Management of Surgical Smoke in the Perioperative Setting 2 •Equipment not available •Surgeons' resistance or refusal •Noise •Cost •Ergonomic difficulty of equipment •Bulkiness --Watson, 2010 •Distraction •Physician •Equipment is Noisy •Complacent staff -- Ball, 2010 •Excessive noise --Edwards & Reiman, 2012 Individual Innovativeness Characteristics (Perioperative staff characteristics) Perceptions of Attributes (Staff perceptions of smoke evacuation recommendations) Organization Innovativeness Characteristics (Organization’s characteristics) Age Relative Advantage Education level Compatibility Descriptors (locale, type) Experience Complexity Size Knowledge Trialability Complexity Training Observability Formalization Presence of respiratory problems Barriers to practice Interconnectedness Leadership support Barriers to practice No compliance Full compliance Compliance with research-based smoke evacuation recommendations * Based on Roger’s Diffusion of Innovations model. Reprinted with permission from Kay Ball, PhD, RN, CNOR, FAAN. Key indicators of compliance: Education Leadership support Easy to follow policies Regular internal collaboration (Ball, K . 2010) 150 different chemicals identified in surgical smoke (Pierce, et al. 2011) Smoke plume and aerosols contain 95% water vapor Water vapor is itself not harmful, but acts as a carrier Gaseous toxic compounds Bio-aerosols Dead and live cellular material (including blood fragments) Viruses Carbonized tissue Bacteria 150 Chemical constituents of plume include: Acrolein Benzene Carbon Monoxide Formaldehyde Hydrogen cyanide Methane Toluene Polycyclic aromatic hydrocarbons (PAH) Carbonized tissue Blood Intact virus and bacteria (HIV, HPV, Hepatitis) 77% of Surgical Smoke Particles are less than 1.1 microns Human Immunodeficiency Virus Human Papilloma Virus Hepatitis B Others Tobacco Smoke = 0.15 micron = 0.055 micron = 0.042 micron = 0.1-3.0 micron Surgical Smoke = 0.1-5.0 micron Bacteria = 0.3-15.0 micron Lung Damaging Dust = 0.5-5.0 micron Smallest Visible Particle = 20 micron Smoke is evenly distributed throughout the operating room Smoke particles can travel about 40 mph When ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet It takes 20 min after the activation of the ESU for the concentration will return to the baseline level (Nicola, et al. 2002). “Each year, an estimated 500,000 workers, including surgeons, nurses, anesthesiologists, and surgical technologists, are exposed to laser or electrosurgical smoke.” Laser/Electrosurgery Plume. Occupational Safety and Health Administration (OSHA) Quick Takes. United States Department of Labor http://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed Dec 5, 2012) Eye, nose, throat irritation Headaches Nausea, dizziness Runny nose Coughing Respiratory irritants Fatigue Skin irritation Allergies Using the CO2 laser on one gram of tissue is like inhaling the smoke from three cigarettes in 15 minutes. Using ESU on one gram of tissue is like inhaling smoke from six cigarettes in 15 minutes. (Tomita et al., 1989) Perioperative staff have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010) Allergies Sinus infections/problems Asthma Bronchitis Soft contact lenses can absorb toxic gases produced by surgical smoke. Recommendation made by an OSHA safety violation not related to plume, 1990 44-year old laser physician developed laryngeal papillomatosis Biopsy identified the same virus type as anogenital condyloma Hallmo, et al (1991) Levels of carboxyhemoglobin of patients who underwent laparoscopic procedures using laser were significantly elevated. (Ott, 1998) Carbon monoxide levels increase in the peritoneal cavity and exceed recommended exposure limits. (Beebe et al 1993) AORN ANSI ECRI NIOSH/CDC OSHA Joint Commission “Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.” Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141. Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156. Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184. Airborne Contaminants: Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any residual plume escaping capture. Independent, nonprofit organization Researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care Electrosurgery smoke is overlooked The spectral content of laser and ESU smoke is very similar https://www.ecri.org/ accessed 12/13/12 The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site The smoke evacuator should be ON (activated) at all times when airborne particles are produced Follow Standard Precautions General Duty Clause: Employer MUST provide a safe workplace environment! The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors. Note: Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide. Environment of care. In Comprehensive Accreditation Manual: CAMH for Hospitals. The Official Handbook. Oakbrook Terrace, IL Joint Commission; 2009: EC-6-EC-6. Smoke Evacuation Methods in the Perioperative Setting In-line filters Smoke evacuator systems Laparoscopic filtering devices Simple Evacuate less than five cubic feet per minute (CFMs) Effective for small amounts of smoke Use and change as recommended by the manufacturer’s instructions Use standard precautions when changing and disposing of in-line filters To wall suction > From the patient> Example of an ULPA filter (add picture) 31 Irrigation/Aspiration System Active System Passive System Strategies for Success Communication with Surgeon and Perioperative Team members Plan for Smoke Evacuation Equipment and Optimal placement of equipment Patient and Team member Smoke Protection Methods Relevant information about smoke evacuation and equipment used Education and Competency Equipment Service Reports We claim to be a “smoke-free” campus… …so why aren’t we?