Management of Surgical Smoke

in the Perioperative Setting

2

•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

Individual Innovativeness Characteristics

(Perioperative staff characteristics)

Perceptions of Attributes

(Staff perceptions of smoke evacuation recommendations)

Organization Innovativeness Characteristics

(Organization’s characteristics)

No compliance

Full compliance

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

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.

Key indicators of compliance:EducationLeadership supportEasy to follow policiesRegular internal collaboration

(Ball, K . 2010)

150 different chemicals identified in surgical smoke (Pierce, et al. 2011)

Smoke plume and aerosols contain 95% water vapor

Water vapor is itself not harmful, but acts as a carrier

Gaseous toxic compoundsBio-aerosolsDead and live cellular material (including

blood fragments)Viruses Carbonized tissueBacteria

150 Chemical constituents of plume include:

Acrolein BenzeneCarbon MonoxideFormaldehydeHydrogen cyanideMethaneToluenePolycyclic aromatic hydrocarbons (PAH)

Carbonized tissueBloodIntact virus and bacteria (HIV, HPV, Hepatitis)

77% of Surgical Smoke Particles are

less than1.1 microns

Human Immunodeficiency Virus = 0.15 micronHuman Papilloma Virus = 0.055 micronHepatitis B = 0.042 micronOthers

Tobacco Smoke = 0.1-3.0 micronSurgical Smoke = 0.1-5.0 micronBacteria = 0.3-15.0 micronLung Damaging Dust = 0.5-5.0 micronSmallest Visible Particle = 20 micron

Smoke is evenly distributed throughout the operating room

Smoke particles can travel about 40 mphWhen ESU is activated, the concentration of

the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feetIt takes 20 min after the activation of the ESU

for the concentration will return to the baseline level (Nicola, et al. 2002).

“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

http://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed Dec 5, 2012)

Eye, nose, throat irritationHeadachesNausea, dizzinessRunny noseCoughingRespiratory irritantsFatigueSkin irritationAllergies

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)

Perioperative staff have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010)

AllergiesSinus infections/problemsAsthmaBronchitis

Soft contact lenses can absorb toxic gases produced by surgical smoke.

Recommendation made by an OSHA safety violation not related to plume, 1990

44-year old laser physician developed laryngeal papillomatosis

Biopsy identified the same virus type as anogenital condyloma

Hallmo, et al (1991)

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)

AORNANSIECRI

NIOSH/CDCOSHA

Joint Commission

“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;2013:125-141.

Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156.

Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184.

Airborne Contaminants:Shall be controlled by the use of ventilation

(ie., smoke evacuator). Respiratory protection for any residual plume escaping capture.

Independent, nonprofit organization Researches the best approaches to improving

the safety, quality, and cost-effectiveness of patient care

Electrosurgery smoke is overlookedThe spectral content of laser and ESU smoke

is very similar https://www.ecri.org/ accessed 12/13/12

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

General Duty Clause:

Employer MUST provide a safe workplace

environment!

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.

Smoke Evacuation Methodsin the Perioperative Setting

In-line filtersSmoke evacuator systems

Laparoscopic filtering devices

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

From the patient>

To wall suction >

Example of an ULPA filter

(add picture)

31

Irrigation/Aspiration SystemActive SystemPassive System

Strategies for Success

Communication with Surgeon and Perioperative Team members

Plan for Smoke Evacuation Equipment and Optimal

placement of equipmentPatient and Team member

Smoke Protection Methods

Relevant information about smoke evacuation and equipment used

Education and CompetencyEquipment Service Reports

We claim to be a “smoke-free” campus…

…so why aren’t we?