Surgical Smoke Safety

Purpose

This document provides guidance on surgical smoke safety precautions to support the perioperative team in establishing a safe environment for both surgical patients and team members through consistent use of control measures.

Surgical smoke is the vaporous and gaseous by-product of the use of surgical energy devices (eg, electrosurgical units [ESUs], lasers, ultrasonic devices, high-speed powered instruments).^1,2  When surgical energy devices raise intracellular temperatures to 100° C (212° F) or higher, the tissue vaporizes, producing surgical smoke.³ 

Electrosurgical devices use radio-frequency current to cut and coagulate; radio-frequency current passing through body tissues generates heat, which causes cell walls to rupture, releasing the cellular fluid as steam and the cell contents into the air. Lasers produce an intense, coherent, directional beam of light and also produce high heat, which raises the temperature within the cell, vaporizing the contents and releasing steam and cell contents.¹  Ultrasonic scalpel devices apply mechanical movement of 55.5 kHz frequency at the tip of the device; mechanisms of cavitation, protein denaturation, and heat generation of 50° C to 100° C (122° F to 212° F) cause temperature and pressure fluctuations within the cells, releasing vapor.⁴  Ultrasonic aspirators produce a fine mist from interaction of the high-speed hollow tip on tissue and the irrigation fluid.¹  High-speed electrical devices (eg, bone saws, drills) cut, dissect, and resect tissue; the mechanical action of the saw or drill combined with the irrigation fluid used to cool the device produces aerosols.⁵ 

Surgical smoke is visible and malodorous.²  The contents of surgical smoke have been widely studied. Researchers began analyzing the contents of surgical smoke as early as 1976.⁶  In a 1981 study, Tomita et al⁷  found that the contents of surgical smoke were similar to the contents of cigarette smoke, with known and suspected carcinogens and mutagens. This finding is supported by a recent concept analysis.² 

Surgical smoke is reported to contain toxic compounds (eg, hydrogen cyanide, toluene, benzene), bio-aerosols, viruses (eg, hepatitis B virus [HBV],⁸  human papillomavirus [HPV],⁹  human immunodeficiency virus [HIV]),¹⁰  viable cancer cells,^11-13  particles (ie, lung-damaging dust of 5.0 µm and smaller),¹⁴  blood fragments, and bacteria.¹⁵  Ultrafine particles of 0.1 µm (ie, 100 nm) and smaller can comprise 70% or more of surgical smoke and concentrations vary based on the type of tissue treated.^16,17  The water vapor content of surgical smoke from laser and vessel-sealing devices ranges from 1% to 11%,^18,19  and experts report that surgical smoke may have a water content of up to 95%.¹ 

The Occupational Safety and Health Administration (OSHA) acknowledges the hazards of surgical smoke and recognizes that many health care workers are exposed to surgical smoke, including surgeons, nurses, anesthesia professionals, and surgical technologists.²⁰  Acute and chronic exposure to ambient concentrations of fine and ultrafine particulate matter have been associated with cardiovascular and pulmonary health effects.²¹  Occupational exposure to volatile organic compounds (VOCs) in surgical smoke remains a concern because of the potential risk of long-term health effects²²  and possible reproductive effects.²³ 

Perioperative nurses report twice the incidence of many respiratory problems (eg, allergies, sinus infections/problems, asthma, bronchitis) compared to the general population.²⁴  Case reports have established a link between inhalation of surgical smoke during excision of anogenital condylomata procedures and transmission of HPV to health care providers.^25-27  For example, a laser surgeon developed laryngeal papillomatosis of the same virus genotype as his patient,²⁷  and experts at a virological institute confirmed a high probability of occupational exposure in a gynecologic perioperative nurse who developed recurrent and histologically proven laryngeal papillomatosis.²⁶ 

Surgical smoke exposure can also be hazardous to patients. Although exposure to surgical smoke might be brief, potential risks to patients include reduced visibility of the surgical field during minimally invasive procedures^28-31  with potential to delay the procedure,³²  possible port site metastasis,^12,33  exposure to carbon monoxide,^34-36  and increased levels of carboxyhemoglobin.^34,35 

