OR Nurses share their perception of surgical smoke dangers

Despite the risks associated with surgical smoke, evacuation devices have yet to be implemented in most operating rooms. A survey conducted by Stryker Instruments sought to quantify the level of OR nursing knowledge regarding surgical smoke exposure and the barriers around smoke evacuation system use.

Karen Giuliano, RN, PhD*, Steve Docsa, Randee Randoll and J. Cris Salinas, MD, surveyed registered nurses at the 2017 AORN Global Conference & Expo, April 1 to April 5, 2017, in Boston, to assess their thoughts on surgical smoke and evacuation machines.

An Institutional Review Board determined the research as exempt and OR nurse participation was anonymous and voluntary. Researchers used the Turning Technologies polling and response program and used the Roy Adaptation Model to provide the theoretical framework for the study. Each survey consisted of five questions focused on demographics or surgical smoke perception

The 212 survey participants issued a total of 198 responses per question. Ninety-three respondents worked for a community hospital and 51 respondents worked for a university medical center. One hundred and ten respondents were RNs or RN first assistants and 42 were clinical managers or senior nurse executives.

Eighty-six percent of respondents acknowledged the dangers associated with surgical smoke. Concerning smoke evacuation equipment use, 25 percent of respondents used the equipment for all procedures, 53 percent for high-risk procedures and 22 percent didn’t use the equipment.

Respondents identified major barriers to utilizing smoke evacuation equipment. The responses were broken down by staff registered nurses (96) or nurse leaders (20):

  • 14 percent of nurses cited a lack of education on the dangers of surgical smoke
  • 33 percent of nurses and 6 percent of leadership said facility leaders dictated equipment use
  • 9 percent of nurses and 23 percent of leadership cited equipment cost
  • 37 percent of nurses and 53 percent of leadership said surgeons dictated equipment use
  • 7 percent of nurses and 18 percent of leadership cited a lack of legislation

Expanding on the findings

The perception that scrubbed members of the surgical team are at the greatest risk for particle inhalation is common but may not be entirely accurate. While surgeons working 20 to 40 centimeters from the point of smoke generation are exposed to the highest concentrations of surgical smoke1, nurses and other OR personnel, including anesthesia providers, are more regularly exposed to surgical smoke. Surgeons operate only a few times per week2, but nurses care for patients in the OR almost every day, heightening their exposure.

The risk of surgical smoke exposure for nurses is exacerbated by the limited use of appropriate protection tools. Particle size varies greatly, and protection is dependent on the device used. Electrocautery devices create the smallest particles (0.07 micrometers)3, laser ablation creates larger particles (0.31 micrometers)4 with ultrasonic scalpels creating the largest particles (0.35-6.5 micrometers)5. Particles that are 5 micrometers or larger are deposited in the oropharyngeal walls, aerosols between 2 micrometers and 5 micrometers are present in airways, and aerosols between 0.8 and 3.0 micrometers reach the pulmonary parenchyma.6

While surgical masks provide a barrier to splashes and droplets, they do not provide protection against airborne particles since most surgical masks are designed to filter particles under 5μm.2

As stated, 86 percent of nurses in the study said they understood the dangers associated with surgical smoke, however only 25 percent of those same nurses used smoke evacuation equipment in all procedures. The results of this study could initiate discussions within hospitals or their institutions about using smoke evacuation equipment in all surgical procedures, which would bring these organizations in line with AORN recommendations.


  1. Hill DS, O’Neill JK, Powell RJ, Oliver DW, Surgical smoke – a health hazard in the operating theater: a study to quantify exposure and a survey of the use of smoke extractor system in UK plastic surgery units. J Plast Resonstr Aesthet Surg. 2012;65:911-916.
  2. Ball K, Update for nurse anesthetists Part 1. The hazards of surgical smoke. AANAJ. 2001;69:125-132.
  3. Heinsohn PA, Jewell DL, Belzer L, Bennett CH, Siepel P, Rosen A. Aerosols created by some surgical power tools: particle size distribution and qualitative hemoglobin content. Appl Occup Environ Hyg. 1991;6:773-776.
  4. Nezhat C, Winer WK, Nezhat F, Nezhat C, Forrest D, Reeves WG. Smoke from laser surgery: is there a health hazard? Laser Surg Med. 1987;7:376- 382.
  5. Ott DE, Moss E, Martinez K. Aerosol exposure from an ultrasonically activated (Harmonic) device. J Am Assoc Gynecol Laparosc. 1998;5:29-32.
  6. American College of Chest Physicians. Aerosols consensus statement. Consensus conference on aerosol delivery. Chest. 1991;100:1106-1109.
  7. Coia JE, Ritchie L, Adisesh A, Makinson Booth C, Bradley C, Bunyan D, et. al. Guidance on the use of respiratory and facial protection equipment. J Hosp Infect. 2013;85:170-182.
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