The days of lighting up a cigarette in airplanes and restaurants may be of a bygone era, but when it comes to the operating room, the exposure to hazardous smoke continues to flourish.

While recent studies show that the latest “silent killer” may be a conventional day in the OR, the Association of periOperative Registered Nurses Go Clear program aims to bring awareness to the harmful effects of surgical smoke and introduces guidelines to protect the health of practitioners and their patients.

The Hidden Dangers of Surgical Smoke

The dangers of inhaling surgical smoke—the byproduct generated from the use of lasers, electrosurgical pencils and ultrasonic devices—have been acknowledged by the medical community at large since the mid-70s. However, shockingly few health care facilities have hard-set requirements when it comes to utilizing scavenging systems to reduce exposure.

“We’ve evolved into a false sense of security that the smoke generated from laser surgery isn’t harmful, but the reality is, this stuff is in a different league than cigarettes,” said Mary J. Ogg, MSN, RN, CNOR, Senior Perioperative Practice Specialist at AORN.

From toxic gases, vapors, and dead and live cellular material including blood fragments and viruses, surgical smoke can wreak biological, carcinogenic, chemical and cytotoxic havoc on practitioners and their patients. To boot, its unique chemical composition makes it particularly hazardous.

“Particles generated by surgical energy devices can be smaller than 1.1 microns in size, meaning they are capable of bypassing the nasopharynx and trachea and can be deposited into the alveoli, the gas exchange regions of the lungs,” Ms. Ogg said. “Even the human papillomavirus (HPV) or the human immunodeficiency virus (HIV) have the potential to be detected in laser plume.”

A 2012 study conducted at the Royal Devon and Exeter NHS Foundation Trust illustrated that the lungs may pay a steep price for a job well done in the OR.

In an effort to quantify the exposure to surgical smoke within a plastic surgery unit, the study examined six human and 78 porcine tissue samples to find the mass of tissue ablated during five minutes of monopolar diathermy. The total daily duration of diathermy within the plastic surgery unit was electronically recorded over a two-month period. The study concluded that the smoke produced daily was “equivalent to 27-30 cigarettes” (J Plast Reconstr Aesthet Surg 2012;65:911-916).

Plastic surgeon Lisa M. Hunsicker, MD, FACS, from Denver, noted that the consequences of long hours in the OR have started to take a toll on her personal health.

“When I work by myself, we use suction retractors. But this has only been available for the past few years,” she lamented. “I’ve been operating for 22 years now, mostly without these tools. I was diagnosed with asthma in 2013. Lung cancer and pulmonary issues are definitely a top concern for me.”

Assessing the Risk for Patients

It goes without saying that patients are a fundamental component of the OR, and when it comes to exposure to surgical smoke, they are not in the clear.

A 2014 study conducted in Poland examined the chemical composition of smoke formed in the abdominal cavity in patients undergoing laparoscopic cholecystectomy. Analysis of the smoke produced during the procedure revealed higher concentrations of a wide variety of potentially toxic chemicals, including benzene, toluene, xylene, dioxins and other substances. The study concluded that “all patients undergoing laparoscopic procedures are at risk of absorbing and excreting smoke by-products” (Int J Occup Med Environ Health 2014;27:314-325).

“Even patients in other rooms sometimes ask, ‘What’s that smell?’” Ms. Ogg said. “Many can detect carbon monoxide from minimally invasive, microscopic surgery happening down the hall.”

Why Aren’t We Doing Anything?

In 1996, the National Institute for Occupational Safety and Health released a hazard alert, warning facilities of the toxicity of surgical plume and presenting several methods of control. But over two decades later, its warnings are largely ignored; surgical smoke continues to be accepted as part of the “chemical soup” that is present during the care of perioperative patients. The lack of alarm begs the question: Where are we going wrong?

“The main crux is that there’s a complete lack of education,” Ms. Ogg said. “Half of health care professionals do not have any education when it comes to understanding the effects of surgical smoke. And as always, there’s a resistance to change.”

She added that while many hospitals have the proper evacuation equipment (evacuator filters, tubing and wands), some practitioners are not even aware that these tools are at their disposal.

“There was an instance in one hospital, where [they owned] a smoke evacuator in every single room, but no one in the hospital even knew they were there, and they went unused. Most of these tools are not a burden to utilize, and yet, we remain resistant.”

Current protocol dictates that it is up to the individual practitioner to take precaution to evacuate surgical smoke, meaning that a decision made by the surgeon may put everyone else in the room—including the nurses, the anesthesiologist and the patient—at risk.

“From what I’ve seen, no one takes precautions,” Dr. Hunsicker said. “My general surgeon partners still won’t use them—they don’t value me, or themselves. We need OSHA [Occupational Safety and Health Administration] to come in and assess the pollution in the OR and document levels, then calculate risks. We need to assess the situation as we would a chemical plant. It’s an occupational health hazard.”

AORN Go Clear Program

Recognizing that the evacuation of surgical smoke should be an administrative buy-in for protecting patients and the individuals who work in ORs, AORN created the Go Clear surgical smoke-free recognition program, aiming to provide comprehensive guidelines for health care facilities. Participating facilities are given one of three designations—bronze, silver and gold—and are rated on education performance, smoke evacuation compliance, and ensuring that the facility has the proper OR equipment, namely, capture devices (wands and tubing), smoke evacuators and medical-surgical vacuums with in-line filters.

AORN’s core guidelines suggest that every health care organization should assess the perioperative risks of surgical smoke, determine hazard exposure, establish safe practices, and recommend that all perioperative team members should wear personal protective equipment (PPE) as secondary protection against residual surgical smoke.

The efficacy of PPE, however, is up for debate.

“None work,” Dr. Hunsicker noted. “You would need a self-contained suit with an alternate air source. The safest person in the OR is the patient, but only if they are intubated. They are breathing on a closed air circuit with an alternate air source.”

Outside of the Go Clear program’s mission to get more institutions on board with proper surgical plume evacuation, another cornerstone is to encourage practitioners to share their stories.

“OR nurses are twice as likely to suffer respiratory symptoms as the general population,” Ms. Ogg said. “While we can’t make a direct correlation, there might be something to hearing clusters of people say, ‘My nose is always running; my eyes are always tearing in the OR.’” She explained that as more health care practitioners tell their stories, more direct correlations can be made.

While progress is being made on an administrative level—the state of California is moving forward with legislation that would require all health care facilities to use scavenging systems—Ms. Ogg noted that far more work needs to be done.

“This is a cause that has become my lifelong commitment,” she said. “With the right combination of education and the right technology, smoke evacuation can become a seamless part of the everyday operating room.”