The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
How Should We Safely Handle Surgical Smoke? Hayley Born, BS; Chandra Ivey, MD QUESTION How should we safely handle surgical smoke?
BACKGROUND Since their introduction, electrocautery and laser technologies have become indispensable for surgical intervention. Unfortunately, the smoke plumes produced by using these techniques contain numerous substances harmful to those who inhale them due to their toxic nature, particulate size, and byproducts. Literature exists describing the dangers of surgical smoke, yet surgeons—including otolarygologists—often do not take adequate precautions to protect themselves and others in the operating room (OR). In this Triological Society Best Practice review, we examine the risks associated with surgical smoke inhalation and the recommended precautions for surgical staff.
LITERATURE REVIEW Surgical smoke has been a topic of discussion in the nursing world and among occupational health organizations for years. This term can refer to any aerosolized substance produced by the use of high-energy medical devices.1 Laser smoke plumes have been researched with greater frequency than more common instruments, including electrocautery, ultrasonic devices, and highspeed electrical drills and burrs. This last category is often forgotten because the plume produced is not associated with the purposeful burning of tissue. Nonetheless, all of these instruments produce heat which, when combined with organic tissue and standard irrigation, produce aerosolized particles capable of causing harm to those exposed. The content of these plumes may have a direct effect on the aerodigestive tract, may contain chemicals that are toxic to the system, and may contain biologically active material that could be harmful or infectious.
From the Department of Otorhinolaryngology, Columbia University, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication on January 27, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Chandra Ivey, MD, 180 Fort Washington Avenue, 7th Floor, New York, NY 10032. E-mail: [email protected] DOI: 10.1002/lary.24624
Laryngoscope 124: October 2014
The mechanical effects of aerosolized particles on the respiratory tract have been documented.1 While it is known that large particulate air pollution may decrease mucociliary clearance of the respiratory epithelium, aerosolized particles in the OR smoke plumes are even more dangerous due to their small size—as small as 0.07 micrometers.2 Figure 1 shows the relative sizes of particles produced by different devices, along with the size of various particles that can be found in plumes. In addition to affecting the oropharyngeal and respiratory epithelium, these tiny particles can lodge in the alveoli and obstruct gas exchange. The microscopic size of these particles also increases the distance and time over which they can remain airborne. This implies a potential effect on those outside the immediate surgical field. Studies have shown that the concentration of particles increases more than 16 times over the baseline level during use of electrocautery. This increased level was seen throughout the OR and remained high for up to 20 minutes after termination of cautery.3 Several studies have examined the toxic nature of surgical smoke. These plumes may contain chemicals such as acetaldehyde, acrolein, benzene, formaldehyde, cyanide, naphthalene, and carbon. Tomita et al.3 compared the mutagenicity of surgical smoke and cigarette smoke. Ablation of 1 gram of tissue using electrical or laser techniques had a toxicity level equivalent to smoking three to six cigarettes in 15 minutes. They found that smoke plumes from electrocautery were twice as mutagenic as the plumes from carbon dioxide laser irradiation. Mutagenicity and subsequent disease can result from either the chemical or infectious contaminants within the smoke plume, and can affect both patients and OR staff. Much of the literature regarding the adverse effects of surgical smoke consists of primarily anecdotal evidence and guidelines based on theory and animal models. One survey-based study of perioperative nurses in the United States revealed that certain respiratory conditions, including allergies, sinus infections, asthma, and bronchitis, were twice as prevalent in this population when compared with the general population.2 Animal models have demonstrated blood vessel hypertrophy, emphysema, and alveolar congestion in respiratory tracts. Many of the specific chemicals found in smoke plumes have been shown to be carcinogenic when exposure exceeds recommended levels, as they do in the OR. Mutagenic effects have been demonstrated in bacteria within 3 feet of the surgical field. Born and Ivey: Surgical Smoke
2213
Fig. 1. (A) Relative sizes of particles found in surgical smoke, modes of production, and thresholds of mask filtration. (B) Detail under 0.5 micrometers.
