Dangers of Smoke in the Operating Room

Cigarette smoking is at an all-time low in the United States1, falling to 15% of adults last year. This is good news because cigarette smoking is the nation’s leading cause of preventable illness, causing more than 480,000 deaths each year.2 However, a far more prevalent and toxic smoke is putting people at risk-surgical smoke. Using an electrosurgery device on 1 gram of tissue is akin to inhaling the smoke of 6 unfiltered cigarettes in 15 minutes.3

When considering the perioperative RNs and other providers exposed to toxic surgical smoke on a daily basis, it’s clear that the epidemic of surgical smoke exposure is far reaching. No one knows this better than the perioperative providers suffering from health issues such as asthma, bronchitis, eye irritation, headache, allergies and more serious problems such as carcinoma and leukemia that can develop following exposure to surgical smoke.3

Just as exposure to cigarette smoke is preventable, it is also possible to protect perioperative providers from exposure to surgical smoke. Education, increased awareness, and buy-in from leadership is needed to make surgical smoke evacuation and other perioperative safety practices for smoke protection common in the operating room. It requires perioperative RNs to speak up and call out for a workplace environment free of toxic surgical smoke.

Know the Facts
A plume of toxic smoke is released into the surgical environment every time a surgeon uses energy-producing equipment, such as lasers, electrosurgical units (ESUs), orthopedic devices, or ultrasonic devices that vaporize tissue. Without a smoke evacuation system and other protective devices and practices in place, perioperative RN’s and other OR clinicians can inhale this toxic plume containing more than 150 gaseous toxic components (including benzene, toluene, formaldehyde, cyanide, and aerolin), as well as bio-aerosols, particulate matter, and viable and non-viable viruses and bacteria.

Potential respiratory ailments caused by inhaling surgical smoke include emphysema, asthma, chronic bronchitis, hypoxia or dizziness, nasopharyngeal lesions, and nose and throat irritation. Other ailments linked to surgical smoke include:

  • eye irritation
  • anemia
  • anxiety
  • carcinoma
  • leukemia
  • cardiovascular dysfunction
  • skin irritation
  • headache
  • hepatitis
  • nausea or vomiting
  • weakness or fatigue
  • allergies

electical surgical smokeResearch on occupational hazards of surgical smoke has developed over the last 35 years. Early study findings identified that 77% of particulate matter in surgical smoke is smaller than 1  micrometer in size and can be inhaled and deposited in the alveoli of the lungs.4 More recent research has found direct viral transmissions to humans occurring when tissues being ablated have high concentrations of virus, such as human papilloma. ESU smoke can produce viable cells, which may cause port-site metastases.5

The carcinogenic potential for polycyclic aromatic hydrocarbons (PAHs) in smoke, which are the byproducts of incomplete combustion, have been found to be 20 to 30 times higher during radiofrequency electrosurgery than in outdoor environments; suggesting that scrubbed OR personnel studied had a higher calculated cancer risk.Surgical smoke can also put patients at risk, such as when they are exposed to increased levels of carbon monoxide, carboxyhemoglobin and methemoglobin during laparoscopic procedures.

SEE ALSO: Going Green

Speak Up
While the long-term effects of surgical smoke are still being investigated, existing evidence and anecdotal reports of chronic laryngitis and other respiratory ailments from perioperative RNs who have spent the last 30+ years exposed to surgical smoke suggest the many risks of OR smoke exposure. Despite these dangers, perioperative nurses and their facility leaders often accept harmful exposure to surgical smoke as part of the job. Perioperative RNs who have experienced health ailments after being exposed to surgical smoke should speak up and share their stories. This open communication can support further research to develop the evidence linking smoke exposure to harm. It can also help perioperative leadership to better understand the potential effects of surgical smoke in their own settings so they can implement a smoke-free environment.

