The hazards of surgical smoke: 3.0 ce

AORN Journal,  April, 2008  by Brenda C. Ulmer

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Surgical smoke is part of the patient care environment wherever surgical or invasive procedures are performed. It is called by a variety of names, including plume, smoke plume, diathermy plume, cautery smoke, aerosols, bioaerosols, vapors, and air contaminants. Surgical smoke results from the interaction of tissue and mechanical tools or heat-producing equipment, such as those that are used for dissection and hemostasis. Surgical smoke can be seen and smelled. Both the visible and the odorous components of surgical smoke are the gaseous by-products of the disruption and vaporization of tissue protein and fat. (1)

Surgical smoke has been described as part of the "chemical soup" that is present during the care of perioperative patients. (2) The components of surgical smoke have been described as being, at the very least, a nuisance and, at worst, carcinogenic. Since 1975 when Mihashi et al (3) expressed concern that smoke particles were small enough to be inhaled, researchers and practitioners have continued to evaluate surgical smoke and document their findings.

One point that has not been made is that surgical smoke is safe. Indeed, some staunchly believe there is no such thing as "safe smoke." Thus, it seems prudent to err on the side of safety and protect patients and health care workers from any potential dangers from surgical smoke. Erin Andersen, MS, RN, OHNP, characterized the issue well in 2005 by raising a provocative question:

   In hindsight, will health care professionals
   be embarrassed about their
   cavalier attitudes toward surgical
   smoke as they once were with cigarette
   smoke? (4(p104))

EFFORTS TO RAISE AWARENESS

AORN hosted its first multidisciplinary roundtable discussion on surgical smoke in January 1996. The outcomes of the discussion were chronicled in Giordano's 1996 article, "Don't be a victim of surgical smoke." (5) The event brought together experts from the Occupational Safety and Heath Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), and the ECRI (eg, formerly known as the Emergency Care Research Institute), as well as researchers, surgeons, RNs, and health care product manufacturers. As a result of the conference, NIOSH sent out a Hazard Alert to all hospitals in the United States in September 1996 recommending that smoke from lasers and electrosurgical units (ESUs) be filtered and evacuated. (6)

AORN continued efforts to raise awareness about the hazards of surgical smoke by hosting a second conference on smoke in February 1997. The second meeting brought together experts from the same groups but added representatives from the American Society of Anesthesiologists, the American College of Surgeons, the American Nurses Association (ANA), and the Joint Commission on the Accreditation of Healthcare Organizations, now known as the Joint Commission. One goal of the awareness effort was to include as many organizations as possible to increase consensus about the best methods to effect change in the regulation of surgical smoke. (7)

The most important outcome of the second smoke conference was the development of a guidance document from OSHA that was intended to support evacuation of surgical smoke. The detailed, 20-page document was sent out to reviewers in 1998 in anticipation of publication and was similar in scope to the 1996 NIOSH alert. (8) By the year 2000, the guidance document still had not been published, and in July 2000, OSHA stated that the delay was caused by a need for more evidenced. (9)

Despite OSHA's failure to publish the guidelines, the concern and controversy surrounding the issue of surgical smoke and air quality in the OR continue. Efforts to improve the quality of work-life circumstances have spread to professional organizations in other countries because the state of caregivers' health is of increasing concern. In 2003, AORN published the "Position statement on workplace safety," which stated,

   The workplace safety culture is of increasing
   importance as workloads increase, due to the
   effects of the nursing shortage, increased patient
   acuity, and emphasis on higher productivity.... The
   multiple occupational hazards
   that create a risk of personal injury that perioperative
   nurses face in the workplace are
   both physical and psychosocial. (10(p169))

The position statement lists the hazards faced by perioperative professionals, including smoke plume. (11)

SMOKE PRODUCTION IN THE OR

A primary mechanism to achieve a desired effect on the tissue (eg, hemostasis, tissue dissection) during surgical procedures is the use of heat-producing devices. These include ESUs; lasers; ultrasonic devices; and high-speed drills, burrs, and saws.

ESUs. The most common heat-producing device used is the ESU. Electrosurgery uses radio-frequency current (ie, high-frequency electrical current). The two basic waveforms are cut (ie, vaporization) and coagulation (ie, fulguration). The cut waveform is a continuous (ie, undampened), low-voltage wave pattern. The continuous current flow heats cell contents to the boiling point of 100[degrees]C (212[degrees]F), thereby exploding the cell wall. (12) Vaporization releases the cellular fluid as steam, and simultaneously spews the cell contents into the air, forming surgical smoke.