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A Short Trial on Surgical Plume Evacuation
Sick of your lungs being the smoke filtration system
OR just plain sick of the smell?
SMOKE EVACUATION TRIAL
Anne Ford
A bit of history
Study: USA National Institute for Occupational Safety and Health: 1990
 Studies conducted to detect harmful chemicals in OR smoke
Findings:
 Benzene levels above recommended limits
 Several harmful hydrocarbons detected
 Most Disturbing: Hydrogen Cyanide (molecule found in rat poison) levels 10 times
recommended limit
Laser Vs. Electrosurgical Smoke
Historical Perspective
1960’s: Introduction of thermal lasers brings hazards of
surgical smoke into question
Likely due to intensity of smoke plume
1980’s: Nursing community begins to take issue with
smoke created during Electrosurgery
Recent Findings: Electrosurgical smoke = potentially
More harmful than Laser smoke
Pre Trial
 A questionnaire was given to 30 staff to ascertain
current knowledge of electrosurgical plume content
and hazards to their health.
 Education was then conducted in the next week and
the same questionnaire repeated a week and a half
later.
 The pre education questionnaire return was 90% but
the post education questionnaire return was only 25%.
Pre and post education questionnaire






Do the Surgeons in your specialty use a
method of smoke evacuation in the operating
room?
If yes or sometimes, what method of smoke
evacuation is used ?
What specialty do you work in? Please
indicate all specialties in which you work if
more than one.
Is the use of smoke evacuation devices
mandated through Workplace Health and
Safety legislation .
Has ACORN has published a standard for
Surgical Plume?
Identify which of the following produces
surgical plume:
Lasers, Electrosurgical units, High speed
burrs, drills, saws, Ultrasonic devices
Do you wear a mask in the operating
room?
What type of face mask do you
wear?
 Does the face mask that you wear
protect you from the inhalation of
surgical smoke?
Is surgical plume hazardous to
healthcare professionals working in the
operating room?
Would you advocate for the use of
smoke evacuation systems in the
operating room?
Are the carcinogenic properties in
cigarette smoke and surgical plume
comparable?
Are you able to identify any of the
chemicals in surgical plume?
The Trial
 The trial was run over 12 operational days in random operating rooms to gauge
compliance of smoke evacuation during procedures. There were 35 procedures
in 4 specialties in 23 operating rooms.
 Surgeons were asked to evaluate the efficacy of smoke evacuation and noise
levels of the machine. There were 31 evaluations returned.
 Nursing staff asked to indicate the driver of using smoke evacuator devices , the
specialty, type of device and compliance on a basic audit tool.
 Compliance was indicated as ‘fully compliant, partially compliant, not
compliant or not applicable’.
What’s the big deal?
 Benzene
Carbon Monoxide
 Formaldehyde
Hydrogen Cyanide
 The above Chemicals represent 4 of the 6 Most
Prominent Chemicals found in Cigarettes
 ALL of which are Present in Surgical Plume
Concerning Smoke Contents
 Benzene, Formaldehyde, Carbon Monoxide,
Hydrogen Cyanide, Methane, Phenol, Styrene,
Toluene,
 Human Papilloma virus, Bovine Papilloma virus, Viral
Matter (Hep B, Hep C and HIV) All Found in Surgical
Plume
Conclusion:
 Surgical Plume Does contain harmful Particulate
Face masks or Evacuators or both?
 Smoke Particles: As small as 0.1 microns in diameter
(study shows 77% of all particles were under 1.1
microns)

Allows particles to be deposited deep within respiratory tract
 Viruses: Range in size from 0.002 microns to 0.04
microns in diameter
 Bacteria: 3 microns
 Surgical Masks: 0.1 micron filtration with a 7 minute
lifespan
 HOW WELL DOES YOUR MASK FIT?
ACORN STANDARDS
 S20
 Statement 1.
 “Personnel shall utilise appropriate equipment and
procedures to prevent exposure to surgical plume”
 Statement 2.
 “Surgical plume shall be confined and contained at the
 at the time it is being generated”
 Statement 3.
 “Policies and procedures shall be developed and
implemented in a health care facility where energy-based
devices are in use.”
Results
Pre Education