Go Clear
Perioperative executives can commit to a surgical smoke-free environment by promoting universal compliance with policies and procedures for smoke evacuation, providing resources for interventions, and helping the perioperative team navigate organizational steps to become smoke free. The safety benefits of a smoke-free perioperative environment include:

  • increased visibility during the surgical procedure,
  • decreased smoke absorption by the patient’s red blood cells that may increase levels of carboxyhemoglobin and methemoglobin during laparoscopic procedures and a decrease in carbon monoxide levels in the peritoneal cavity during minimally invasive procedures; and
  • reduced perioperative team member exposure to surgical smoke and the hazards associated with surgical smoke.

One way to move toward a smoke-free surgical environment is to implement the AORN Go Clear Award. This surgical smoke-free recognition program includes:

  • pre-testing to evaluate team members’ understanding of surgical smoke exposure risks and prevention strategies,
  • interprofessional education with post-testing through online modules about surgical smoke safety, and
  • compliance monitoring to measure surgical procedures where surgical smoke is evacuated, the number of smoke evacuators, and current usage of smoke evacuation soft goods such as smoke evacuator tubing, smoke evacuator filters, in-line filters, and laparoscopic filters.Go Clear Award Logo

Following the completion of the education portion and implementation of smoke evacuation for all procedures generating smoke, post-testing, post implementation gap analysis, and compliance auditing, the facility may apply for the recognition award. Criteria to achieve the award include percentage of team members completing the education modules and percentage of team members with a passing grade on post-testing. The facility receives a plaque and a listing on the AORN Go Clear website that designates their facility as smoke free. The facility can use the AORN Go Clear Award logo in their promotional and recruiting materials.

In addition to participating in this safety campaign, hospital leaders can take immediate action to protect staff members from surgical smoke by making sure to implement and audit compliance with safe practices for reducing exposure to surgical smoke currently present in AORN guidelines for lasers, electrosurgery, and minimally invasive sssurgery 7.

AORN will also be publishing a forthcoming guideline on surgical smoke, which is slated for release later this year. The guideline will incorporate updated practices recommended in previous guidance documents, as well as the latest evidence to provide one set of practices that health care facilities can adopt into policies and procedures to standardize protective practices that reduce staff and patient exposure to surgical smoke.

Tolerating surgical smoke exposure puts patients and providers at risk. Perioperative RNs have the knowledge and the voice to speak up and share the evidence of the dangers of surgical smoke and the strategies to prevent harmful smoke exposure in their perioperative settings.


1. U.S. Smoking Rate Does Something It Hasn’t in Years http://www.cbsnews.com/news/us-smoking-rate-does-something-it-hasnt-in-years
May 24, 2016

2. U.S. Centers for Disease Control and Prevention Tobacco Related Mortality. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htmFebruary 17, 2016

3. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Surgical smoke and infection control. J Hosp Infect. 2006;62(1):1-5.

4. Mihashi, S., Geza, J.J., Incze, J., Strong, M.S and Vaughan, C.W. 1975. “laser surgery in otolaryngology: interaction of CO2 laser and soft tissue.” Annals of NY Academy of Sciences, 267 263-294.

5. Garrett, WL, and SM Garber. 2003. “Surgical smoke – a review of the literature.” Surgical Endoscopy 979-987.

6. Tseng, H., Liu, S., Uang, S., Yang, L., Lee, S., Liu, Y., & Chen, D. 2014. “Cancer risk of incremental exposure to polycyclic aromatic hydrocarbons in electrocautery smoke for mastectomy personnel.” World Journal of Surgical Oncology 1-17.

7. AORN. 2016. “Guidelines for Perioperative Practice.” By AORN. Denver, CO: AORN.

Mary J. Ogg, a perioperative nursing specialist, is a staff member of the Association of PeriOperative Registered Nurses (AORN). Brenda Ulmer is a healthcare consultant and surgical smoke safety educator from Snellville, Ga., who worked with AORN to develop the “Go Clear” program.

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