Where there’s smoke: Quick Safety article recommends safety precautions

Surgical smoke—a harmful byproduct created through the thermal destruction of tissue by medical devices such as lasers, electrosurgical systems, radio-frequency devices, hyfrecators, ultrasonic scalpels, power tools, and other heat-destructive devices—can be detrimental to the health of surgeons, nurses, health care professionals, and patients in an operating room (OR).

The smoke may contain small-particle toxins and proinflammatory agents, as well as carcinogens. Although the risk of patient exposure is low and short-lived, surgeons and other members of the OR team may be exposed to surgical smoke daily.1 At high concentrations, surgical smoke can cause ocular and upper respiratory tract irritation and create visual problems for the surgeon. Therefore, surgeons should be aware of the hazards surgical smoke can cause.

Common toxins

A recent issue of Quick Safety examines the dangers surgical smoke presents, citing studies that confirm that the surgical smoke plume may contain toxic gases and vapors, including the following:2

  • Benzene
  • Hydrogen cyanide
  • Formaldehyde
  • Bioaerosols
  • Dead and live cellular material (including blood fragments)
  • Viruses

The Quick Safety article states that in some disciplines, such as orthopaedics, dentistry, and plastic surgery, it is possible to generate particulates and metal fumes.3

According to the article, research showed that nanoparticles comprise 80 percent of surgical smoke and “are the real danger of inhaled smoke.”4 Measuring at less than 100 nanometers, these tiny particulates can enter a person’s blood and lymphatic circulatory systems after inhalation and travel to vital organs.5

The “Environment of care” chapter of The Joint Commission’s accreditation manuals for hospitals, critical access hospitals, and ambulatory care and office-based surgery centers includes a standard that requires these facilities to minimize risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors. The standard includes the following note: “Hazardous gases and vapors include, but are not limited to, ethylene oxide and nitrous oxide gases; vapors generated by glutaraldehyde; cauterizing equipment, such as lasers; waste anesthetic gas disposal; and laboratory rooftop exhaust.”6

The Quick Safety article bolsters the standard by noting some government agencies and professional organizations that have issued recommendations or standards related to surgical smoke or the use of lasers. Examples include the Association of periOperative Registered Nurses, the Occupational Safety and Health Administration, the National Institute of Occupational Safety & Health, and the American National Standards Institute.

Precautionary measures

The Quick Safety article suggests some safety actions health care centers might consider implementing to address this issue, such as instituting a standard procedure for the removal of surgical smoke and plume using engineering controls, including smoke evacuators and high-filtration masks.6 Although N95s offer optimal protection, high-filtration masks with a smoke evacuator may provide staff with compatible protection.

Other safety recommendations are as follows:6

  • Use specific insufflators for patients undergoing laparoscopic procedures that lessen the methemoglobin buildup in the intra-abdominal cavity. For example, a laparoshield smoke evacuation device—a filter that attaches to a trocar—helps clear the field inside the abdomen.
  • During laser procedures, apply standard precautions, such as those promulgated in the Bloodborne Pathogen Standard (29CFR1910.1030) and the Centers for Disease Control and Prevention’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings—to prevent exposure to the aerosolized blood, blood byproducts, and pathogens in surgical smoke plumes.
  • Establish and periodically review policies and procedures for surgical smoke safety and control.
  • Make these policies and procedures available to staff in all areas where surgical smoke is generated.
  • Provide the OR team with initial and ongoing education and competency verification, including the facility’s policies and procedures.
  • Conduct periodic training exercises to assess surgical smoke precautions and consistent evacuation of the surgical suite or procedural area.

The Quick Safety article is available online.


The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. Schultz L. An analysis of surgical smoke plume components, capture & evacuation. AORN J. 2014;99(2):289-298.
  2. Centers for Disease Control and Prevention. HC 11—Control of Smoke from Laser/Electric Surgical Procedures. Available at: www.cdc.gov/niosh/docs/hazardcontrol/hc11.html. Accessed January 27, 2021.
  3. Dobrogowski M, Wesolowski W, Kucharska M, Sapota A, Pomorski LS. Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy—assessment of the risk to the patient. Int J Occup Med Environ Health. 2014;27(2):314-325.
  4. Buzea C, Pacheco I, Robbie K. Nanomaterials and nanoparticles: Sources and toxicity. Biointerphases. 2007;2(4):MR17-MR71.
  5. Nemmar A, Hoet PHM, Vanquickenborne B, et al. Passage of inhaled particles into the blood circulation in humans. Circulation. 2002;105(4):411-414.
  6. The Joint Commission. Quick Safety, Issue 56: Alleviating the dangers of surgical smoke. Available at: www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-56/quick-safety-issue-56/. Accessed March 22, 2021.



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Roger Hurst
Roger Hurst
1 year ago

The smoke generated from the kitchen in the hospital cafeteria is more likely to be a health hazard than the smoke generated from electrocautery in an operating room with it’s high-volume laminar flow ventilation. Multiple environmental studies that sampled actuarial operating room air have shown no significant amounts of hazardous compounds, even with excesses use of electrocautery.


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