Surgical plume and its implications : A review of the risk and barriers to a safe work place

Every year thousands of health care professionals worldwide are exposed to surgical smoke. There is evidence that this smoke consists of toxic gases, pathogens and particulate matter that is a hazard for patients and the perioperative team. Past research indicates that perioperative staff inconsistently comply with smoke evacuation recommendations. The aim of this study was to identify, review and discuss the issues related to surgical plume and its implications for patients and perioperative staff. The findings of this review relate to: surgical smoke content, its risks to the health of the perioperative staff, preventative measures, infection control measures, compliance with smoke evacuation systems, staff knowledge and barriers to implementing smoke evacuation practices. Of particular importance, the literature indicated that strong support from management and the implementation of regular staff education could improve practice for the management of surgical plume in the operating theatre.


Introduction
Surgical plume, also known as surgical smoke, cautery smoke, smoke-plume, diathermy plume, aerosol, bio-aerosol, vapour and air-contaminants 1,2 , is a dangerous by-product produced by the electrosurgical instruments used to dissect tissue, provide haemostasis and perform laser ablation. These instruments include electrosurgery units, lasers, ultrasonic devices, high speed drills, burs and saws that produce heat and allow the surgeon to achieve the desired tissue effect 3,4 . Surgical plume is created by the thermal damage of tissue which releases cellular fluid as steam and spews cell contents into the air. Chemical analysis lists its constituents to be 95 per cent water vapour and 5 per cent other chemicals and cellular fragments 5 . Surgical plume can pose health risks to thousands of health care workers on an annual basis 6 . This article provides a review of the contemporary literature in relation to surgical plume, its composition, the risks it creates and management strategies.

Background
In this review, the authors aimed to identify, review and discuss the issues related to surgical plume and its implications for patients and perioperative staff. Health professionals in the perioperative environment are routinely exposed to surgical smoke, plume and aerosols produced by instruments used to dissect tissue and provide haemostasis. This can pose significant health risks, in particular for nurses and anaesthetists who spend more time in the operating room than ancillary workers, such as Peer-reviewed article orderlies, and surgeons because of clinic or ward schedules 3 . Strategies to educate perioperative staff about the risks and the use of smoke evacuation systems are essential for improved health outcomes.
Research has shown conclusively that surgical smoke is hazardous to personnel who are exposed to it daily 2,3,7 and hence concerns have been raised regarding the infective, mutagenic and cytoxic properties of surgical smoke from all the aforementioned devices 7 .
According to the Association for Perioperative Practice 8 and Ulmer 2 , surgical smoke is always present and it forms part of the patient-care environment whenever surgical or invasive procedures are performed. Surgical plume consists of 95 per cent water and 5 per cent other matter containing chemicals, dead and live cellular material (blood fragments, bacteria, viruses), toxic gases, vapors (e.g. benzene, hydrogen cyanide, formaldehyde) and lung-damaging dust 2,3,5,[9][10][11] . These components of the surgical plume are classified as 'physical', 'biological' and 'chemical' 1 .
The physical component consists of particles that range in size from less than 0.01 microns to more than 200 microns 1 . The largest particles (0.35 microns to 6.5 microns) are produced by ultrasonic devices, laser ablation produces particles of 0.3 microns and electrocautery produces particles of less than 0.1 micron. These ultrafine particles create a very fine dust 1 and anything less than 0.3 microns is able to bypass the lungs normal filtration mechanism and deposit in the alveolar region 1,7 . Particles that settle in the tiny air sacs transfer biological material and possibly cause infection, congestion and aggravation of conditions such as chronic obstructive pulmonary disease and asthma 6 . Repeated inhalation of surgical smoke can induce acute and chronic inflammatory changes including congestion, pneumonia, bronchiolitis and emphysematous changes in the respiratory tract 4

Findings
The findings of this study relate to the risks associate with surgical plume, the measures taken to prevent these risks and compliance with implementing preventative measures.

