Thursday, March 28, 2013

Surgical smoke: Is it dangerous to your health?

An operating room nurse from the UK has asked me to comment on the burning issue of surgical smoke. [Pun intended.] I don’t think she’s going to like what I have to say.

For several years, studies have found that all kinds of chemicals and organic bits can be found in smoke plumes generated by electrocautery and lasers in the operating room. Some of the chemicals are said to be carcinogens and the organic material reportedly contains intact viral genetic material.

Many organizations have called for the establishment of government regulations regarding the amount of stuff that should be allowable in OR smoke. However, OSHA has been surprisingly reluctant to do anything and has not officially commented on the subject since 1996. The OSHA website does say that about half of the states have various regulations in place.

Some groups, particularly nursing organizations, are calling for the placement of smoke evacuators in all operating rooms. As you might suspect, these efforts are being vigorously supported by the manufacturers of smoke evacuators.

I attempted to find some real evidence about all this, but it is hard to come by. There have been no randomized trials involving surgical smoke.

A very interesting presentation by a group from the Centre Hospitalier Universitaire de Québec (CHUQ) at the 2011 Cochrane Canada Symposium addressed the subject in a health technology assessment.

For biologic and chemical substances, the CHUQ health technology assessment said the risks of transmission of diseases were unclear.

They measured the air in operating rooms and said, “[A]mbient air concentrations of carbon monoxide, volatile organic compounds, and particulate matter are very low and far below the occupational exposure limits.”

They concluded, “There is no clear evidence that surgical smoke may represent health hazard,” but hedged by saying that smoke evacuators should be restricted to specific types of cases such as breast surgery. They offered no evidence to support that recommendation.

There are only two case reports in the literature claiming transmission of viruses in surgical smoke from patients to healthcare workers. These case reports are frequently cited by advocates of smoke evacuation devices.

The first case report, cited in PubMed 16 times but many more times in other documents, is from Norway. Here is the complete abstract. I added emphasis in bold.

A 44-year-old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA types 6 and 11. Past history revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patient may have been caused by inhaled virus particles present in the laser plume.

The second case report, cited 3 times, is from Germany. Here is its abstract.

A 28-year-old gynecological operating room nurse, who assisted repeatedly in electrosurgical and laser surgical excisions of anogenital condylomas, developed a recurrent and histologically proven laryngeal papillomatosis. The expert opinion of a virological institute confirmed a high probability of correlation between the occupational exposition and the laryngeal papillomatosis so that it was accepted as occupational disease. HPV-DNA has been repeatedly detected in laser-plume after excision of papillomas and condylomas. As of the present an exact proof that these particles are infectious has not been brought forward.

There are other ways to acquire HPV virus in one’s throat.

The CDC reports that 48 million inpatient operations were performed in the United States in 2009. In the last 25 years, not a single case of proven (or unproven) transmission of any disease by surgical smoke has been diagnosed. Had such a case been found, it no doubt would have made headlines.

The Anesthesia Quality Institute estimates that there are 35,000-45,000 operating rooms in the United States. A smoke evacuation machine costs a minimum of $1000, not including the costs of disposable tubing for every case and filters which need periodic replacement.

Let’s say 40,000 ORs X $1000/smoke evacuator = $40,000,000 to prevent exactly zero cases of disease. This does not take into account the costs of disposable tubing.

In these economic times, can anyone think of a better place to spend $40,000,000?


NeuroTrumpet said...

During the early part of my surgery rotation, I wasn't thrilled with the fumes I inhaled during extensive use of the "Bovie," but nobody else seemed to mind the smoke so I just shrugged it off.

Later on in the rotation one of the attendings put me in charge of "suctioning" the electrocautery smoke with the same suction tool we used for blood before it had a chance to reach our nostrils. I couldn't believe more surgeons weren't employing this technique (easy thing to do if you have a med student around). The experience was much more pleasant.

