The Ottawa Hospital OPERATING ROOM NURSING POLICY, PROCEDURE, PROTOCOL MANUAL

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1 The Ottawa Hospital OPERATING ROOM NURSING POLICY, PROCEDURE, PROTOCOL MANUAL TITLE: Smoke plume evacuation during surgical procedures. NO. NSG-I-## PAGE: 1 of 5 SOURCE: Unit Policy and Procedure Manual The Ottawa Hospital General, Riverside and Civic Campus. DATE ISSUED: June 24, 2004 APPROVED BY: Surgery Management Committee LAST REVISION: O R POLICY STATEMENT: To ensure the safety of patients and perioperative team members, a smoke plume evacuation system should be used for any surgical procedure which produces smoke plume. This is at the discretion of the perioperative team which is composed of the nursing staff, anesthesia staff, surgeons, and any support staff in the room. Electrosurgical units are useful tools in surgical procedures. Many studies have shown, however, that the smoke plume produced by ESU's is a health hazard if inhaled or absorbed by patients or inhaled by surgical team members. To eliminate this hazard, a smoke evacuator should be used during any surgical procedure in which ESU smoke plume is produced. Chemical analysis of the laser plume has shown that a variety of organic compounds can be present, including formaldehyde, acrolein, benzene, and polyaromatic hydrocarbons. In sufficient concentrations, some of these contaminants can cause irritation of the eyes and upper respiratory tract; others have been shown to have mutagenic and carcinogenic potential. There is a potential for transmission of viral infections by exposure to particulates in the laser plume. Precautions shall be taken to minimize exposure of patients and staff to the laser plume. Please refer to The Ottawa Hospital Laser Safety Policy sections 4.4.6, , , 1

2 , , , and DEFINITIONS: Smoke plume: is smoke produced by combustion of human tissue. During surgical procedures using a laser or electrosurgical unit, the thermal destruction of tissue creates a smoke byproduct. Research studies have confirmed that this smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, and 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 creates visual problems for the surgeon. The smoke has unpleasant odors and has been shown to have mutagenic potential. Electrosurgical Unit (ESU): is defined as the generator, the foot switch with cord (if applicable); and the electrical plug, cord, and connections. Crystal Vision Smoke Evacuation Unit: A device used to remove the smoke plume generated during electrosurgery or laser surgery. The smoke evacuation unit contains both a charcoal and ULPA (ultralow penetration air filter) to eliminate smoke and viral particles. Laser: A device that produces an intense, coherent, directional beam of light by stimulating electronic or molecular transitions to lower energy levels. An acronym for Light Amplification by Stimulated Emission of Radiation. NURSING ALERTS: Smoke evacuation systems should be used according to manufacturers written instructions. When a smoke evacuation device is used, the capture device should be placed as close to the source of the smoke plume as possible, which will maximize smoke capture and enhance visibility at the surgical site. Replace the Output filter as soon as odors become noticeable, or every 4 months, whichever occurs first. High filtration surgical masks may be worn to minimize personnel exposure to chemical byproducts and noxious odors during operative procedures that generate smoke plume. For best results during laparoscopic procedures, use with insufflators that deliver flow rates greater than 6 liters/minute, you must use LOW FLOW setting. In LOW FLOW cases, it is useful to set the time delay/adjust to between 8-12 seconds. 2