Finally, there is a theoretic risk of infection secondary to bacterial and viral particles in the smoke plumes.4 Although it has been shown that viral DNA and blood products can be found in surgical smoke, in vivo infections are not well documented. Two cases exist in the literature reporting the possible transfer of the human papilloma virus from laser removal of condyloma to surgical staff, causing subsequent laryngeal papillomatosis. Further studies refute the proposed risk of infection, and the issue remains controversial. 5 Patients may be subject to the same plume exposures and have increased risks due to this. Techniques to prevent unnecessary smoke exposure in surgical suites have been studied and reviewed, although standardized methods and legal mandates currently do not exist. Recommendations have been made by many different organizations, including the American Nurses Association, the Association of Perioperative Registered Nurses, the American National Standards Institute, the National Institute for Occupational Safety and Health, the Joint Commission, and the Occupational Safety and Health Administration. These guidelines generally center on a few key areas: proper ventilation, personal protective equipment (PPE), and smoke evacuation.1 OR ventilation standards require a minimum of 15 exchanges per hour. Filters must be mainLaryngoscope 124: October 2014
2214
tained and replaced according to manufacturer’s instructions. PPE includes the use of barrier equipment such as sterile gowns and gloves and the use of high filtration masks. High filtration masks are also referred to as laser masks, and they filter particles as small as 0.1 micrometers in diameter. These should be used at all times when a plume is created. Details on filtration levels of various masks can be found on manufacturer websites or on mask packaging and should be considered prior to choosing an appropriate mask. Masks should be tied tightly to create a seal and should be replaced after each case. Evacuation of smoke should be accomplished through various means, depending on the amount of smoke produced during the procedure. Small amounts of smoke can be adequately cleared using wall suction with an inline filter. This clears 5 cubic feet of air per minute. Commercial smoke evacuation systems—either portable or central—with filters should be utilized for more extensive plume evacuation. To be maximally effective, suction devices should be placed within 2 centimeters of the point of smoke production. These techniques should also be used during laparoscopic procedures for the protection of the patient. Use of these techniques varies widely among surgical staff.5 Surveys have shown that less than one-half of OR staff utilized proper evacuation technique. Born and Ivey: Surgical Smoke
Compliance was lowest during electrosurgical procedures. Surveys showed that smoke evacuator use is highest during condyloma vaporizations, presumably due to perceived infection risk. Several predictors of evacuation technique compliance have been characterized and should guide proper use education and training. Education of surgical staff should reinforce that risks of surgical smoke are present, and actually more extensive, in nonlaser procedures. Respiratory health regarding exposure to surgical smoke, analogous to exposure to cigarette smoke, should be emphasized.
health outcomes of physicians and other surgical staff should be followed to determine if these protective measures are sufficient for the protection and prevention of surgical smoke-related pathology.
LEVEL OF EVIDENCE The level of evidence of the articles used were one level 1, one level 2, and three level 5.
BIBLIOGRAPHY BEST PRACTICE As surgeons, we should take into consideration our health and the health of the surgical staff when using techniques that produce smoke plumes. Current recommendations can be found on many institutional websites and include the use of PPE such as laser masks, proper OR design such as effective filtration systems, and smoke evacuation with the appropriate devices. Standardized, evidence-based guidelines and legal mandates should be instated to increase compliance. Long-term
Laryngoscope 124: October 2014
1. Ulmer BC. The Hazards of Surgical Smoke. AORN Journal 2008;87:721– 738. 2. Sanderson C. Surgical smoke. J Perioper Pract 2012;22:122–128. 3. Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutat Res 1981;89:145–149. 4. Mellor G, Hutchinson M. Is it time for a more systematic approach to the hazards of surgical smoke? Reconsidering the evidence. Workplace Health Saf 2013;61:265–270. 5. Manson L, Damrose E. Does exposure to laser plume place the surgeon at high risk for acquiring clinical human papillomavirus infection? Laryngoscope 2013;123:1319–1320. 6. Ball K. Surgical smoke evacuation guidelines: compliance among perioperative nurses. AORN J 2010;92:e1–23.
Born and Ivey: Surgical Smoke
2215
Rhinological and Otological Society, Inc.
