Surgical Smoke Inhalation: Dangerous Consequences for the Surgical Team
Posted on by
In 1996, after conducing multiple health hazard evaluations, NIOSH released a bulletin recommending the control of surgical smoke created during laser or electric surgical procedures. Since the 1990s the Association of Perioperative Registered Nurses (AORN) has recommended the evacuation of all surgical smoke. Yet, surgical smoke is still inhaled daily by nurses in the operating room. In a 2016 study, NIOSH surveyed health care personnel who were exposed to surgical smoke. Their results indicated that of respondents who worked within five feet of the source of surgical smoke only 14% reported that it was evacuated during electrosurgery and 47% during laser surgery (Steege et al.).
During surgical procedures, smoke is produced when energy generating devices such as lasers or electrosurgical units also known as cautery are used to stop bleeding or incise tissue. The energy generating devices raise the intracellular temperature to boiling (i.e., 100° C /212° F). At these high temperatures the tissue vaporizes producing surgical smoke. The smoke is often not visible and has an unpleasant odor. The smoke may contain ultra-fine particles, toxic compounds (e.g., benzene, toluene, hydrogen cyanide), viruses (e.g., human papilloma virus [HPV]), and cancer cells (Guideline for Surgical Smoke Safety).
| Chemical Contents of Surgical Smoke | ||||
| Acetonitrile | Acetylene | Acroloin | Acrylonitrile | Alkyl benzene |
| Benzaldehyde | Benzene | Benzonitrile | Butadiene | Butene |
| 3-Butenenitrile | Carbon monoxide | Creosol | 1-Decene | 2,3-Dihydro indene |
| Ethane | Ethyl benzene | Ethylene | Formaldehyde | Furfural |
| Hexadecanoic acid | Hydrogen cyanide | Indole | Methane | 3-Methyl butenal |
| 6-Methyl indole | 4-Methyl phenol | 2-Methyl propanol | Methyl pyrazine | Phenol |
| Propene | 2-Propylene nitrile | Pyridine | Pyrrole | Styrene |
| Toluene | 1-Undecene | Xylene | ||
Used with permissionUlmer BC. The hazards of surgical smoke. AORN J. 2008;87(4):721-734.
Inhaling surgical smoke may be hazardous to anyone breathing it in including the patient and all members of the surgical team—nurses, doctors, and technologists. The Occupational Safety and Health Association (OSHA) has estimated that more than half a million heath care workers are exposed to surgical smoke every year. Repeated exposure to the contents of surgical smoke may be cumulative and increases the possibility of developing adverse health effects (Alp et al.). At high concentrations the smoke causes eye and upper respiratory tract irritation in health care personnel and creates visual problems for the surgeon. The smoke also has the potential to cause gene mutation.
AORN is leading legislative efforts for surgical smoke-free operating rooms across the United States. Rhode Island and Colorado became the first U.S. states to require surgical smoke evacuation policies by law.
Mary J. Ogg, MSN, RN, CNOR, is a Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN).
This blog is part of a series hosted by NIOSH to commemorate nurses during the Year of the Nurse. The views expressed by guest authors do not necessarily reflect the views of CDC or NIOSH.
Other blogs in the series include:
Managing Fatigue During Times of Crisis: Guidance for Nurses, Managers, and Other Healthcare Workers
Nurses’ and Other Health Professionals’ Wellness and Safety Resource Update
Safety Culture and Health Care
Work Ability among Older Nurses
The Unique Occupational Environment of the Home Healthcare Worker
Can Exoskeletons Reduce Musculoskeletal Disorders in Healthcare Workers?
19 comments on “Surgical Smoke Inhalation: Dangerous Consequences for the Surgical Team”
Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».
Thank you author for such a nice post.
Thanks for sharing the informative post.
Is there any update on when NJ OSHA is going to make it a regulation that the closed suction system for fluid and smoke in the OR?
Hi Laura, there is legislation in New Jersey to ensure surgical smoke evacuation. Assembly Bill 3982 was introduced in May 2020 and carries over for consideration this year. The next step in the process would be when the bill is posted to the NJ Assembly Health Committee.
What about TN or Florida?
The Florida legislature has adjourned its regular session for 2021, and surgical smoke evacuation legislation was not considered. There was surgical smoke evacuation legislation in TN in 2020 that was put on hold this year due to the pandemic.
Diathermy has been around for over 100 hundred years and has been in particularly heavy use over the past 60 years. When you add up the number of theater staff and their exposure time its many millions of hours of exposed to risk; ie we have a massive amount of data on humans that, to my knowledge, shows no significant impact – if so it would have been recognized by life insurance companies with resultant increased premiums and many regulatory bodies would have acted long ago. Please let me know if you have other human data – just trying to reconcile the obvious disconnect between laboratory/animal studies and 60 odd years of actual epidemiologic evidence in humans.
