The effects of surgical smoke during electrosurgical procedures is debated despite associations, including the International Council on Surgical Plume (ICSP) and the Association of periOperative Registered Nurses (AORN), that recognize it as a hazard. Occupational Safety and Health Administration (OSHA) addresses smoke evacuation and protection in its General Duty clause, stating facilities need to provide a safe work environment, but no details are included so facilities are left to do their own research to see if clinician safety is jeopardized.
The hazards of surgical smoke is a viable issue. The next step is finding protection for staff. Suppliers offer many options – specialized
smoke evacuators for open and laparoscopic procedures, suction equipment, smoke filters and others. The investment in this equipment, suppliers argue, is nominal compared to the potential clinician and patient safety lawsuits. But, the additional case cost associated with the equipment, especially the single-use items, such as surgical smoke pens and tubing, causes hesitation. As a result, some clinicians turn to face masks and respirators for protection, but suppliers and some organizations say that is not enough.
“Surgical masks are intended for use as a barrier to protect the wearer’s face from large droplets and splashes of blood and other body fluids,” said Catherine Engstrom, clinical resource manager of perioperative consulting services at Medline. “They help protect the patient and environment from microbial contamination by organisms carried in the provider’s mouth or nose, and the mark also provides protection for the wearer from exposure to blood, body fluids or other potentially infectious materials.”
Not on this list are carcinogens reportedly created during the cauterizing process, or the bacteria and viruses reportedly released from the patient and carried by the plume into the lungs of clinicians. That is because the particles are too small to be filtered by a surgical mask.
Joe Palomo, engineering manager in Global Engineering and Tech Support at Cardinal Health, added: “The filtration tests for surgical masks are not as stringent as surgical N95 respirators. Surgical masks, including high-filtration surgical laser masks, do not seal to the face and may allow dangerous contaminants to enter the healthcare worker’s breathing zone.”
The Journal of Endourology reported these surgical smoke particles are commonly 500 nanometers and smaller. Surgical masks can filter particles as small as five microns, which converts to about 5,000 nanometers. Although this is ideal for protecting the wearer from the large particles of blood and bodily fluids, research says it is not effective for filtering the smoke. This was confirmed in a 2013 AORN Journal article and other recent publications.
Respirators are commonly turned to as the next option. These can be effective but only to an extent, Engstrom says. “Filtering face piece respirators greatly reduce a wide size range of particles from entering the wearer’s breathing zone and are designed to protect the user from both droplet and airborne particles,” she elaborated. “In certain clinical situations, potential exposure to airborne contaminants and infections necessitates the use of respiratory personal protection equipment (PPE), such as an N95 respirator, which helps stop the passage of a wide size range of hazardous airborne particulate matter from entering the wearer’s breathing space.”
“Surgical and high filtration masks do not seal the face and dangerous contaminants may be allowed to enter the breathing zone if the OR staff. More
importantly they should not be used as a replacement for surgical smoke evacuation equipment. Masks such as the N95 respirator may be considered for use in conjunction with smoke evacuation equipment for transmissible cases such as human papillomavirus or during transmissible aerosol procedures such as tuberculosis,” states Robert Scroggins, clinical programs manager for Buffalo Filter. “The use of surgical N-95 respirators requires a 30–45 minute fit test for every staff member. This also requires surveillance by management or infection control to ensure proper use. From personal experience, I have found that OR staff members do not like tight fitting masks around their face and seldom use the N-95 mask correctly.”
Associations are often turned to in debate on surgical plume, and AORN is one of them. It developed guidelines on surgical smoke management as part of its Tool Kit and plans to launch a Be Clear campaign to award facilities that are taking action to reduce and eliminate surgical smoke. AORN experts also outlined a sample policy that met its guidelines in 2013. It specifically notes smoke evacuation devices with a 0.1-micron filtration capability for both laparoscopic and open procedures, in addition to using respiratory protection, such as a fit-tested N95 filtering face piece respirator, high-filtration surgical mask.
To get more information on why this combination is important, Surgical Products connected with Mary Ogg, MSN, RN, CNOR, senior perioperative practice specialist at AORN.
What benefit to N95 filtering face piece respirators offer clinicians?
Ogg: While the use of a N95 filtering face piece respirator may seem like a less costly alternative to a smoke evacuator and the capture equipment, there are costs associated with the N95 filtering face piece respirators such as the higher price of this type of respiratory protection, fit testing before use, and training to use the respirator properly. Since a N95 filtering face piece respirator greatly reduces a wide size range of particles from entering the wearer’s breathing zone and protects the user from both droplet and airborne particles, it does afford the clinician protection.
Is it advised for patients to wear PPE to prevent surgical smoke exposure?
Ogg: There is a theoretical risk that a patient may be exposed to a previous patient’s unevacuated surgical smoke. A study by Brandon and Young determined the particle size and distribution of unevacuated surgical smoke in the operating room. Their results showed high concentrations of smoke particles throughout the entire room. The significance of this result is that everyone in that OR is exposed to the unevacuated surgical smoke. Another significant finding is that it took 20 minutes to return to baseline. In a fast paced OR where turnover times are less than 20 minutes the smoke particles may still be in the room when the subsequent patient enters. If the facility is not evacuating surgical smoke, they should perform a risk assessment to determine the potential exposure to their patients and the need for the patients to wear respiratory protection.
It’s important to note that smoke evacuation and protection should be considered for the patient, as well. AORN’s recommendation in the Guideline for Minimally Invasive Surgery is “Surgical smoke should be removed by use of a smoke evacuation system in minimally invasive procedures to prevent patient and health care worker exposure to surgical smoke contaminants.”
If the smoke generated in the pneumoperitoneum during laparoscopic procedures accumulates in that closed cavity, it becomes more concentrated than smoke generated from an open surgical procedure. Reported negative patient effects from surgical smoke exposure include port site metastasis; increased levels of carboxyhemoglobin; occurrence of methemoglobin; exposure to carbon monoxide; and nausea, vomiting, and headaches postoperatively.