N95 use questioned for surgical smoke
More data needed, CDC panel decides
Surgical smoke plumes might contain intact viral DNA, but with no definitive evidence to show it's infectious, a federal advisory panel said the use of N95 respirators during smoke-generating procedures is not warranted.
The hazards of surgical smoke have long been a concern of perioperative nurses. The Association of periOperative Registered Nurses (AORN) recommends the use of smoke evacuation systems for electrocautery and laser procedures and says facilities "should consider" N95 respirators as personal protective equipment when procedures involve infectious material.
The issue before the Healthcare Infection Control Practices Advisory Committee (HICPAC), an expert advisory panel to the Centers for Disease Control and Prevention, related to laser and electrocautery procedures for human papilloma virus (HPV), such as smoke-producing procedures to remove HPV warts. A CDC research review of 25 articles found evidence of whole HPV genome in smoke plume. In one study, viable bovine papilloma virus was generated in smoke plume and then injected into cows. All three of them acquired the infection. But that didn't mimic occupational exposure, and other studies did not clearly show a link between occupational exposures and HPV infection, said David Kuhar, MD, medical officer with CDC's Division of Healthcare Quality Promotion.
"The epidemiology of disease is not here," says Kuhar. "With that piece missing, it makes it difficult to say there's disease transmission happening, because it hasn't been demonstrated.
Case reports also are lacking, he says. "We've had 20 years of these exposures happening and no clear signal of disease," he says.
Smoke evacuation use lacking
Nurses have long complained about irritation from surgical smoke plume, including exacerbation of asthma and allergic sensitivities. A 2010 web-based survey found that only about one in four (24%) of OR nurses said smoke evacuation was used "always" or "often" during cosmetic or plastic surgery that involved electrocautery or electrosurgery.1
The National Institute for Occupational Safety and Health (NIOSH), a division of the CDC, recommends the use of smoke evacuators within 2 inches of the surgical site in laser or electrosurgery procedures. There is no regulation from the Occupational Safety and Health Administration (OSHA) related to surgical smoke.
In a 2001 health hazard evaluation at a Virginia hospital, NIOSH researchers found formaldehyde, acetaldehyde, and toluene in OR air samples during five procedures that used electrocautery. Half of the OR nurses, technicians, and nurse anesthetists said they had symptoms associated with surgical smoke, including physician-diagnosed asthma.2
Amber Jones, MSN, RN, CNOR, CIC, CPN, a perioperative nursing specialist and AORN liaison to HICPAC, said she was glad that the panel addressed the issue. "The message is getting out about the hazards of surgical smoke," Jones says. "We feel that further research is needed on this topic."
Several toxic and carcinogenic chemicals have been detected in surgical smoke, and as Kuhar noted in his HICPAC presentation, "live and infectious HPV seems likely to be in smoke plumes."
HICPAC members agreed that smoke evacuation is important, but they worried that respirator use could have other consequences, such as healthcare workers touching their faces with contaminated hands to adjust uncomfortable respirators. "We have to base [recommendations] on the risk we think is associated with exposure," said Mark Russi, MD, chair of the Medical Center Occupational Health section of the American College of Occupational and Environmental Medicine (ACOEM) and director of occupational health at Yale — New Haven Hospital. Russi is the ACOEM liaison to HICPAC.
"The data are pretty scant on the impact of respirator use in operating rooms," he said. [Editor's note: AORN provides a free surgical smoke toolkit that includes a sample policy and awareness posters at www.aorn.org/smoketoolkit.]
- Edwards BE and Reiman RE. Comparison of current and past surgical smoke practices. AORN Journal 2012; 95:337-350.
- King B and McCullough J. Health Hazard Evaluation Report 2000-0402-3021, National Institute for Occupational Safety
- and Health. November 2006. Available at http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0402-3021.pdf.