Surgical Smoke - Intra-operative patient and personnel safety

See also Standard Positioning for more intro-operative safety

Introduction

1. Surgical smoke refers to any aerosolized substance produced by high-energy devices in the operative suite
2. Production is increasing with increased use of tools such as electrocautery, laser, and mechanical drills
3. Safety is the responsibility of everyone in the operating room, but surgeons have a particular role in assuring proper protocols are followed
4. Smoke can include aeorsolized tissue, viral, or bacterial particles in addition to carcinogous substances produced in the combustion process similar to those produced by cigarette smoking

Risks

1. Risk extends beyond the immediate field to entire operating room as shown by diffusion studies
   1. Patients are also at risk and do not routinely wear masks even when not intubated during procedures
2. 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 according to one study, producing chemicals such as acrolein and formaldehyde
3. Allergies, sinus infections, asthma, and bronchitis, were twice as prevalent in perioperative nurses than in the general population
4. Animal models have demonstrated blood vessel hypertrophy, emphysema, and alveolar congestion in respiratory tracts
5. Theoretic risk of infection as blood products and viral particles are smaller than those particles aerosolized and found in surgical smoke samples
   1. Especially relavent in treatment of HPV related disease such as papilloma or squamous cell carcinoma
   2. Two case reports of personnel acquiring respiratory papillomas after treatment of HPV related disease

Protection

1. No legal mandates, though occupational health organizations have guidelines
2. Personal protective equipment should be used including surgical grade masks that have filtration sizes small enough to filter out aerosolized particles (0.1 microns)
   1. Called laser or high filtration masks
   2. Should be used any time plumes are created - includes in office laser procedures
   3. Must be tied tightly to be effective
   4. Use of respirator fit masks during HPV lesion excision has been recommended but is not supported by current research
3. Suction should be used in all plume-creating procedures
   1. Small amounts are ok to use wall suction with inline filter
   2. Commercial grade systems should be used for more extensive plume creation
   3. Should be placed within 2 cm of plume origin to be effective

SUMMARY: Use suction and proper masks at all times when using high-energy equipment such as cautery, laser, and drills.  

Based on:

Born, H. and Ivey, C. (2014), How should we safely handle surgical smoke?. The Laryngoscope. doi: 10.1002/lary.24624

References

Ball K. Surgical smoke evacuation guidelines: compliance among perioperative nurses. AORN J 2010;92:e1–23.

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.

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.

Sanderson C. Surgical smoke. J Perioper Pract 2012;22:122–128.

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.

Ulmer BC. The Hazards of Surgical Smoke. AORN Journal 2008;87:721–738.