Surgical Smoke in Dermatologic Surgery Gagik Oganesyan, MD, PhD,*† Sasima Eimpunth, MD,‡ Silvia Soohyun Kim, BA,* and Shang I Brian Jiang, MD*

BACKGROUND Potential dangers associated with smoke generated during electrosurgery have been described. However, the use of smoke management in dermatology is unknown. There is no objective data showing the amount or the composition of the smoke generated in dermatologic surgeries. OBJECTIVE To assess the use of smoke management in dermatologic surgery and provide data on the amount and chemical composition of surgical smoke. METHODS A total of 997 surveys were sent to dermatologic surgeons across the United States to assess the use of smoke management. Amounts and concentrations of particulates and chemical composition were measured during electrosurgery using a particulate meter and the Environmental Protection Agency-standardized gas chromatography–mass spectrometry analysis. RESULTS Thirty-two percent of the surgeons responded to the survey, and 77% of the respondents indicated no use of smoke management at all. Only approximately 10% of surgeons reported consistent use of smoke management. Active electrosurgery produced significant amounts of particulates. In addition, surgical smoke contained high concentrations of known carcinogens, such as benzene, butadiene, and acetonitrile. CONCLUSION Surgical smoke contains toxic compounds and particulates. Most dermatologic surgeons do not use smoke management within their practices. Raising the awareness of the potential risks can help increase the use of smoke management. The authors have indicated no significant interest with commercial supporters.

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lectrosurgery is a common technique used in many surgical disciplines including dermatologic surgery for achieving intraoperative hemostasis. In addition, electrosurgery is used more widely in dermatology for the treatment of various benign cutaneous neoplasms and conditions.1–3 Dangers associated with the smoke generated during these procedures have been reported previously.4–8 Although there are guidelines provided by the Occupational Health and Safety Agency and National Institute for Occupational Safety and Health (NIOSH) for respiratory protection at the workplace using electrosurgery, these guidelines are not regulated, and many institutions have made

the implementation of these recommendations voluntary.7,9–12 As a result, most physicians are unaware of these guidelines and fail to implement any respiratory protection for patients and their staff. Hence, smoke management is not considered to be the standard of practice by most physicians. The actual use of smoke management within the dermatologic community is still unclear. Furthermore, there are no studies that have evaluated the actual size, amount, and chemical composition of surgical smoke in a standardized manner during routine dermatologic surgeries. In this study, the authors have surveyed dermatologic surgeons across the United States to evaluate the use of smoke

*Department of Medicine, Division of Dermatology, University of California, San Diego, California; †Sutter Medical Group of the Redwoods, Sutter Pacific Medial Foundation, Santa Rosa, California; ‡Faculty of Medicine Siriraj Hospital, Bangkok, Thailand Supported by the Cutting Edge Research Grant (CERG) from the American Society of Dermatologic Surgery.

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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:1373–1377 DOI: 10.1097/DSS.0000000000000221

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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.

SURGICAL SMOKE IN DERMATOLOGIC SURGERY

management. They have also conducted measurements of the physical and chemical composition of the smoke produced during electrosurgery.

TABLE 1. Use of Smoke Management by Dermatologic Surgeons Use of Smoke Management Percentage (n)

None

Smoke Evacuator

N95 Mask

77 (243)

18 (58)

5 (15)

Methods Internal review board exemption was obtained from the UCSD Human Research Protection Program office before initiation of this study. For the survey part of this project, Kwik Surveys on-line survey tool was used to send e-mail surveys to 997 dermatologic surgeons across the United States. The data were kept anonymous for the analysis. For smoke ultrafine particulate matter measurements, a P-track ultrafine particulate meter was used to measure particulate concentrations of the electrosurgery smoke during live surgery. For volatile organic compound (VOC) measurements, electrosurgery smoke from live surgery was collected in 250-mL canisters and submitted for TO-15 gas chromatography–mass spectrometry (GC-MS) analysis by an Environmental Protection Agency (EPA)-certified laboratory.13,14 The probe for collection of the smoke during active electrosurgery was placed at 16 to 18 inches above the cautery point, approximately the same point where the surgeons’ head would be located under normal operating position. Monoterminal electrodessication and electrofulguration was used throughout the study (Hyfrecator-2000). Acu-Evac I (AcuDerm Inc) smoke evacuator was used for smoke evacuation.

Results The authors first aimed to assess the prevalence of the use of smoke management among dermatologic surgeons. To do this, they sent out an anonymous survey to 997 dermatologic surgeons across the United States and received 316 responses back (32% response rate). When asked whether smoke management is used in their practice, 77% of the respondents indicated that no smoke management was used (Table 1). The results further show that approximately 10% of surgeons used smoke management occasionally (25%–50% of the time) and only 10% of surgeons used it consistently (75%–100% of the time), which includes either

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the use of a smoke evacuator or a N95 mask (Tables 2 and 3). To understand the dangers of smoke produced during dermatologic procedures, the authors investigated the chemical nature of the small particulate matter as well as the larger-sized organic compounds and measured the quantity of these chemicals in electrosurgical smoke. First, the authors assessed the composition and amount of the small particulate matter in the electrosurgical smoke. There was a significant increase (approximately tenfold) in the quantity of fine (

Surgical smoke in dermatologic surgery.

Potential dangers associated with smoke generated during electrosurgery have been described. However, the use of smoke management in dermatology is un...
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