While research studies are being published that demonstrate the harmful effects of exposure to surgical smoke, it is not as easy to make the direct correlation of an illness or health effect to the exposure of surgical smoke. If you cut your finger with a scalpel in the OR, you are certain that the injury is a result of the sharp scalpel. The health effects of inhaling surgical smoke happen over time, and one may not associate adult-onset asthma to breathing surgical smoke.
Results of two of the studies are listed. Ilce et al. conducted a descriptive study of nurses and doctors working in operating rooms. The problems experienced as a result of surgical smoke exposure included headaches, watering of the eyes, cough, sore throat, nausea, drowsiness, dizziness, sneezing, and rhinitis.
A study by Asdornwised et al. surveyed 377 perioperative nurses regarding their health problems related to smoke and bio-aerosol exposures. The reported health problems included headache, sore throat, coughing/sneezing, weakness, eye irritation, nausea, dizziness, chronic bronchitis, and asthma.
Anecdotal stories of health effects abound. An orthopedic surgeon, Dr. Hedley, from Arizona shared his story with idiopathic pulmonary fibrosis and double lung transplant that he attributes to surgical smoke exposure. Available at http://magazine.outpatientsurgery.net/homepage-stream/surgical-smoke-nearly-killed-me-subscribe-to-outpatient-surgery-magazine-february-2018-4 During legislative testimony in Rhode Island, Colorado, and Georgia numerous nurses shared their personal stories of asthma and a cancer diagnosis. Angela Hohm’s story from Georgia was most compelling. Available at Outpatient Surgery Magazine – Personal Battle – March 2021 – Outpatient Surgery Magazine
Thirty years ago, Tomita et al. demonstrated that the contents of surgical smoke are similar to cigarette smoke likening 15 minutes of exposure to electrosurgical smoke to smoking 6 cigarettes in 15 minutes. Another way that surgical smoke is like cigarette smoke is that it took years and years to recognize the harmful effects of smoking cigarettes. Hopefully, we can learn from that experience.
References
Ilce A, Yuzden GE, Yavuz van Giersbergen M. The examination of problems experienced by nurses and doctors associated with exposure to surgical smoke and the necessary precautions. Clin Nurs. 2017. 26(11):1555-1561.
Asdornwised U, Pipatkulchai D, Damnin S, Chinswangwatanakul V. Recommended practices for the management of surgical smoke and bio-aerosols for perioperative nurses in Thailand. J of Perioperative Nursing. 2018:31(1): 33-41.
Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutat Res. 1981;89(2):145-149.
I’m working on the dangers of surgical smoke inhalation for my BSN Capstone project and have been trying to find information as to whether Michigan has any regulations presently or possibly in legislature for surgical smoke evacuation but have been unsuccessful. I’m wondering if you may be aware of any?
There is no current or pending legislation or regulations regarding surgical smoke in the state of Michigan. The AORN website contains the current AORN surgical smoke policy agenda and resources.
I was wondering if there have been any links to surgical smoke and MS. Several of my fellow co-workers have recently been diagnosed. I was looking for any other cases you may be aware of…
I’ve worked in preoperative for 20 years the doctor I’ve worked with for years was diagnosed with lymphoma last year, I have lymphoma and reoccurring liver cancer was diagnosed in 2021. I’m a surgical tech and the nurse I’ve worked for years died 4 years ago with lung cancer. More has to be done, this is not a coincidence!
First, I am very sorry to hear that you and your coworkers have cancer and lymphoma. Progress is being made in multiple states requiring smoke evacuation. AORN is leading the efforts to make smoke evacuation the law across the country and ensure that all operating rooms are surgical smoke-free. Ten states – Arizona, Colorado, Connecticut, Georgia, Illinois, Kentucky, New York, Oregon, Rhode Island, and Washington – have gone surgical smoke-free. If your state does not have legislation, AORN has resources that you may be interested in when considering sharing your story with legislators: AORN Surgical Smoke Evacuation Legislation Checklist.
If your facility does not have a policy to evacuate surgical smoke, AORN has the Go Clear program. Go Clear is a comprehensive program to help facilities go smoke-free that is available to AORN members and non-members.
Another consideration is to contact an epidemiologist at your facility or at the state level. Epidemiologists are public health workers who investigate patterns and causes of disease and injury.
The information regarding “Surgery Smoke Plume” MUST be made known to the general public. To do otherwise is something I consider a very serious derelict of duty.
