Plume management, smoke evacuation or site specific air purification in the operating room environment continues to be an emerging concern. 

1. Biological
    - Virus - HIV, HPV, hepatitis B and C, etc
    - Bacteria - S. Aureus, M tuberculoisis, E. coli, spores, etc;
    -  - carbonized tissue, aerosolized blood, etc.
2. Chemical
    - Mutagens, carcinogens, allergens, irritants to respiratory tract, toxic gases
    - Chemical byproducts include:

1. Acrolein is highly toxic if inhaled or ingested.  Its vapors irritate the nose and throat and can severely irritate the yes causing reddening of the eyelids, tearing and swelling.  Sever exposure, although unlikely, may result in shortness of breath, nausea, pulmonary edema, vomiting, diarrhea, prostration and loss of consciousness.
2. Benzene is an industrial degreasing agent that increases the risk of leukemia with prolonged low-level exposure.  Prolonged skin contact or excessive inhalation may cause irritation of the eyes, nose and respiratory tract; euphoria; nausea; drowsiness; headaches; dizziness; or intoxication.
3. Formaldehyde is an embalming fluid that is carcinogenic, very toxic and corrosive to skin and mucous membranes.  Gas and vapors are irritating at very low levels.  It is one of the most common causes of occupational skin disease.  Excessive or repeated exposure may cause kidney damage. 
4. Hydrogen Cyanide (HCN) is found in rat poison.  Inhalation of large quantities causes tachypnea (rapid breathing); resulting in increased cyanide intake, followed by dyspnea, paralysis, convulsions and respiratory arrest.  Death may occur within minutes.  Less concentration can cause headache, vertigo, nausea, and vomiting.  HCN levels of 100 ppm have been measured at lasing sites - 10 times higher than recommended limits. 
5. Toluene is an industrial solvent that is irritating to the eyes, nose and respiratory tract.  Inhalation of high concentrations produces a narcotic effect, sometimes leading to coma as well as liver and kidney damage.  Chronic poisoning has resulted in anemia, leucopoenia, and bone marrow hyperplasia.  Chronic inhalation during pregnancy has been associated with teratogenic effects on the fetus. 

It has been established that surgical smoke and aerosol smells bad, limits visibility and contains potential biological and chemical hazards as listed above.  But do these "potential" hazards cause any actual harm?  Are the biological and chemical constituents of surgical smoke and aerosol present in sufficient quantities to cause infection or other adverse effects on personnel and patients present in the operating room?  Let's examine its documented impacts. 

Decreased Vision.  Surgical smoke an aerosol occludes the vision of the surgeon and the rest of the team in both open and minimally invasive surgical procedures.  This lack of visibility can lengthen the procedure, adding to costly OR time and subjecting the patient to increased time under anesthesia. 

Noxious Odors.  Aesthetically, the odor of surgical smoke and aerosol is extremely offensive to surgeons, nurses, patients and others in the operating room.  It attaches to hair, surgical attire, and any exposed skin surfaces.  It can irritate the eyes and cause nausea and vomitting¹.  There is also evidence that the unpleasant smell heightens patient anxiety.  Plume odor is more than a nuisance; it is a warning.  If you smell plume you are also inhaling harmful gases, such as hydrogen cyanide, formaldehyde, benzene, phenol and toluene (see hazards above) ². 

Lung Disease.  Scientists have studied the effects of carbon dioxide laser plume on the lungs of rats.  In rat lungs exposed to laser plum for various periods of time, they found:

- Congestive Interstitial Pneumonia
- Bronchitis
- Emphysema

The severity of pulmonary pathology increased proportionately with the duration of exposure to carbon dioxide laser plume³.   Wenigh el al. studied the effects of electrosurgery and Nd:YAG laser plume in both contact and noncontact modes on the respiratory systems of rates.⁴ in all modes, histologic analysis of cardiorespiratory specimens revealed Alveolar congestion and Emphysematous changes.  in a study done on sheep exposed to laser smoke, researchers discovered a depression of mucociliary function even more distinct than depressions shown in studies of cigarette smoke.  the lungs may be damaged if the cilia of the respiratory tract are unable to clear the particles from the lungs.⁵ 

