Recommended Guidelines

Although laser or surgical smoke evacuation is presently not legally mandated, there are a number of professional organizations that have developed guidelines and standards in an effort to protect health care workers from the potential health hazards associated with surgical smoke plume. Stricter guidelines and recommendations continue to be introduced. The following are some current recommendations that may assist health practitioners in establishing policies and guidelines for smoke evacuation in their own workplace.

American National Standards Institute (ANSI) Z136.3

“The Safe Use of Lasers in Healthcare Facilities,” 2005

“In operations that produce vaporized target tissue through the disruption of cells, LGAC (laser generated airborne contaminants) is a resulting hazard, requiring appropriate management. Analysis of the LGAC produced during laser surgical procedures has shown the presence of gaseous toxic compounds, bio-aerosols, dead and live cellular material, and viruses…At certain concentrations some of the LGAC can cause ocular and upper respiratory tract irritation, have unpleasant odors, create visual problems for the user and have been shown to have mutagenic and carcinogenic potential.”

“NOTE: Electrosurgical devices and instrumentation are often used both separately and simultaneously with health care laser systems. These devices have been found to produce the same type of airborne contaminants as produced by laser-tissue interactions, which should be evacuated from the surgical suite.”

National Institute of Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC)

“Control of Smoke from Laser/Electric Surgical Procedures,” 1998

“During surgical procedures using a laser or electrosurgical unit, the thermal destruction of tissue creates a smoke byproduct in the operating room. Research studies have confirmed that this smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material(including blood fragments), and viruses. At high concentrations the smoke causes ocular and upper respiratory tract irritation in health care personnel, and created visual problems for the surgeon. The smoke has unpleasant odors and has been shown to have mutagenic potential…NIOSH research has shown airborne contaminants generated by these surgical devices can be effectively controlled…The two major…approaches to reduce surgical smoke levels for health care personnel are portable smoke evacuators and room suction systems.”

Association of periOperative Registered Nurses (AORN) AORN Recommended Practice for Electrosurgery RP XIV

“Exposure to smoke plume generated during electrosurgery should be minimized.”

This Recommended Practice states that surgical smoke generated by electrosurgery should be evacuated with the use of smoke evacuation system or in-line filters used with all suction devices. The plume created from electrosurgery is just as hazardous as the smoke generated during laser surgery. Both can contain toxic gases and vapors, chemical byproducts, blood fragments, and viruses. In high concentrations, surgical smoke can cause ocular and upper respiratory tract irritation. NIOSH recommends that appropriate smoke evacuation systems be used to prevent acute and chronic health problems to patients and personnel. OSHA addresses the need to evacuate surgical smoke through the General Duty Clause that state a safe work environment must be provided. The Recommend Practice further states that smoke evacuation systems and accessories should be used according to the manufacturer’s instructions and that the suction wand should be positioned as close to the tissue impact site as possible to maximize smoke capture and enhance visibility at the surgical site. (AORN Recommended Practices, p.490-1)

AORN Recommended Practice for Laser Safety in Practice Settings RP VI

“Personnel working in the laser environment should avoid exposure to smoke plume generated during laser surgery.”

This Recommended Practice stresses that surgical smoke should be reduced by using local exhaust ventilation controls such as wall suction units with in-line filters or smoke evacuation units. The collection device should be held as close to the point where the plume is generated. The Recommend Practice continues to state that high-filtration masks should be worn during laser procedures to filter particulate matter and reduce noxious odors but should not be viewed as the absolute protection from chemical contaminants. An in-line filter connected to a wall suction line can be used to evacuate when very small amounts of surgical smoke are generated. When large amounts of plume are created, then a mechanical smoke evacuation system with a high-efficiency filter should be used. Standard precautions should be used during laser procedures since surgical smoke has been shown to contain toxic gaseous compounds, bio-aerosols, and dead and living cell material. The potential for bacterial and/or viral contaminations from the surgical smoke remains controversial. (AORN Recommend Practices, p.567-8)

American Society for Laser Medicine and Surgery (ASLMS)

Recommendation, 1999

“All medical personnel should consider the vaporized tissue plume to be potentially hazardous both in terms of the particulate matter and infectivity…Evacuator suction systems should be used at all times to collect the plume.”

Occupational Safety and Health Administration (OSHA)

OSHA is presently aligned with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Joint Commission Resource, Inc. (JCR) to provide education and compliance assistance to healthcare organization to reduce exposure to biological and airborne hazards in health care. In 1999, OSHA developed a monograph on the hazards of surgical smoke based on conclusive research that demonstrated the problems experienced with exposure to surgical smoke. Unfortunately, this monograph was never distributed. Instead OSHA relies on the General Duty Clause which states that facilities must provide a safe work environment. If workers report that a facility is not promoting a safe work environment by not providing smoke evacuation devices, then OSHA can inspect and penalize a facility if an unsafe work environment is discovered.