Management of Surgical Smoke in the Perioperative Setting
Jan 20, 2016
Management of Surgical Smoke
in the Perioperative Setting
2
•Equipment not available
•Physician
•Equipment is Noisy
•Complacent staff-- Ball, 2010
•Surgeons' resistance or refusal
•Cost
•Bulkiness
•Excessive noise--Edwards & Reiman, 2012
•Noise
•Distraction
•Ergonomic difficulty of equipment--Watson, 2010
Individual Innovativeness Characteristics
(Perioperative staff characteristics)
Perceptions of Attributes
(Staff perceptions of smoke evacuation recommendations)
Organization Innovativeness Characteristics
(Organization’s characteristics)
No compliance
Full compliance
Age
Education level
Experience
Knowledge
Training
Presence of respiratory problems
Relative Advantage
Compatibility
Complexity
Trialability
Observability
Barriers to practice
Descriptors (locale, type)
Size
Complexity
Formalization
Interconnectedness
Leadership support
Barriers to practice
Compliance with research-based smoke evacuation recommendations
* Based on Roger’s Diffusion of Innovations model. Reprinted with permission from Kay Ball, PhD, RN, CNOR, FAAN.
Key indicators of compliance:EducationLeadership supportEasy to follow policiesRegular internal collaboration
(Ball, K . 2010)
150 different chemicals identified in surgical smoke (Pierce, et al. 2011)
Smoke plume and aerosols contain 95% water vapor
Water vapor is itself not harmful, but acts as a carrier
Gaseous toxic compoundsBio-aerosolsDead and live cellular material (including
blood fragments)Viruses Carbonized tissueBacteria
150 Chemical constituents of plume include:
Acrolein BenzeneCarbon MonoxideFormaldehydeHydrogen cyanideMethaneToluenePolycyclic aromatic hydrocarbons (PAH)
Carbonized tissueBloodIntact virus and bacteria (HIV, HPV, Hepatitis)
77% of Surgical Smoke Particles are
less than1.1 microns
Human Immunodeficiency Virus = 0.15 micronHuman Papilloma Virus = 0.055 micronHepatitis B = 0.042 micronOthers
Tobacco Smoke = 0.1-3.0 micronSurgical Smoke = 0.1-5.0 micronBacteria = 0.3-15.0 micronLung Damaging Dust = 0.5-5.0 micronSmallest Visible Particle = 20 micron
Smoke is evenly distributed throughout the operating room
Smoke particles can travel about 40 mphWhen ESU is activated, the concentration of
the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feetIt takes 20 min after the activation of the ESU
for the concentration will return to the baseline level (Nicola, et al. 2002).
“Each year, an estimated 500,000 workers, including surgeons, nurses, anesthesiologists, and surgical technologists, are exposed to laser or electrosurgical smoke.”
Laser/Electrosurgery Plume. Occupational Safety and Health Administration (OSHA) Quick Takes. United States Department of Labor
http://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed Dec 5, 2012)
Eye, nose, throat irritationHeadachesNausea, dizzinessRunny noseCoughingRespiratory irritantsFatigueSkin irritationAllergies
Using the CO2 laser on one gram of tissue is like inhaling the smoke from three cigarettes in 15 minutes.
Using ESU on one gram of tissue is like inhaling smoke from six cigarettes in 15 minutes.
(Tomita et al., 1989)
Perioperative staff have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010)
AllergiesSinus infections/problemsAsthmaBronchitis
Soft contact lenses can absorb toxic gases produced by surgical smoke.
Recommendation made by an OSHA safety violation not related to plume, 1990
44-year old laser physician developed laryngeal papillomatosis
Biopsy identified the same virus type as anogenital condyloma
Hallmo, et al (1991)
Levels of carboxyhemoglobin of patients who underwent laparoscopic procedures using laser were significantly elevated. (Ott, 1998)
Carbon monoxide levels increase in the peritoneal cavity and exceed recommended exposure limits. (Beebe et al 1993)
AORNANSIECRI
NIOSH/CDCOSHA
Joint Commission
“Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.”
Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141.
Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156.
Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184.
Airborne Contaminants:Shall be controlled by the use of ventilation
(ie., smoke evacuator). Respiratory protection for any residual plume escaping capture.
Independent, nonprofit organization Researches the best approaches to improving
the safety, quality, and cost-effectiveness of patient care
Electrosurgery smoke is overlookedThe spectral content of laser and ESU smoke
is very similar https://www.ecri.org/ accessed 12/13/12
The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site
The smoke evacuator should be ON (activated) at all times when airborne particles are produced
Follow Standard Precautions
General Duty Clause:
Employer MUST provide a safe workplace
environment!
The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.
Note: Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide.
Environment of care. In Comprehensive Accreditation Manual: CAMH for Hospitals. The Official Handbook. Oakbrook Terrace, IL Joint Commission; 2009: EC-6-EC-6.
Smoke Evacuation Methodsin the Perioperative Setting
In-line filtersSmoke evacuator systems
Laparoscopic filtering devices
Simple Evacuate less than five cubic feet per minute
(CFMs) Effective for small amounts of smoke Use and change as recommended by the
manufacturer’s instructions Use standard precautions when changing
and disposing of in-line filters
From the patient>
To wall suction >
Example of an ULPA filter
(add picture)
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Irrigation/Aspiration SystemActive SystemPassive System
Strategies for Success
Communication with Surgeon and Perioperative Team members
Plan for Smoke Evacuation Equipment and Optimal
placement of equipmentPatient and Team member
Smoke Protection Methods
Relevant information about smoke evacuation and equipment used
Education and CompetencyEquipment Service Reports
We claim to be a “smoke-free” campus…
…so why aren’t we?