Inhibition of Tissue Oxygenation.  Dr. Douglas Ott measured methemoglobin levels in 25 female patients who were operated on using smoke-generating devices, as compared to a control group of 25 women having laparoscopy without the use of a smoke-generating device.  Patients in the group having smoke-generating procedures had an abnormal and statistically significant elevation of methemoglobin levels compared to controls.  In contract to oxyhemoglobin, methemoglobin is formed from unoxyginated hemoglobin and is not capable of carrying oxygen to tissue.  Methemoglobin also increased the oxygen affinity of the remaining normal hemoglobin by shifting the oxyhemoglobin dissociation curve to the hemoglobin/methemoglobin ratio due to peritonial smoke absorption with resultant methemoglobinemia establishes the toxicity and hazard of intra-abdominal surgical smoke and aerosol and confirms that it should be evacuated as rapidly and efficaciously as possible. ⁶

Mutations.  NIOSH evaluated the mutagenic potential of the electrosurgical smoke and aerosol produced during routine reduction mammoplasty.  Airborne particles were collected on glass-fiber filters, samples were extracted and concentrated extracts were tested for mutagenic activity in two strains of Salmonella typhimurium using the standard Ames test.  the smoke was found to be mutagenic to one of the two strains.⁷ 

In another study, Japanese researchers used the Ames test to measure the mutagenicity of 40 mg of smoke generated when 1 g of tissue was vaporized by a carbon dioxide laser or an electrosurgical devise.  The mutagenicities of the laser and electrosurgical smoke and aerosol condensates are equivalent to that generated by 3 and 6 sigarettes.⁸

These results are not surprising, because it is known that frying and broiling meat releases mutagens.  It was not determined in either study whether the smoke actually posed a serious health risk to perioperative personnel, but safe levels of ambient mutagens have not been determined and probably never will be. 

Verrucae.  Labraico et  al. conducted the first clinical study of the risks of laser plume with respect to Human Papilloma Virus.  Using a written questionnaire, they were able to identify an association between the use of the carbon dioxide lasers for treating of verrucous lesions and the development of such lesions by physicians administering the treatment.9  Later, Sawchuk et al. used a bioassay to demonstrate that smoke from bovine warts contained infectious Bovine Papilloma Virus particles.  The study conclusively demonstrated the infectivity of this virus in surgical smoke and aerosol; the smoke did, in fact, cause disease.¹⁰

HIV Infection.  Concern about the transmission of infectious diseases from patients to health care workers is increasing, spurred on by reports of health care workers becoming infected with HIV through injuries with sharp objects and through exposures to blood and other body fluids.  An important questions that is yet to be answered is whether operating personnel can be infected by a blood aerosol containing a bloodborne pathogen such as HIV or HBV.  No documented cases of human infection have occurred through this route, but smoke or aerosols produced when lasers or powered surgical instruments were used on cell cultures infected with HIV have resulted in other cell cultures becoming infected. 

Summary.  Although few of these studies have demonstrated clinical harm to health care professionals or patients caused by exposure to surgical smoke and aerosol, their finding have been significant enough to cause a number of experts to recommend implementation of techniques to limit surgical smoke and aerosol exposure.  the next section describes steps that can be taken to protect both patients and perioperative personnel.

Surgical smoke and aerosol is typically produced during procedures utilizing lasers and electrosurgical equipment.  Research shows that both laser and electrosurgical smoke and aerosol have very similar makeup.  Aerosolized particles are also created by the mechanical action of surgical instruments like bone augers and saws.  These small particles and gases are potentially hazardous if inhaled.  If they are not evacuated, they become airborne and can be inhaled. 

Sources of Surgical Smoke and Aerosol

The amount of plume, smoke, or aerosol generated varies with the:

 - Surgical procedure
 - Target tissue
 - Surgical technique
 - Duration of application of thermal/mechanical energy
 - Instrument used to vaporize/aerosolize the tissue

Two general types of surgical instruments are of interest: those that impart thermal energy to tissue, such as surgical lasers and electrosurgery; and those that impart mechanical energy, such as bone saws, reamers and drills. 

Thermal Energy.  Although lasers and electrosurgical devices may cause different degrees of explosive responses in tissue cells, both can heat tissue to 100 degrees Celsius.  At that temperature, cell membranes rupture, causing the release of water vapor that is permeated with cellular particulates and potentially toxic chemicals.  Research finding indicate that there is little difference between the smoke generated by electrosurgery and that generated by lasers.  Electrosurgical smoke and aerosol can be just as noxious and hazardous as laser plume.

