Managing surgical plume exposure in healthcare

What is surgical plume?

Surgical plume, also known as surgical smoke, cautery smoke, smoke-plume and diathermy plume, is a by-product from the use of electrosurgical instruments when cutting, vaporizing or coagulating tissue during surgical procedures.

Surgical plume is generated when thermal damage of tissue causes a release of smoke. The smoke is often not visible and has an unpleasant odour.

Surgical plume can contain a mixture of potentially hazardous components including ultra-fine particulates, bacteria, viruses, cellular debris, noxious and toxic aerosols, gases, vapours and fumes. Human papillomavirus (HPV) and the human immunodeficiency virus (HIV) have also been found in the plume, although it has not been confirmed if that includes infective virus.

The composition and exposure hazards associated with surgical plume depend on a variety of factors such as the type of surgical procedure and device (eg. laser, electrosurgical, ultrasonic), type and infectious nature of the tissue, extent of tissue ablation, the duration of surgery, and the employee's proximity to the surgical field.

Exposure to surgical plume can cause:

• visibility issues
• eye, nose and throat irritation
• headache

Whilst there is insufficient scientific research on adverse health effects from exposure to surgical plume, there is evidence that smoke from surgical plume is a potential health hazard, at least similar to smoking cigarettes, and research emphasises the basic principle that exposure to smoke of any kind should be minimised.

It is therefore recommended that a precautionary approach to exposure to surgical plume in workplaces is taken and exposure is controlled.

Plume evacuation systems

Plume evacuation systems are the most effective method of controlling exposure to surgical plume as they remove the plume at the point of generation using local extraction ventilation.

A plume evacuation system should:

• have an intake that can be effectively positioned at or near the point of plume generation
• have a filtration system that includes an activated carbon bed for trapping gases and an ultra-low particulate air (ULPA) filter (0.1 microns at 99.999% efficiency). The device should also indicate when a filter needs replacing
• have an exhaust system
• meet the requirements of regulations and standards for electrical safety and medical devices
• have sufficient capacity to handle the anticipated level of plume for all procedures within its expected application
• be designed so that changing filters and maintenance is easy to carry out and does not create ergonomic or infection control risks
• be easy to use, with minimal disruption to the surgical view

Wall suction units are considered unsuitable for plume evacuation because they do not effectively filter surgical plume and are difficult to maintain. Purpose-built plume evacuation systems that meet the criteria above should be used.

Additional plume controls

Where surgical plume is generated and an assessment of the procedure has determined that plume evacuation systems introduce other risks (for example visibility issues), alternative controls should be used, for example:

• using tools that generate less plume, for example 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
• ensure settings on diathermy tools are as low as possible to reduce the amount of plume
• ensure the room has specialised ventilation with air exchange rates such as those applicable to operating theatres

System of work for surgical plume

All staff who work with or near surgical plume should be provided information, instruction and training on:

• the potential risks associated with surgical plume
• specific roles and responsibilities in controlling the risk of surgical plume exposure (eg surgeon, theatre nurse, theatre technician)
• systems of work for controlling the risk of surgical plume
• how to use plume evacuation equipment safely and effectively according to manufacturer's instructions and operating procedures
• how to use and store personal protective equipment
• standard infection control procedures and precautions

Personal Protective Equipment

Where it is determined that a risk remains to employees after implementation of other control measures, then PPE should be used to further reduce the risk so far as reasonably practicable. PPE should only be used when no other practical control measures (such as plume evacuation) are available, or to supplement other controls.

Where required, the following PPE can be used to reduce the risk from airborne contaminants in surgical plume:

• fit-tested respiratory protection, eg minimum of an approved P2/N95 disposable respirator
• face shields and eye protection
• gowns and other standard surgical wear such as foot covers and gloves

Surgical masks are not considered adequate PPE in relation to fine aerosols which are constituents of surgical plume.