliance in which nurses would be more apt to evacuate surgical smoke. These key indicators include:

Individual innovativeness characteristics

• 
Increased knowledge and training by the individual nurse on surgical smoke hazards and control measures
• 
The presence of respiratory symptoms in the nurse encourages compliance with smoke evacuation recommendations – weakly supported.

Perceptions of guideline attributes

• 
Positive perceptions by the perioperative nurse on the attributes of smoke evacuation recommendations regarding relative advantage (nurses realize the obvious advantage of using smoke evacuation 
devices over other methods)
• 
Compatibility (nurses report that smoke evacuation practices are compatible with procedures being performed)
• 
Observability (the nurse is able to 
observe positive effects when using 
smoke evacuation devices)
• 
Easy to understand and implement smoke evacuation recommendations (recommendations not being complex).

Organization innovativeness characteristics

• Increased facility size
• 
Increased number of different specialties offered
• 
Greater interconnectedness (and communication) within the organization
• 
Strong leadership support for smoke evacuation
• 
Urban facilities are is more compliant with smoke recommendations than rural facilities
• 
Freestanding surgery centers are more compliant with smoke evacuation recommendations than hospital surgery departments
• 
Academic settings are more compliant with smoke evacuation recommendations than military or government hospitals.

Also revealed in the outcomes of this study is that perioperative nurses report twice the incidence of many respiratory problems (Table 1) as compared to the general population. This information is alarming, as the incidence of respiratory problems between the groups should have been similar. Inhalation of surgical smoke can potentially be the major source in the increased respiratory problems in the nursing community.

The study also notes the barriers reported by the nurses that were preventing them from complying with smoke evacuation recommendations. The barrier most frequently reported is not having smoke evacuators or supplies available for use. Since smoke evacuation equipment is considered a capital expenditure, many purchasing groups may not consider this a priority for purchase.  

The second major barrier is physicians requesting that smoke evacuation not be used during his or her cases. Physicians are only exposed to surgical smoke during their own procedures, but perioperative nurses are exposed on a continual basis, thus increasing their exposure level tremendously. Therefore, nurses are usually more passionate and adamant about using smoke evacuation devices.  

The third barrier noted to smoke evacuation implementation is the distracting noise that some smoke evacuators create. Older smoke evacuators were very noisy and often interfere with the concentration needed to perform surgery. 
Newer smoke evacuators are padded to dampen any offensive noise.  

Also, automatic and foot-pedal activation devices are now available so that the smoke evacuator is only on when plume is created.

The fourth barrier reported by nurses is staff complacency. A smoke evacuator may be available, but some staff members are reluctant to use it or the staff may just not understand how it works or how it can effectively clear the air of smoke contaminants.  

Realizing these top four barriers to using appropriate smoke evacuation practices helps nurses plan and implement educational programs and compliance directives.

Promoting a safe surgical environment has always been a top priority for perioperative nurses. By identifying and exploring the key predictors that influence compliance with smoke evacuation practices, a better understanding of the many factors that influence perioperative nurse practices is fostered.  
Nurse training programs can be developed that directly target and address these key predictors so that a safe and healthy surgical environment free from surgical smoke can be promoted.

Erin Anderson in 2005 posed this powerful question (p. 103), “In hindsight, will healthcare professionals be embarrassed about their cavalier attitudes toward surgical smoke as they once were with cigarette smoke?”18

The outcomes of this study indicate that compliance with smoke evacuation recommendations continues to be lacking. Key indicators of compliance have been identified and can be used to create comprehensive educational programs about surgical smoke hazards and evacuation practices.

Perioperative professionals must address the barriers that impede the evacuation of all surgical smoke. We know the hazards, we have the technology to effectively clear the air of surgical smoke. Until practices are changed and smoke evacuation becomes a requirement, surgical smoke will continue to survive within the air of surgery suites and also within our lungs.

References

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Barrett W & Garber S. Surgical smoke – a review of the literature. Business Briefing: Global Surgery. 1-7; (2004).       
2. 
Alp E et al. Journal of Hospital Infections 2006;62(1):1-5.
3. 
Ott DE. Surgical Services Management 1997: 3(3):11-13.
4. Ball K. Lasers: The Perioperative Challenge (3rd ed.). Denver, CO: AORN; 2004.
5. Ulmer BC. AORN Journal 2008;87(4):721-34.
6. 
Mihashi S et al. 4th Congress of the International Society for Laser Surgery. Tokyo, Japan. Society for Laser Medicine, 1981.
7. 
Baggish MS et al. Lasers in Surgery & Medicine 1988;8(3):248-53.
8. 
Taravella MJ et al. Journal of Cataract Refractory Surgery 2001;27(4):604-7.
9. 
Brandon HJ et al. Surgical Services Manager 1997;3(3):14-16.
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11. 
Garden JM et al. 
Arch Dermatol. 2002;38:1303-1307.
12. 
Hallmo P & Naess O. European Archives of Oto-Rhino-Laryngology 1991;248(7):425-7.
13. 
Volen. Clinical Laser Monthly 1987;5:101-103.
14. 
Ball K. (2010). Surgical smoke evacuation guidelines:  Compliance among perioperative nurses. AORN J 92 (August 2010) e1-e23. © AORN, Inc, 2010. doi: 10.1016/j.aorn.2009.10.026.  
15. 
Edwards BE & Reiman RE. AORN Journal 2008;87(4):739-49.
16. 
American National Standards Institute. (2005). American national standard for safe use of lasers in health care facilities. (ANSI Z136.3). Orlando, FL, LIA.
17. 
Rogers EM. Diffusion of Innovations, 5th ed. New York. Free Press, 2003.
18. 
Andersen E. AAOHN J. 2005;53(3):103-4.