Transcript Management of Surgical Smoke
Management of Surgical Smoke in the Perioperative Setting
Thank You
This Tool Kit was funded through the AORN Foundation and supported by ConMed Electrosurgery
Overview and Goal
• • Surgical smoke is hazardous and can negatively affect the health of surgical patients and the perioperative team members. The purpose of this activity is to discuss perioperative nursing care and recommended practices for operative and/or invasive procedures that have a potential to expose patients and the perioperative team to surgical smoke. The goal of this activity is to educate perioperative RNs about the hazards of surgical smoke and the associated nursing care to promote patient and worker safety.
Objectives
• • • After completion of this continuing nursing education activity, the participant will be able to: Identify the hazardous contents of surgical smoke.
Discuss recommendations for surgical smoke evacuation and control.
Describe perioperative nursing care to minimize the hazards of surgical smoke.
Management of Surgical Smoke in the Perioperative Setting
What is Surgical Smoke/Plume?
• Smoke Plume or Smoke Aerosol is the vaporization of substances (i.e. tissue, fluid, blood) into a gaseous form and are the by-products of surgical instruments used to destroy tissue.
• Instruments: Lasers, Electrosurgery, Orthopedic, and Ultrasonics Devices. • Chemical Mixes - may produce plume or aerosols
What generates Surgical Smoke/Plume?
– Laser – Powered Surgical Equipment – ESU unit – Ultrasonic equipment
Content of Surgical Smoke
• • • • • • Gaseous toxic compounds Bio-aerosols Dead and live cellular material (including blood fragments) Viruses Carbonized tissue Bacteria
Composition of Surgical Smoke 150 different chemicals identified in surgical smoke (Pierce, et al. 2011)
Water Vapor
• Smoke plume and aerosols contain 95% water vapor • Water vapor is itself not harmful, but acts as a carrier
So..
is Surgical Smoke Harmful?
Past Misconceptions: “Surgical Smoke is not Hazardous” “Surgical Smoke is Sterile”
Surgical Smoke is Hazardous!
Inhalation and Exposure Potential to Harm
•
Patients
•
Perioperative Staff Members
•
Others
(anyone in the procedure)
Hazards
•
Odor
•
Particulate Matter
•
Viable/non-viable virus or bacteria
Inhaling Surgical Smoke
• 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)
Toxic Gases
•
Chemical Constituents
150 Chemical constituents of plume Acrolein Benzene Carbon Monoxide Formaldehyde Hydrogen cyanide Methane Toluene Polycyclic aromatic hydrocarbons (PAH) Some Are Carcinogenic!
(Pierce, 2011)
Chemical Effect
Soft contact lenses can absorb toxic gases produced by surgical smoke.
Recommendation made by an OSHA safety violation not related to plume, 1990
Particulate Matter
• • Carbonized tissue Blood • Intact virus and bacteria (HIV, HPV, Hepatitis)
Size of Particulate Matter
77% of Surgical Smoke Particles are less than 1.1 microns
Virus Sizes
Human Immunodeficiency Virus = 0.15 micron Human Pappillomavirus Hepatitis B Others • • • • • Bacteria = 0.055 micron = 0.042 micron Tobacco Smoke = 0.1-3.0 micron Surgical Smoke = 0.1-5.0 micron = 0.3-15.0 micron Lung Damaging Dust = 0.5-5.0 micron Smallest Visible Particle = 20 micron
Particle Distribution
(Nicola, et al. 2002) • • • 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.
Air Pollution and Women
Results: Long time exposure to fine particulate air pollution associated with incidence of CV disease & death among postmenopausal women.
Case Report
44-year old laser physician developed laryngeal papillomatosis Biopsy identified the same virus type as anogenital condyloma Hallmo, et al (1991)
Surgical Smoke: It’s a Universal Concern
Surgical smoke evacuation guidelines: Compliance among
perioperative nurses
. ( Ball, 2010) Chemical composition of gases
surgeons
resections. (Weston et al. 2009) are exposed to during
endoscopic urological
Surgical smoke: a concern for
infection control practitioners
. (Ortolano, 2009) Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in
UK plastic surgery units .
