What is it?

Surgical smoke, also known as diathermy plume or cautery smoke, is a hazardous byproduct of surgeries performed using an energy-based tool – such as electrosurgery units, lasers, ultrasonic devices, burrs and high-speed electrical drills.

The rapid action of the devices heats up the target until the skin/bone/blood/tissue matter ruptures, releasing a plume of smoke into the air in the form of a (largely) visible bio aerosol that contains a mixture of noxious and toxic materials.[1]

In this article, we ask the question ‘is surgical smoke actually bad for you’?

 

Who does it effect?

It’s been estimated that over 80% of surgeries produce surgical smoke[2] with more than 500,000 Operating Room staff being exposed to smoke every year.[3]

Unsurprisingly, studies have shown that surgeons and operating staff in the immediate vicinity of surgical smoke are subject to very high levels of particle and chemical exposure.[4] However, the force at which particles are expelled through surgical smoke means that anyone in the room, including the patient, is at immediate risk of inhaling potentially hazardous substances as a result of the surgical smoke.4 One study found that particles in surgical smoke remain airborne for as long as 20 minutes afterwards, prolonging the potential risk.[5]

 

Viral hazard

Surgical smoke has the potential to aerosolize live viruses living in the subject, such as HIV, HPV and Hepatitis B, potentially putting any unprotected person in the room at risk of infection.[6] [7]

M Rioux et al share the stories of two gynecology surgeons who were diagnosed with HPV positive tonsillar cancer, traced back to pro-longed exposure to surgical smoke with poor ventilation and no form of respiratory protection.[8]

 

Particle hazard

The majority of particles inside surgical smoke are smaller than 2.5 µm, so small that they can easily be breathed in and penetrate the innermost areas of the lungs. This can cause long-term damage.

Prolonged exposure may induce acute inflammatory changes in the respiratory tract, causing pulmonary conditions such as pulmonary fibrosis, emphysema, occupational asthma and bronchitis.[9]

An American study which surveyed thousands of perioperative and general nurse nurses on their respiratory conditions, found that those that worked regularly in the operating room were twice as likely to have suffered with sinus infections and bronchitis and significantly more likely to suffer from occupational asthma and general allergies.[10]

 

Chemical hazard

In addition to the potential viral and respiratory concerns, research reveals that surgical smoke inhaled from operating on just 1 gram of tissue is equivalent of smoking 6 unfiltered cigarettes.[11] With so many operations producing surgical smoke, it’s estimated that one shift in the Operating Room is equivalent to smoking as many as 30.[12]

And like cigarette smoke, surgical smoke has the potential to contain a range of toxic and carcinogenic chemicals.[13] These include:

Acrolein, Acrylonitrile, Acrylamide, Ammonia, Benzene, Butadiene, Carbon Monoxide, Formaldehyde, Hydrogen Cyanide, Methane, Toluene and dozens more.

While levels of these toxic components are “probably” below hazardous exposure levels, many of the substances produced are known carcinogens and exposure should be avoided to minimise risk.[14]

 

The challenge

Despite decades of research and COSHH’s clear imperative that employer’s have a legal duty to do everything in their power to minimise the risk of occupational ill-health for their employees[15] – there is no national standard, with the use of controls to reduce exposure being left up to the hospital, ward or sometimes the surgeon on duty.

This currently leaves it up to the hospital, department, or sometimes surgeon, as to what measures are put in place to reduce the surgical smoke.

However, if things are to change there needs to be a greater understanding of the topic – the potential risks and the possible solutions.

 

The solution

Many scientific and medical studies have been undertaken to better understand the potential risk of surgical smoke to people’s health. While each study has their own particular focus, many recommend a three-step process for handling the potential hazard:[16]

1) Minimise the production of smoke

With most surgeries being necessary procedures and over 80% producing surgical smoke, not producing surgical smoke is rarely an option.  However, minimising the amount produced sometimes can be.

A recent study, titled The characterization of surgical smoke[17], studied the different levels of particulate release found in surgical smoke when operating on different parts of the body. For example, performing electrosurgery on a liver produces a much higher amount of particle matter than electrosurgery on lung tissue or skin.

Similarly, the type of surgical device used has also been shown to have an impact on the amount and size of particles produced. Electrocautery creates the smallest particles (averaging 0.07 μm), while laser surgery particles average 0.31 μm and surgical smoke created by an ultrasonic scalpel averaged between 0.35-6.5 μm.[18]

2) Evacuate the smoke

On its own, general room ventilation is not a suitable means of evacuating surgical smoke – as the smoke is not removed before it is a risk.[19] Furthermore, general room ventilation can have the unwanted side-effect of circulating the hazard around the room, rather than extracting it.

Local Exhaust Ventilation (LEV) however is proven to be much more effective at reducing the airborne particles and volatile organic compounds present in surgical smoke.[20]

Despite being highly effective, LEV has the potential to not work effectively through improper maintenance or improper use.[21]

Subsequently, much research recommends the use of RPE (respiratory protective equipment) in addition to utilizing LEV.[22] [23] [24]

3) Wear RPE

Unlike surgical masks, which offer little-to-no protection against surgical smoke; high-filtration RPE can provide an effective barrier against the particulate and virus matter found in the plume.[25]

Full Support’s Custom Fit Easimask® FFP3 respirator provides the highest level of protection, filtering at least 99% of airborne particles.