What are your thoughts on that? Does suctioning in this manner actually sequester the smoke, or does it just divert it and it will eventually leak into the room anyway (but it's not as noticeable or potent)? Should more surgeons do this?

Frankly it doesn't matter to me either way. I matched in neurology and I don't plan on assisting in any more surgeries in my life :)

Skeptical Scalpel said...

Neuro, congratulations on matching in your chosen field.

I am not sure how efficient at removing smoke an OR suction is. I don't know if it's ever been studied. Lot's of people do it. I'm also not sure where smoke that is suctioned that way ends up. Does it get into the hospital's ventilation system anyway? Or is it vented to the outside air?

Mike Cyra said...

Unfortunately, I've inhaled my share of bovie smoke over the years. Depending on the procedure though, we always had access to, and used, smoke evacuator systems on the more "toxic" cases.
(A side note to you Doctor) I wanted to share with you, primarily, a story of mine that was recently published, titled, "Butt Smoke" that deals with this subject quite well.
I put the story on a page on my web site that can only be accessed with this link. I know you moderate the comments prior to posting, (that's a good thing) If you just want to read it, I think you'll get a kick out of it. If you want to share it with others, that is fine with me. I'm not a spam kind of guy, it's just not often that you see someone else talking about surgical smoke. Here's the link, again I love your blog. Thank you.

Skeptical Scalpel said...

Mike, it's a good story and quite accurate.

Mike Cyra said...

Thank you Sir.
Turns out the OR suction system is pretty efficient at eliminating smoke. It vents to the same hospital suction system as the waste anesthesia scavenging units. It's also the same system that the smoke evacuators are hooked to, they're just filtered more and I think they have additional lines to increase the volume of air. Everything is vented to the cafeteria, I mean to atmosphere on the roof. Yea, that's it.
I hope that helps NeuroTrumpet sleep better tonight.
I wanted to comment on the whole robotic surgery thing....Not impressed. I scrubbed at least two dozen cases. Huge learning curve. I'll take human hands, thank you very much.
Have a good evening Sir.

Albert L. de Richemond, M.S., P.E. said...

See what ECRI did in the early 1990s on smoke evacuators. The components of surgical smoke contain toxins, carcinogens, and some organic material along with water, carbon dioxide and some other innocuous materials. As I recall there were documented cases of papilloma transmission that were referenced. Also see the Canadian standard on surgical plume evacuation. Surgical smoke is worse than smoking cigarettes and it doesn't have to be a hazard of the job. Use smoke evacuators.

Skeptical Scalpel said...

Albert, I would appreciate seeing links to what you have said. If the cases of papilloma transmission are documented, I have not found them. Where can I find the ECRI report? I searched their site and could not find it.

Carolsparks said...

Just becasue there are no published randomized clinical trials to prove smoke plume in the OR is hazardous doesn't mean that it isn't. There are toxins in surgical smoke plume which has been well documented. Plain and simple,when something smells bad it isn't good for you. Having been in the perioperative field for over 35 years I have seen many OR nurses develop reactive airway disease which I am sure is from exposure to multiple toxins including surgical smoke, methylmecrylate fumes and glutaraldehyde. I wish someone would do clinical trials so we would have some evidence to substantiate this.

Skeptical Scalpel said...

I agree there is no proof either way. My point was that in the absence of proof and in today's economy, is investing in smoke evacuators for every OR in the US at a minimum cost of $40M not including disposables a good idea?

romanschapter8 said...

While it appears implausible that science will ever quantify increased cancer rates due to surgical smoke exposure in specific, what can be quantified is increased rates of cancer due to chronic exposure to high concentrations of ultrafine particles (Brunekreef and Holgate 2002; Pope et al. 2002) in the diameter range of 10nm to 1um; which are commonly produced in high concentration via use of electrosurgical devices 1 . Over 40 different chemicals have been isolated within surgical smoke, including formaldehyde which was recently reassigned as a “human carcinogen” 2 by the U.S. Department of Health & Human Services due to “Sufficient evidence of cancer from studies in humans: nasopharyngeal cancer, sinonasal cancer, and lymphohematopoietic cancer, specifically myeloid leukemia” 2.

