Medical plume (i.e., surgical smoke) is an insidious hazard that poses a health risk to operating room occupants during almost all surgical procedures. Surgical smoke is released into the air when energy-based surgical devices such as lasers, electrocautery and ultrasonic devices are used on surgical patients.

Surgical smoke is known to contain respirable particulates, biohazardous materials and chemicals that present known health hazards. Put into greater detail, surgical smoke can contain:

  • Fine (PM2.5) and ultrafine (PM0.1) particulate matter;
  • Mutagens, carcinogens, allergens, bacteria and live viruses; and
  • Other chemicals, including hydrogen cyanide, benzene, butene, carbon monoxide, ethane, formaldehyde, methane, acrolein and toluene.

Exposure levels in operating rooms

Operating room (OR) staff, including surgeons, nurses and support personnel face significant exposure to surgical smoke. According to a report from the Occupational Safety and Health Administration, OR staff may inhale substances present in surgical smoke at concentrations up to 50 times the permissible exposure limits set by the National Institute for Occupational Safety and Health. General room ventilation is not by itself sufficient to capture contaminants generated by use of energy-based surgical devices.

Unveiling the dangers of surgical smoke

The health risks associated with exposure to surgical smoke are manifold. Studies have linked prolonged exposure to an increased risk of respiratory and ocular issues among OR staff. The inhalation of toxic substances present in surgical smoke, such as benzene, formaldehyde and acrolein, has been associated with both short- and long-term health consequences.

Chronic exposure to surgical smoke has been linked to respiratory symptoms, including coughing, wheezing and nasal congestion. In addition to causing respiratory illness, asthma and allergy-like symptoms, surgical smoke may contain viruses like HPV. There are documented cases of HPV transmission from patients to providers via surgical smoke inhalation. Surgical smoke can cause cancer cells to metastasize in the incision sites of patients having cancer removal surgery. These findings underscore the importance of proactive measures to mitigate the risks posed by surgical smoke in the OR.

Evolving NFPA 99 standards for health and safety

Recognizing the need for updated guidelines in the face of emerging health concerns, the 2024 edition of the National Fire Protection Association (NFPA) 99, Health Care Facilities Code, introduced crucial changes to address the management of surgical smoke. This is consistent with the 2024 edition’s renewed emphasis on creating safer environments for health care workers, aligning with the broader commitment to occupational health and safety.

Section 9.3.8 of the updated NFPA 99 requires health care facilities to capture surgical smoke as close as possible to the point of generation (i.e., where the energy device contacts the tissue). Facilities may use a dedicated local exhaust ventilation system, connection to return or exhaust duct after air cleaning through ultra-low particulate air (ULPA) and gas phase filtration (e.g., activated carbon), a surgical smoke evacuation tool at the point of use, and/or (for small amounts of surgical smoke plume) a medical-surgical vacuum system with an in-line filter with ULPA and gas filtration. This is distinct from whole room smoke evacuation that is intended for smoke generated from a fire.

Most facilities already have these systems. The 2024 code update will ensure they are consistently in use to secure respiratory safety for the OR personnel in the room. 

Clearing the air for a healthier future

As the health care industry continues to evolve, prioritizing the well-being of OR staff is paramount to ensuring continued effectiveness of the advancements in medicine. The updated provisions in the 2024 edition of NFPA 99, including specifically the requirement to evacuate surgical smoke at the source, reflect a collective commitment to mitigating the health risks associated with surgical smoke exposure and creating safer working environments for all.

Erin Kyle, DNP, R.N., CNOR, NEA-BC, editor-in-chief, Guidelines for Perioperative Practice.