Unlike other P3 respirators, the Custom Fit features:

  • Pre-formed nose-bridge for quicker, easier donning
  • 360 inner seal for a more secure and comfortable fit
  • Dolomite tested for improved breathing resistance

Giving you a secure, comfortable fit, every time.

 

For more information on Surgical Plume, respiratory hazards in the workplace or respiratory protective equipment, get in touch.

 

 


References

[1] IFPN. (2013). IFPN Guideline for Smoke Plume. IFPN. 1012 (3), p1.

[2] https://digitalcommons.otterbein.edu/cgi/viewcontent.cgi?article=1000&context=nurse_fac

[3] K Ball, Surgical smoke evacuation guidelines, AORN J 2010 Aug;92(2) – https://www.ncbi.nlm.nih.gov/pubmed/20678599

[4] I Bruske-Hohlfield, et. al., Surgical smoke and ultrafine particles, J Occup Med Toxicol. 2008 [accessed on 24.06.2019] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621226/

[5] Brandon HJ, Young LV. Characterization and removal of electrosurgical smoke. Surg Serv Manage. 1997;3(3):14-16. [accessed 20.06.2019] https://www.surgimedics.com/Research%20Articles/Electrosurgical%20Plume/Characterization%20And%20Removal%20Of%20Electrosurgical%20Smoke.pdf

[6] Markus Karjalainen. et al (2018) The characterization of surgical smoke from various tissues and its implications for occupational safety, PLoS One 13(4), 2018 – accessed on 21.06.2019 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896939/

[7] Capizzi P.J et al, Microbiologic activity in laser resurfacing plume and debris, Lasers Surg Med 1998;23(3):172-4 – accessed on 05.07.19 https://www.ncbi.nlm.nih.gov/pubmed/9779652

[8] Rioux M, Garland A, Webster D, Reardon E. HPV positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg. 2013;42(1):54. https://doi.org/10.1186/1916-0216-42-54.

[9] Brüske-Hohlfeld I, Preissler G, Jauch KW, Pitz M, Nowak D, Peters A and Wichmann HE (2008). “Surgical smoke and ultrafine particles”. Journal of Occupational Medicine & Toxicology; 3, 31.

[10] Ball, K. (2012). Surgical smoke. Journal of Perioperative Practice . 22 (4), p124.

[11] Moot A.R., Ledingham K.M., Wilson P.F. Composition of volatile organic compounds in diathermy plume as detected by selected ion flow tube mass spectrometr. ANZ J Surg. 2007;77(1-2):20–23.

[12] Tomita Y., Mihashi S., Nagata K. Mutagenicity of smoke condensates induced by CO2- laser irradiation and electrocauterizatio. Mutat Res. 1981;89(2):145–149.

[13] https://kebomed.co.uk/files/9/making_things_clear_uk.pdf

[14] C.J.Krones et al, Chemical composition of surgical smoke, European Surgery 2007 39/2: 118-121 – https://link.springer.com/article/10.1007/s10353-006-0305-1

[15] HSE, Control of substances hazardous to health regulations 2002 (as amended), 2013 http://www.hse.gov.uk/pubns/priced/l5.pdf

[16] E.g. Joe King-Man Fan, et. al., Surgical Smoke, Asian Jorurnal of Surgery Vol 32 No. 4, pg 253-257 [accessed on 21.06.2019] https://www.sciencedirect.com/science/article/pii/S1015958409604036

[17] Markus Karjalainen, et. al., The characterization of surgical smoke from various tissues and its implications for occupational safety, PLoS One 13(4), 2018 – [accessed on 21.06.2019] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896939/

[18] I Bruske-Hohlfield, et. al., Surgical smoke and ultrafine particles, J Occup Med Toxicol. 2008 [accessed on 24.06.2019] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621226/

[19] DHHS (NIOSH) Publication Number 96-128, 1996, – accessed on 05.07.19 https://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html

[20] Joe King-Man Fan, et. al., Surgical Smoke, Asian Jorurnal of Surgery Vol 32 No. 4, pg 253-257 [accessed on 21.06.2019] https://www.sciencedirect.com/science/article/pii/S1015958409604036

[21] Garden J.M. et al. (1988). Papillomavirus in the Vapor of Carbon Dioxide Laser-Treated Verrucae. The Journal of the American Medical Association. 259 (8), p1199-1201

[22] Kevin Bree, et. al., The Dangers of Electrosurgical Smoke to Operating Room Personell, AAOHN vol 65, no. 11 2017 [first accessed on 21.06.2019] https://journals.sagepub.com/doi/full/10.1177/2165079917691063

[23] T Lee, et. al., Surgical smoke control with local exhaust ventilation, J Occup Environ Hyg, 15(4) 2018 [accessed on 21.06.2019] https://www.ncbi.nlm.nih.gov/pubmed/29283318

[24] González-Bayón L, González-Moreno S, Ortega-Pérez G. Safety considerations for operating room personnel during hyperthermic intraoperative intraperitoneal chemotherapy perfusion. Eur J Surg Oncol. Elsevier; 2006;32: 619–624. https://linkinghub.elsevier.com/retrieve/pii/S0748798306001144

[25] Erin Sanchez, Filtration efficiency of surgical masks, Graduate Theses and Dissertations 2010 [accessed on 20.06.2019] https://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=2759&context=etd

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