Your OR should have a smoke evacuator

Outpatient Surgery Magazine (ghostwritten)

Smoke-filled rooms tend to breed politics.

If you are coughing and wheezing from the smoke generated by a laser or electrosurgical unit in your OR, it might be time to clear the air with a little discreet political work within your organization.

Go to your supervisor and make your case. While lasers have brought medical enormous progress that we would never want to give up, they produce some very noxious fumes when they burn through human tissue . One study found that the smoke from burning one gram of tissue can harm your lungs as much as smoking three cigarettes.

You can build a strong case for purchasing the best protection available, a freestanding smoke evacuator at a cost of about $1,600 to $4,000.

But your work is not over yet. You still need to convert your surgeons. They will decide whether the machine actually is used. Many smoke evacuators installed with the best of intentions end up gathering dust in the closet.

Unconverted surgeons shouldn't be blamed for being suspicious about yet another contraption they could trip over on the operating room floor.

After all, they have been working for years with smoke from a laser or ESU billowing around them and maybe no protection whatsoever, except a common surgical mask. When you warn them about the smoke, they might point out they are closer to it than anyone else. If they aren't complaining, why should you?

Well, not so long ago cars came without seatbelts, syringes came without guards, and we didn't complain about that, either. But times have changed. We found out more about the risks and we reconsidered our stance.

If he is willing to hear you out, you might also gently remind your surgeon that while he may be closest to the plume, scrub nurses probably breathe in more of it. They tend work a greater number of cases per week than doctors.

Surgical smoke is nasty-smelling. Anyone who has breathed it in -- as I have -- knows the pungent odor, like burnt hair. You can feel it all the way down into your lungs.

But fortunately, I haven't needed to campaign for protections here at the Laser and Surgical Services At Center for Sight in Sarasota, Fla., a busy eye surgery center in Sarasota , Fla. We have five ophthalmologists perform more than 10,000 procedures a year in two ORs.

A surgeon who's taken up protections

Most of our surgeons do not use a smoke evacuator because laser eye surgery produces a minimal amount of plume. But one surgeon, John Fezza, M.D. , specializes in plastic surgery of the face, which involves a fair amount of harmful smoke.

Dr. Fezza, however, never fought against buying a smoke evacuator. In fact, when our center opened in January 2001, he brought with him a smoke evacuator he had already been using for five years. We just replaced it this year.

His machine is about the size of a small wastebasket placed on its side and makes almost as much noise as a vacuum cleaner, but it goes on only when there is smoke. An assistant holds the intake tube two inches from the site of surgery to swallow the entire plume.

Dr. Fezza told me how he came to acquire his evacuator. Back when he was first using a Co2 laser, he would go home at night wheezing and coughing. He said his lungs felt congested, as though he had just puffed down a few cigarettes.

Like cigarette smoke in a bar, the smell attaches to you hair, clothes and exposed skin. The smoke can leave an irritating feeling in your nostrils and even make you nauseated.

“I really worried about having the same problems that a smoker would get, such as emphysema or lung cancer,” Dr. Fezza told me. In fact, he found out that he has adult-onset asthma and needed to take strong steps to protect himself.

He can't understand how other doctors could do his surgeries without the machine and leave their staff unprotected. “If you have no evacuation system you're really doing yourself bodily harm,” he says. “Just for general health you should use it.”

How surgical smoke harms you and your staff

Half a million OR workers are exposed to the smoke each year, including surgeons, nurses, anesthesiologists and surgical technologists . One study shows that surgical nurses may be exposed to surgical smoke for up to 90% of their assigned work hours.

We are only beginning to understand the effect of the smoke. Lasers have been around for a few decades and ESUs a little longer, compared with centuries when the only surgical tool was a sharp knife.

Heating tissue to about 100 degrees Celsius, a laser or ESU emits a plume containing mostly water vapor. In an hour-long procedure, smoke is produced during a total of just 10 to 15 minutes. But without proper evacuation, it can hang in the room for as long as 20 minutes.