Mechanical Energy.  Plume and aerosolized debris can also be generated by mechanical devices.  Any instrument that oscillates, vibrates, or spins, within surgical sites can generate tissue aerosols that contain potentially harmful components.  Power tools, such as bone drills and surgical saws and hand tools, such as reamers are used frequently in orthopedic procedures.  These tools are known to produce large blood droplets that splatter surgical garments and protective equipment.  They have been also shown to produce aerosol particles in the respirable size range (< 5 microns in diameter).  This aerosol can be just as dangerous as the smoke produced in laser or electrosurgical procedures. 

In one study, preliminary analysis of data obtained by NIOSH showed that relatively large concentrations of aerosol were produced in hip replacement procedures, and that a large fraction of the particles in that aerosol were in the respirable size range.  The aerosol had a multimodeal size distributions, with each mode attributable to the use of a given surgical tool.³

Endoscopic Surgery.  Surgical smoke and aerosol generated in an open operating room environment is absorbed primarily via the respiratory tract, but the harmful constituents of surgical smoke and aerosol can also be absorbed by the skin and the mucous membranes.  During laparoscopic or endoscopic surgery, smoke is produced in the closed space of the peritoneal or thoracic cavity, where it remains until it is evacuated through on the ports or a suction device. 

In laparoscopic procedures, smoke evacuation is critical to the surgeon's visibility as well as to prevent absorption through tissue into the patient's bloodstream.  The absorptive capacity of the peritoneal cavity is well knows, and the increased intra abdominal pressure caused by laparoscopic pneumoperitoneum can cause a significant increase in the absorption rate.  During laparoscopic surgery, the harmful constituents of surgical smoke and aerosol can remain in contact with the patient's mucous membranes for a long time, allowing for peritoneal absorption of toxic chemicals.  Later, rapid decompression through a large trocar valve may result in the release of biological contaminants into the atmosphere of the OR. 

Pathogenic Potential.  All personnel in the OR are exposed to measurable amounts of smoke when lasers or electrosurgery are used, but the extent of that exposure is highly variable among the personnel present.  Scrub nurses and circulators work 3-5 cases per day.  Surgeons will scrub twice a week on average.  so, although surgeons have a more concentrated dose of smoke, the individuals that have multiple daily exposure face the greatest long-term chronic risks.  These personnel are acutely aware of the presence of smoke and aerosolized debris in both open and less invasive surgical procedures. 

1. Emergency Care Research Institute. Smoke Evacuation systems, Surgical. Healthcare Product Compariosn system. Plymouth Meeting, PA; ECRI, December 195. 20pp
2. Patterson, Pat. "OR exposure to electrosurgery smoke a concern." OR Manager 9 (June 1994)" 1, 6-7
3. Patterson, Pat. "OR exposure to electrosurgery smoke a concern." OR Manager 9 (June 1994)" 1, 6-7
4. Eindyin, Vhstlrnr. "The effects of smoke plume generated during laser and electrosurgical procedures.: Minimally Invasive Surgical Nursing 8 (1994): 99-102
5. "Laser Smoke Effect on the Bronchial System. " Lasers in Surgery and Medicine, March 1987
6. Ott, Douglas E. "Safety concerns in endoscopy."  Presented at Interational Society of Lasers in Medicine and surgery, November 5, 1991. Plume facts 2 (fourth quarter 1991): 3-4
7. Frandel, SG. "National Institute for Occupational Safety and Health (NIOSH) identifies potential hazards in plume." Clinical Laser Monthly 5:67, 1990
8. Patterson, Pat. "OR exposure to electrosurgery smoke a concern.: OR Manager 9 (June 1993): 1, 6-7
9. Lobraico, RV, Schifano, NJ, Brader, R. "A retrospective study on the hazards of the carbon dioxide laser plume." Journal of Laser Application, 1988 1:6-8
10. Sawchuck, W., Weber, P., Lowy, D., Dzubow, L. " Infecrtious Papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulator: Detection and protection." Journal of American Academy of Dermatology, July 1989, p 45

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