(Hill et al. 2012) Occupational hazards facing
orthopedic surgeons .
( Lester et al. 2012), Becker’s
ASC
Review reprint of Understanding and Controlling the Hazards of Surgical Smoke (Novak et al March 28, 2011) Surgical smoke and the
dermatologist
. (Lewin et al Sept 2011)
Smoke Evacuation Compliance Study • • Surgical smoke compliance study 2009 To identify key indicators of compliance with surgical smoke evacuation recommendations Ball, K. (2010).
Compliance Model*
Individual Innovativeness Characteristics (Perioperative nurse characteristics) Age Education level Experience Knowledge Training Presence of respiratory problems Perceptions of Attributes (Nurses’ perceptions of smoke evacuation recommendations) Relative Advantage Compatibility Complexity Trialability Observability Barriers to practice Organization Innovativeness Characteristics (Organization’s characteristics) Descriptors (locale, type) Size Complexity Formalization 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.
Smoke Evacuation Compliance Study
• • • • Key indicators of compliance: Education Leadership support Easy to follow policies Regular internal collaboration (Ball, K . 2010)
Perioperative RN Survey
• • • • • November 2010 Survey e-mailed to current, active members of AORN North American health care facilities 1,356 responses /10,000 email requests Compared findings from 2007 similar study Edwards & Reiman 2012
Study Results Indicate:
• • • • Use of the wall suction during laser procedures (excepting laser hair removal and LASIK) is similar to that for electrosurgery, electrocautery, diathermy (ES/EC/D), or ultrasonic scalpel procedures.
Lower incidence of smoke evacuator use than wall suction use Smoke evacuator use rates have not changed significantly from 2007 to 2010 Indicate that few facilities routinely used effective respiratory protection for surgical smoke (Edwards & Reiman 2012)
Patient Safety: Exposures to Surgical Smoke
How can the patient be protected from surgical smoke?
Laparoscopic procedures present unique exposures to smoke to the patient.
Minimally Invasive Surgery (MIS)
Laparoscopic Surgical Procedures
• • 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)
MIS and Smoke
• Loss of Visibility of Surgical Field – Potential to delay the procedure • • Health effects to Patient Health effects to Perioperative Staff – When pneumoperitoneum is released into the OR without filtration • Important to use a filtering device or a closed evacuation system
Worker Safety: Exposures to Smoke/Plume “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)
Health Effects Reported by Healthcare Workers
• • • • • • • • • Eye, nose, throat irritation Headaches Nausea, dizziness Runny nose Coughing Respiratory irritants Fatigue Skin irritation Allergies
Respiratory Problems
Perioperative nurses have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010) – Allergies – Sinus infections/problems – Asthma – Bronchitis
Healthcare and Regulatory Standards and Recommendations • • • • • • • AORN ANSI ECRI International Federation of Perioperative Nurses Joint Commission NIOSH/CDC OSHA
ANSI Standard 7.4 of Z136.3 - 2011 (Safe Use of Lasers in Healthcare)
Airborne Contaminants: Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any residual plume escaping capture.
Note: ESU produces the same type of airborne contaminants as lasers.
NIOSH/CDC:
Ventilation
Ventilation combination of general room and local exhaust ventilation (LEV). • portable smoke evacuators • room suction systems.
NIOSH/CDC: Work Practices • 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
Follow Standard Precautions at the completion of the Procedure
• All smoke evacuator tubing, filters, and absorbers -considered infectious waste -disposed appropriately. • New filters and tubing should be installed on the smoke evacuator for each procedure. • Local Exhaust Ventilation systems -regularly inspected and maintained
OSHA General Duty Clause: Employer
MUST
provide a safe workplace environment!
