It has been known to cause genital warts in the noses of anesthesiologists. A surgeon developed a rare throat tumor caused by the human papillomavirus (HPV) because of this. It has been linked to miscarriages among nurses. In a hospital in London, Ont., red flags were raised around it after an orthopedic surgeon died of lung cancer, but he was not a smoker. The human immunodeficiency virus (HIV) and hepatitis have also been found in it.
The culprit? Surgical smoke.
“Viruses and bacteria will live in surgical smoke, as does DNA, for up to 72 hours,” says Heather Pottery, clinical nurse educator for operating rooms at St. Paul’s Hospital in Vancouver. “We do quite a number of cancer cases and with the destruction of those tissues, those compounds, or those viruses, can be in the air as well.”
Surgical smoke (also known as plume) is generated whenever a hot tool interacts with human tissue. In the operating room (OR), lasers, electrosurgical units (ESUs), ultrasonic instruments, plasma generators, bone saws and drills create smoke during electrocautery, electrosurgery and mechanical operations.
Surgical smoke also carries harmful chemical components, such as benzene (a documented trigger for leukemia), toluene, formaldehyde, carbon monoxide, hydrogen cyanide and methane (see sidebar for more). Researchers have identified more than 600 organic compounds in plume generated by vaporized tissue.
One puff of plume can be the same as three puffs from an unfiltered cigarette, according to research cited by the CSA Group. Plume can also cause respiratory problems; eye, nose and throat irritation; severe headaches; nausea; and liver and kidney damage, according to the CSA.
“Asthmatics, people who have upper respiratory illness, somebody who is prone to sinusitis, for instance, there have been complaints of eye irritation and those people who are particularly sensitive from a respiratory perspective aren’t able to tolerate it,” says Rupinder Khotar, OR nursing supervisor at St. Paul’s Hospital and past president of the Operating Room Nurses Association of Canada.
Occupational health and safety professionals, industrial hygienists and occupational health nurses working in hospitals need to be increasingly aware of the risk of plume and how to properly control it as surgical procedures are on the rise. The global surgical procedures volume market stood at 1.3 billion procedures in 2014 and is estimated to reach 2.2 billion by 2023, according to Transparency Market Research.
In 2009, the CSA Group introduced the first version of CSA Z305.13-09 Plume Scavenging in Surgical, Diagnostic, Therapeutic, and Aesthetic Settings, which was revised in 2013. It was the fastest standard the CSA ever developed, taking only 18 months, because there was no real opposition to it, says Barry Hunt, president and CEO of Class 1, a medical gas pipeline company in Cambridge, Ont., and member of the CSA technical committee on perioperative safety.
“The evidence of the problem was overwhelming and a need for the standard was overwhelming and that was the world’s first national standard to address that issue, saying if you produce smoke in the OR, you have to capture it,” he said.
There are certain factors that affect the severity of the surgical smoke hazard, such as the type of procedure and duration of surgery.
“The volume of plume that is generated is a big factor and some procedures have a very miniscule amount of smoke that is produced and some have a very large volume,” says Hunt. “Breast reduction is probably the largest smoke producer. You are cutting away a lot of tissue.”
Anyone in the operating room can be affected by surgical smoke — nurses, surgeons, anesthetists and anyone who comes into the OR after the case is done. Those who are downstream of the plume are at the greatest risk, says Hunt, such as shorter nurses or anesthetists who are sitting during the procedure.
“I know at one point a lot of surgeons thought they would be the most affected by this but what they didn’t realize (is that) it’s that OR nurse who is in the room five days a week, eight hours a day — it’s the one that’s in there consistently,” says Susan Taylor, vice-chair of CSA’s plume scavenging committee and retired nurse educator/laser safety officer for St. Joseph’s Health Care in London, Ont., adding anesthetists are also regularly in the room with nurses. “(The surgeon) has maybe one day of booking per week and then he’s gone.”
Control the smoke
The first step in addressing surgical smoke is to properly ventilate the operating room. According to CSA Z305.13-13, 20 air changes per hour are required.
Next, plume scavenging systems need to be put in place, and there are a variety of options available. One option is the portable smoke evacuation system, which is the most versatile as it can be moved around.
The portable system may be activated manually by a foot switch or automatically when the laser or electrosurgical unit is turned on. The smoke goes through a triple filter system consisting of a pre-filter, an activated carbon filter and an ultra-low particulate air (ULPA) filter. Various capture devices are used, such as those that can be attached to the ESU pencil or large tubing that is usually within 5 centimetres of the plume source.