3 Do not exceed 27mmHg intra-abdominal pressure. Disposable sterile tubing sets and disposable ESU shrouds are SINGLE USE ONLY. EQUIPMENT: Electrosurgical Unit Electrosurgical active electrodes Crystal Vision Smoke Evacuation High filtration masks as necessary Filter, output multiple use # Filter, input mutiple use # Tubing sterile intra abdominal plume eliminator prn # Tubing speculum non-sterile prn # Blade telescopic extendable w/torque penevac prn # Pencil attachment w/torque w/8 tubing prn # PROCEDURE: 1. The circulating nurse must inspect the smoke plume evacuation system for electrical safety and filter patency before each use. 2. The scrub person is responsible for ensuring proper use of the smoke plume evacuation system on the surgical field. 3. The smoke plume evacuation system is to be used for ESU smoke evacuation only. Another means of suctioning must be used for body secretions. If the surgical case will result in fluid or tissue suction, an inline fluid collection unit should be used. 4. Smoke plume evacuation systems filters are changed according to the manufacturers recommendations. 5. When the Crystal Vision Smoke evacuation system is not being used replace the red plastic cap on the input filter. 6. Sterile smoke plume evacuation tubing will be opened aseptically and given to the scrub person. When in use, the end of the tubing should be within 1 inch of the site generating smoke to be most effective. 7. Plug the ESU sensor connector into the ESU connector on the Crystal Vision front panel. 8. Hook the clip on the end of the ESU sensor over the electrical cord that is attached to the active ESU accessory (such as an ESU hand switching pencil) that is being used with the ESU generator. The sensor should be placed over the cord and as close to the ESU generator as possible. 9. The Crystal Vision will now turn on any time that the accessory is activated. 10. The smoke plume evacuation system must be turned on and set to the lowest level that eliminates all visible smoke particles. It is not necessary to run the smoke 3

4 evacuator at 100% at all times. 11. Dispose of spent filters in the regular garbage. Laparoscopic Procedures: 1. Use the Crystal Vision unit in LOW FLOW setting. 2. Set the time delay/adjust to between 8-12 seconds. 3. Aseptically open the laparoscopic smoke evacuation tubing. 4. The scrub nurse will hand the circulator the connection end to attach to the input filter. 5. Scrub nurse will connect the smoke evacuation tubing to the 5mm trocar sheath. 6. The OVER PRESSURE indicates pressure-exceeding 27mmHg in the pneumoperitoneum. This condition causes the vacuum pump to start in order to reduce the pressure in the pneumoperitoneum. At pressures over 30mmHg, a pressure relief valve opens. This situation can be caused by factors such as the surgeon pressing on the abdomen and this will cause intra-abdominal pressure to rise. Correct the cause before continuing. 7. If smoke persists when the pump stops, be sure that: a. Luer lock on the cannula is open b. Tubing is not crimped c. Filter is clean, it may need to be replaced if it is clogged d. Inspect the time control if there are no leaks e. If the time control is set to maximum time, use the MANUAL button until the abdominal cavity is smoke free. Do not use it excessively, or the pneumoperitoneum will collapse. DOCUMENTATION: Document the use of the smoke evacuation unit and serial number on the perioperative care record. REFERENCES: 1. AORN, (2002). Recommended practices for electrosurgery. Standards and Recommended Practices, pages AORN Journal: October 2002, Clinical Issues. 3. A:\Infection Control today New Technology Addresses Surgical Staff Objections to Removal of Surgical Plume.htm 4. A:\Occupational Health Hazard Surgical Smoke.htm 5. A:\SmokeEvacuationSystemsfor Surgical Plume-Recommendations.htm 6. Barrett, W.L., Garber, S.M., 2003, Surgical Smoke a review of the literature, Is it just hot air? Surgical Endoscopy, pages Control of smoke from laser/electric surgical procedures, National Institute of 4

5 Occupational Safety and Health, 8. Crystal Vision Model 350-D, (2001). Operating and Installation Manual, Phoenix, Arizona. 9. Lanfranchi, Joy Anne, Smoke Plume Evacuation in the OR, AORN Journal, vol 65, No 3,March 1997, Denver, page Meeker, M.H., & Rothrock, J.C., (1998). Alexander s Care of the Patient in Surgery, (11 th edition). St. Louis: Mosby. 11. ORNAC, (1998), ORNAC Standards and Recommended Practices, page Ott, Douglas, (March,1997), Smoke and Particulate Hazards During Laparoscopic Procedures, Surgical Services Management, volume 3, Number Recommended practices for laser safety, in Standards, Recommended Practices and Guidelines (Denver: AORN, Inc., 2002) page Ulmer, Brenda, 1997, Air Quality in the Operating Room, Surgical Services Management, Volume 3 Number Surgical Smoke, What We Know Today Laser/Electrosurgery Plume. 5