How Should We Safely Handle Surgical Smoke? Hayley Born, BS; Chandra Ivey, MD QUESTION How should we safely handle surgical smoke?
BACKGROUND Since their introduction, electrocautery and laser technologies have become indispensable for surgical intervention. Unfortunately, the smoke plumes produced by using these techniques contain numerous substances harmful to those who inhale them due to their toxic nature, particulate size, and byproducts. Literature exists describing the dangers of surgical smoke, yet surgeons—including otolarygologists—often do not take adequate precautions to protect themselves and others in the operating room (OR). In this Triological Society Best Practice review, we examine the risks associated with surgical smoke inhalation and the recommended precautions for surgical staff.
LITERATURE REVIEW Surgical smoke has been a topic of discussion in the nursing world and among occupational health organizations for years. This term can refer to any aerosolized substance produced by the use of high-energy medical devices.1 Laser smoke plumes have been researched with greater frequency than more common instruments, including electrocautery, ultrasonic devices, and highspeed electrical drills and burrs. This last category is often forgotten because the plume produced is not associated with the purposeful burning of tissue. Nonetheless, all of these instruments produce heat which, when combined with organic tissue and standard irrigation, produce aerosolized particles capable of causing harm to those exposed. The content of these plumes may have a direct effect on the aerodigestive tract, may contain chemicals that are toxic to the system, and may contain biologically active material that could be harmful or infectious.
From the Department of Otorhinolaryngology, Columbia University, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication on January 27, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Chandra Ivey, MD, 180 Fort Washington Avenue, 7th Floor, New York, NY 10032. E-mail: [email protected] DOI: 10.1002/lary.24624
Laryngoscope 124: October 2014
The mechanical effects of aerosolized particles on the respiratory tract have been documented.1 While it is known that large particulate air pollution may decrease mucociliary clearance of the respiratory epithelium, aerosolized particles in the OR smoke plumes are even more dangerous due to their small size—as small as 0.07 micrometers.2 Figure 1 shows the relative sizes of particles produced by different devices, along with the size of various particles that can be found in plumes. In addition to affecting the oropharyngeal and respiratory epithelium, these tiny particles can lodge in the alveoli and obstruct gas exchange. The microscopic size of these particles also increases the distance and time over which they can remain airborne. This implies a potential effect on those outside the immediate surgical field. Studies have shown that the concentration of particles increases more than 16 times over the baseline level during use of electrocautery. This increased level was seen throughout the OR and remained high for up to 20 minutes after termination of cautery.3 Several studies have examined the toxic nature of surgical smoke. These plumes may contain chemicals such as acetaldehyde, acrolein, benzene, formaldehyde, cyanide, naphthalene, and carbon. Tomita et al.3 compared the mutagenicity of surgical smoke and cigarette smoke. Ablation of 1 gram of tissue using electrical or laser techniques had a toxicity level equivalent to smoking three to six cigarettes in 15 minutes. They found that smoke plumes from electrocautery were twice as mutagenic as the plumes from carbon dioxide laser irradiation. Mutagenicity and subsequent disease can result from either the chemical or infectious contaminants within the smoke plume, and can affect both patients and OR staff. Much of the literature regarding the adverse effects of surgical smoke consists of primarily anecdotal evidence and guidelines based on theory and animal models. One survey-based study of perioperative nurses in the United States revealed that certain respiratory conditions, including allergies, sinus infections, asthma, and bronchitis, were twice as prevalent in this population when compared with the general population.2 Animal models have demonstrated blood vessel hypertrophy, emphysema, and alveolar congestion in respiratory tracts. Many of the specific chemicals found in smoke plumes have been shown to be carcinogenic when exposure exceeds recommended levels, as they do in the OR. Mutagenic effects have been demonstrated in bacteria within 3 feet of the surgical field. Born and Ivey: Surgical Smoke
2213
Fig. 1. (A) Relative sizes of particles found in surgical smoke, modes of production, and thresholds of mask filtration. (B) Detail under 0.5 micrometers.