Risks
According to Ulmer 2 , surgical smoke can be seen and smelled and these visible and odorous components of surgical smoke are the gaseous by-products of the disruption and vaporisation of tissue protein and fat. Surgical smoke has been described as being a nuisance at the very least and, at worst, carcinogenic 2,10 .
Additionally the carbon monoxide generated during electrocautery can cause headaches, burning and watery eyes, nausea and respiratory problems 1 . These components irritating the lungs have a similar mutagenicity to cigarette smoke 1,19 .
Recent studies quantified the average daily exposure of surgical smoke in the operating room as equivalent to 27 to 30 cigarettes 4,19 and the ablation of 1 gram of tissue as creating surgical plume with the mutagenic effect of smoking six unfiltered cigarettes 12,19 . Benson et al. 9 confirm that particles smaller than 5 microns are categorised as lung-damaging, and can result in acute and chronic respiratory changes which include emphysema, asthma and chronic bronchitis. Nascent Surgical 20 highlighted that poorly maintained theatre environments resulted in an increase in staff absenteeism and decreased productivity due to acute respiratory illness.
Studies with mice and rats have highlighted these significant health risks. Baggish and associates 21 compared the effects of unfiltered laser smoke on rats' lungs. They all developed hypoxia and pulmonary congestion with bronchial hyperplasia and hypertrophy. A comparison control group were subjected to filtered plume, with no lesions identified 3 . Another study using mice showed that melanoma cells were released into the surgical plume after application of electrocautery to malignant tissue 14 , these cells were viable and cultured 22 demonstrating that an organism can survive electrocautery 23 .
In addition to airborne contamination, Ulmer 2 and Ball 15 note that surgical smoke has a potential risk for patients during laparoscopic surgery and endoscopic procedures whereby the contaminants of the surgical smoke are absorbed into the patient's vascular system.
Concerns about the danger of surgical smoke are not new. In fact, 22 years ago concerns were raised that smoke absorbed through the peritoneal membrane resulted in an increase in methaemoglobin and carboxyhaemoglobin in the blood stream. This effect reduces the oxygen capacity of red blood cells, producing falsely elevated oxygen readings that could result in unrecognised patient hypoxia 2,12 .

Electrocautry devices
According to Weld et al. 24 36 noted that there was a fundamental lack of understanding of the potential health risks from exposure to surgical plume, and recommended continuous professional development to improve staff knowledge about the risks to health and the use of local exhaust ventilation (LEV). The focal point of this exercise is to improve behaviours and practices in relation to the use of smoke evacuation tools and infection control procedures -a priority for perioperative nurses even in a general sense 37 . Educating perioperative staff about the dangers of surgical smoke will support a culture whereby smoke evacuation is seen as a necessity and a key factor for workplace safety 2 45 demonstrated that an improvement in staff knowledge correlated with increased use of surgical smoke management systems. Dawes 46 recommended that perioperative nurses become experts in the use of available tools to minimise exposure to surgical smoke. To assist with this education the smoke evacuator manufacturers 40 should be invited to provide regular in-service and onsite training.

Attitudes and barriers
According to Marsh 40 and Giordano 47 , the cost of a smoke evacuation system, the significant price difference between a standard facemask and a high filtration one, misconception by staff that a standard facemask will provide sufficient protection against inhaling surgical smoke and a lack of knowledge about the dangerous risk of surgical smoke are all barriers to implementing efficient smoke evacuation procedures and taking preventive measures. Ball 44 stated that the greatest barriers to implementing smoke evacuation practices were the unavailability of smoke evacuation equipment, the refusal by surgeons to allow smoke evacuation devices to be used, the noise produced by the smoke evacuators and the complacency of perioperative staff. Bigony 22 and Lewin et al. 10 state that resistance to smoke evacuation can be attributed to expense, inconvenience, time constraints and a general lack of knowledge regarding the potential hazards associated with surgical plume exposure. Steege et al. 48 reported that the most frequent reasons for not using LEV and PPE during laser surgery and electrosurgery were 'not part of the protocol', 'not provided by the employer', 'exposure was minimal', 'not readily available in work area'. One 'other' reason for using a mask was when a patient had a known infectious disease, hence the most common 'other' reason for not using a respirator during electrosurgery was prior confirmation of the patient not carrying an infectious agent.

Role modelling and support
A cross-sectional survey conducted in the United States indicated that strong support from management was a key component to improved compliance 49 . Chavis et al. 45 found that perioperative managers who were supportive of education programs and had allocated funds and time to support and encourage staff members to participate during their regularly scheduled work hours and over the year had also adopted and established best practice for the management of surgical plume in the operating room. This is further supported by Ball 50 who found that appropriate smoke evacuation practices improved when leaders supported the use of smoke evacuators.

Discussion
Improving compliance with best practice management of surgical plume in the operating theatre can be achieved through staff education and a supportive leadership team. Education should include evidencebased practices and strategies 44 Informative posters can be displayed in operating theatres, staff rooms and along theatre corridors to attract staff attention.
Policies that are simple and easy to follow should be developed to guide perioperative staff in creating an environment that reduces the exposure of patients and perioperative personnel to surgical plume [55][56][57] . Health care site policy should articulate that when surgical plume is generated smoke will be captured and filtered through the use of smoke evacuators or in-line filters positioned on suction lines [55][56][57] . The policy should also state that smoke evacuation devices or equipment must be listed on all surgeon procedure cards for procedures that produce any surgical smoke 44 . Smoke evacuation policies must be communicated to all perioperative staff 44 . Compliance with smoke evacuation policies should be monitored as part of the quality improvement process 2,44 .

Conclusion
The literature describes the hazards of surgical plume and concerns around the lack of compliance with prevention strategies. Since surgical plume is a controllable environmental occupational hazard, efforts to eliminate it can help to minimise health costs and improve the health of perioperative personnel and patients. Regular education sessions to assist staff to understand the danger of surgical plume and preventative measures can be an effective way to minimise exposure to surgical plume and improve compliance with using personal protection and smoke evacuation equipment.