Rhode Island recently became the first state to require healthcare facilities to take measures to protect healthcare workers from the hazardous plume. With other states likely to follow, infection preventionists may want to revisit this issue, particularly the presence of toxic chemicals in the plume and the risk of possible infections and disease.
“Transmission of HPV [human papillomavirus] through surgical smoke has been documented,” the National Institute for Occupational Safety and Health (NIOSH) warns.1 “Surgical smoke has been shown to be mutagenic, cytotoxic and genotoxic.”
In the case NIOSH cited, a laser surgeon developed laryngeal papillomatosis with DNA types suggesting a link to the patients treated. “These findings suggest that the papillomas in [the surgeon] may have been caused by inhaled virus particles present in the laser plume,” the authors reported.2
“Surgical smoke has been shown to contain a variety of toxic gases, vapors, and particulates including carbon monoxide, polyaromatic hydrocarbons, benzene, hydrogen cyanide, formaldehyde, viable and non-viable cellular material, viruses, and bacteria,” NIOSH states.
Though cigarette smoking is an obvious parallel, NIOSH has not been able to link surgical plume with cancer. “Surgical smoke has been shown to induce acute and chronic inflammatory changes (e.g., emphysema, asthma, chronic bronchitis) in the respiratory tract of animal models. Scientific data on long-term effects of exposure to surgical smoke are unsystematic and scarce,” NIOSH states.
Though some kind of dose-disease effect seems intuitive, another study found that the “potentially carcinogenic components of surgical smoke are sufficiently small to be respirable. Infective and malignant cells are found in the smoke plume, but the full risk of this to the theater staff is unproven.”3
A study looking at nurses found that “long-term exposure to surgical smoke, as measured by the duration of operating room employment, does not appear to increase the risk of lung cancer.”4
Still, the litany of respiratory problems cited by healthcare workers exposed to surgical plume was sufficient to sway Rhode Island lawmakers.
Testifying before passage of the bill recently was Julie Greenhalgh, RN, an operating room nurse with 42 years’ experience in Cranston, RI.
She attributed her chronic lung disease to decades of occupational exposure to surgical smoke.
“I have a constant cough, bronchitis, and asthma,” she said. “I have never smoked cigarettes and never had asthma as a child.”
Testifying at a Feb. 14, 2018, hearing on the bill, Greenhalgh held up a plastic bag of medications she uses to treat her lung disease.
“I have three inhalers that I use every day as well as some oral medications,” she said. “I have been trying to promote this for many years. Passing this bill will allow nurses to work to save patient lives without putting their own lives in danger.”
Effective Jan. 1, 2019, the Rhode Island law gives hospitals and surgical centers 90 days to submit a policy to state health officials detailing their plan for “evacuation of surgical smoke plume [as] required in operating rooms.”5
The Association of periOperative Registered Nurses (AORN) is lobbying for similar bills in other states, with California and Colorado both considering some type of legislation or occupational health standard.
“Perioperative nurses are twice as likely as the general public to develop respiratory illnesses,” says Danielle Glover, MPA, associate director of government affairs at AORN. “[They] are being exposed to smoke on a daily basis — all of the toxins and the mutagenic, carcinogenic substances in it.”
A Risk to Patients
A recent study assessed the risk of surgical site infections in patients, trying to determine whether procedures conducted with plume evacuated resulted in lower SSI rates than those where the smoke was not removed.
The lead author of the study is Christian DiPaola, MD, a surgeon at the University of Massachusetts Medical School in Worcester, who promotes the use of surgical plume removal and uses the evacuation equipment for all of his procedures.
The research question was since viable bacteria and viruses can survive in the smoke, can they contaminate the surgical wound and cause infection? Clearly, the burden of biomaterials was being removed in the experiment, but no statistical significance was found between the infection rates in ORs with smoke and those that removed plume, DiPaola says.
“Our study was underpowered,” he says.
The study included 1,312 spine surgeries, with cases divided into a control group and an intervention group that removed surgical smoke.
“Of the 712 cases in the control group, 24 SSIs occurred (11 deep, 13 superficial), for an overall incidence of 3.4%,” DiPaola and colleagues concluded.6 “Of the 600 cases in the smoke evacuator group, 12 SSIs occurred (8 deep, 4 superficial), for an overall incidence of 2%. The observed difference in SSI incidence was not statistically significant (p = 0.17).”
“The idea is there, but proving it in a study is very hard to do,” he says. “This paper was a way to first consider it as a potential factor. We do all kinds of layers of infection mitigation in everything we practice. You scrub your hands, you sterilize your equipment, there are many layers of infection control practices. We wanted to think about the smoke plume as a potential source. Let’s at least include that as variable for future studies.”
While establishing an infectious threat to patients may be a bridge too far for plume removal advocates, in a time of consumer advocacy, the theoretical threat and the known toxins in the plume could be enough to spur calls for change.
Although the actual risk to patients may be diminishingly small, a line listing of the various toxins and mutagenic materials in plume may certainly give them pause.
“If I were lying on a surgical table, it is certainly not something I would want to be exposed to,” says Gayle Davis, director of corporate communications at AORN.
In that regard, a research team in Poland assessed the exposure of patients to organic surgical smoke during laparoscopic cholecystectomy. “The selected biomarkers of exposure ... included benzene, toluene, ethylbenzene, and xylene. Their concentrations in the urine samples [were assessed before and after surgical procedures],” the authors stated.7
“Qualitative analysis of the smoke produced during laparoscopic procedures revealed the presence of a wide variety of potentially toxic chemicals such as benzene, toluene, xylene, dioxins, and other substances,” the authors reported. “Exposure of the patient to emerging chemical compounds is usually a one-time and short-term incident, yet concentrations of benzene and toluene found in the urine were significantly higher after the surgery than before it.”
- Steege AL, Boiano JM, Sweeny MH. Secondhand Smoke in the Operating Room? Precautionary Practices Lacking for Surgical Smoke. Am J Ind Med 2016;59(11):1020–1031.
- Hallmo P1, Naess O. Eur Arch Otorhinolaryngol. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon.1991;248(7):425-7.
- Mowbray N, Ansell J, Warren N, et al. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc 2013;(9):3100-3107.
- Gates MA, Feskanich D, Speizer FE, et al. Operating room nursing and lung cancer risk in a cohort of female registered nurses. Scand J Work Environ Health. 2007;33(2):140-147.
- Rhode Island General Assembly. An Act Relating to Health and Safety — Licensing of Health Care Facilities. 2018-H 7082, 2018-S 2238. 2018: https://bit.ly/2OgPbLf.
- Krueger S, Disegna S, DiPaola C. The effect of a surgical smoke evacuation system on surgical site infections of the spine. Clin Microbiol Infect Dis 2018 3:DOI:10.15761/CMID.1000132.
- Dobrogowski M, Wesołowski W, Kucharska M, et al. Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy — assessment of the risk to the patient. Int J Occup Med Environ Health 2014;27(2):314-325.