Coleman, Scott A. BSN, RN, CNOR, CPT, AN
The primary reason hospital staff wear surgical masks in the OR is to reduce the risk of transmitting harmful bacteria and viruses from the staff to the patient and/or the surgical field.1 Respiratory protection should also be worn to reduce the risk of inhaling surgical smoke. Surgical smoke is the gaseous by-product emitted from heat-producing devices used during surgical or invasive procedures. These devices include electrosurgical units (ESUs), lasers, ultrasonic devices, and high-speed drills, burrs, and saws.2 During the procedure (cut, coagulate, vaporize, or ablate tissue), the target cells are heated to the point of boiling, causing the membranes to rupture and disperse fine particles into the air or pneumoperitoneum.3 These particles have different names, such as plume, smoke plume, diathermy plume, cautery smoke, aerosols, bioaerosols, vapors, and air contaminants.2 Although these terms have been used interchangeably, the difference between them is the particle size.
Lasers and ultrasonic devices produce plume, which contains larger particulate matter than smoke. Larger particulate matter is of more concern as a biological hazard. Smoke results from the use of electrosurgical tools; it contains a smaller particle mass than plume but is still considered dangerous because of its chemical composition.4
For the purposes of this article, all airborne surgical by-products will be referred to as “surgical smoke.” Surgical smoke can be seen by the naked eye and has an offensive smell. It's made up of 95% water or steam and 5% cellular debris in the form of particulate material.2 The particulate matter is made up of blood and tissue particles, viruses, bacteria, and chemicals. A study by Chung and colleagues found 16 compounds present in surgical smoke samples.5 Acrylonitrile, one of the compounds that was found, has toxic effects due to the formation of cyanide. Short-term effects include nausea, vomiting, headache, and lightheadedness. Long-term exposure has caused cancer in lab animals and has been associated with higher incidences of cancer in humans.3 Propylene and isobutylene, which are highly flammable chemicals, were also found. The use of local exhaust ventilation (LEV) (a smoke evacuator or wall suction with in-line ultra-low penetration air filter) and respiratory protection (a fit-tested surgical N95 filtering facepiece respirator or high-filtration mask) should used simultaneously, since neither one on their own is 100% effective in preventing surgical smoke inhalation injuries.6 The Occupational Safety and Health Administration (OSHA) offers no specific standards for surgical smoke hazards generated from lasers or ESUs.7
Clinical practice issue
The purpose of this clinical inquiry project was to answer the following question: Are OR personnel who don't use a smoke evacuator and wear the proper respiratory protection at increased risk for surgical smoke inhalation injury compared to those who use a smoke evacuator and wear the proper respiratory protection?
After completing a search of the literature using Public/Publisher Medical Literature Analysis and Retrieval System Online (PubMed), eight articles met two to three elements of the clinical question, and therefore, were retained for synthesis. All articles in this literature synthesis identified two levels of protection to prevent surgical smoke inhalation injury. The first level of protection is the use of a smoke evacuation system, and the second level is wearing personal respiratory protection, such as a basic surgical mask, high-filtration mask, or an N95 respirator. Four of the eight articles discussed surgical smoke evacuation systems, and the remaining four discussed the use of basic surgical masks, high-filtration masks, and/or N95 respirators (see Evidence synthesis table).
All eight articles show that surgical smoke is hazardous to healthcare personnel in the OR environment. Viruses, bacteria, and chemicals have been found in samples of surgical smoke, yet OSHA still hasn't mandated the use of smoke evacuation systems and the use of N95 respirators. Several studies have shown a lack of adherence to smoke evacuation recommended practices, including using respiratory protection higher than a standard surgical mask.2,8–11 Clearly, more studies, attention, and education are necessary in this area.
Clinical decisions and implications for practice
To protect against surgical smoke inhalation injuries, there are two lines of defense that should be used simultaneously during procedures that produce surgical smoke. The first is LEV, which includes wall suction and smoke evacuators. Edwards and Reiman state that there's a unanimous agreement that the first measure to protect against surgical smoke is LEV, which should be used when surgical smoke is produced.10 The consistent use of smoke evacuation systems is recommended during procedures that produce surgical smoke to prevent inhalation injuries.4 The Association of periOperative Registered Nurses (AORN) recommends a smoke evacuation system be used to remove smoke plume during open and laparoscopic procedures.11
The second line of defense is respiratory protection and shouldn't be considered as an absolute protection. All surgical masks and respirators have different filtration capabilities and should be chosen with care based on the surgical procedure and the size of organisms that will potentially be contained within the surgical smoke.8 Procedures that use an ultrasonic scalpel generate surgical smoke with particles 0.35 to 6.5 micrometers in size, and laser procedures generate particles 0.31 micrometers in size; therefore, a high-filtration mask and a smoke evacuator would be appropriate protection.2 Surgical smoke generated from a procedure using an ESU can produce particles 0.07 micrometers in size; therefore, a smoke evacuator and an N95 respirator would be considered the best protection in preventing inhalation injuries.2 Chowdhury and colleagues provide a list of infectious organisms and their sizes.12 According to the authors, the hepatitis C virus is 0.040 micrometers, hepatitis B virus is 0.042 micrometers, human papillomavirus is 0.045 micrometers, HIV is 0.180 micrometers, and Mycobacterium tuberculosis is 0.500 micrometers. According to Ulmer:
Surgical masks generally filter particles to about 5 micrometers in size. High-filtration masks, also referred to as laser masks, filter particles to about 0.1 micrometers in size. Approximately 77% of the particulate matter in smoke is 1.1 micrometers and smaller. ...viral particles can be much smaller than 0.1 micrometers.2
It's important to note that OR personnel will often select a standard surgical mask regardless of the surgical procedure being performed. AORN recommends that during procedures that generate surgical smoke, the staff should wear high-filtration surgical masks that are specifically designed to filter particulate matter that's greater than 0.1 micron in size.11 Surgeries that use ESUs produce particles 0.07 micrometers in size.2 Lasers produce particles 0.31 micrometers in size, and ultrasonic scalpels produce particles 0.35 to 6.5 micrometers in size.2 Masks and/or respirators should fit properly and should be changed for each case or more frequently as necessary. Surgical personnel should also try to avoid large areas of smoke when possible.