Risk to the OR team is further complicated by this particulate matter and nanoparticles found within surgical smoke, and their potential of being deposited into the pulmonary alveoli 3. And, perhaps of equal concern if the potential for nanoparticles to take route through the alveoli or trachea and to translocate (Donaldson et al. 2001; Donaldson and Tran 2002; Nemmar et al. 2002, 2004; Schins et al. 2004) into other organs of the body 4 .

Although surgical masks are worn, these masks are not designed to capture particles of the size and nature commonly found within surgical smoke, nor the chemicals inherent within the smoke. Consequently, according to OSHA, the “primary objective shall be to prevent atmospheric contamination… by accepted engineering control measures.” 5. In Addition, there standards and recommendations from, OSHA, The Joint Commission 6 , CDC-NOSH 7 , et al, which exist due to the increasing evidence of the hazards associated with exposure to surgical smoke.

(1) Surgical smoke and ultrafine particles, Brüske-Hohlfeld, et al 2008
(2) 12th Report on Carcinogens, US DHHS, National Toxicology Program, 2011
(3) ISSA, Section on Prevention of Occupational Risks in Health Services, Surgical Smoke, 2011
(4) Environmental Health & Safety, Business Affairs, University of Florida, UFEH&S-LSP, 2010
(5) OSHA, Standards – 29CFR, 1910.134(a)(1)
(6) Joint Commission EC.02.02.01, EP 9
(7) CDC NIOSH Hazard Controls HC11

Skeptical Scalpel said...

Thanks for the detailed and referenced comments. As far as I know, OSHA has not mandated the installation of smoke evacuators in every OR. Do you have information to the contrary?

The OSHA standard you cited says "This section applies to General Industry (part 1910), Shipyards (part 1915), Marine Terminals (part 1917), Longshoring (part 1918), and Construction (part 1926)."

romanschapter8 said...

OSHA Surgical Suite Module (1) recommends...

- Have a smoke evacuator available for every operating room where plume is generated.

- Evacuate all smoke, no matter how much is generated.

Anonymous said...

I think there are some things to consider relating to the cost analysis shown. Most facilities in the United States, Western Europe and Canada own smoke evacuation systems of some form already, so there would not be a 40m outlay. It is true that a disposable capture device is typically used but these are inexpensive and well worth the cost for protection. For anyone that has worked in the OR, that smell of burning tissue is a telling sign that gases are present. The powerpoint presentation shown above appears to demonstrate a spot check although it is not referenced, and does not deal with the variability within cases based on how much electrosuergy or lasers are used, the type of tissue being interacted with, and the duration.

With regards to OSHA, although they indicate that there is no specific standards that exist that call out surgical smoke, they do indicate that applicable standards exist in 1910.134 (respiratory protection) and 1910.1030 (bloodborne pathogens). Additionally as romanschapter8 mentions above, the Joint Commission also has an applicable standard in the their Environment of Care Standard (EC.02.02.01) that addresses the management of hazardous gases while using cauterizing equipemnt and lasers.

A recent article from the Journal of Plastic Reconstructive Surgery (Hill, D.S.2012) equated the daily secondary smoke exposure over 44 days in a Plastic Surgery suite and found that it amounted to 27-30 unfiltered cigarettes each day. Regardless of the difficulty of correlating viral and bacterial transmission directly to surgical smoke, smoke is smoke and known to be hazardous to your health. With regards to biological transmission, contrary to the powerpoint presented, there are studies that not only demonstrate the viability of virus in the plume (meaning that transmission is possible) but also when that virus was extracted from the plume and reinoculated in foreign tissue, growth occurred (Garden, et. al. 2002 Arch Dematology).

