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March 29, 2019

Hazards of Surgical Smoke

Surgical smoke, also called electrosurgery plume or cautery smoke, is not a new problem in the operating room1. However, advancements in energy-based surgical tools have created new and potentially hazardous sources of air contaminants in the perioperative environment1,2. Despite the scope of this problem, there is limited awareness about the negative impacts of surgical plume3. Further, significant gaps in research make it difficult to ascertain the risks associated with long-term exposure to cautery smoke. The most common sources of surgical plume are

  • High-speed electrical devices, often used in plastic and orthotic surgery1,3
  • Thermal, ultrasonic, and laser scalpels used in cellular ablation and various cosmetic surgeries1,
  • Electrocautery and diathermy units used in laparoscopic surgeries2

 

Risk of Exposure to Viable Cells, Respirable Particles, and Toxic Gases

“I’ve always wondered about the health impact of surgical smoke from electrocautery,” notes Ms. Albrecht, an anesthesiologist certified in emergency medicine, currently working in a level-3 intensive care unit in Germany. “I assumed it was respirable dust and that it would settle in my lungs.” Several studies have identified carcinogenic ultrafine particles (UFP) in smoke produced by various energy-generating surgical tools4,5,6,. Other harmful substances found in these plumes include

  • Viable bacterium such as Staphylococcus aureus, Neisseria, and Corynebacterium2
  • Infectious aerosols such as Mycobacterium tuberculosis (TB)4
  • Transmittable cells of Human Papilloma Virus (HPV) Hepatitis B (HBV)7
  • Toxic gases such as, benzene, formaldehyde, methane, carbon monoxide, and hydrogen cyanide1,8

Without epidemiological data, the exact impact of electrocautery smoke on surgical personnel and patients remains unclear9. Ms.Albrecht explains, “Real data does seem scarce, but I’d like to see more studies on particle size, because we know what particle size is problematic”. The mere presence of these substances may not be sufficient evidence to calculate any specific degree of risk associated with exposure to surgical smoke, but it does warrant further investigation as an occupational hazard for perioperative personnel.

 

Surgical Smoke,the Perioperative Environment, and Occupational Health

The potential risk of infection or irritation from respirable particles is not the only negative impact associated with these plumes. Surgical smoke obstructs the line of sight, especially in laparoscopic procedures that yield high concentrations of smaller particles1,2. For many in perioperative care, the pungent odor is the most distressing characteristic of surgical smoke. Ms. Albrecht elaborates, “The smell, depending on tissue, can be nauseating. We obviously always wear masks, but those aren’t made for respiratory protection, much less anti-nausea.” As shown above, these conditions are also detrimental to the safety and efficacy of patient care because they create distractions in the OR.“Having a smoke evac system would be a tremendous improvement if only in terms of OR personnel comfort, and I definitely believe it would do our lungs good,” confirms Ms. Albrecht.

 

Awareness, Compliance, Intervention and Prevention

Although debates about the specific impacts of surgical smoke persist, healthcare professionals can make several useful and actionable inferences from existing literature, such as

  • The lack of awareness about the dangers of surgical smoke is evidenced by the lack of educational resources and training. This results in low compliance with recommended procedures for evacuating smoke from the OR 9.
  • Further research is needed  about the potency or communicability of viable cells in particulate matter such as surgical vapor1. However, this does not prevent healthcare providers and institutional bodies from taking steps to protect patients and personnel from surgical pollutants
  • Best practice dictates that many electrosurgical and ultrasonic procedures must include a smoke evacuation system or related policies in order to provide the safest and most effective quality of care1.
  • Given these points, it is necessary to equip healthcare providers and researchers with the resources to adequately train perioperative personnel and investigate the long-term effects of surgical smoke through large-scale epidemiological studies.

While these conclusions may not point toward a “smoking gun” that tells us the full extent of damage caused by surgical smoke, they do offer several avenues of inquiry that may help us more deeply understand the relationship between surgical smoke and occupational health in the OR. Through common sense preventative care and rigorous dedication to awareness, training, and compliance10, healthcare providers can clear a new path for the next generation of perioperative professionals.

 

References and Further Reading

 Fencl, Jennifer L. “Guideline implementation: surgical smoke safety.” AORN journal 105.5 (2017): 488-497

Weld, Kyle J., et al. “Analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility.”

Mowbray, Nicholas, et al. “Is surgical smoke harmful to theater staff? A systematic review.” Surgical endoscopy 27.9 (2013): 3100-3107

Karjalainen, Markus, et al. “The characterization of surgical smoke from various tissues and its implications for occupational safety.” PloS one 13.4 (2018): e0195274.

Hill, D. S., et al. “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.” Journal of Plastic, Reconstructive & Aesthetic Surgery65.7 (2012): 911-916

Okoshi, Kae, et al. “Health risks associated with exposure to surgical smoke for surgeons and operation room personnel.” Surgery today 45.8 (2015): 957-965.

Kwak, Han Deok, et al. “Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery.” Occupational Health and Safety.

Jamal, Sidra, et al. “Surgical Smoke–Concern for Both Doctors and Patients.” Indian Journal of Surgery 77 (2015): 1494

Controls, NIOSH Hazard. “Control of Smoke from Laser/Electric Surgical Procedures-HC11.” (2007)

 AORN Go Clear Program 

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