Smoke plume: calls for mandatory protection

We are often reminded of the dangers of smoke inhalation, in relation to the general population, and there is now UK legislation preventing exposure to cigarette smoke in the workplace. However, there is still a lack of mandatory regulation regarding surgical smoke inhalation in the operating theatre and the use of smoke plume extraction continues to depend largely on the attitudes of individual surgeons and willingness of theatre staff to challenge the status quo. “In Scandinavia, smoke extraction is mandatory and in Denmark it is used in every theatre. The UK is lagging behind these countries in protecting its healthcare workers,” commented Paul Frandsen, managing director of Inter Global Surgical – a supplier of electro surgical solutions. Speaking to The Clinical Services Journal at the 2012 congress of the Association for Perioperative Practice, he said: “Theatre nurses, who experience the most exposure to smoke inhalation throughout their working week, tend to be more aware of the issues and want better protection, but surgeons remain a key barrier to adoption of smoke extraction systems. Theatre nurses need to make a stand and challenge current practice, in order to protect themselves, as well as others, in the theatre environment.” To drive improvement, various organisations and literature have called for further investigation into the impact of surgical smoke plume on long-term health – the Health & Safety Executive, in particular, has identified what it perceives to be a ‘knowledge gap’ in this area.1 While there is a need for further study, there is already a growing body of research to support the view that exposure presents a hazard to theatre workers’ health.

The problem of smoke plume

The Medicines and Healthcare products Regulatory Agency (MHRA) states that: “Smoke plume may contain hair particles, viable cells, bacteria, viruses, prions and other deleterious matter. Numerous toxic and carcinogenic gases will also be given off.” It adds that “inhalation of the smoke plume may adversely affect staff and patients”, and recommends that employers should carry out an assessment of the risks of plume exposure and ensure that steps are implemented to reduce risks.2 The Health and Safety Executive further states that, where a risk assessment indicates, the Control of Substances Hazardous to Health Regulation (COSHH) may apply. Although the HSE acknowledges that the quality and quantity of evidence is limited, mainly due to the study designs employed, it concludes there is “sufficient published evidence to consider the use of surgical smoke extraction devices and their effectiveness in reducing the levels of smoke exposure for UK healthcare workers.”1 Of particular concern is the toxicity of surgical smoke plume. Barrett and Garber identified a long list of chemicals present in surgical smoke – including benzene, formaldehyde, carbon monoxide, acrylonitrile and hydrogen cyanide. Acrylonitrile is a volatile, colourless chemical that can be absorbed through the skin and lungs, which liberates hydrogen cyanide. Hydrogen cyanide is toxic, colourless and can also be absorbed into the lungs, through the skin and via the gastrointestinal tract.3 They also pointed out that electro cautery has been ‘shown to increase intraabdominal CO to ‘hazardous’ levels, leading to small yet significant elevations of carboxyhaemoglobin (COHb)’. Another concern is the fact that hydrogen cyanide acts ‘synergistically with CO in impairing tissue oxygenation’.3 Previous studies have shown that burning one gram of muscle tissue, during procedures using electro surgery, is the equivalent of smoking six unfiltered cigarettes. However, a study by Hill et al, from the department of plastic surgery, Royal Devon and Exeter Foundation Trust, investigated this further.4 The researchers studied six human and 78 porcine tissue samples to find the mass of tissue ablated during five minutes of monopolar diathermy. The total daily duration of diathermy used in a plastic surgery theatre was electronically recorded over a two-month period. On average the smoke produced daily was equivalent to 27-30 cigarettes.4 It has also been suggested that the contents of surgical smoke plume may be adversely affecting the respiratory health of theatre staff – a survey of AORN members in the US (Association of periOperative Registered Nurses) concluded that perioperative nurses had twice the incidence of some respiratory problems when compared to general nurses.5 Kay Ball, nurse consultant/educator, highlighted statistics indicating the prevalence of respiratory conditions as shown in Table 1. There have been further reports of surgeons contracting diseases potentially caused from pathogens transmitted within surgical smoke. In one case, a 44-year-old laser surgeon presented with laryngeal papillomatosis. DNA samples from these tumours revealed human papillomavirus DNA types 6 and 11 and past history revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbour the same viral types. The authors suggested that the papillomas in the surgeon may have been caused by inhaled virus particles present in the laser plume.6