Management of Surgical Smoke in the Perioperative Setting

1. Management of Surgical Smoke in the Perioperative Setting

2. Service/Surgeon Compliance

3. Barriers to Compliance

4. Compliance Model Individual Innovativeness Characteristics (Perioperative staff characteristics) Perceptions of Attributes (Staff perceptions of smoke evacuation recommendations) Organization Innovativeness Characteristics (Organization’s characteristics) 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 No compliance Full compliance 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.

5. Smoke Evacuation Compliance Study Key indicators of compliance: • Education • Leadership support • Easy to follow policies • Regular internal collaboration (Ball, K . 2010)

6. Composition of Surgical Smoke 150 different chemicals identified in surgical smoke (Pierce, et al. 2011)

7. Water Vapor • Smoke plume and aerosols contain 95% water vapor • Water vapor is itself not harmful, but acts as a carrier

8. Content of Surgical Smoke • Gaseous toxic compounds • Bio-aerosols • Dead and live cellular material (including blood fragments) • Viruses • Carbonized tissue • Bacteria

9. Toxic Gases 150 Chemical constituents of plume include: • Acrolein • Benzene • Carbon Monoxide • Formaldehyde • Hydrogen cyanide • Methane • Toluene • Polycyclic aromatic hydrocarbons (PAH)

10. Particulate Matter • Carbonized tissue • Blood • Intact virus and bacteria (HIV, HPV, Hepatitis)

11. Size of Particulate Matter 77% of Surgical Smoke Particles are less than 1.1 microns

12. Virus Sizes Human Immunodeficiency Virus = 0.15 micron Human Papilloma Virus = 0.055 micron Hepatitis B = 0.042 micron Others • Tobacco Smoke = 0.1-3.0 micron • Surgical Smoke = 0.1-5.0 micron • Bacteria = 0.3-15.0 micron • Lung Damaging Dust = 0.5-5.0 micron • Smallest Visible Particle = 20 micron

13. Particle Distribution • Smoke is evenly distributed throughout the operating room • Smoke particles can travel about 40 mph • When ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet • It takes 20 min after the activation of the ESU for the concentration will return to the baseline level (Nicola, et al. 2002).

14. Worker Safety:Exposures to Smoke/Plume “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)

15. Reported Health Effects • Eye, nose, throat irritation • Headaches • Nausea, dizziness • Runny nose • Coughing • Respiratory irritants • Fatigue • Skin irritation • Allergies

16. Inhaling Surgical Smoke • 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)

17. Respiratory Problems Perioperative staff have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010) • Allergies • Sinus infections/problems • Asthma • Bronchitis

18. Chemical Effect Soft contact lenses can absorb toxic gases produced by surgical smoke. Recommendation made by an OSHA safety violation not related to plume, 1990

19. Case Report 44-year old laser physician developed laryngeal papillomatosis Biopsy identified the same virus type as anogenitalcondyloma Hallmo, et al (1991)

20. Patient Safety: Laparoscopic Surgical Procedures • 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)

21. Healthcare and Regulatory Standards and Recommendations • AORN • ANSI • ECRI • NIOSH/CDC • OSHA • Joint Commission

22. AORN Recommended Practices “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.

23. ANSI Standard 7.4 of Z136.3 - 2011 (Safe Use of Lasers in Healthcare) Airborne Contaminants: Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any residual plume escaping capture.

24. ECRI • Independent, nonprofit organization • Researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care • Electrosurgery smoke is overlooked • The spectral content of laser and ESU smoke is very similarhttps://www.ecri.org/ accessed 12/13/12

25. NIOSH/CDC: Work Practices • 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

26. OSHA General Duty Clause: Employer MUST provide a safe workplace environment!

27. Joint Commission • 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.

28. Smoke Evacuation Methods in the Perioperative Setting • In-line filters • Smoke evacuator systems • Laparoscopic filtering devices

29. In-Line Filter • 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

30. In-Line Filters with Wall Suction To wall suction > From the patient> Example of an ULPA filter

31. Smoke Evacuator System • (add picture)

32. Laparoscopic Filtering Systems • Irrigation/Aspiration System • Active System • Passive System

33. Strategies for Success

34. Team Briefing • Communication with Surgeon and Perioperative Team members • Plan for Smoke Evacuation • Equipment and Optimal placement of equipment • Patient and Team member Smoke Protection Methods

35. Documentation Relevant information about smoke evacuation and equipment used

36. Quality Monitoring • Education and Competency • Equipment Service Reports

37. We claim to be a “smoke-free” campus… …so why aren’t we?