“You can take it from room to room, the filters are easy to change and you can monitor very easily how used up your filter is,” says Taylor. “It evacuates the plume right at the source.”
This past fall, St. Paul’s Hospital in Vancouver started using new smoke evacuators in all of its operating rooms. It installed portable systems that are directly connected to the electrosurgery unit and function automatically.
“It is pre-assembled where the tubing that provides the suction around the cautery pen itself is all a single unit,” says Khotar. “You don’t have to assemble it, so in some ways it makes it mandatory to use because it won’t function unless you have the system.”
The previous systems required the nurses to assemble the smoke evacuator so there was more of an option to use it or not. Sometimes surgeons did not like using the device because it limited their line of sight.
“Although it sounds like it makes perfectly good sense — why wouldn’t everyone use it all the time? — the systems were somewhat limiting because they were cumbersome. It’s like vacuuming your drapes always with the rug attachment. It’s just not the easiest thing to do,” says Khotar. “And when you can’t actually see your surgical site, you have other safety issues now.”
Fortunately, technology is always evolving to take into consideration the factors that would improve compliance, added Khotar. For example, a device introduced last year by a company in the United States offers the surgeon three ergonomic use options so the ESU pencil is comfortable and adapts to his personal preference.
Noise level is always something that needs to be taken into consideration when selecting a smoke evacuation system.
“The sound of the suction is the equivalent of listening to your vacuum going. In some systems, the vacuum is going on all the time; in others it’s instigated by the activation of the cautery pen itself, so one directly correlates to the other. It’s not on all the time, it’s intermittent based on the use of the cautery,” says Pottery.
A central smoke evacuation system is another option for eliminating plume from the OR. This system is permanently installed and a capture device evacuates the smoke through a filter and into piping that exhausts outside the building.
These systems are generally quieter than their portable counterparts and can be activated with a foot pedal or automatically.
The updated CSA medical gas pipeline system standard is coming in 2017 and will require all new hospitals — or renovated ones — in Canada to be built with a central pipeline system for plume scavenging, says Hunt.
Disposable endoscopic or laparoscopic smoke evacuators are also an option for minimally invasive surgical procedures. These single-use devices allow for better visibility during surgery.
Medical vacuums, which are used to aspirate fluids and secretions in the OR, should not be used for smoke evacuation as they do not have a filter. Unfortunately, some hospitals are still using this method, which was a stop-gap solution in ORs many years ago before smoke evacuation systems were available.
Taylor recalls visiting a hospital in New Brunswick in the early 2000s where the medical vacuums were being used to eliminate surgical plume. Eventually, the wall suction was not working properly and the nurses investigated the cause.
“They actually cut the yellow tubing that went from the regulator into the port in the wall and they said all this brown gluck came pouring out. They were just grossed out and (they said) ‘That’s when we realized we should not be using the wall suction,’” says Taylor. “It’s a good place for bacteria to grow, so you can end up with sick building syndrome and you cannot clean these pipes.”
When determining what type of smoke evacuation system is right for your OR, there are a few things to keep in mind.
“The more automatic it is the better, the closer to the surgical site the better, the more integrated the better, the more intuitive the better, the quieter the better,” says Hunt.
It’s also a good idea to have a unit with an adjustable air flow. For example, a breast reduction will need 800 litres per minute of flow (LPM) while a laparoscopic surgery will need 8 LPM.
“You need a very adaptable, versatile system that can generate small flows and large flows and everything in between,” says Hunt. “You need to cover a broad range and be able to do it very effectively.”
To get buy-in for improved smoke evacuation systems, health and safety professionals can always crunch the numbers to show how it can impact the bottom line.
“A typical hospital-acquired infection in Canada is assumed to be $20,000 to treat and a surgical site infection can be double that. So, if you are capturing the smoke, that helps to reduce, in particular, surgical site infections which could be up to $40,000 each. Saving one infection is three times the cost of a machine,” says Hunt.
Having a physician champion is a great asset as well, says Taylor. When portable smoke evacuators were first installed in St. Joseph’s in the late 1980s, there was a surgeon who threw his support behind them.
“He loved them. He said, ‘I don’t want to breathe that stuff in, it reeks. I can smell it when I walk out of the OR for a day,’” recalls Taylor. “If his residents didn’t use the plume evacuator, oh they got a real dressing down, so he was there making sure our physicians used it. And if we didn’t have enough, he made sure it was in the budget for us to get more.”
