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Surgical smoke and infection control

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Summary

Gaseous byproducts produced during electrocautery, laser surgery or the use of ultrasonic scalpels are usually referred to as ‘surgical smoke’. This smoke, produced with or without a heating process, contains bio-aerosols with viable and non-viable cellular material that subsequently poses a risk of infection (human immunodeficiency virus, hepatitis B virus, human papillomavirus) and causes irritation to the lungs leading to acute and chronic inflammatory changes. Furthermore, cytotoxic, genotoxic and mutagenic effects have been demonstrated. The American Occupational Safety and Health Administration have estimated that 500 000 workers are exposed to laser and electrosurgical smoke each year. The use of standard surgical masks alone does not provide adequate protection from surgical smoke. While higher quality filter masks and/or double masking may increase the filtration capability, a smoke evacuation device or filter placed near (2–5 cm) the electrocautery blade or on endoscope valves offers additional (and necessary) safety for operating personnel and patients.

Introduction

The term ‘smoke’ is used to describe any gaseous byproduct containing bio-aerosols, including viable and non-viable cellular material. In the medical literature, the terms ‘smoke’, ‘plume’ and, sometimes, ‘aerosol’ are used to describe the product of laser tissue ablation and electrocautery. The product of ultrasonic scalpels is frequently referred to as ‘plume’, ‘aerosol’ and ‘vapour’.

The generation of surgical smoke by electrocautery and laser systems has the same mechanism. 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. The qualities of surgical smoke produced by these two methods are very similar. During the use of ultrasonic scalpels, aerosols are produced without a heating (burning) process. This process is generally referred to as ‘low-temperature vaporization’. On the whole, this low-temperature vapour has a higher chance of carrying viable and infectious particles than higher temperature aerosols.

The mean aerodynamic size of particles generated varies greatly depending on the energy method used. Electrocautery creates particles with the smallest mean aerodynamic size (<0.1 μm), laser tissue ablation creates larger particles (∼0.3 μm), and the largest particles are generated by use of an ultrasonic scalpel (0.35–6.5 μm). These particles travel greater distances from their point of production (up to 100 cm). The nature of small particles presents a hazard to patients and personnel. Particles of 0.5–5.0 μm are frequently referred to as ‘lung-damaging dust’ since they can penetrate to the deepest regions of the lung. Surgical smoke can induce acute and chronic inflammatory changes, including alveolar congestion, interstitial pneumonia, bronchiolitis and emphysematous changes in the respiratory tract (Table I).

Furthermore, the type of procedure, the surgeon's technique, the pathology of the target tissue (e.g. whether particular bacteria or viruses are present), the type of energy imparted, the power levels used, and the extent of the surgery (cutting, coagulation or ablating) are other factors influencing the quantity and quality of the surgical smoke.

Surgical smoke has also been demonstrated to be cytotoxic, genotoxic and mutagenic.1

Section snippets

Electrosurgery

Electrosurgery is one of the most commonly used energy systems in laparoscopic surgery. Two major categories of potential complications related to electrosurgery are mechanical trauma and electrothermal injury. Electrothermal injuries and the burning of proteins and lipids produces a noxious odour noticeable in the operating room (OR). In addition to possible long-term effects, these chemicals may cause headaches, irritation and soreness of the eyes, nose and throat.2 The American Occupational

Recommendations by national organizations

OSHA estimates that 500 000 workers are exposed to laser and electrosurgical smoke each year, including surgeons, nurses, anaesthesiologists and surgical technologists. Surgical masks are good at capturing larger sized particles, generally 5 μm and larger, but they do not provide adequate protection in filtering smoke. Various studies demonstrated that specially designed masks (respirators) are still insufficient barriers. Furthermore, leakage of the mask's seal to the face is another source of

Recommendations for infection control

During open surgery, there are various ways for OR personnel to avoid surgical smoke, e.g. by moving or turning away from large plumes and thereby avoiding inhalation. They can engage higher quality filter masks or double masking. A simple smoke evacuation system suction device can be placed near the electrocautery blade (2–3 cm) when smoke is produced; if placed too far away, only 50% of the smoke will be evacuated.1, 19 The three components of an efficient evacuation system should be: a

Conclusion

Surgical smoke and aerosols are irritating to the lungs and have approximately the mutagenicity of cigarette smoke. Risks from exposure are cumulative and are greater for those closer to the point of smoke production. OR personnel should decide which, if any, methods they want to utilize to minimize their exposure. Smoke evacuators and high-efficiency filtration masks/respirators can help to prevent the transmission of infectious agents.

References (20)

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