Surgical plume, often referred to as surgical smoke, is a gaseous byproduct generated during surgical procedures that utilize energy-based devices. This occurs when devices such as electrosurgical units, lasers, and ultrasonic devices vaporize human tissue. Its presence within the operating room environment poses a recognized safety concern for healthcare professionals and patients alike.
Understanding Its Makeup and Creation
Surgical plume forms through the thermal damage of tissue, releasing a complex mixture of substances into the air. These devices heat tissue to high temperatures, causing cells to rupture and their contents to become airborne. This vaporization creates a visible or invisible plume.
The composition of surgical plume is varied, consisting of both biological and chemical components. Biological constituents include cellular debris, blood fragments, bacteria, and even viruses, such as Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV). While the plume is approximately 95% water vapor, the remaining 5% contains potentially hazardous matter. These hazardous chemical components include toxic gases like benzene, toluene, hydrogen cyanide, formaldehyde, and carbon monoxide.
Polyaromatic hydrocarbons and various particulate matter are present within surgical plume. The size of these particles varies significantly, with many being ultrafine, some as small as 0.007 micrometers. Certain devices produce smaller particles, which can remain suspended in the air for extended periods. The specific makeup of the plume depends on factors like the surgical device used, the type of tissue being treated, and the duration of the procedure.
Potential Health Risks
Exposure to surgical plume presents several potential health risks for individuals in the operating room, including surgeons, nurses, anesthesiologists, and to a lesser extent, patients. Respiratory issues are a primary concern, as inhaling the plume can lead to upper respiratory tract irritation, coughing, and symptoms similar to asthma or bronchitis. The small size of many plume particles allows them to penetrate deeply into the respiratory system, potentially causing long-term damage.
Beyond respiratory effects, direct exposure can cause irritation to the eyes, leading to watering or discomfort. Skin irritation has also been reported among healthcare workers. The chemical compounds within the plume, such as benzene and formaldehyde, have been identified as having mutagenic and carcinogenic properties, raising concerns about potential long-term health effects.
The presence of viable cells, blood products, and viral fragments in the plume raises questions about the potential for infectious disease transmission. While direct infectious disease transmission through surgical smoke has not been widely documented, the possibility of generating infectious viral fragments exists, particularly during certain procedures. The dense nature of surgical plume can also obscure the surgical field, making it difficult for the surgeon to maintain clear visibility. Some comparisons suggest that exposure to one gram of surgical plume is equivalent in toxicity to smoking between three to six cigarettes.
Controlling Exposure in Surgery
Various strategies and technologies are employed in operating rooms to control and minimize exposure to surgical plume. Source capture methods are among the most effective, utilizing smoke evacuators and suction devices to remove plume at its point of origin. For optimal effectiveness, the intake nozzle of a smoke evacuator should be positioned within two inches of the surgical site and remain activated throughout the procedure.
These specialized systems incorporate multi-stage filtration to trap both particulate matter and gaseous contaminants. They typically include Ultra-Low Particulate Air (ULPA) filters, which can capture particles as small as 0.1 micrometers with 99.999% efficiency. Activated carbon filters are also used to absorb toxic gases and odors from the plume. High-Efficiency Particulate Air (HEPA) filters are generally not sufficient for surgical plume, as they only filter particles down to 0.3 micrometers.
Personal protective equipment (PPE) also plays a role in reducing exposure, though it is considered supplementary to source capture. Fit-tested respirators, such as N95 or P2 masks, offer a minimum level of protection against airborne contaminants, and eye protection or face shields can guard against ocular exposure. However, standard surgical masks alone are not sufficient to filter out all the ultrafine particles and gases found in surgical plume.
Operating room ventilation systems, including general room ventilation and adequate air changes per hour, contribute to overall air quality by diluting airborne contaminants. Institutions implement policies and provide training for staff on proper plume management techniques, and regularly inspect and replace filters in evacuation systems. Adjusting surgical techniques, such as using lower power settings on energy devices or employing bipolar coagulation instead of monopolar, can also reduce the amount of plume generated.