Surgical plumes have contents similar to other smoke plumes, including carbon monoxide, polyaromatic hydrocarbons and a variety of trace toxic gases. One study reported in the British Journal of Surgery showed that laser smoke contained HIV DNA that remained viable for 14 days. Researchers have also suggested that the smoke may act as a vector for cancerous cells that could be inhaled by the surgical team.

But it has been difficult for researchers to establish a solid link between surgical smoke and illnesses. For example, it's hard to prove that an OR tech contracted emphysema from surgical smoke and not for outdoor air pollution or shared cigarette smoke.

Experts on surgical smoke, however, have noted a link in at least two cases, both involving physicians contracting pathogens.

One study cites a European doctor who contracted lesions from human papilomavirus, or HPV, a variant of genital warts, on his vocal chords. And two ophthalmologists are believed to have contracted idiopathic thrombocytopenic purpura, a condition in which the body's immune system produces antibodies that attack and destroy platelets.

Safety measures that fall short

People tend to think they are already taking adequate precautions against surgical smoke, but these measures cannot trap the very fine particles found in smoke.

For example, the common surgical mask is great at blocking relatively large droplets from coughing, sneezing and speaking, but not particles of less than 5 microns in diameter. The Occupational Safety and Health Administration states that “surgical masks used to prevent contamination of the patient are not certified for respiratory protection of medical employees.”

To afford some protection from smoke, OR personnel should wear special ventilated laser masks , which Dr. Fezza and his staff use in our facility. They employ an adhesive seal around the nose and have finer filters that can trap smaller particles. But even these masks “ should not be viewed as absolute protection from chemical contaminants,” according to the Association of Operating Room Nurses .

People also try to suck smoke out of the room through wall units that are located in every OR, to be used primarily to remove liquids. Provided that you install an in-line filter to trap the smoke, AORN recognizes this protection “in situations in which minimal plume is generated.”

But wall units are not powerful enough to draw out the large amounts of smoke produced in plastic surgery, for example, according to Penny Smalley, a risk management consultant at Technology Concepts International in Chicago . Smalley says fat cells produce more smoke than skin, and operations like breast reductions, remove a great deal of fat.

How can you tell if your wall unit is effective? AORN says if you can smell an odor , you are not capturing the smoke adequately. This is also a good test for a freestanding smoke evacuator.

What you need from a smoke evacuator

You can take all kinds of precautions, but the gold standard for protecting your staff against surgical smoke is the freestanding smoke evacuator with a hose that ventilates directly at the site of surgery.

You can choose from a wide variety of manufacturers that have been continually refining their models so that they are smaller, quieter and easier to use.

The American National Standards Institute, a private body that identifies voluntary standards across many industries, endorses this type of machine.

“Airborne contaminants shall be controlled by the use of ventilation and respiratory protection,” ANSI says. “Local exhaust ventilation is used to capture airborne contaminants as near as practicable to the site of evolution to produce an effective removal rate.”

Now, when you buy a laser or ESU, the assumption is that you will need to get a smoke evacuator. They are often sold as a package. In fact, we bought our evacuator, a Stackhouse VersaVac, manufactured by Viasys Healthcare Medsystems based in Wheeling , Ill. , from Nidek, the Japanese-based medical laser manufacturer.

Our evacuator is compact: 9 inches wide by 17 inches deep by 9.5 inches high. Alison Sanders, senior product marketing manager for Stackhouse products, tells me the VersaVac is a little less powerful than the company's top-of-the-line VitalVac, but both use the same Ultra Low Penetrating Air (ULPA) filter, a must for capturing fine-plume particles.

Independent government and private evaluators say the ULPA filter can capture 99.999% of all material as small as 0.12 microns in diameter in a machine with the proper capture velocity, which should be 100 to 150 feet per minute at the inlet nozzle .

When you change the filter, you will notice traces of dark brown sediment, which show that your evacuator is working. “That would otherwise be in your lungs,” Dr. Fezza says.

