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The Real Risks: Surgical Smoke

By Don Sadler

Would you be surprised if someone told you that being in an operating room for a full day could expose you to the same amount of smoke plume as smoking more than a pack of cigarettes?

It’s true. An estimated 500,000 health care workers are exposed to potentially dangerous surgical smoke each year. Unfortunately, many OR nurses are unaware of the harm that inhaling surgical smoke could be causing to their health.

What Causes Surgical Smoke?

Any procedure that uses an energy-generating device will produce some amount of surgical smoke. These devices include electrosurgical units (ESU), lasers, electrocautery and ultrasonic devices, and powered instruments such as bone saws and drills.

“Surgical smoke is the by-product of using these energy-generating devices that raise intracellular temperatures to 100 degrees Celsius (212 degrees Fahrenheit) or higher,” says Mary J. Ogg, MSN, RN, CNOR, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN).

“When the tissue vaporizes, this produces surgical smoke,” says Ogg.

“Surgical smoke contains toxic gases and biological/viral products from tissue destruction,” says Beth S. Slater, RN, MEd, CNOR, IS Specialist/Educator, Surgical Services with UPMC Horizon in Greenville, Pennsylvania. “All OR team members and patients are exposed to the respiratory intake of this potentially harmful smoke.”

Ogg lists a number of hazards that surgical smoke poses to patients. These include a lack of visibility during laparoscopic procedures, delays during the procedure to clear the smoke, increased levels of carbon monoxide, and port-site metastasis.

According to G Thomas Ruiz, M.D., an OB-GYN in Orange County, California, an estimated 85 percent of the 24 million procedures performed annually in the U.S. use electrocautery.

“Perioperative nurses have twice the incidence of many respiratory problems as the general public, and few doubt there’s a connection between this and their long-term exposure to surgical smoke,” says Ruiz.

“The problems encountered with surgical smoke aren’t always readily apparent,” says Slater. “But who’s to say that respiratory illnesses or irritation suffered by OR personnel haven’t been precipitated by exposure to surgical smoke?”

Priority Pollutants

Even though surgical smoke is mostly water vapor, Ruiz says it contains more than 150 chemicals, including 16 that are listed as “priority pollutants” by the EPA.

“When you’re vaporizing tissue, you can also vaporize and transmit viruses and disease, including cancer,” says Ruiz. “There have been reported cases of surgeons contracting the viruses of their patients during surgery.”

In discussing the dangers of surgical plume, most people talk about biological contaminants like infectious bacteria and viruses, says Ren Scott-Feagle, MSN/Ed, BSHS/M, RN, CNOR, Clinical Educator for Surgical Services in the Clinical Education Department at the University Medical Center of Southern Nevada in Las Vegas.

“However, many staff fail to also recognize the dangers of chemical and micro-particle residue,” she says.

Scott-Feagle says she has participated in procedures that resulted in an excessive amount of surgical plume that not only intermittently obstructed the surgical field, “but also caused some staff to cough and even complain of nausea post-operatively,” she says.

Promoting a Safe and Healthy Workplace

There are currently no specific OSHA standards for laser/electrosurgery plume hazards, according to Scott-Feagle.

“However, health care organizations have a responsibility to promote a safe and healthy workplace,” she says.

Eliminating the dangers of surgical smoke in the OR require both changes in OR practices and the use of technology, says Ogg.

“On the equipment side are smoke evacuators, disposable tubings, filters, ESU pencils with tubing and in-line filters,” she says.

“The best way to remove smoke plume from the OR is to use some kind of smoke evacuation device,” adds Ruiz. “There are several different approaches, but the most effective are those that remove smoke as close to the source as possible, like electrocautery devices with suction at the tip.”

“Certainly, changing to a smoke evacuation system that includes a filtration system is the easiest and most cost-efficient way to remove smoke from the OR,” Slater says.

According to Robert Scroggins, BSN, RN, CMLSO, Clinical Programs Manager with Buffalo Filter, which designs and manufactures surgical smoke evacuation systems, hospitals and staff are looking for cost-effective solutions to evacuate surgical smoke from the operating room in an effort to keep patients and staff safe.

“For example, new designs in surgical smoke evacuation pencils offer surgeons electro-cautery with smoke evacuation that feature compact, slim ergonomic designs,” he says. “There are also a myriad of smoke evacuator choices – from freestanding devices to those integrated into booms.”

And for laparoscopic surgery, there are solutions that easily attach to standard trocars and utilize readily available suction systems providing noiseless operation, he adds.

“With all these technology options, there is no reason that surgical smoke should not be filtered and evacuated from the operating room,” says Scroggins.

Changing OR Practices

As for changes in OR practices, Ogg stresses that smoke evacuation must be used for every procedure that generates smoke, regardless of how much smoke is generated.

“The effects of smoke inhalation are cumulative, so no matter the amount, it is imperative to evacuate the smoke,” she says.

Ogg recognizes that with any change to OR practices there are barriers to adoption.

“Identifying the barriers to surgical smoke evacuation allows the health care organization to develop relevant strategies and interventions to improve evacuation,” she says.

Ruiz has seen these barriers to adoption of smoke evacuation devices first-hand.

“The biggest obstacle to eliminating surgical smoke isn’t access to technology solutions – it’s changing the status quo,” he says.

“Many surgeons don’t like change, especially when it involves how we perform a procedure,” Ruiz adds. “But we as surgeons should be the ones driving this change. If we display leadership, this will provide health care organization with the motivation to adopt these devices.”

The AORN Go Clear Award

Ogg says that AORN has partnered with Medtronic through the AORN Foundation to create the AORN Go Clear Award.

“This program is a comprehensive approach to protecting patient and worker safety by promoting a smoke-free environment wherever surgical smoke is generated,” says Ogg.

For facilities that have not implemented smoke evacuation or that only evacuate smoke occasionally, the AORN GO Clear program includes all the tools and protocols needed to start or enhance smoke evacuation practices. It breaks smoke evacuation down into a 10-step process.

“The program includes an implementation manual explaining in detail how to accomplish each step, as well as supplemental resources such as templates for competencies, policies and procedures, and a product evaluation,” says Ogg. “In designing the program, AORN has developed all types of resources for successful adoption and implementation of smoke evacuation processes.”

Ogg lists a number of benefits facilities may realize by participating in the AORN GO Clear program, including the following:

  • Attract and retain the best clinicians due to a healthier, smoke-free environment.
  • Ensure the safety of all surgical patients by protecting them from the hazards of surgical smoke.
  • Provide education for perioperative team members on the risks of surgical smoke and teach implementation methods for smoke evacuation.
  • Increase smoke evacuation compliance on all surgical smoke generating procedures.

To learn more about the AORN GO Clear program, visit



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