Surgical Plumes from Lasers

What are surgical plumes?

Surgical plume, also called surgical smoke, cautery smoke, smoke-plume, or diathermy plume, is the result of using electrosurgical tools to cut, vaporize, or coagulate tissue during surgery. When tissue gets heated during these procedures, it releases a kind of smoke that we usually can't see, but it often has an unpleasant smell.

What are the issues?

This surgical plume can contain various potentially harmful things, like tiny particles, bacteria, viruses, cell debris, noxious fumes, and gases. It's even been found to contain viruses like HPV and HIV, though it's not confirmed if they are infectious in this form. Exposure to surgical plume can lead to problems like reduced visibility, irritation of the eyes, nose, and throat, and headaches.

The exact makeup of surgical plume and how harmful it can be depends on several factors, like the type of surgery, the surgical tools used (like lasers or electrosurgical devices), the kind of tissue being worked on, how much tissue is being removed, how long the surgery takes, and how close employees are to the surgical area. 

Although most workplaces have controls in place to manage surgical plume exposure. Oftentimes the implementation of these controls and education and training for staff is lacking. For example, surgical plume evacuation equipment is not being used in all surgical procedures. One survey of 955 nurses and other surgical practitioners  in the UK identified other issues that have also been noted in Australia such as the underreporting of health symptoms and lack of training. In the survey, about 72% of respondents had experienced negative health symptoms associated with surgical smoke exposure, including headaches, coughing, eye irritation, and shortness of breath. However, only 12% of those who experienced symptoms reported them, and in most cases, no action was taken to address the concerns.

What are employer obligations around surgical plumes?

Employers have a duty under the OHS Act 2004 to provide a safe workplace so far as is reasonably practicable. This means minimizing exposure to and harm from surgical plumes. Employers also have a duty to consult health and safety representatives on matters of health and safety and meaningfully consider their views under section 35 of the OHS Act. This means that if you identify surgical plumes as a hazard in your workplace, your employer must work with you to mitigate this hazard.

Below are some strategies that can be used to control the risk of surgical plumes. These strategies are linked to their position in the hierarchy of controls. In consultation with your employer, you can bring these suggestions to them. 

1. Elimination/Substitution:

   • Use of Smoke-Evacuation Systems: Installing smoke evacuation systems directly at the source of plume generation, such as ESUs or lasers, can help eliminate the plume before it enters the room.
     
     
   • Opt for tools that produce less plume, like bipolar coagulation.
   • Using multiple tools, for example initially using bipolar diathermy with extraction then using monothermy where greater visibility is required and extraction cannot be used.

2. Engineering Controls:

   • Local Exhaust Ventilation: Implementing local exhaust ventilation systems with high-efficiency filters can capture and remove surgical plumes at the source, reducing their dispersion into the surgical environment.
     
     
   • Make sure the settings on diathermy tools are kept at their lowest to minimize plume production.
     

3. Administrative Controls:

   • Surgical Plume Policies and Training: Develop and enforce policies for the safe management of surgical plumes. Provide training to healthcare workers on plume hazards and safe practices.

4. Personal Protective Equipment (PPE):

   • Respirators: Employers must provide healthcare workers with fitted and tested N95 respirators or higher-level respiratory protection to reduce their exposure to surgical plumes when evacuation systems are not available or insufficient. Other PPE that can be used includes face shield and eye protection, gowns and other surgical wear such as foot covers and gloves. Surgical masks are not considered adequate PPE as they cannot capture the fine aerosols of surgical plume.

5. Work Practices:

   • Minimize Plume Generation: Workers can use lower power settings on energy-based devices, use the shortest activation time possible, and minimize the number of device activations to reduce plume generation.
   • Maintain Proper Distance: Maintain a safe distance from the plume source to reduce exposure.

6. Medical Surveillance:

   • Health Monitoring: Employers should conduct regular health check-ups and monitoring of healthcare workers exposed to surgical plumes can help detect any adverse health effects early.
     
     

7. Regulatory and Policy Controls:

   • Compliance with Regulations: Ensure that healthcare facilities comply with relevant occupational safety and health regulations related to surgical plume control.
     
     

8. Education, Training and Outreach:
   
   

   • Workers should be trained on practices that will reduce health risks from exposure to surgical plumes and informed about the health effects of exposure to surgical plumes. These training sessions should be conducted so as to be accessible to all staff that will be exposed to the hazard.

Plume evacuation systems, what should they look like?

Plume evacuation systems are the most effective method of controlling exposure to surgical plumes. By removing the smoke directly from the source, plume evacuation systems significantly reduce the risk that workers will inhale surgical plumes. A plume evacuation system should:

• Be equipped with an intake that can be placed effectively at or near the source of plume generation.
• Include a filtration system comprising an activated carbon bed to capture gases and an ultra-low particulate air (ULPA) filter with a 0.1-micron rating, offering 99.999% efficiency. Additionally, the system should have a feature to indicate when a filter requires replacement.
• Possess an exhaust system.
• Conform to the regulations and standards concerning electrical safety and medical devices.
• Have a capacity sufficient to manage the expected volume of plume for all applicable procedures.
• Be designed in a way that makes changing filters and performing maintenance easy without creating ergonomic or infection control hazards.
• Be user-friendly, causing minimal disruption to the surgical field's view.

What training and guidance must employers provide workers exposed to surgical plumes?

Workers working  in proximity to surgical plume should receive the following:

• Thorough information and training about the potential risks associated with surgical plume.
• Clarity on their specific roles and responsibilities in managing the risk of exposure to surgical plume, with variations depending on their job roles (e.g., surgeon, theater nurse, theater technician).
• Familiarization with established protocols and procedures for effectively reducing the risk linked to surgical plume.
• Instruction on the proper and safe utilization of plume evacuation equipment in accordance with the manufacturer's guidelines and operational procedures.
• Guidance on the correct utilization and storage practices for personal protective equipment.
• Understanding of standard infection control procedures and precautions.

Further Reading:

WorkSafe's topic page on surgical plumes

NSW Health advice on managing exposure to surgical plumes and the health implications of exposure

United States National Library of Medicine Research on the health impacts of surgical plumes

ANMF Policy on Surgical Plumes from Lasers