OSHA Respiratory Protection
Recognizes:
Lasers and electrosurgical plume contains toxic, mutagenic, and carcinogenic elements
Mandates and Identifies:
Removal of atmospheric contaminants with acceptable engineering controls, local ventilation, including smoke evacuation systems
ECRI
• • • • 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
Joint Commission
• • 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.
International Federation of Perioperative Nurses
• • • • • • • Position Statement Includes: Recognition of blood borne pathogens and potential for viral transmission Identification of smoke as a workplace safety hazard and requirement for compliance with IEC Face masks of 0.1 micron filtration worn according to infection control policy and procedure Use of standard precautions Use of LEV with ULPA filter Collection of smoke not > 2cm from evolution point Use of in-line filters when LEV not available
Canadian Standards
• • • • • •
Surgical Plume Scavenging for Health Care
The First Dedicated Standard World Wide - MODEL Covers all plume from surgical & therapeutic devices Addresses all systems: • dedicated, central, in-line, free standing “Will seek IEC and ISO for endorsement” Affects all provinces and practice settings Published early 2009
AORN
• • Electrosurgery Safety Laser • Minimally Invasive Surgery (MIS) • AORN Position Statement Surgical Smoke and Bio-Aerosols
AORN Recommended Practices
“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.
AORN Electrosurgery RP X • “Evacuate smoke with a smoke evacuation system in open and laparoscopic procedures • Use standard precautions and dispose of smoke evacuator filters, tubing and wands (considered as potentially infectious waste) • Used smoke evacuator filters, tubing, and wands should be disposed of as potentially infectious waste following standard precautions” Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141.
AORN Recommendations: Laser RP. V “Potential hazards associated with surgical smoke generated in the laser practice setting should be identified and safe practices established.” Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156.
AORN Recommendations Minimally Invasive Surgery (MIS) “IV.j.1. Surgical smoke should be removed by use of a smoke evacuation system in both open and laparoscopic procedures.
IV.j.2. Surgical smoke should be evacuated and filtered during the laparoscopic procedure and at the end of the procedure when the pneumoperitoneum is released.” Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184.
AORN Recognizes Surgical Smoke is Hazardous • • • • Recommends Wear appropriate PPE Remove smoke with an evacuation system for open procedures and MIS procedures Place capture device close to the source of the smoke Use evacuation system according to manufacturer’s written instructions for use
Smoke Evacuation in the Perioperative Setting
Smoke Evacuators First Line of Defense Smoke evacuator systems: Larger amounts of plume In-line filters: Smaller amounts of plume Laparoscopic filtering devices
Evaluating Smoke Evacuators • • • Many products Evaluate the features and benefits Selection
Characteristics Smoke Evacuation Systems • • • • • • • Ease of use Quiet Foot pedal activation/automatic on-off Portability and access Indicators for filter changes Efficiency Cost
Critical Features of Smoke Evacuators
Efficiency -Filtering capability -Suction power
Smoke Capture Depends on Motor Rating Tubing Size Site Proximity Amount of Smoke Generated
Triple Filter System
• Pre filter (captures large particles) • ULPA filter (captures small particles) • Charcoal filter (captures toxic gases and odors)
Ultra-low Penetration Air Filtration (ULPA) Only one in a million particles will escape capture
Wall Suction:
Use an In-Line Filter!
• • • • • Simple Evacuate less than five cubic feet per minute (CFMs) Effective for small amounts of smoke Use an In-line filter!
Use and change as recommended by the manufacturer’s instructions • Use standard precautions when changing and disposing of in-line filters
From the patient >
In-Line Filters with Wall Suction
To wall suction > Example of an ULPA filter
Evacuator Filters for MIS Procedures
• • • Irrigation/Aspiration System Active System Passive System
Wall Suction Problems
• When there is no in-line filters: – Damage to healthcare facility air exchange – Less suction • 3.5 – 5 CFM Wall Suction • 25-50 CFM Smoke Evacuators CFM is a measure of air flow rate
Disposal and Changing Smoke Evacuation Filters
• • • It’s an occupational hazard Wear PPE Dispose of used smoke evacuation filters per manufacturer’s instructions and your facility’s procedures
Perioperative Nursing Care
Perioperative Nursing Care • • • • • Patient assessment – Will your patient be exposed or potentially exposed to surgical smoke?
