Smoke lingers in the surgical suite

Health effects can be significant

Many hospitals have banned smoking from their campuses, but exposure to smoke continues to cause health problems — in the operating room.

"On the front door of the hospital, it says no smoking. But go up to the OR and we're smoking like crazy," says Kay Ball, PhD, RN, CNOR, FAAN, associate professor of nursing at Otterbein University in Westerville, OH, and an expert on surgical smoke. "We have to breathe in noxious compounds [that are byproducts of electrosurgery]."

Although hospitals are more likely to use wall suction to clear the air, there's been little progress in smoke evacuation during electrocautery, according to a 2010 web-based survey of 1,356 operating room nurses. Wall suction is considered to be effective for smaller amounts of surgical smoke, but smoke evacuation is required for larger volumes.

For example, only 24% of respondents said they "always" or "often" use smoke evacuation for cosmetic or plastic surgery that uses electrocautery or electrosurgery. That is a modest increase from the rate of 20% in 2007.1

Surgical smoke contains small concentrations of hazardous chemicals, such as benzene and toluene. A health hazard evaluation by the National Institute for Occupational Safety and Health found the levels were not above the recommended or permissible exposure limits.

Yet the health effects on nurses still can be significant. "The symptoms that we're hearing about over and over again are symptoms of allergic sensitization, allergic rhinitis and allergic asthma," says Ben Edwards, MS, CLSO, CHP, radiation safety officer at Vanderbilt University in Nashville and co-author of the article on the survey in the AORN Journal.

Edwards cites industrial hygiene literature indicating that up to 40% of the workers who are regularly exposed to surgical smoke may develop allergic sensitivity.3

"[The Centers for Disease Control and Prevention] says that some 500,000 people a year are occupationally exposed to surgical smoke. Sixty percent of those will never have any problem," he says. "But 200,000 [workers], if they continue in this line of work, ultimately are going to get sensitization and are really going to be bothered by the surgical smoke."

For some, the sensitivity can be career-altering. Ball tells of an OR nurse who carries an asthma inhaler to treat the effects from surgical smoke.

"She's just one of the many out there who have come up to me and said, 'I can't work in that environment anymore but I'm afraid to say anything because I don't want to lose my job,'" Ball says.

Clearing the air

It's time to change the paradigm, say Ball and other OR nursing leaders. Lasers were introduced into hospitals with built-in smoke evacuators, and hospitals generally adhere to the ANSI (American National Standards Institute) standard on laser smoke evacuation.2

While smoke evacuation with lasers varied widely, the survey found that it was consistently higher than with electrocautery. For example, while 68% of nurses reported using smoke evacuation with electrocautery for condyloma or dysplasia (the highest of any procedure), 84% reported using an evacuator when the same procedure was done with a laser.

Some physicians and OR managers don't realize that the technology of smoke evacuation has improved significantly. "The older smoke evacuators are loud. It's like having a vacuum cleaner in the room," says Edwards. "That's a safety issue. Communication within the surgical team is critical. The newer smoke evacuators have addressed that."

In her research on compliance with surgical smoke evacuation, Ball found that physician attitudes toward its use and lack of availability of the equipment were the greatest barriers. "Freestanding surgical centers are more likely to evacuate smoke than hospital departments," she says. "Nurses will be more apt to evacuate if they have attended a course or read an article that educated them on the negative consequences of surgical smoke."

Edwards also found that nurses reported physician resistance to evacuator use as the greatest barrier.

"This is a workplace safety issue," says Ball. "No physician should ever have any say against workplace safety."

The Association of peri-Operative Registered Nurses (AORN) has worked to raise awareness about smoke evacuation and the hazards of surgical smoke. AORN provides a surgical smoke toolkit to members, including a sample policy, awareness posters, and background information on the hazards.


1. Edwards BE and Reiman RE. Comparison of current and past surgical smoke practices. AORN Journal 2012; 95:337-350.

2. Ball, K. Surgical smoke evacuation guidelines: Compliance among perioperative nurses. AORN Journal 2012; 92:e1-e23.

3. Burge HA and Hoyer ME. Indoor air quality. The occupational environment – its evaluation and control. Ed. Salvatore DiNardi. Fairfax, VA: American Industrial Hygiene Association Press, 1997. 400.