Because spine surgery can produce smoke-filled operating rooms, surgeons need to unite with their operating room teams to petition, if not demand, that administrators develop policy that supports efficient smoke evacuation.
The compelling reasons to do so are as follows:
- Chronic inhalation of nanoparticles, which comprise 80 percent of surgical plume, can, depending on genetics and/or pre-existing conditions, result in neurodegenerative, collagen and cardiac diseases as well as cancers.1
- Live bacteria, usually originating in the patient, can be carried by the plume a distance from the wound and perhaps throughout the OR It has yet to be proven that this is the source of contaminated surfaces or even of the wound itself.2
- NIOSH, the research arm of OSHA, has issued a "Warning Letter" stating that the plume contains both mutagenic and carcinogenic materials.3
- OSHA's Blood Bourne Pathogen Rule4 mandates protection of staff from splash-back of potentially infected body liquids such as blood. Not included, however, is protection from body fluid from the same potentially infected patient which is present as vapor in smoke that is inhaled through loosely fitted non-respirator facemasks.
- There are less than currently allowable traces of toxic chemicals in surgical plume which includes benzene, formaldehyde, hydrogen cyanide and carbon monoxide as well as some 600 others.5
These reasons should be enough to gain the attention of spine surgeons. Coincidentally, the marketplace has recently introduced a no touch smoke capture technology that requires no clinician involvement. It is attached to the wound area and connected to suction that is capable of providing 25 to 35 cubic feet per minute (cfm) of air flow.
The device has an open cell foam core encased in non-porous polyethylene that replaces the hand held suction tube such as the 7/8th" I.D. "wand" and the 3/8th" I.D. tube component of the electrosurgical "pencil" or "pen" ("ESU pencil/pen"). It has been documented to have a 99.5 percent smoke capture efficiency.6 Also, there are central, rather than desk-top ULPA filter-based smoke evacuator systems now available than can remove captured plume and channel it entirely from the room to a remote processing site. Such a system avoids recirculation of nanoparticles into the operating room, as occurs with current desk-top units.
In fact, recent research has shown that ULPA filters, despite their high cost, work well below their stated specifications when used at clinically required air flow rates that are 10 times greater than that used to develop their specifications (25-35 cfm vs. 8L/min).7
Administrators should be made aware of these advances in capture and evacuation because on-going education of operative teams about the long term health risks of chronic inhalation of smoke plume, without use of recently available efficient evacuation technology, could put hospitals at potentially significant financial risk. Think asbestos inhalation and mesothelioma and contrast that with nanoparticles and a plethora of associated diseases. The disability and civil liability risks could be considerable. Remember that OSHA has clearly stated that it is the hospital’s responsibility to provide a safe, healthy environment for their employees who now represent increasing numbers of allied and professional clinicians.
If all of the above does not yet resonate as reason enough for spine surgeons to advocate with nurses for clean air in the work environment, remember that Canadian and Scandinavian countries have self-mandated strict surgical plume removal policies for years. They either are not in a state of denial or perhaps they just want to do the right thing.
Lastly, administrators should be made aware that doing the right thing; that is, protecting their employees' health, can actually reduce current costs. The capture devices have a similar nominal cost. It is the short-lived ULPA filters that are the expensive "razor blade." Construction of a central system for smoke evacuation does require a significant initial capital expenditure but since they do not require use of ULPA filters, they usually pay for themselves, depending upon extent of use, within one to two years and they last, almost service-free, for 20 or more years.
Surgeons, nurses and administrators need to educate themselves about modern choices and reasons for a smoke-free environment. It is hoped that this editorial is a reasonable beginning toward that goal.
1. Buzea C, Blandino IIP, Robbie K. Nanomaterials and nanoparticles: Sources and toxicity. Biointerphases. 2007;2(4):MR17-MR172.
2. Unpublished data. Schultz L. Microorganism Dispersal Study. August 28, 2013.
3. U.S. Department of Health and Human Services (DHHS). National Institute of Occcupational Safety and Health (NUIOSH). Publication No. 96-128 (Hazard Control 11), 1998, March 2.
4. OSH Act of 1970 Standard 1910.1030. Bloodborne Pathogens, paragraph (D) (3)(I). Re3vision date: 14April1999. Accessed on http://www.osha/gov/pls/oshaweb/owadisp.shodocument?p table=s.
5. Saagar PM, Meagher A, Sobczak S, Wolff BG. Cemical composition and potential hazards of electrocautery smoke. Brit. J. Surg. 1996:83(12):1792-1799.
6. Unpublished data. Schultz l, Olson B, Schultz JT. Comparison of Efficiency of Surgical Smoke Capture Devices. November 21, 2011.
7. Unpublished data. Schultz L, Olson, B. Efficiency of ULPA Filters During Smoke Evacuation at Clinical Air flow Rates. August 27, 2013.