The smoke factor: things you should know.
Surgical smoke is a regular hazard that the majority of
perioperative personnel are exposed to. Many staff are unaware of the
risks of surgical smoke and many more may take it for granted that a
surgical facemask provides enough protection. This article provides
detail on the composition of surgical smoke and highlights the potential
dangers that theatre staff face and what could be done to protect them.
It will demonstrate the potential harm for the patient with particular
reference to laparoscopic procedures as these are becoming more
favourable in general and gynaecological specialities and are of
particular interest to the author.
KEYWORDS Surgical smoke / Diathermy / Laser / Plume
(Beliefs, opinions and attitudes)
Smoke (Health aspects)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: March, 2012 Source Volume: 22 Source Issue: 3|
|Product:||Product Code: 8622000 Medical Associations NAICS Code: 81392 Professional Organizations SIC Code: 8621 Professional organizations|
|Organization:||Organization: Nursing and Midwifery Council; Association of Operating Room Nurses|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Surgical smoke is generated from tools, such as diathermy and lasers, which are used in the majority of operations conducted in theatres worldwide. This article will break down the components of surgical smoke and explore the hazards possibly arising from it. Constraints to implementing precautionary measures will be highlighted and legal, ethical and professional issues and recommendations for future practice will be considered.
Surgical smoke, or 'plume', is the result of thermal destruction of bone or tissue. Toxic substances, pathogens, mutagens and carcinogens can be released into the atmosphere by electrosurgery, powered instruments and lasers (Phillips 2004). For the purpose of this article surgical smoke will be discussed generically, differentiations will not be made between diathermy or laser plume. However, the author has witnessed that precautions are taken when using lasers in theatre, namely the use of high filtration face masks, but that the same considerations are not made for diathermy. This could be because early studies highlighted laser plume as a hazard (Biggins & Renfree 2002).
Biggins and Renfree (2002) cited that originally diathermy smoke was viewed as sterile, possibly due to the fact that diathermy requires high temperatures. But, as Rimmer (2009) has shown, organisms can still be retrievable although there is a reduced risk of a disease actually being transmitted. Tomita et al (1981) proclaim that diathermy smoke is actually twice as mutagenic as laser generated smoke, due to the charring of the tissues. More recently it appears generally agreed in the literature that diathermy and laser plume should be given the same precautions so as to provide consistent levels of protection (Biggins & Renfree 2002). To put surgical smoke into context, Moot et al (2007) advocate that the content concentration is less than that of one cigarette. Alp et al (2006) contradict this by saying that the mutagenic effect is equivalent to 6 cigarettes for electrocautery or 3 cigarettes for laser plume.
Chemical and biological constituents
Components of surgical smoke can be broken down into two categories: biological and chemical. Biological is the particulate matter that we can observe microscopically in the atmosphere i.e. tissue, blood, bacteria and viruses (Biggins & Renfree 2002). These components arise as a result of the steam caused by heating the tissues, which are largely composed of water, for the purpose of coagulation or ablation. The chemical constituents are the toxins which are present in the gases and are largely responsible for the offensive smell associated with diathermy. There are thought to be over 80 chemicals present in surgical smoke and many are believed to have a carcinogenic effect (Barrett & Garber 2004). The most serious of the chemicals is carbon monoxide (CO) and acrylonitrile. The toxic effects of acrylonitrile are due to the formation of cyanide, and exposure to such a substance may cause headache, sneezing, eye irritation and light-headedness (Alp et al 2006).
Smoke and laparoscopic procedures
Carbon monoxide has been found to be prominent in surgical smoke and is profuse during laparoscopic procedures. When laparoscopic cases require diathermy CO can be easily absorbed from the peritoneal cavity into the bloodstream resulting in systemic intoxication. Carboxyhaemoglobin (HbCO) and methaemoglobin (MetHb) are formed after CO and haemoglobin combine (Alp et al 2004). Should an excessive accumulation of MetHb and HbCO arise in a healthy adult the result can be hypoxic stress as the body has a decreased capacity to carry oxygen in the blood (Alp et al 2004). This has further implications for patients with impaired cardiovascular and respiratory systems. In addition to this O'Riley (2010) has commented that, during laparoscopic procedures for cancer surgery and where diathermy is a necessary intervention, concentrated surgical smoke in the peritoneal cavity may lead to port site metastases. Cancer could be spread through the aerosolised cells and toxicity to the peritoneal area.
Risks to perioperative staff
In 2008 the Occupational Safety and Health Administration estimated that around half a million theatre personnel per year are exposed to surgical smoke which is potentially harmful to their health (OSHA 2008). Alp et al (2006) have documented that the risks involved can include acute and chronic inflammatory changes in the respiratory tract as well as eye irritation, nausea, headaches and light-headedness. More seriously, they also add carcinoma, cardiovascular dysfunction, hepatitis and the risk of being exposed to the human immunodeficiency virus (HIV). To support this, Baggish (1993) expressed that there is an infection risk from laparoscopic surgery associated with the evacuated peritoneal air because HIV particles could be found.