The concern with saying that no direct connection has been made is that this is true of most viral transmissions. If you woke up this morning with the flu, could you trace its origin back to the exact source? True, even though the surgical case studies you reference indicate a similar DNA type to that of patients recently treated that does not definitively mean it came from these patients, but knowing it's present in the plume, why wouldn't we want to take precautions as we do with hand washings, gloves, etc?

Just some points to consider. Waiting for additional people to definitively tie the plume to illness seems like a risk not worth taking in lieu of the evidence that exists.

Skeptical Scalpel said...

Sorry. The link you provided falls far short of a mandate.

It says, "The research is *limited* on transmission of disease through surgical smoke, but the *potential* for generating infectious viral fragments, particularly during treatment of venereal warts, *may* exist. Researchers have *suggested* that the smoke *may* act as a vector for cancerous cells which *may* be inhaled by the surgical team and other exposed individuals." [I added the asterisks for emphasis]

That reads more like a radiology report.

The link goes on the offer "Possible Solutions" such as the ones you mentioned.

Skeptical Scalpel said...

Anon, thanks for the comments. You make some good points. But I don't think that most hospitals have the $1000 evacuators sitting around.

I was not aware of the Journal of Plastic Reconstructive Surgery paper you cited. That is interesting.

If indeed the plume amounts to the equivalent of 27-30 unfiltered cigarettes each day, would you not expect that there would be a higher incidence of lung cancer in OR nurses and techs as well as surgeons? That does not seem to be the case.

Anonymous said...

Hopefully hospitals that have smoke evacuators are using them. This original article is loaded with lots of misinformation. For example, OSHA DOES mandate that employers provide a safe workplace environment. They don't have to specifically comment on surgical smoke. Inhaling surgical smoke is a WORKPLACE SAFETY ISSUE so all surgical smoke must be evacuated properly. This comment section does not have enough room for the corrections for all of the other inaccuracies within that first article. Why are you trying to discount all of the hardwork so many of us have done to promote surgical smoke evacuation and clean air in the OR. My PhD research study on surgical smoke evacuation compliance shows that perioperative nurses are reporting twice the incidence of some respiratory problems in many facilities where smoke evacuation is not practiced. Perioperative nurses' exposure to surgical smoke is much greater than surgeons who visit the OR a few times each week. We must focus on providing safe workplace environments to surgical team members. (Kay Ball, PhD, RN, CNOR, FAAN - past president AORN.)

Skeptical Scalpel said...

Kay, thanks for the thoughtful and obviously heartfelt comments.

Nurses could possibly be at greater risk since they obviously are in the OR for more hours, although we surgeons are usually much closer to the smoke source thatn scrub techs and certainly circulating nurses.

I'm all for workplace safety and if we all had unlimited funds, I would be first in line to buy a smoke evacuator.

Kathy said...

Dear Skeptical Scalpel,
Thank you for your comments. Special thanks to Kay from AORN and Romanschapter8. I am the UK nurse who raised the topic. I am fortunate to work in a private hospital with 8 theatres. In each theatre we have a smoke evacuator and guess what? They come from Utah! We tested it for Megadyne and our surgeons happily use it. Is it so wrong that we care for our colleagues, our patients and the whole surgical team not forgetting the company reps who are sometimes in the theatre inhaling this carcinogenic plaque. In most countries, cigarettes are banned in public places yet we encourage smoking in the theatres and surgical smoke is more harmful than cigarettes! In my clinical environment, we discourage the consultants from using suction to evacuate smoke. Our smoke evacuators are fitted with charcoal filters and no, they do not go into the scavaging system, we change our filters regularly. To all my fellow theatre nurses out there in the US if you have a smoke evacuator in your theatre, think about using it and encourage others. The research is out there, you only need to look for it. Ask Megadyne if you want, it's on Google. Thank you.

Skeptical Scalpel said...

Kathy, thanks for commenting. You say "surgical smoke s more harmful than cigarettes!" Please cite a reference for that statement.

I looked at the Megadyne website but couldn't find anything to corroborate that.

Daniel Thoene said...