Do the Surgeons in your specialty use a method of smoke
evacuation in the operating room? Sometimes 60%
If yes or sometimes, what method of smoke
evacuation is used
stackhouse, sucker, laprascopic
What specialty do you work in? Please indicate all specialties in
which you work if more than one.
Most indicated all
Is the use of smoke evacuation devices mandated through
Workplace Health and Safety legislation 50% not sure
ACORN has published a standard for Surgical Plume? 65%
yes
Identify which of the following produces surgical plume:
Lasers, Electrosurgical units, High speed burrs, drills
saws, Ultrasonic devices
ESU 70%
Do you wear a mask in the operating room? Yes 70%
What type of face mask do you wear?
General 70%
Does the face mask that you wear protect you from the
inhalation of surgical smoke?
45% yes 45 % no
Is surgical plume hazardous to healthcare professionals working
in the operating room?
99% yes
Would you advocate for the use of smoke evacuation systems in
the operating room? 80% yes
Are the carcinogenic properties in cigarette smoke and surgical
plume comparable? 60% yes
Are you able to identify any of the chemicals in surgical plume?
Post Education














Do the Surgeons in your specialty use a method of smoke
evacuation in the operating room? Sometimes 50%
If yes or sometimes, what method of smoke
evacuation is used
suction, evacuator
What specialty do you work in? Please indicate all specialties in
which you work if more than one.
Most indicated all
Is the use of smoke evacuation devices mandated through
Workplace Health and Safety legislation 50% yes
ACORN has published a standard for Surgical Plume? 100%
yes
Identify which of the following produces surgical plume:
Lasers, Electrosurgical units, High speed burrs, drills
saws, Ultrasonic devices
increase in ‘yes ‘answers
Do you wear a mask in the operating room? 100% yes
What type of face mask do you wear? Fluid shield 75%
Does the face mask that you wear protect you from the
inhalation of surgical smoke?
95% no
Is surgical plume hazardous to healthcare professionals working
in the operating room? 100% yes
Would you advocate for the use of smoke evacuation systems in
the operating room? 95% yes
Are the carcinogenic properties in cigarette smoke and surgical
plume comparable? 100 % yes
Are you able to identify any of the chemicals in surgical plume?
Audit results
Compliance
Barriers
 The audit showed the major
 Separate education sessions
driver in using smoke
evacuation at the site of an
open procedure was nursing
staff most cases.
 Laparoscopic plume
evacuation was a routine
exercise driven by surgeons
more for visibility than
chemical hazard.




of medical and nursing staff.
Historical attitudes.
Resistance from a particular
specialty.
Low questionnaire return
post inservice from nursing
staff.
A more comprehensive
survey in progress at the same
time.
Variables
The size of the cohort
completing the questionnaire
prior and post education.
Skill mix of staff completing
the first questionnaire.
It is not known if the same
staff who completed the ‘post’
questionnaire attended the
education session.
Observation did not reflect the
post education questionnaire
results.
Conclusions
 It is clear that there are viable chemicals in surgical
plume that we do not want in our lungs.
 It is also clear that nurses (and medical staff) have not
considered the risks associated with surgical plume.
 Nurses can provide the equipment but we need
Medical staff on board as well.
 Education on the current research related to surgical
plume needs to continue just as it has about cigarette
smoke for the protection of staff and patients.
 In a climate of budgetary constraint care can still be
taken to eliminate surgical plume as much as possible.
Bibliography
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
ACORN Standards and Guidelines, 2012
AORN Journal May, September, October, 2012 (Workplace Safety Equals Patient Safety.
Implementing AORN recommended Practices for Minimally Invasive Surgery. Implementing AORN
recommended Practices for Laser Laser safety.)
Ball K. Complications with Surgical Smoke Evacuation guidelines: Implications for Practice. AORN
Journal Vol.92 No. 2 August 2010
Ball K. surgical smoke evacuations Guidelines: Compliance Among Perioperative Nurses. AORN
Journal Vol 92 No 2, August 2010.
Technology and Engineering (Urology). Chemical Composition of Gases Surgeons are Exposed to
During Endoscopic Urological Resections, 2009.
Dissemination of Melanoma Cells within Electrocautery Plume. The American Journal of surgery,
1999.
Surgical smoke – a health hazard in the operating theatre: A study to quantify exposure and a
survey of the use of smoke extractor systems in UK plastic surgery units. Journal of Plastic,
Reconstructive & Aesthetic Surgery, 2012.
Surgical Helmets & SARS infections. Derrick & Gommersall, Prince of Wales Hospital Hong Kong.
Emerging Infectious Diseases on line Feb., 2004.
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