AORN, the National Institute for Occupational Safety and Health (NIOSH),³⁷  and other professional organizations^38-41  have recommended surgical smoke evacuation for more than 25 years. However, perioperative team members continue to demonstrate a lack of knowledge of the hazards of surgical smoke^42,43  and a lack of compliance in evacuating surgical smoke and adhering to surgical smoke safety practices.^24,42-51  Even though smoke generated by electrosurgery is more hazardous than laser-generated surgical smoke,⁷  there is greater compliance with smoke evacuation for laser procedures.^50,51 

The COVID-19 pandemic required the health care community to implement transmission-based precautions. As a result, a renewed interest developed in protecting health care workers from the potential for viral transmission from surgical smoke during operative or other invasive procedures. Researchers who performed a systematic scoping review through June 2020 to assess the risk of viral transmission from surgical smoke during intraabdominal surgery found no evidence to support the presence of respiratory viruses in peritoneal fluid.⁵²  In a subsequent prospective pilot study conducted in Italy to evaluate the presence of the SARS-CoV-2 virus in surgical smoke, the researchers concluded that theoretically, SARS-CoV-2 might be transmitted through surgical smoke and aerosolized from fluid in the abdominal cavity.⁵³ 

Because the presence, viability, and transmission potential of the SARS-CoV-2 virus in surgical smoke remain unknown,⁵⁴  authors of professional society consensus documents,^55,56  literature reviews,^54,57-62  and expert opinion articles^63-65  recommend adhering to surgical smoke safety practices to guide safe perioperative care while protecting health care workers from possible exposure to the novel coronavirus that causes COVID-19. For further guidance on transmission-based precautions, such as respiratory protection recommendations for aerosol-generating procedures, refer to the AORN Guideline for Transmission-Based Precautions.⁶⁶  Specific guidance on infection control practices related to SARS-CoV-2 is available from the Centers for Disease Control and Prevention (CDC).⁶⁷ 

Surgical smoke is often referred to as surgical plume, smoke plume, bio-aerosols, laser-generated airborne contaminants, and lung-damaging dust. For the purpose of this document, the term surgical smoke will be used unless another term has been specifically used in a reference source.

Evidence Review

This systematic review is an update to the Guideline for Surgical Smoke Safety, which was published December 16, 2016. A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2015 through June 2020. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until April 2021. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included (active or passive) [close to] filtration, aerosol generating procedures, aerosol generating procedures and (surg* or device or instrument), air pollutants (occupational), bacterial aerosols, bioaerosol*, cautery and (surg* or device or instrument), cautery smoke, coronavirus infections, COVID-19, diathermy, diathermy and (surg* or device or instrument), diathermy fume, diathermy mist, diathermy plume, diathermy smoke, diathermy (surgical) and (surg* or device or instrument), dissection, dissection and (surg* or device or instrument), (electrosurg* or laser or ultrasonic) and (surg* or device or instrument), electrocautery, electrocautery and (surg* or device or instrument), electrocautery exhaust, electrocautery fume, electrocautery mist, electrocautery plume, electrocautery smoke, electrocoagulation, electrocoagulation and (surg* or device or instrument), electrostatic precipitation, electrosurg*, electrosurg* and (surg* or device or instrument), electrosurg* exhaust, electrosurg* fume, electrosurg* mist, electrosurg* plume, electrosurg* smoke, HIV, human immunodeficiency virus, human papillomavirus, laparoscopy, laparoscopy and (surg* or device or instrument), laser exhaust, laser fume, laser mist, laser plume, laser smoke, laser surgery, laser surgery and (device or instrument), laser therapy smoke, lasers, lasers and (surg* or device or instrument), local exhaust ventilation, occupational air pollutants, occupational hazards, operative procedures, operative procedures and (surg* or device or instrument), Papillomaviridae, particulate matter, (smoke or aerosol) [close to] evacuation, (surgery, operative+) and smoke, smoke extract*, smoke inhalation injury, surg* fume, surg* mist, surg* plume, surg* smoke, surgical procedures (operative) and smoke, surgical smoke precipitator, tissue ablation, tissue ablation and (surg* or device or instrument), (ultrastatic or ultrafine) [close to] particulate, viral aerosols, and virus aerosols.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available. Citations from the original guideline were retained when newer research was not available or the citations remained relevant in explaining the rationale for a practice recommendation (Figure 1).

Figure 1

Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and three evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference, as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.