OSHA’s next assignment: Protecting operating room staff from surgical smoke
Surgical plume contains toxic chemicals, viral matter
For hours every day, nurses, surgeons, and technicians hover around patients in the operating room while electrosurgical devices release plumes of smoke. Tiny particles invade their masks and reach their lungs. Their eyes sting, their hair and clothes reek, and they may even feel a wave of nausea or abdominal cramping.
Proper smoke evacuation can greatly reduce the discomfort and potential hazards of surgical smoke, but the use of evacuation devices isn’t required by federal regulations. Even so, hospitals may face growing pressure to address the issue of surgical smoke.
In a move that operating room nurses say is long overdue, the U.S. Occupational Safety and Health Administration (OSHA) is drafting a technical bulletin with guidelines for evacuation of surgical smoke. The National Institute for Occupational Safety and Health issued a hazard alert in 1997, recommending the use of surgical smoke evacuators.1
"There are hundreds of chemical by-products that have been identified in surgical smoke," says Kay Ball, RN, MSA, CNOR, FAAN, a perioperative educator and consultant based in Columbus, OH. "That’s the odor we smell. Some of these chemicals are gases that are known carcinogens."
Researchers have identified benzene, formaldehyde, carbon monoxide, and even human papilloma virus in surgical smoke.2 In one case, a surgeon contracted laryngeal papillomatosis with human papillomavirus DNA types identical to those of patients he had treated with laser therapy. "These findings suggest that the papillomas in our patient [the surgeon] may have been caused by inhaled virus particles present in the laser plume," the treating otorhinolaryngologists concluded.3
But so far, the health effects of surgical smoke are largely anecdotal. Most research focuses on the contents of the smoke. Controlled studies of exposed workers are virtually impossible to conduct, says Ball.
"Just think of it practically and logically," she says. "You don’t want to be in a room filled with cigarette smoke, and this plume is worse than cigarette smoke."
ESUs may be worse than lasers
When surgeons first began using lasers, safety guidelines included provisions for evacuating the smoke produced by the burning of human tissue. But for decades, surgeons had already been routinely using electrosurgical devices that burned tissue and produced smoke in much the same way lasers do — but without any special smoke evacuation.
In fact, electrosurgery units (ESUs) are used in 75% to 80% of all surgical procedures, says Ken Ross, senior project engineer at ECRI, a technology assessment firm in Plymouth Meeting, PA.
"There’s research that shows that ESUs make nastier smoke than lasers," says Ross. "It has to do with how the smoke is created. With lasers, the energy is sent to such a fine location that the cells are vaporized completely. With the ESU, the power is more dissipated. There’s a circular gradient where cells are damaged but not completely destroyed," Ross explains. "The ESU or laser heats up the fluid that’s in the cell. It bursts the cell. With the ESU, it’s not focused. There are portions of cells that are aerosolized, but they’re not completely burned."
The plume from electrosurgery can contain viral material, including hepatitis B, hepatitis C, and HIV, although the likelihood of transmission through surgical smoke is remote, Ross says. Operating room personnel are much more likely to breathe in various gases that pass through surgical masks.
Smoke also creates practical problems in the operating room, as it can momentarily cloud a surgeon’s visual field. It can be particularly troublesome for nurses, who remain in the operating room for long periods, while surgeons may perform several cases and then leave.
"Nurses are sometimes in the operating room 12 hours a day," notes Candace Romig, MS, director of governmental affairs at the Association of periOperative Registered Nurses (AORN) in Denver. "Smoke is circulating, and sometimes they are very close to the patient and are affected by it. They’re developing respiratory problems, eye irritation, and general overall malaise."
While AORN standards call for the use of smoke evacuators, the association has been pressing for stronger federal action on surgical smoke. But the efforts have been somewhat hampered by the lack of research data on the health effects in the OR environment.
Most studies have focused on measuring the content of the smoke. For example, a 1989 study showed that the plume from vaporizing 1 g of tissue with an ESU was equivalent to smoking six unfiltered cigarettes.4 Other studies showed that bacteria and viral material in the plume remain viable.5
But when NIOSH reviewed literature on surgical smoke, there was only anecdotal evidence of actual health effects. "There are some real issues there, but I don’t know if anyone has conclusively shown that there’s a major health hazard," says Gene Moss, a NIOSH health physicist. "We’re trying to minimize a hazard by using control measures."
Surgical smoke itself varies considerably depending on the type of tissue involved, notes Moss. "In certain types of procedures, certain smokes are very heavy," he says. "Brain tissue is much heavier than gut tissue. Depending on the amount of fat, muscle, bone — the compounds are different."
To remove any potential hazard, "you should use a smoke evacuator," he says. "You should try to capture the smoke where it’s being produced."
General ventilation of the room won’t adequately remove the smoke, says Moss. Currently, there are three basic types of smoke evacuators, with varying price levels. (For information on purchasing smoke evacuators, see related article on p. 40.)
Ball says hospitals have begun to recognize the potential hazards and are purchasing evacuators for every operating room. Of course, they also have to be activated in each case.
"We just want people to use the smoke evacuation technology we have to get rid of this hazard," she says. "We need to educate them. The nurses are an easy sell. It’s the doctors who are a little bit harder [to convince]."
References
1. National Institute for Occupational Safety and Health. NIOSH Hazard/Controls: Control of Smoke from Laser/Electrical Surgical Procedures. 1998; DHHS (NIOSH) Publication No. 96-128.
2. Hoglan M. Potential hazards from electrosurgical plume. Canadian Operating Room Nursing Journal 1995; 13:10-16.
3. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991; 248:425-427.
4. Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2 laser irradiation and electrocauterization. Mutat Res 1989;145-189.
5. Garden J, O’Banion M, Shelnitz L, et al. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA 1988; 259:1,199-1,202.
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