Having a hospital with a strong safety culture certainly helps get updated systems in place, such as at St. Paul’s, which sees a smoke evacuator as a basic work tool.
“We have a department that stays well informed… and we are very connected and concerned with standards of practice,” says Khotar. “We have a defined OR safety culture and people are not afraid to speak up.”
Educate workers
All workers who go into the operating room need to be educated on what’s in the plume, why it’s bad for them and how to prevent it, says Taylor. Most hospitals set aside one hour per week for in-servicing, which provides a great opportunity to educate workers on this hazard. There are also e-learning modules that hospitals have developed on surgical smoke.
“There is no reason why they can’t put something like that (in place) and have it be a mandatory thing on an annual basis like they do for fire safety,” says Taylor. “It’s still safety for the staff and they need it.”
However, nearly one-half of workers exposed to surgical smoke have never received training on its hazards, according to a study from the National Institute of Occupational Safety and Health (NIOSH) in the United States.
Workers also need instructions on how to keep the equipment in good working order.
It’s important for all workers to understand that a surgical mask does not provide protection from surgical smoke. A surgical mask’s main purpose is to provide droplet protection. It generally filters particles to about 5 micrometres in size, while a laser mask filters to 0.1 micrometres, neither of which protect from viral particles, which can be much smaller than 0.1 micrometres.
N95 respirators do not provide adequate protection either.
“People wear masks and they think it gives them protection from plume but it’s a false sense of security,” says Taylor. “The rating for an N95 mask is that it filters out 95 per cent of particulate matter 0.3 micrometre and larger… Anything smaller than that and you can breathe it right in. And they don’t protect you from any of the chemicals, such as toluene, benzene or formaldehyde.”
The only way to really protect workers is to gather plume at the source by implementing smoke evacuation systems. However, only one-half of employees in the NIOSH survey said local exhaust ventilation was always used during laser surgery and 15 per cent reported it was always used during electrosurgery.
Hospitals across the country need to get on board — and soon, says Taylor.
“At this point, nurses and any of the staff that are in the OR are going to become a very limited resource because of the fact that budgets are so tight, and they need to keep this resource as healthy as possible,” she says. “Bringing in these plume evacuators and ensuring they are used will help towards the goal of cutting down on sick time and making sure their staff is as safe as possible.”
This article originally appeared in the August/September 2016 issue of COS.
The culprit? Surgical smoke.
“Viruses and bacteria will live in surgical smoke, as does DNA, for up to 72 hours,” says Heather Pottery, clinical nurse educator for operating rooms at St. Paul’s Hospital in Vancouver. “We do quite a number of cancer cases and with the destruction of those tissues, those compounds, or those viruses, can be in the air as well.”
Surgical smoke (also known as plume) is generated whenever a hot tool interacts with human tissue. In the operating room (OR), lasers, electrosurgical units (ESUs), ultrasonic instruments, plasma generators, bone saws and drills create smoke during electrocautery, electrosurgery and mechanical operations.
Surgical smoke also carries harmful chemical components, such as benzene (a documented trigger for leukemia), toluene, formaldehyde, carbon monoxide, hydrogen cyanide and methane (see sidebar for more). Researchers have identified more than 600 organic compounds in plume generated by vaporized tissue.
One puff of plume can be the same as three puffs from an unfiltered cigarette, according to research cited by the CSA Group. Plume can also cause respiratory problems; eye, nose and throat irritation; severe headaches; nausea; and liver and kidney damage, according to the CSA.
“Asthmatics, people who have upper respiratory illness, somebody who is prone to sinusitis, for instance, there have been complaints of eye irritation and those people who are particularly sensitive from a respiratory perspective aren’t able to tolerate it,” says Rupinder Khotar, OR nursing supervisor at St. Paul’s Hospital and past president of the Operating Room Nurses Association of Canada.
Occupational health and safety professionals, industrial hygienists and occupational health nurses working in hospitals need to be increasingly aware of the risk of plume and how to properly control it as surgical procedures are on the rise. The global surgical procedures volume market stood at 1.3 billion procedures in 2014 and is estimated to reach 2.2 billion by 2023, according to Transparency Market Research.
In 2009, the CSA Group introduced the first version of CSA Z305.13-09 Plume Scavenging in Surgical, Diagnostic, Therapeutic, and Aesthetic Settings, which was revised in 2013. It was the fastest standard the CSA ever developed, taking only 18 months, because there was no real opposition to it, says Barry Hunt, president and CEO of Class 1, a medical gas pipeline company in Cambridge, Ont., and member of the CSA technical committee on perioperative safety.