Diagnosis Planning care Interventions and evaluation of outcomes Patient outcomes
Surgical Attire Wear appropriate PPE
Surgical Masks Remember, local exhaust ventilation is the first line of protection from surgical smoke.
• • • A Surgical Mask prevents release of potential contaminants into the environment protects the wearer from large droplets , ie greater than 5 microns, when the mask is fluid resistant does not seal the face and may allow contaminants to enter the wearer’s breathing zone A High Filtration Mask has a filtering capacity of particulate matter at 0.3 to 0.1 microns in size
Wear Respiratory Protection Wear a fit-tested surgical N95 filtering face piece respirator or a high-filtration mask during procedures that generate surgical smoke High-filtration mask (0.3 microns to 0.1 microns) This mask does not seal the face and may allow contaminants to enter the wearer’s breathing zone
Wear Respiratory Protection • • • Wear a fit-tested surgical N95 filtering face
piece respirator for
Disease transmissible cases (HPV) Aerosol transmissible diseases (TB, Varicella, Rubeola) Aerosol generating procedures (e.g., bronchoscopy)
Team Briefing
• Communication with Surgeon and Perioperative Team members • • Plan for Smoke Evacuation Equipment and Optimal placement of equipment • Patient and Team member Smoke Protection Methods
Hand off Communication
• • Discuss PPE and Respiratory Protection/Masks Options Type of Smoke Evacuation Method
Safe Handling
• Use standard precautions when disposing of used smoke filter devices and other used smoke equipment.
Documentation
Relevant information about smoke evacuation and equipment used
Smoke Evacuation Program
Smoke Evacuation Program • • • Increase awareness of the hazards of surgical smoke Promote and implement safe practices Interdisciplinary Team – Include Perioperative RNs, Anesthesia providers, Surgeons, Administration, Infection Preventionist, Employee Health, Safety Officer, Risk Managers
Administration: Director Infection Prevention Safety Risk Management OR Colleagues: Educate Monitor Best Practices Consider Physicians: Support with data Include in process of product selection Financials: Contracts Capital Cost Analysis
Implementing Smoke Evacuation Practices • • Must have data and analyses: – Scientific research data – Financial analysis Must have support from: – Administrative Safety Committee – Infection Control – Risk Management
Barriers to Compliance for Smoke Evacuation Practices • Equipment not available • Physician • Equipment is Noisy • Complacent staff
-- Ball, 2010
• Surgeons' resistance or refusal • Cost • Bulkiness • Excessive noise
--Edwards & Reiman, 2012
• Noise • Distraction • Ergonomic difficulty of equipment
--Watson, 2010
Policies and Procedures
• • • • • • Address best practices for the patient and the perioperative team National Regulatory and Professional Standards Credentials, Competency and Training Equipment Operational Guidelines Patient and health care worker incidents
Staff Education and Competency • • • • • Aware of surgical smoke hazards for the patient and the perioperative team members?
Aware of the PPE required for perioperative team members?
Know how and when to use filtering devices and smoke evacuators?
Able to set up the smoke evacuators available in the work setting?
Know about cleaning, decontamination, and maintenance of smoke evacuation equipment and accessories?
Use a Variety of Educational Activities
• • • • • • • Quality and Safety Committee Reports Educational programs – perioperative nursing care – research on hazards Equipment, Device, Supply Inservices Reminder signs AORN Posters Checklists Monitor practices
Quality Monitoring
• • Education and Competency Equipment Service Reports
Are Hospitals Really Smoke Free?
• • Thousands of hospitals make that claim Let’s advocate to make the Perioperative Setting Smoke-free as well.
Protect our Patient-Our Colleagues-Ourselves from the Hazards of Surgical Smoke
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