Canadian Occupational Safety

18 Canadian Occupational Safety www.cos-mag.com t has been known to cause genital warts in the noses of anesthesiolo- gists. A surgeon developed a rare throat tumor caused by the human papillomavirus (HPV) because of this. It has been linked to miscar- riages among nurses. In a hospital in London, Ont., red fl ags were raised around it after an orthope- dic surgeon died of lung cancer, but he was not a smoker. The human immunodefi ciency virus (HIV) and hepatitis have also been found in it. The culprit? Surgical smoke. "Viruses and bacteria will live in surgical smoke, as does DNA, for up to 72 hours," says Heather Pottery, clinical nurse educator for operating rooms at St. Paul's Hospital in Vancouver. "We do quite a number of cancer cases and with the destruction of those tissues, those compounds, or those viruses, can be in the air as well." Surgical smoke (also known as plume) is generated whenever a hot tool interacts with human tissue. In the operating room (OR), lasers, elec- trosurgical units (ESUs), ultrasonic instruments, plasma generators, bone saws and drills create smoke during electrocautery, electrosurgery and mechanical operations. Surgical smoke also carries harm- ful chemical components, such as benzene (a documented trigger for leukemia), toluene, formaldehyde, carbon monoxide, hydrogen cyanide and methane (see sidebar for more). Researchers have identifi ed more than 600 organic compounds in plume generated by vaporized tissue. One puff of plume can be the same as three puffs from an unfi ltered ciga- rette, according to research cited by the CSA Group. Plume can also cause respiratory problems; eye, nose and throat irritation; severe headaches; nausea; and liver and kidney damage, according to the CSA. "Asthmatics, people who have upper respiratory illness, somebody who is prone to sinusitis, for instance, there have been complaints of eye activated carbon fi lter and an ultra- low particulate air (ULPA) filter. Various capture devices are used, such as those that can be attached to the ESU pencil or large tubing that is usually within 5 centimetres of the plume source. "You can take it from room to room, the fi lters are easy to change and you can monitor very easily how used up your fi lter is," says Taylor. "It evacuates the plume right at the source." This past fall, St. Paul's Hospi- tal in Vancouver started using new smoke evacuators in all of its oper- ating rooms. It installed portable systems that are directly connected to the electrosurgery unit and function automatically. "It is pre-assembled where the tubing that provides the suction around the cautery pen itself is all a single unit," says Khotar. "You don't have to assemble it, so in some ways it makes it mandatory to use because it won't function unless you have the system." The previous systems required the nurses to assemble the smoke evacu- ator so there was more of an option to use it or not. Sometimes surgeons did not like using the device because it limited their line of sight. "Although it sounds like it makes perfectly good sense — why wouldn't everyone use it all the time? — the sys- tems were somewhat limiting because they were cumbersome. It's like vacu- uming your drapes always with the rug attachment. It's just not the easiest thing to do," says Khotar. "And when you can't actually see your surgical site, By Amanda Silliker activated carbon fi lter and an ultra- activated carbon fi lter and an ultra- low particulate air (ULPA) filter. Operating room staff face exposure to carcinogens, viruses if plume not properly evacuated You are cutting away a lot of tissue." Anyone in the operating room can be affected by surgical smoke — nurses, surgeons, anesthetists and anyone who comes into the OR after the case is done. Those who are down- stream of the plume are at the greatest risk, says Hunt, such as shorter nurses or anesthetists who are sitting during the procedure. "I know at one point a lot of sur- geons thought they would be the most affected by this but what they didn't realize (is that) it's that OR nurse who is in the room fi ve days a week, eight hours a day — it's the one that's in there consistently," says Susan Taylor, vice-chair of CSA's plume scavenging committee and retired nurse educa- tor/laser safety offi cer for St. Joseph's Health Care in London, Ont., adding anesthetists are also regularly in the room with nurses. "(The surgeon) has maybe one day of booking per week and then he's gone." CONTROL THE SMOKE The fi rst step in addressing surgical smoke is to properly ventilate the operating room. According to CSA Z305.13-13, 20 air changes per hour are required. Next, plume scavenging systems need to be put in place, and there are a variety of options available. One option is the portable smoke evacuation system, which is the most versatile as it can be moved around. The portable system may be activated manually by a foot switch or automatically when the laser or electrosurgical unit is turned on. The smoke goes through a triple fi lter system consisting of a pre-fi lter, an irritation and those people who are particularly sensitive from a respira- tory perspective aren't able to tolerate it," says Rupinder Khotar, OR nursing supervisor at St. Paul's Hospital and past president of the Operating Room Nurses Association of Canada. Occupational health and safety pro- fessionals, industrial hygienists and occupational health nurses working in hospitals need to be increasingly aware of the risk of plume and how to properly control it as surgical pro- cedures are on the rise. The global surgical procedures volume market stood at 1.3 billion procedures in 2014 and is estimated to reach 2.2 billion by 2023, according to Trans- parency Market Research. In 2009, the CSA Group introduced the fi rst version of CSA Z305.13-09 Plume Scavenging in Surgical, Diagnos- tic, Therapeutic, and Aesthetic Settings, which was revised in 2013. It was the fastest standard the CSA ever developed, taking only 18 months, because there was no real opposition to it, says Barry Hunt, president and CEO of Class 1, a medical gas pipeline company in Cambridge, Ont., and member of the CSA technical com- mittee on perioperative safety. "The evidence of the problem was overwhelming and a need for the stan- dard was overwhelming and that was the world's fi rst national standard to address that issue, saying if you pro- duce smoke in the OR, you have to capture it," he said. There are certain factors that affect the severity of the surgical smoke hazard, such as the type of procedure and duration of surgery. "The volume of plume that is generated is a big factor and some procedures have a very miniscule amount of smoke that is produced and some have a very large volume," says Hunt. "Breast reduction is probably the largest smoke producer.

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