5 Steps to Smoke-Free Surgery

This article originally appeared in Outpatient Surgery Magazine.

Last June, Rhode Island became the first state in the nation to mandate the evacuation of surgical smoke during plume-producing procedures performed in hospitals and surgical centers. Perioperative nurses around the country celebrated the news and hoped their state would be next to protect them from dangerous pollutants that waft through the OR air. Why wait for state legislators to force your hand when you already have the authority to transform your ORs from smoky dens to smoke-free work spaces?

1. Know the risks

The long-term effects of exposure to surgical smoke may not be fully understood yet, but the list of potential hazards contained in plume reads like a sign at a toxic waste site. There's benzene, for example, which can cause anemia by suppressing the production of red blood cells, and which can also damage the immune system by altering blood levels of antibodies. There's hydrogen cyanide, which is potentially deadly, because it prevents cells from properly absorbing oxygen. There's also formaldehyde, which can cause a whole host of problems, including nasal and eye irritation, sore throats, nosebleeds, neurological effects and an increased risk of asthma.

Those are just a few of the concerns. Smoke particles travel fast — up to 40 mph. When electrosurgical units are activated, the concentration of particles can quickly increase from 60,000 particles per cubic foot to more than 1 million particles per cubic foot. It takes another 20 minutes for levels to return to normal.

It's believed that inhaling the smoke caused by cauterizing 1 gram of tissue is like smoking 6 cigarettes in 15 minutes. Carbon dioxide lasers, often used to treat skin conditions, are only about half that toxic, but how do you think your health would be affected if several times a day you smoked 3 cigarettes in a 15-minute period?

Physicians may only be exposed while they're performing a given procedure, but OR staff can be exposed for 8 to 10 hours a day. When we see surgical professionals having respiratory problems, headaches, bronchitis, eye irritations, fatigue and other maladies, we can't be sure their problems are caused by surgical smoke, but we can be pretty darned sure that the exposure isn't helping.

2. Make the case

Some surgeons push back against the use of smoke evacuators, believing the devices are obtrusive and might hamper their maneuvering around the surgical site. Staff therefore need to be able to advocate for smoke-free ORs. They could say, for example, Did you know that surgical smoke contains carcinogens and other toxins? Encourage staff to talk to the other surgeons about plume hazards and to suggest that they use the new devices. Surgeons are bound to listen.

To help the cause, hang up dramatic posters that explain the hazards of surgical smoke. Place them in areas where staff members congregate so they see and absorb the information.

Our hospital's administration had some legitimate concerns about adding smoke evacuators because we'd be wasting the disposable electrocautery pencils that already came in our surgical packs. That would be true, but what about the nurse who keeps having bronchitis and sinus issues? What about the tech who keeps getting pneumonia? What are those costing us? That recognition helped get management on board.

3. Assess the options

Talk to vendors about the cost and the design of their smoke evacuation pencils and narrow down the options to a couple for your surgeons to trial. Limiting the options limits the number of opinions you have to listen to and consider before making a purchasing decision. I know from experience that less is more when it comes to product trials. Surgeons who have balked at using smoke evacuators in the past because of concerns about how loud they are and how much they get in the way at the surgical site need to check out the latest options, which are lightweight, ergonomic and quieter than previous generations.

4. Don't forget the filters

We understood that surgical plumes could be hazardous, but we typically used suction devices to clear the smoke from the surgical field. What we didn't understand was that suctioning wasn't actually eliminating the hazard, because we weren't filtering the smoke.

We learned that to protect staff, surgical smoke needs to be pulled through a HEPA filter, or else the toxins remain present. Make sure every member of the surgical team understands that smoke has to be drawn through the HEPA filter for the smoke evacuation system to work.

5. Make it easy

Provide staff with a "smoke evacuation setup" document, which outlines the step-by-step process of preparing smoke evacuation pencils for use and encourage team members to let you know if they have any questions. Add the devices to surgeons' preference cards. That way they'll be pulled in advance and always available for smoke-producing cases.

If there was anything about our hospital's smoke-free initiative that surprised me, it was how quickly and easily our surgeons came around to incorporating evacuators into their cases. A few took a little while to make the transition, but we were pretty bold and determined. Staff would simply open up a device and hand it to them on the field. It worked — surgeons started using them until the practice became routine.

A clear improvement

After going smoke-free, the difference has been pretty remarkable. On those rare occasions when we walk into an operating room and discover that people aren't using an evacuator system correctly, it's very noticeable — like walking into a room where people have been smoking cigarettes. The first question is always, Aren't you guys using smoke evacuation in here? Working in smoke-filled ORs is now the exception, not the norm, and that lets us all breathe much, much easier.