By Don Sadler
Concerns about air quality in the OR during surgical procedures have been around for a long time. In fact, the first documentation that particulate matter in surgical smoke can be inhaled and deposited in the alveoli of the lungs occurred in 1975.
However, progress toward protecting health care workers and patients by ensuring a smoke-free perioperative environment has been frustratingly slow. The good news is that momentum is starting to build toward the passage of legislation requiring hospitals and ASCs to adopt and implement policies that prevent human exposure to surgical smoke by using smoke evacuation systems.
Rhode Island and Colorado were the first two states to pass such legislation. Rhode Island’s law went into effect in 2019 and Colorado’s law will go into effect in 2021.
In addition, a number of other states are considering similar legislation. Such legislation could pass in Oregon, Utah, Iowa, Kentucky, Tennessee, Georgia, Maryland and New York as soon as this year.
As Bad as Cigarette Smoke
Believe it or not, spending a full day in the OR could expose health care workers to as much smoke plume as smoking up to 30 cigarettes.
Brenda C. Ulmer, RN, MN, CNOR, has been active for the past two years in getting surgical smoke legislation passed in Georgia. She points to research indicating that surgical smoke is just as mutagenic and dangerous as cigarette smoke.
“More than 150 chemicals have been identified in surgical smoke, each with its own health concerns and side effects,” says Ulmer.
One of these chemicals is benzene, which OSHA regulates to protect workers from potential hazards including leukemia in susceptible people.
“The evidence clearly establishes the presence of harmful chemicals in surgical smoke,” says Mary J. Ogg, MSN, RN, CNOR, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN). “And many of these chemical compounds, such as benzene and toluene, are carcinogenic.”
Ogg says there are case reports of occupational transmission of Human Papilloma Virus (HPV) to the respiratory tracts of three surgeons and an OR nurse.
“All four of the infected individuals were involved in different types of surgical procedures removing anogenital condylomas,” says Ogg. “Anecdotally, I have heard of at least that many or more that have never been published as a case report.”
According to Vangie Dennis, MSN, RN, CNOR, CMLOS, the Executive of Director Perioperative Services for the Atlanta Medical Center, OR personnel report twice as many incidences of respiratory illness as the general population.
“Ultra-fine particulate matter acts similar to air pollution and tobacco smoke in the lungs,” says
Dennis. “It can cause or exacerbate bronchiolitis, asthma, COPD/emphysema, atherosclerosis and thrombogenesis.”
What Causes Surgical Smoke?
Surgical smoke in the OR results from the of use of energy-generating devices such as electrosurgical units (ESUs), lasers, electrocautery and ultrasonic devices, and powered instruments like bone saws and drills.
“Surgical smoke is the by-product of using these devices during surgery,” says Ogg. “For example, drills, saws and ESUs are used during major orthopedic cases.”
“A review of the published evidence supports that surgical smoke and its components are a danger to perioperative personnel and are capable of producing physical symptoms,” says Ulmer.
According to Ogg, the known hazards or risks associated with surgical smoke exposure are respiratory or particulate, chemical, viral and blood.
“Perioperative team members do experience respiratory issues such as asthma, acute and chronic bronchitis, and emphysema,” she says. “The particles in surgical smoke generated by surgical energy-generating devices are within the respirable range. They are able to be inhaled and deposited in the alveoli, or the gas exchange regions of the lungs, which can lead to respiratory problems.”
Ogg cites a 2019 qualitative study of 672 OR nurses that determined that 73 percent of the nurses who routinely breathed in surgical smoke had at least one symptom related to smoke exposure. These included acute and chronic respiratory changes, headaches, nausea and vomiting, throat irritation, hypoxia and dizziness.
Surgical smoke also poses risks to patients, Ogg adds, including a lack of visibility during laparoscopic procedures, delays during the procedure to clear the smoke, increased levels of carbon monoxide and port-site metastasis.
Ulmer elaborates: “Smoke inside the abdomen is absorbed through the peritoneal membrane,” she says. “This results in an increase in the methemoglobin and carboxyhemoglobin concentrations, which reduces
the oxygen carrying capacity of red blood cells.”
Take a Comprehensive Approach
Ulmer encourages health care facilities to adopt a comprehensive approach to ensuring a smoke- free environment wherever surgical smoke is generated.
“Components of the program include smoke knowledge testing, interprofessional education, gap analysis and compliance monitoring,” she says.
Recommendations on eliminating surgical smoke have been included in the AORN Guidelines since 2004 and as a stand-alone guideline since 2017. “Perioperative team members should use the guidelines to establish policies and procedures to eliminate smoke from the surgical environment,” says Ulmer.
According to Ogg, the National Institute for Occupational Safety and Health (NIOSH) and AORN recommend using a combination of ventilation techniques to control the airborne contaminants of surgical smoke.
“Because general room ventilation of 20 air exchanges per hour is insufficient to capture the contaminants, smoke evacuation — also known as local exhaust ventilation — is also necessary,” says Ogg. “General room ventilation and smoke evacuation are the first lines of protection against the hazards of surgical smoke.”
Smoke evacuation technology has made vast improvements over evacuators used in the 1990s. “These were sometimes louder than a vacuum cleaner,” says Ogg.
“Today’s evacuators are quieter and the electrosurgical pencil with the attached evacuation tubing is less cumbersome,” she adds. “The newer evacuators are automatically activated when the electrosurgery unit is in use.”
Dennis recommends the use of inline filters at 0.1 microns for small smoke-generated cases, a 0.1 ULPA Filter Smoke evacuator for large smoke-generated cases, and insufflators that lower the cumulative effects of smoke during laparoscopy.
“When determining methodology of correct algorithms for smoke evacuation, OR personnel should consider the procedure and the culture of the surgeon and staff while taking care not to interfere with the rhythm of surgery,” says Dennis. “If you can smell the surgical smoke, then you’re not evacuating the smoke.”
Barriers to Reducing Surgical Smoke
Unfortunately, barriers exist to the adoption of practices and technologies to eliminate surgical smoke in the OR.
“The biggest barriers to adoption typically include educating perioperative personnel about smoke evacuation equipment, getting surgeon buy-in to use the equipment due to perceived interference with surgeries, hooking equipment up correctly and the cost of the equipment,” says Dennis.
Ogg says that AORN has worked for years to educate perioperative nurses about the dangers of surgical smoke and the need for surgical smoke evacuation.
“Through education and awareness programs like Go Clear, AORN members across the country have convinced many hospitals and ASCs to go surgical smoke-free,” she says.
The AORN Go Clear program is a comprehensive approach to protecting patient and worker safety by promoting a smoke-free environment wherever surgical smoke is generated. It includes all the tools and protocols needed to start or enhance smoke evacuation practices.
The program includes an implementation manual explaining in detail how to accomplish each step. “It also includes supplemental resources such as templates for competencies, policies and procedures, and a product evaluation,” says Ogg.
Since the program was implemented, more than 1,000 facilities have registered for the Go Clear program and 68 facilities have received the Go Clear award. “In addition, more than 13,000 staff are enrolled in the education portal,” says Ogg.
To learn more about the AORN Go Clear program, visit https://www.aorn.org/member_apps/Product/Detail?productID=9709.