The machine's powerful motor is almost as noisy as a household vacuum cleaner. That can make it hard to communicate in the OR and or play music during the operation, as many surgeons like to do. But manufacturers have been taking steps to reduce the noise and have added switching mechanisms to the machines so that they can be turned off whenever they are not in use.

Almost all evacuators now can be easily turned on and off through a foot pedal, and some do it automatically whenever the laser or ESU turns goes on or off.

Surgeons don't welcome having another machine on the OR floor with cables to trip over, so some makers have designed evacuators that can be hung from the ceiling, with the intake hose hooked up to the surgery boom overhead.

In many cases in my own facility, someone has to hold the nozzle, which has to be at most two inches away from the source of the smoke. But this is not a big cost for us because we use people who are in the OR already, such as the circulating nurse or the first assist, and the holding work is very intermittent. It is so much a part of what we do now that I rarely hear the old joke, “This job sucks.”

At some facilities, surgeons clip the nozzle to rigid piece in the field of surgery, such as a laryngoscope, and even the patient's surgical gown. Manufacturers have also designed surgical “pens” that can piggy-back the suction nozzle, but this the only works for electrosurgery and not laser surgery. Also, the hose can only be ¼ inch wide, compared with 1¼ inches for the widest hose.

Another innovation is models that show when you need to change the filter, which can reduce the cost of changing after each procedure. It costs $10 to $15 each time you replace the filter and nozzle.

Smoke evacuators can also be used in laparoscopic surgery. To see what they are doing, s urgeons normally release the smoke periodically through a trocar valve. Rather than let the plume into the air, the trocar value is hooked up directly to the smoke evacuator.

Making your case for smoke protections

In you want smoke protections, your first step is to talk with your surgeon or your immediate supervisor. If that doesn't work, you might then talk to the administrator in a small facility or the laser safety officer in a large hospital.

They'll want to know if freestanding smoke evacuators are required under federal regulations. The answer is a qualified maybe.

The Occupational Safety and Health Administration oversees workplace safety for all industries and has specific healthcare regulations in such areas as containment of bloodborne pathogens.

OSHA officials have said that a case for surgical smoke protections could be made under the agency's “general duty clause,” an umbrella regulation stating that workplaces should be “free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

Also, because some living viruses have been detected in surgical smoke, OSHA officials have at various times suggested that this area might be subject bloodborne pathogen regulations, but this interpretation remains controversial.

But AORN officials and other experts say no one has successfully filed a complaint with OSHA about inadequate surgical smoke protection.

OSHA fines only a few employers in all industries each year. They can be fined up to $7,000 for each “serious” and “other than serious” violation and up to $70,000 for each “willful” violation. Willful violations also can lead to the possibility of a criminal action, with a fine of up to $250,000 for an individual or $500,000 for a corporation.

Even lacking OSHA standards, Penny Smalley, the Chicago risk management consultant, says surgical techs could cite industry standards like ANSI's in a civil suit against a recalcitrant employer. But Smalley does not know of any such cases.

The fact is, non-regulatory warnings of the hazards of surgical smoke have been issued by the Centers for Disease Control and Prevention, the CDC's National Institute for Occupational Safety and Health, and even OSHA itself.

AORN sets down the most comprehensive standards. ”An evacuation system should be used to remove surgical smoke,” an AORN recommended practice states. “Placement of the evacuator suction...should be as close to the source of the smoke as possible to...maximize smoke capture and enhance visibility at the surgical site.”

Now the job of spreading the work on surgical smoke may get easier, thanks to a new initiative between OSHA, the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission Resources, a JCAHO affiliate that conducts educational programs .

In August, the three organizations announced that they have joined forces to educate the health care community on safety and health issues for healthcare workers, including airborne hazards.

The groups say they will provide education and compliance assistance to healthcare organizations and others with information and access to training resources. The announcement did not provide a timetable for the effort.

Now can you make a strong case for surgical smoke protections?

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