Worldwide views on surgical smoke
It is interesting to note from the literature the worldwide differences in attitudes to surgical smoke. In America, the Association of Operating Room Nurses (AORN) has recommended that staff and patients should be protected from inhaling smoke plume due to its toxicity (AORN 1997). The American author Rothrock (1999) provides the notion that smoke evacuation should occur whenever any plume is generated and in its simplest form should involve 'on tip' extraction, meaning that a small suction device is added onto the pencil diathermy. Other authors, including Hunter (1996) also promote specialised suction units which safely draw away the smoke via an effective filter system. The Australian College of Operating Room Nurses (ACORN 2006) also make recommendations for preventing inhalation of surgical smoke for all who enter the operating room.
When reviewing the articles from the UK we can see that perioperative personnel are now starting to take an interest in surgical smoke. Many perioperative books that discuss theatre practice in general go into great depth about diathermy but then mention that plume does pose a risk but that little is known about the consequences (Nightingale 1999). More recently however, the Medicines and Healthcare products Regulatory Agency (MHRA 2009), has published a smoke plume poster. This briefly describes the hazards posed and the methods to reduce or remove the risks; it is a good reference point for all staff.
The discussion above has highlighted the dangers posed by surgical smoke plume. However, there are no legal requirements to provide intervention. This is where local trusts have evidence that they are not breaking any laws by not insisting on smoke evacuation. This is supported by Ulmer (2008) who considered much of the above information but repeated that smoke evacuators are not compulsory. This is largely because, although theoretically surgical smoke is known to be a hazard, evidence is lacking to prove that actual harm has been caused.
There is however guidance for employers and practitioners; for example the Health and Safety Executive stated that if exposure to plume cannot be prevented then it should be sufficiently controlled (HSE 2002). They give examples of local exhaust ventilation (LEV) systems namely an 'on tip' extraction system. This would then help to comply with the Control of Substances Hazardous to Health Regulations (COSHH) (HSE 2002) as it would satisfy the request that risk assessments from hazardous substances should take place and that exposure should be prevented at source. The British Occupational Health Society (BOHS 2006) has supported this guidance by saying that general ventilation alone in theatres is not adequate to remove smoke plume, therefore effective LEV systems should be considered. Hutchinson (2004) also agrees with this notion and adds that to use regular suction, i.e. yankeur sucker and standard tubing, is also inadequate.
A reason why there is a lack of legal support on this topic is likely to be because it is difficult to prove that patients and staff have come to harm after spending time in the operating room. We have seen that there is evidence that surgical smoke is composed of lethal substances but as yet there is no known documented case of anyone coming to serious harm after exposure.
Barrett and Garber (2004) highlighted that patients are at risk of absorbing carbon monoxide during laparoscopic surgery and that this is detrimental to their recovery. Therefore, should a patient come to evident harm they could potentially sue the trust under the term of negligence, but again, proving that it was the surgical smoke that caused the harm remains a grey area. In examining the evidence, studies are limited due to the ethical considerations. For example Champault et al (2007) highlighted that viable cells were present in surgical smoke in the peritoneum during laparoscopies but admitted that their research was restricted due to the fact that they could not purposefully coagulate malignant tissue.
The Department of Health (DH 2010) has recently published the white paper Equity and Excellence which focuses on patient safety as the foundation for its proposals. With this in mind, as practitioners we should be doing our best to protect our patients whilst they are in our care, so lessening the risks of exposure to surgical smoke should be paramount. A further hazard of surgical smoke is that it impedes the surgeon's view (Hirschfeld & Niloff 1992), which could potentially have an impact on patient safety whilst on the operating table.
Evaluating the legal aspects brings us to question the professional issues surrounding this topic. For guidance the author looked to the codes of conduct of the Nursing and Midwifery Council (NMC 2008) and the Health Professions Council (HPC 2008). These regulatory bodies safeguard the health and wellbeing of the general public. They stipulate that we must ensure that the care of our patients is our first concern. Should a problem arise in the care environment that puts people at risk, the NMC code enforces that we should report our concerns in writing. This would have implications after conducting the advised risk assessments and should hopefully assist in managing the risks. As nurses and perioperative practitioners we have a duty of care to the patients we look after so, as we aware of the dangers of surgical plume, we should be obliged to protect our patients.
It has been demonstrated that smoke extractors should be available to evacuate the smoke at source but there is also another measure that we can take to protect ourselves, namely facemasks. When considering such interventions it is imperative that we look at the size of the particulate matter: 77% of the particles are less than 1.1microns and there is the potential for 3-33,000 particles to be present per litre of smoke. Scott et al (2004), and Ulmer (2008) added that small particles can migrate to the alveoli and bronchioles. The smaller the particle, the further it can travel, which implies that it is not just the direct scrub staff and surgeons who need to take precautions but anyone in that theatre.