When it comes to preventing surgical smoke inhalation injuries in the OR, the first line of defense is smoke evacuation. Studies have shown that most nurses are more adherent to the use of wall suction versus smoke evacuators.9,10 A lack of knowledge, accessibility of equipment, noise, and resistance from physicians and healthcare institutions are some barriers in using smoke evacuation equipment.11 The second line of defense is respiratory protection. Numerous studies have shown that the best protection is an N95 respirator.1,8,12–14 However, other studies have shown that the majority of nurses use standard surgical masks, which offer little, if any, respiratory protection.1–3,8,10,13,14 It's important to remember that standard surgical masks are there to prevent the spread of infection to the patient, not to the staff.2
The literature identifies the hazards of surgical smoke; however, regulatory agencies like OSHA have not published mandatory guidelines for the use of smoke evacuators and respiratory protection. OSHA has established permissible exposure limits for the exposure of staff to an array of substances that are found in surgical smoke, but it doesn't require staff to use smoke evacuation and filtering systems.3 The National Institute for Occupational Safety and Health (NIOSH), a part of the CDC, doesn't have regulatory or enforcement authority, but they do evaluate potential health hazards and make recommendations to OSHA. In 1996, NIOSH published a Hazard Alert document on their website regarding the control of smoke from electrosurgical and laser procedures; it's also published on the OSHA website.2 (It can be accessed on the CDC/NIOSH or OSHA website at www.cdc.gov/niosh/docs/hazardcontrol/hc11.html or osha.gov/SLTC/laserelectrosurgeryplume/index.html.) Smoke evacuation devices have been shown to reduce the potential health hazards of surgical smoke but are not used on a routine basis in many ORs due to resistance on the part of the healthcare organizations, surgeons, and perioperative personnel.4 Equipment expense, inconvenience of equipment setup, and general lack of knowledge concerning the hazards of surgical smoke are some of the reasons for resistance.4 Physicians are compounding the issue of adherence to smoke evacuation by refusing to allow the use of smoke evacuators during their surgical cases.10 Although surgeons don't always spend their entire day in the OR, they're at equal risk for exposure to the hazards of surgical smoke due to their proximity to the surgical site exposing them to more concentrated amounts of surgical smoke.4
Although the smoke evacuators and surgical masks/respirators aren't intended to be used independently of each other, the proper selection and utilization of surgical masks/respirators should be emphasized due to the lack of adherence involving smoke evacuation devices. Respirators are not always kept in stock and/or are not always properly fit tested, making the choices for respiratory protection very limited. Once they become a requirement, hospitals would have to institute a written respiratory protection program and have trained administrators to oversee the program. It's very expensive and difficult for hospitals to maintain a respiratory protection program because it also includes equipment, training, and medical evaluations at no cost to the staff. The lack of education and concern among nursing staff in regards to the potential hazards of surgical smoke are just as important. Nurses need to educate themselves and support the recommended practices for the use of both smoke evacuation systems and personal respiratory protection. AORN offers a Surgical Smoke Tool Kit, which is available online and contains valuable resources to assist in implementing adherence practices.9 With this valuable resource, nurses can collaborate with physicians, educate others on the use of smoke evacuation equipment, make sure supplies are available, and monitor adherence to any written smoke evacuation policies in their institution.9
Gaps in the literature and future directions
The topic of surgical smoke and the proper prevention of inhalation injuries remain controversial to healthcare workers. There are numerous studies that have been conducted on lab animals demonstrating that surgical smoke is hazardous.4 Conducting human studies poses an ethical dilemma when attempting to replicate lab conditions performed on animals to show direct correlation between surgical smoke exposure and the hazards to healthcare personnel. In the absence of evidence-based studies, regulatory agencies such as OSHA, NIOSH, and the CDC are falling short of mandating the use of smoke evacuators in combination with N95 respirators as the highest level of respiratory protection. However, conducting longitudinal studies with OR personnel to collect data related to respiratory health (for example, pulmonary function testing, arterial blood gases, mask selection) could provide foundational evidence to support practice recommendations. Additional studies should focus on obtaining particulate matter samples of healthcare workers' masks and respirators–both the inside and outside of the mask–to quantify the exposure risk of surgical smoke. Potential research questions that should be addressed include: When should a smoke evacuator be used, and how far from the source should it be placed in order to be effective; are standard eye protection glasses used to prevent splash injuries sufficient protection in preventing surgical smoke injuries to the eyes; are staff members who wear contact lenses during procedures that produce smoke at increased risk for surgical smoke injuries to the eyes; and, if basic surgical masks aren't designed as a filtration device to prevent surgical smoke inhalation injuries, why are they used in the OR at all?