Dear Kathy
Dear Skeptical Scalpel
We (VmP-GmbH) are the distributor for Megadyne Products in Germany, Austria, Netherland and Luxemburg.
On our website you will find the information that burning 1g of tissue is equivalent to smoking 6 unfiltered cigarettes.
You also will find a Working document for occupational safety and health specialists about Surgical smoke risks and preventive measures.
You can download this in German, English and French.
The Dept of plastic Surgery and Burn Centre of the University Hospital of Luebeck in Germany is working on a study with us to show that you can work smoke free in the OR by using an ACE Blade , our Generator with ACE Mode and the Smoke evacuator
If you like to get more information, please contact us .
Daniel Thoene
Director of VmP GmbH

Skeptical Scalpel said...

When I operated, I didn't inhale the smoke.

Curious said...

I wonder how many perioperative personnel have experienced above average incidence of respiratory/pharyngeal/laryngeal/sinus cancer? Also how often perioperative personnel experience upper respiratory tract infection compared to that experienced by the general population? Surely both could be studied then crosschecked against the workplace and environmental exposure. Does anyone know of any existing research in either query?

Skeptical Scalpel said...

Curious, good questions. I am unaware of any studies that show an increase in respiratory tract cancers or infections in OR personnel. You would think that if such problems existed, they would have come to light by now.

Anonymous said...

Regardless of what you can/can't catch from the smoke plume - Why would you want to breathe in other peoples blood particles and tissue ???? You don't go round licking peoples skin and drinking blood do you ! Unless your a vampire of course

Skeptical Scalpel said...

I'm not sure there are blood particles or tissue in surgical smoke. I never went out of my way to breath the smoke, but sometimes it happened. It's happened to every surgeon, unless she never used cautery.

Anonymous said...

Have you seen this paper? "Heinsohn, P., and Jewett, D. L. (1993). Exposure to blood-containing aerosols in the operating room: a preliminary study. American Industrial Hygiene Association Journal, 54(8): 446-453."
As a perioperative nurse I have my own personal "smoke story" and have long been a proponent of clean air in the operating room because of it. In 1996-1997 OSHA did develop language that would mandate smoke evacuation. There was a bill introduced into Congress and attached to an Omnibus Reconciliation Act. During final votes in Congress, that part of the bill was eliminated. Its a long story, but Dr. Ralph Yodiaken, who was the OSHA doctor at the time, left OSHA, the administration changed, and all work to that point was simply put on the OSHA website and is still there today. I was there at the time and part of the work and the effort. It takes a great deal of time (and money, and lobbying) to get something mandated by OSHA--neither of which most nurses have. It is a health workplace safety issue, and as you say, nurses and OR technicians are likely more at risk simply because of the greater time that they spend in the OR. Progress has been slow, but over the years more agencies and organizations have adopted the position that health care workers should be protected from inhaling surgical smoke. You quoted a figure of $1000 for a smoke evacuator. Not every operating room needs a dedicated smoke evacuator. Many cases that do not produce a lot of smoke can use an inline ULPA filter--much less expensive but still filters the smoke. Using room suction without an inline filter doesn't do anything to clean up the air. You should also read the paper on how room air currents distribute surgical smoke throughout the room in a matter of minutes, so you may think you didn't breathe the smoke, but if you were in the room, you did. I can send you that reference too--if you want it. Brenda C Ulmer

Skeptical Scalpel said...

Brenda, thanks for commenting. I had not seen the Heinsohn paper. I read the abstract, which says, "These data show that the mucous membrane lining of the upper respiratory tract and alveolar macrophages in the gas-exchange region are likely to be exposed to aerosolized blood in the operating room. Until further research determines the potential of infected blood aerosols to transmit disease, the authors recommend the proper use of respiratory protection equipment instead of surgical masks because the latter do not offer adequate protection."

It's been more than 20 years since the paper was published in 1993. Is anyone using "respiratory protection equipment"? Where is the "further research"? Where is the definitive proof that surgical smoke has caused even one illness?

Raul Prestes said...