A standard facemask is designed to be comfortable and hence loose fitting. They are however, unable to filter matter of less than 5 microns, so a high filtration facemask should be used when there is the hazard of surgical smoke entering the environment (Scott et al 2004). Barrett and Garber (2004) discuss that different facemasks perform very differently and depend on whether they are fitted correctly. Some masks have been proved to have a filter efficiency of 97% but again this relies heavily on them being sealed properly. In doing so this often makes the wearing of such masks uncomfortable when worn for a longer period of time.
Educating the workforce
Educating staff on the dangers of surgical smoke would provide a culture where smoke evacuation is seen as a necessity. This topic is due to gain national publicity as a cause for concern after the publication of a detailed poster highlighting the dangers of diathermy smoke and laser plume and the interventions to protect ourselves (AfPP 2009). In addition, the Royal College of Nursing (2010) has conducted a surgical smoke survey as it aims to revisit concerns regarding this issue. This author is promoting the topic by using it as a discussion point during an audit session and by displaying the AfPP (2009) 'Surgical smoke: what we know' poster in the work place for all to see. The MHRA (2009) advocates that education is imperative and should be conducted by suitably qualified personnel and may include the smoke evacuator manufacturers.
The HSE (2011) validated that risk assessments are vital steps to protect the workforce, in addition to complying with the law. A careful examination of the potential risks should be undertaken so that the employer can decide whether they have taken adequate precautions. As the employee we all have a right to be protected from harm that is a result of a failure to take reasonable precautionary measures. It is to be expected that the risks may not be totally eliminated but employees should be protected as much as is reasonably practicable. The risk assessment itself would essentially identify the hazard and decide who might be harmed and how. With knowledge of the components of plume and possible side effects, particular members of staff may undergo further occupational health surveillance e.g. asthmatics and those whose immune system may be compromised.
Why, in some cases, is smoke evacuation not available?
There are barriers to implementing efficient smoke evacuation procedures and taking preventative measures. The cost of smoke evacuation systems is an obvious and common issue although Bigony (2007) strongly believes that it shouldn't be. There is a significant price difference between a standard facemask and a high filtration one. There is also the misconception by staff, highlighted by Wicker (2000), that a standard facemask will provide sufficient protection against inhaling surgical smoke. Indeed some staff, including surgeons, are oblivious to the dangers posed by surgical smoke. As practitioners with knowledge on board, conducting a relevant risk assessment and formally handing it to our managers could encourage action to be taken. As a minimum, expense shouldn't be spared on high filtration face masks. Bigony (2007) champions that apathy, convenience and expense are unacceptable obstacles when the health and safety of the surgical team may be compromised without such interventions.
The resulting smoke from electrosurgery and laser is, theoretically, hazardous to the health of staff and patients. There are three main reasons why smoke should be evacuated. First, the harmful substances could be detrimental to the health of staff if inhaled. Second, patients are at risk of carbon monoxide toxicity and port site metastases during laparoscopies and, lastly, the surgeon's visibility is reduced. There are no legal requirements for employers to provide smoke evacuation systems, however, hopefully, an increase in knowledge, awareness and publicity could change this. Risk assessments should be carried out in each department and as a minimum staff should be wearing properly fitted high filtration facemasks. At best, efficient LEV should be utilised and managed effectively. Diathermy is an everyday tool used in the operating theatre, therefore perioperative personnel need to be managing the associated risks as standard practice. If knowledge is power, we are now aware of the potential hazards so it is imperative that we do something about it.
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Association of Operating Room Nurses 1997 Standards, recommended practices and guidelines Denver, AORN
Australian College of Operating Room Nurses 2006 Standards/surgical plume Sydney, ACORN
Association for Perioperative Practice 2009 Surgical smoke: what we know Available from: www.afpp.org.uk/filegrab/1SmokePlume-FINAL1.pdf?ref=1112 [Accessed January 2012]
Baggish M 1993 Comparison of smoke and sprayback leakage from two different trocar sleeves during operative laparoscopy Journal of Gynaecological Surgery 9 (2) 62-76
Barrett W, Garber S 2004 Surgical smoke - a review of the literature Business Briefing: Global Surgery 1-7
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Department of Health 2010 Equity and excellence: Liberating the NHS London, DH
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Correspondence address: Day surgery, Alexandra Hospital, Redditch, B98 7UB. Email: firstname.lastname@example.org
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication January 2012.
About the authors
Steph Marsh BSc, RGN, PGCert
Staff Nurse, Day Surgery, Alexandra Hospital, Redditch
No competing interests declared
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