Surgical Smoke Evacuation: a Survey of OR Nursing Staff

Introduction

Electrosurgery devices, laser ablation and ultrasonic scalpels are widely recognized as major advances in surgical technology. Electrosurgery is used in more than 85% of 24 million surgeries performed annually in the US.1

More than 150 different chemical constituents have been identified in surgical smoke, some with the capacity for causing human cell damage, cancer and infectious disease.2

Smoke evacuation devices are effective for limiting exposure. However, despite AORN recommendations, smoke evacuation devices have not been implemented into routine use in most operating rooms.

The purpose of our survey was to identify the level of OR nursing knowledge regarding the risks of surgical smoke exposure, and nursing perceptions on the barriers to routine smoke evacuation system use.

Methodology

A convenience sample of OR nurses was obtained from attendees at the 2017 AORN Global Conference & Expo in Boston, MA. IRB review determined the research as exempt and OR nurse participation was anonymous and voluntary.

Survey data was collected using Turning Technologies (Youngstown, OH) polling and response program. The Roy Adaptation Model provided the theoretical framework for this study.

Each survey consisted of five questions (Table 1). Each question focused on demographics or surgical smoke perception.

QuestionType
What is your role at your hospital or medical facility?Demographic
In what type of facility do you work?Demographic
Indicate the types of procedures where you would normally use some type of smoke evacuation equipment?
Multiple Choice
Select how strong you agree or disagree with the following statement, “I understand the dangers associated with surgical smoke”?Multiple Choice
What do you think is the biggest barrier to using smoke evacuation equipment in your facility?Multiple Choice

Table 1. Survey Questions

Results

Of the 212 active participants, 198 responses were received per question, for a participation rate of 93%. Nearly half, 47% of respondents worked for a community hospital (n=93), and 26% worked for a university medical center (n=51). RNs, or RN first assistants comprised 57% of the respondents (n=110), and 22% were clinical managers or senior nurse executives (n=42).

Discussion

There is a common belief that inhaling smoke poses the greatest risk to scrubbed members of the surgical team. While surgeons working 20-40 cm from the point of smoke generation are exposed to the highest concentrations of surgical smoke3, nurses and other OR personnel, including anesthesia providers, are constantly exposed to the hazards of surgical smoke. Surgeons typically operate only a few times per week4, while nurses care for patients in the OR most days per week, heightening their exposure.

Particle size generated varies and is dependent on the device used; electrocautery creates the smallest particles (0.07μm)5, larger particles are created by laser ablation (0.31μm)6, and the largest particles are those generated by ultrasonic scalpels (0.35-6.5μm)7. Particles that are 5μm or larger are deposited in the oropharyngeal walls, aerosols between 2 and 5μm are delivered to the airways and aerosols between 0.8 and 3.0μm reach the pulmonary parenchyma.8

Surgical masks are commonly used in the OR to provide a barrier to splashes and droplets impacting the wearer’s nose, mouth and respiratory tract. However, they do not provide protection against airborne particles9since most surgical masks are designed to filter particles >5μm.4

Most, 86% of nurses in this study agreed or strongly agreed that they understand the dangers associated with surgical smoke, yet only 25% use smoke evacuation in all procedures.

The results of this study provide a reference to nurse perception on surgical smoke evacuation and may help facilitate a discussion to support hospital goals and introduce smoke evacuation to all surgical procedures in alignment with AORN recommendations.

References

  1. Ball K, “No Smoking in the OR”, Outpatient Surgery, November 2003.
  2. Pierce JS, et al, “Laser-Generated Air Contaminants from Medical Laser Applications: A State-of-the-Science Review of Exposure Characterization, Health Effects, and Control,” Journal of Occupational and Environmental Hygiene, July 2011
  3. 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.
  4. Ball K, Update for nurse anesthetics Part 1. The hazards of surgical smoke. AANAJ. 2001;69:125-132.
  5. 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.
  6. 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.
  7. Ott DE, Moss E, Martinez K. Aerosol exposure from an ultrasonically activated (Harmonic) device. J Am Assoc Gynecol Laparosc. 1998;5:29-32.
  8. American College of Chest Physicians. Aerosols consensus statement. Consensus conference on aerosol delivery. Chest. 1991;100:1106-1109.
  9. 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.