Thank you for your comment. Rest assured, information about hazards from surgical smoke together with information about other hazardous exposures faced by healthcare workers will always be provided by NIOSH to everyone who needs it. For many of these hazards, including surgical smoke, protecting workers also improves patient safety.
I have a question I hope will get some attention. I am an anesthesiologist, my best friend is a female anesthesiologist w/ over 25yrs exp. She was recently Dx’d with primary breast CA found only in lung tissue, breast tissue fine. She has no H/O prior CAs . Is healthy otherwise and no family Hx of breast or lung CA. No social factors (tobacco exposure) except for repeated exposure to OR smoke. I can’t find any info on the development of CAs attributed to OR smoke, only possible COPD from multiple compounds in OR smoke. We both independently came to the following same conclusion when the facts of her case were analyzed…HYPOTHESIS: Does OR cauterization viably aerosolize CA cells of any types which then can cause the formation of de novo primary CAs of said tissue in the lungs (or other unrelated tissue areas) with repeated inhalation of/exposure to the cautery smoke by OR staff? Anyone have a similar case? Or care to comment? my guess is that although its a provocative hypothesis, someone would have seen and studied the correlation already.
Thank you for your post. I am sorry to hear about your friend’s breast cancer. There are studies examining the correlation between surgical smoke exposure and the development of cancer by the perioperative team. A study by Tseng et al1 investigated particle number concentrations, size distribution, and gaseous and particle phase polycyclic aromatic hydrocarbons as the tracers of surgical smoke in the OR. Through their investigation of polycyclic aromatic hydrocarbon concentrations, the potential cancer risk can be estimated for the OR team exposed to electrosurgery smoke. The surgeon was exposed to the highest level of polycyclic aromatic hydrocarbons, approximately 1.5 times higher than the anesthesia provider. Although the anesthesia provider’s levels were lower than the surgeon’s, longer hours working in the OR increased the risk. The researchers concluded that the submicron particles in the smoke contained carcinogenic chemicals that could threaten the health of the OR team through respiration of the particles. Using the toxicity equivalency factor, the average cancer risk in a 70-year lifetime for the surgeons and the anesthesia providers was calculated to be 117 × 10-6 and 270 × 10-6, respectively.1
The AORN Guideline for Surgical Smoke Safety discusses additional studies of the carcinogenic hazards of surgical smoke. 2
To bring this issue to the attention of the perioperative community, I would encourage you to write and publish a case report regarding your friend’s cancer in your national and local journals. Also, presenting at national and local conferences is another way. At the hospital level, start discussions in the OR. Maybe someone else with a similar diagnosis has not made the same connections that you have. I hope your friend achieves a positive outcome with treatment.
Mary J. Ogg, MSN, RN, CNOR
1.Tseng HS, Liu SP, Uang SN, et al. Cancer risk of incremental exposure to polycyclic aromatic hydrocarbons in electrocautery smoke for mastectomy personnel. World J Surg Oncol. 2014; 12:31.
2. Guideline for surgical smoke safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023:1105-1152.
Additional References
Dobrogowski M, Wesolowski W, Kucharska M, et al. Health risk to medical personnel of surgical smoke produced during laparoscopic surgery. Int J Occup Med Environ Health. 2015;28(5):831-840.
Fletcher JN, Mew D, Descôteaux JG. Dissemination of melanoma cells within electrocautery plume. Am J Surg. 1999;178(1):57-59.
In SM, Park DY, Sohn IK, et al. Experimental study of the potential hazards of surgical smoke from powered instruments. Br J Surg. 2015;102(12):1581-1586.
Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? A systematic review. Surg Endosc. 2013;27(9):3100-3107.
Nahhas WA. A potential hazard of the use of the surgical ultrasonic aspirator in tumor reductive surgery. Gynecol Oncol. 1991;40(1):81-83.
Tokuda Y, Okamura T, Maruta M, et al. Prospective randomized study evaluating the usefulness of a surgical smoke evacuation system in operating rooms for breast surgery. J Occup Med Toxicol. 2020; 15:13.
I found it strange that there is so little RECENT data on measurement of the different chemical components of surgical smoke in the air of the operating room with and without LEV. The data I found are mostly far below the TLV. Could somebody provide me more measurement data?
After spending 43 in surgery as a 1st assistant I have been now 2023, diagnosed with COPD, asthma, chronic bronchitis and have never smoked cigarettes. I have been reading the CDC’s research data regarding exposure of cautery smoke. My life has definitely been affected by this diagnosis. I’m 76 years old. Last year I was resuscitated 3 times with intubation and multiple days in ICU. If only we had known back in 1967 when I began my career.