“The evidence of the problem was overwhelming and a need for the standard was overwhelming and that was the world’s first national standard to address that issue, saying if you produce smoke in the OR, you have to capture it,” he said.
There are certain factors that affect the severity of the surgical smoke hazard, such as the type of procedure and duration of surgery.
“The volume of plume that is generated is a big factor and some procedures have a very miniscule amount of smoke that is produced and some have a very large volume,” says Hunt. “Breast reduction is probably the largest smoke producer. You are cutting away a lot of tissue.”
Anyone in the operating room can be affected by surgical smoke — nurses, surgeons, anesthetists and anyone who comes into the OR after the case is done. Those who are downstream of the plume are at the greatest risk, says Hunt, such as shorter nurses or anesthetists who are sitting during the procedure.
“I know at one point a lot of surgeons thought they would be the most affected by this but what they didn’t realize (is that) it’s that OR nurse who is in the room five days a week, eight hours a day — it’s the one that’s in there consistently,” says Susan Taylor, vice-chair of CSA’s plume scavenging committee and retired nurse educator/laser safety officer for St. Joseph’s Health Care in London, Ont., adding anesthetists are also regularly in the room with nurses. “(The surgeon) has maybe one day of booking per week and then he’s gone.”
Control the smoke
The first step in addressing surgical smoke is to properly ventilate the operating room. According to CSA Z305.13-13, 20 air changes per hour are required.
Next, plume scavenging systems need to be put in place, and there are a variety of options available. One option is the portable smoke evacuation system, which is the most versatile as it can be moved around.
The portable system may be activated manually by a foot switch or automatically when the laser or electrosurgical unit is turned on. The smoke goes through a triple filter system consisting of a pre-filter, an activated carbon filter and an ultra-low particulate air (ULPA) filter. Various capture devices are used, such as those that can be attached to the ESU pencil or large tubing that is usually within 5 centimetres of the plume source.
“You can take it from room to room, the filters are easy to change and you can monitor very easily how used up your filter is,” says Taylor. “It evacuates the plume right at the source.”
This past fall, St. Paul’s Hospital in Vancouver started using new smoke evacuators in all of its operating rooms. It installed portable systems that are directly connected to the electrosurgery unit and function automatically.
“It is pre-assembled where the tubing that provides the suction around the cautery pen itself is all a single unit,” says Khotar. “You don’t have to assemble it, so in some ways it makes it mandatory to use because it won’t function unless you have the system.”
The previous systems required the nurses to assemble the smoke evacuator so there was more of an option to use it or not. Sometimes surgeons did not like using the device because it limited their line of sight.
“Although it sounds like it makes perfectly good sense — why wouldn’t everyone use it all the time? — the systems were somewhat limiting because they were cumbersome. It’s like vacuuming your drapes always with the rug attachment. It’s just not the easiest thing to do,” says Khotar. “And when you can’t actually see your surgical site, you have other safety issues now.”
Fortunately, technology is always evolving to take into consideration the factors that would improve compliance, added Khotar. For example, a device introduced last year by a company in the United States offers the surgeon three ergonomic use options so the ESU pencil is comfortable and adapts to his personal preference.
Noise level is always something that needs to be taken into consideration when selecting a smoke evacuation system.
“The sound of the suction is the equivalent of listening to your vacuum going. In some systems, the vacuum is going on all the time; in others it’s instigated by the activation of the cautery pen itself, so one directly correlates to the other. It’s not on all the time, it’s intermittent based on the use of the cautery,” says Pottery.
A central smoke evacuation system is another option for eliminating plume from the OR. This system is permanently installed and a capture device evacuates the smoke through a filter and into piping that exhausts outside the building.
These systems are generally quieter than their portable counterparts and can be activated with a foot pedal or automatically.
The updated CSA medical gas pipeline system standard is coming in 2017 and will require all new hospitals — or renovated ones — in Canada to be built with a central pipeline system for plume scavenging, says Hunt.
Disposable endoscopic or laparoscopic smoke evacuators are also an option for minimally invasive surgical procedures. These single-use devices allow for better visibility during surgery.
Medical vacuums, which are used to aspirate fluids and secretions in the OR, should not be used for smoke evacuation as they do not have a filter. Unfortunately, some hospitals are still using this method, which was a stop-gap solution in ORs many years ago before smoke evacuation systems were available.