Every patient presents with their own unique medical history (for example, cancer, HIV, genital warts), and every surgical procedure has its own potential health hazards such as surgical smoke, which places the unsuspecting healthcare worker at risk. Leaders and managers need to bring awareness in order to educate and ensure that the necessary resources are available and that the recommended practices are adhered to prevent surgical smoke inhalation injuries. Nurses and other healthcare workers–especially physicians–need to speak out as never before regarding the potential hazards of surgical smoke.
More than 500,000 healthcare workers are exposed to the hazards of surgical smoke annually.8 Surgical smoke has been shown to contain hazardous chemicals, live malignant viruses, and bacteria, with up to 77% being 1.1 micrometers or smaller (with viral particles being much smaller than 0.1 micrometers).2 High-filtration masks, often referred to as laser masks, protect against particles that are 0.1 micrometers and larger.13 Although standard surgical masks and high-filtration masks provide protection during certain procedures, it also means that they're not adequate protection against all types of surgical smoke. Current literature implies healthcare personnel who don't use a smoke evacuator and wear the proper respiratory protection during procedures that generate surgical smoke are at increased risk for surgical smoke inhalation injury. Only N95 respirators that are NIOSH-approved combined with smoke evacuators will give the highest protection possible. They should only be used as indicated by the surgical procedure being performed and the particle size it can potentially generate.9 The most important thing nursing staff can do to protect themselves is to routinely use smoke evacuators and wear adequate respiratory protection.
Managers must solicit the expertise of the Perioperative Clinical Nurse Specialist (PCNS) as a clinical leader, evidence-based researcher, consultant, and educator to assist in writing, evaluating, and implementing evidence-based policies. The PCNS is a prime resource for managers to help collaborate with multidisciplinary teams, assist in developing institutional standards of practice, oversee the implementation of polices, and educate healthcare workers. By focusing on the big picture, PCNS can evaluate practices and procedures and make recommendations to increase the use of smoke evacuators, respirators, and high-filtration mask adherence among healthcare workers. Until there are official mandates from OSHA, it's every OR manager's responsibility to provide the necessary resources to ensure a safe environment for patients and healthcare workers in order to prevent surgical smoke inhalation injuries.
1. Diaz KT, Smaldone GC. Quantifying exposure risk: surgical masks and respirators. Am J Infect Control. 2010; 38:(7):501–508.
2. Ulmer BC. The hazards of surgical smoke. AORN J. 2008; 87:(4):721–734.
3. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Surgical smoke and infection control. J Hosp Infect. 2006; 62:(1):1–5.
4. Bigony L. Risks associated with exposure to surgical smoke plume: a review of the literature. AORN J. 2007; 86:(6):1013–1020.
5. Chung YJ, Lee SK, Han SH, et al. Harmful gases including carcinogens produced during transurethral resection of the prostate and vaporization. Int J Urol. 2010; 17:(11):944–949.
6. Spruce L, Braswell ML. Implementing AORN recommended practices for electrosurgery. AORN J. 2012; 95:(3):373–384.
8. Balazy A, Toivola M, Adhikari A, Sivasubramani SK, Reponen T, Grinshpun SA. Do N95 respirators provide 95% protection level against airborne viruses, and how adequate are surgical masks. Am J Infect Control. Mar 2006; 34:(2):51–57.
9. Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. AORN J. 2010; 92:(2):142–149.
10. Edwards BE, Reiman RE. Comparison of current and past surgical smoke control practices. AORN J. Mar 2012; 95:(3):337–350.
11. AORN. Recommended practices for safe environment of care. In R. Conner and J. Blanchard, Perioperative Standards and Recommended Practices. Denver, CO: AORN;2013:217–242.
12. Chowdhury KK, Meftahuzzaman SM, Rickta D, Chowdhury TK, Chowdhury BB, Ireen ST. Electrosurgical smoke: A real concern. Mymensingh Med J. Jul 2011; 20:(3):507–512.
13. Lawrence RB, Duling MG, Calvert CA, Coffey CC. Comparison of performance of three different types of respiratory protection devices. J Occup Environ Hyg. Sep 2006; 3:(9):465–474.
14. Oberg T, Brosseau LM. Surgical mask filter and fit performance. Am J Infect Control. 2008; 36:(4):276–282.
Lippincott Williams & Wilkins.