OR Manager - May 2020 - 17
COVID-19
Using algorithms to contain surgical smoke
and aerosolized particulates
he hazards of surgical smoke are
well documented. As far back as
2004, AORN began publishing
guidelines to reduce exposure to surgical
smoke and aerosolized particles
during operative and invasive procedures.
These guidelines can also be adopted
to help protect COVID-19 patients
and frontline healthcare staff who are
exposed to viral particles and virus-containing
human tissue (sidebar, p 18).
A resource document published by
T
the Society of American Gastrointestinal
and Endoscopic Surgeons highlights the
increased concern related to COVID-19:
" There is a constant influx of new
information regarding the virology of severe
acute respiratory syndrome coronavirus
2 (SARS-CoV-2) and the disease,
COVID-19. What we know so far
regarding the SARS-CoV-2, is the RNA
virus has a size range of 0.06 to 0.14
microns. Along with the nasopharynx,
the upper respiratory tract and lower
respiratory tract, the virus has been
found in the entire gastrointestinal tract
from the mouth to the rectum. The virus
has been found in nasal swabs, saliva,
sputum, throat swabs, blood, bile, and
feces. Urine and CSF [cerebrospinal
fluid] evaluations have been negative.
The virus has also been found within
the cells lining the respiratory tract and
gastrointestinal tract. It is suspected
that the virus has multiple modes of
transmission. "
With no vaccines to protect us
against COVID-19, healthcare systems
are looking to the Centers for Disease
Control and Prevention (CDC) for guidance
on how to protect healthcare workers
as they care for both diagnosed and
undiagnosed patients. The CDC recommends
standard precautions, contact
precautions, airborne precautions, and
eye protection as personal protection
equipment (PPE) for healthcare workers.
In this article, we discuss ways to
mitigate the hazards of both surgical
smoke and COVID-19, and we offer sevwww.ormanager.com
eral
algorithms to use as a roadmap
for decision making in multiple types of
surgical procedures, as well as during
intubation and extubation.
Surgical smoke components
Surgical smoke-also called aerosols,
plume, bio-aerosols, vapor, air contaminants,
or mist-results from the interaction
of tissue and mechanical tools
and/or heat-producing devices such as
those used for dissection and hemostasis.
More than 150 chemicals have
been identified in surgical smoke, each
with its own health concerns and side
effects. Benzene, for example, is a trigger
for leukemia in susceptible people,
and the Occupational Safety and Health
Administration sets permissible exposure
limits to protect workers from the
hazards associated with inhaling benzene.
The
polycyclic aromatic hydrocarbons
(PAHs) in smoke are odorous pollutants
that are the byproducts of incomplete
combustion and pose carcinogenic
potential. Radiofrequency electrosurgery
current produces significant PAHs,
which can be inhaled. Tseng et al found
that electrosurgery during mastectomy
produced PAH concentrations that were
20 to 30 times higher than in outdoor
environments. Using a toxicity equivalency
factor for cancer risk,
they determined
that scrubbed personnel had
higher calculated cancer risks and that
the carcinogenic effects of PAHs on surgical
staff should not be neglected.
A review of the published evidence
indicates the danger of surgical smoke
and its components to perioperative
personnel (sidebar, p 21). Physical
symptoms include dizziness, eye irritation,
nausea, vomiting, headache,
sneezing, weakness, and throat irritation.
The symptoms and potential
risks-including emphysema, asthma,
bronchitis, dermatitis, and cardiovascular
dysfunction-are consistent with anecdotal
reports from healthcare professionals
and researchers over the last
four decades and reinforce the fact that
there is no such thing as safe smoke.
Patients are also at risk from surgical
smoke during laparoscopic surgery.
Smoke inside the abdomen is absorbed
through the peritoneal membrane. The
result in the patient's bloodstream is an
increase in the methemoglobin and carboxyhemoglobin
concentrations, which
reduces the oxygen carrying capacity
of red blood cells. Carboxyhemoglobin
and methemoglobin are dsyshemoglobinemias,
which give a falsely elevated
oxygen reading that could result in unrecognized
patient hypoxia.
What are the long-term health effects
from exposure to surgical smoke? A definitive
answer is unclear, but decades'
worth of evidence indicates that there
are dangers. For example, a 2013 case
report by Rioux and associates from
Canada documents human papillomavirus
(HPV) positive tonsillar cancer in two
laser surgeons. Their history revealed
no other risk factors for oropharyngeal
cancer or HPV aside from occupational
exposure. In a study by Ball, perioperative
nurses reported twice the incidence
of respiratory problems compared to the
general population.
It took many years for society to
accept that cigarette smoke was unhealthy
and contributed to disease and
death. Although we are well along the
path where greater protection of healthcare
workers should be routine and uniform,
we are not there yet.
Using algorithms
What do algorithms have to do with providing
bedside care during a surgical or
invasive procedure? Algorithms are written
by programmers to tell computers
what to do through complex numerical
codes. Nurses are not computers. The
task is to separate the definition from
a complex computation and make it
simple.
Continued on page 18
OR Manager | May 2020
17
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