Taylor recalls visiting a hospital in New Brunswick in the early 2000s where the medical vacuums were being used to eliminate surgical plume. Eventually, the wall suction was not working properly and the nurses investigated the cause.
“They actually cut the yellow tubing that went from the regulator into the port in the wall and they said all this brown gluck came pouring out. They were just grossed out and (they said) ‘That’s when we realized we should not be using the wall suction,’” says Taylor. “It’s a good place for bacteria to grow, so you can end up with sick building syndrome and you cannot clean these pipes.”
When determining what type of smoke evacuation system is right for your OR, there are a few things to keep in mind.
“The more automatic it is the better, the closer to the surgical site the better, the more integrated the better, the more intuitive the better, the quieter the better,” says Hunt.
It’s also a good idea to have a unit with an adjustable air flow. For example, a breast reduction will need 800 litres per minute of flow (LPM) while a laparoscopic surgery will need 8 LPM.
“You need a very adaptable, versatile system that can generate small flows and large flows and everything in between,” says Hunt. “You need to cover a broad range and be able to do it very effectively.”
To get buy-in for improved smoke evacuation systems, health and safety professionals can always crunch the numbers to show how it can impact the bottom line.
“A typical hospital-acquired infection in Canada is assumed to be $20,000 to treat and a surgical site infection can be double that. So, if you are capturing the smoke, that helps to reduce, in particular, surgical site infections which could be up to $40,000 each. Saving one infection is three times the cost of a machine,” says Hunt.
Having a physician champion is a great asset as well, says Taylor. When portable smoke evacuators were first installed in St. Joseph’s in the late 1980s, there was a surgeon who threw his support behind them.
“He loved them. He said, ‘I don’t want to breathe that stuff in, it reeks. I can smell it when I walk out of the OR for a day,’” recalls Taylor. “If his residents didn’t use the plume evacuator, oh they got a real dressing down, so he was there making sure our physicians used it. And if we didn’t have enough, he made sure it was in the budget for us to get more.”
Having a hospital with a strong safety culture certainly helps get updated systems in place, such as at St. Paul’s, which sees a smoke evacuator as a basic work tool.
“We have a department that stays well informed… and we are very connected and concerned with standards of practice,” says Khotar. “We have a defined OR safety culture and people are not afraid to speak up.”
Educate workers
All workers who go into the operating room need to be educated on what’s in the plume, why it’s bad for them and how to prevent it, says Taylor. Most hospitals set aside one hour per week for in-servicing, which provides a great opportunity to educate workers on this hazard. There are also e-learning modules that hospitals have developed on surgical smoke.
“There is no reason why they can’t put something like that (in place) and have it be a mandatory thing on an annual basis like they do for fire safety,” says Taylor. “It’s still safety for the staff and they need it.”
However, nearly one-half of workers exposed to surgical smoke have never received training on its hazards, according to a study from the National Institute of Occupational Safety and Health (NIOSH) in the United States.
Workers also need instructions on how to keep the equipment in good working order.
It’s important for all workers to understand that a surgical mask does not provide protection from surgical smoke. A surgical mask’s main purpose is to provide droplet protection. It generally filters particles to about 5 micrometres in size, while a laser mask filters to 0.1 micrometres, neither of which protect from viral particles, which can be much smaller than 0.1 micrometres.
N95 respirators do not provide adequate protection either.
“People wear masks and they think it gives them protection from plume but it’s a false sense of security,” says Taylor. “The rating for an N95 mask is that it filters out 95 per cent of particulate matter 0.3 micrometre and larger… Anything smaller than that and you can breathe it right in. And they don’t protect you from any of the chemicals, such as toluene, benzene or formaldehyde.”
The only way to really protect workers is to gather plume at the source by implementing smoke evacuation systems. However, only one-half of employees in the NIOSH survey said local exhaust ventilation was always used during laser surgery and 15 per cent reported it was always used during electrosurgery.
Hospitals across the country need to get on board — and soon, says Taylor.
“At this point, nurses and any of the staff that are in the OR are going to become a very limited resource because of the fact that budgets are so tight, and they need to keep this resource as healthy as possible,” she says. “Bringing in these plume evacuators and ensuring they are used will help towards the goal of cutting down on sick time and making sure their staff is as safe as possible.”
This article originally appeared in the August/September 2016 issue of COS.