Skeptical Scalpel said...

Raul, thanks for the very interesting link to the report of 2 cases of HPV-16-related squamous cell carcinoma of the throat. These are by far the most suggestive I have seen implicating smoke as a cause of the disease. As the authors say, this is not conclusive proof. But a gynecologist who has an extensive practice involving such surgery might want to take the precautions noted in the paper.

Anonymous said...

Chronic exposure to surgical smoke can transmit viruses; lead to respiratory illness; and increase the risk of more serious conditions, including Alzheimer disease, collagen and cardiac diseases, and cancer. Despite this, surgical smoke plume capture and evacuation devices are often used sporadically or not at all, and do not necessarily reduce costs per procedure. In addition, the current choices for smoke plume capture are varied, and health care providers may make decisions about what type of method to use based on marketing materials rather than facts, leaving most clinicians and managers frustrated and cynical about supporting the effort to capture surgical smoke plume. This article presents current data and information that purchasing teams can use to help choose the best available technology for their practice patterns. It also provides analysis to help those responsible for choosing smoke evacuation systems make rational decisions in their quest to provide a clean, safe environment in the OR.

An Analysis of Surgical Smoke Plume Components, Capture, and Evacuation. AORN Journal (AORN J), 2014; 99 (2): 289-98. (22 ref)

Skeptical Scalpel said...

Anonymous, thank you for commenting. I apologize for the delay in responding, but I wanted to obtain a full text copy of the paper you referred to.

There is nothing new in this paper except for linking surgical smoke to diseases such as Alzheimer's, collagen and cardiac diseases, and cancer. The problem is that the paper upon which that statement is based was not a study of surgical smoke but rather, a study of air pollution and vital statistics in Japan. I do not see how it is relevant.

Even more concerning is the fact that the paper was written by the CEO of Nascent Surgical, a company that makes operating room smoke evacuators.

I like the way the journal handled this. Here's the statement printed at the end of the paper: "As chairman of the board and an employee of Nascent Surgical, Dr Schultz has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article." Really, ya think?

Anonymous said...

Hi skeptical scalpel,
It's disappointing to me as one of your colleagues in the medical field that you would take the perspective of: unless it is proven to harm, let's not prevent. You as a doctor also rightfully should know the first rule of medicine: do no harm. When you don't know if something will or will not do harm (in this case, the "something" is smoke), but we know very well with LOTS of substantiated evidence that the contents DO cause harm (see above comments, lots of good studies above), you should know that there is definitely a reasonable risk of harm that hospitals should NOT take on behalf on their personnel. It isn't an issue of coming up with more money from thin air -- it is about resource reallocation. Instead of the thousands of other things we waste in the hospital (sutures, tools misused and thrown away inappropriately, wasteful use of PPE, many more), inefficiencies can be cut to make room for something even as simple as a convidien dial bovie-suction tool. Something as simple as that. But to you somehow, it's not worth it. It's either go hard - buy expensive smoke evacuation equipment - or go home. Why didn't you make a comment about other less expensive equipment?

Finally, your review of studies is painful and disappointing. You're basically expecting someone to conduct some high level case control study - expensive and long and THERE IS LITTLE FUNDING for preventative research studies like this, not to imagine the long term nature of a study that waits for the development of lung cancer - and sitting around for this impossible study to happen. Waiting for this study that will never happen and saying until you see that, there is no need to take action. We wait until we get sick.

Shame on you, seriously.

Skeptical Scalpel said...

Anon, you are entitled to your opinion. I'm not sure which studies you are referring to when you say lots of good studies. I hope you don't mean the one written by the CEO of a company that makes smoke evacuators. It's been two years since I wrote this post. To my knowledge, very little has changed. Why do you suppose that is?

I agree the there's a lot of waste in hospitals, and resources could be better allocated. You must be aware that hospitals are overcharging patients and making tons if money. If staff were passionate enough about smoke, they would be demonstrating in the atrium lobby. They're not. Why not?

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