Finally, there is a theoretic risk of infection secondary to bacterial and viral particles in the smoke plumes.4 Although it has been shown that viral DNA and blood products can be found in surgical smoke, in vivo infections are not well documented. Two cases exist in the literature reporting the possible transfer of the human papilloma virus from laser removal of condyloma to surgical staff, causing subsequent laryngeal papillomatosis. Further studies refute the proposed risk of infection, and the issue remains controversial. 5 Patients may be subject to the same plume exposures and have increased risks due to this. Techniques to prevent unnecessary smoke exposure in surgical suites have been studied and reviewed, although standardized methods and legal mandates currently do not exist. Recommendations have been made by many different organizations, including the American Nurses Association, the Association of Perioperative Registered Nurses, the American National Standards Institute, the National Institute for Occupational Safety and Health, the Joint Commission, and the Occupational Safety and Health Administration. These guidelines generally center on a few key areas: proper ventilation, personal protective equipment (PPE), and smoke evacuation.1 OR ventilation standards require a minimum of 15 exchanges per hour. Filters must be mainLaryngoscope 124: October 2014
2214
tained and replaced according to manufacturer’s instructions. PPE includes the use of barrier equipment such as sterile gowns and gloves and the use of high filtration masks. High filtration masks are also referred to as laser masks, and they filter particles as small as 0.1 micrometers in diameter. These should be used at all times when a plume is created. Details on filtration levels of various masks can be found on manufacturer websites or on mask packaging and should be considered prior to choosing an appropriate mask. Masks should be tied tightly to create a seal and should be replaced after each case. Evacuation of smoke should be accomplished through various means, depending on the amount of smoke produced during the procedure. Small amounts of smoke can be adequately cleared using wall suction with an inline filter. This clears 5 cubic feet of air per minute. Commercial smoke evacuation systems—either portable or central—with filters should be utilized for more extensive plume evacuation. To be maximally effective, suction devices should be placed within 2 centimeters of the point of smoke production. These techniques should also be used during laparoscopic procedures for the protection of the patient. Use of these techniques varies widely among surgical staff.5 Surveys have shown that less than one-half of OR staff utilized proper evacuation technique. Born and Ivey: Surgical Smoke
Compliance was lowest during electrosurgical procedures. Surveys showed that smoke evacuator use is highest during condyloma vaporizations, presumably due to perceived infection risk. Several predictors of evacuation technique compliance have been characterized and should guide proper use education and training. Education of surgical staff should reinforce that risks of surgical smoke are present, and actually more extensive, in nonlaser procedures. Respiratory health regarding exposure to surgical smoke, analogous to exposure to cigarette smoke, should be emphasized.
health outcomes of physicians and other surgical staff should be followed to determine if these protective measures are sufficient for the protection and prevention of surgical smoke-related pathology.
LEVEL OF EVIDENCE The level of evidence of the articles used were one level 1, one level 2, and three level 5.
BIBLIOGRAPHY BEST PRACTICE As surgeons, we should take into consideration our health and the health of the surgical staff when using techniques that produce smoke plumes. Current recommendations can be found on many institutional websites and include the use of PPE such as laser masks, proper OR design such as effective filtration systems, and smoke evacuation with the appropriate devices. Standardized, evidence-based guidelines and legal mandates should be instated to increase compliance. Long-term
Laryngoscope 124: October 2014
1. Ulmer BC. The Hazards of Surgical Smoke. AORN Journal 2008;87:721– 738. 2. Sanderson C. Surgical smoke. J Perioper Pract 2012;22:122–128. 3. Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutat Res 1981;89:145–149. 4. Mellor G, Hutchinson M. Is it time for a more systematic approach to the hazards of surgical smoke? Reconsidering the evidence. Workplace Health Saf 2013;61:265–270. 5. Manson L, Damrose E. Does exposure to laser plume place the surgeon at high risk for acquiring clinical human papillomavirus infection? Laryngoscope 2013;123:1319–1320. 6. Ball K. Surgical smoke evacuation guidelines: compliance among perioperative nurses. AORN J 2010;92:e1–23.
Born and Ivey: Surgical Smoke
2215
