Ambient Ambient Environmental Environmental

Hazards in the ORHazards in the OR

Ambient Ambient Environmental Environmental

Hazards in the ORHazards in the OR

Kay Ball, RN, MSA, CNOR, FAANKay Ball, RN, MSA, CNOR, FAAN

Lewis Center, OHLewis Center, OH

Kayball@aol.comKayball@aol.com

Red Team – April 17, 2007

ObjectiveObjectiveObjectiveObjective

Discuss control measures Discuss control measures for inhalation hazards for inhalation hazards

in the OR.in the OR.

Inhalation HazardsInhalation Hazards

Transmissible diseasesTransmissible diseases Toxic fumesToxic fumes

Anesthesia gasesAnesthesia gases GlutaraldehydeGlutaraldehyde Surgical smokeSurgical smoke

Spaulding’s ClassificationsSpaulding’s Classifications

Critical (Sterilize) Critical (Sterilize) Semi-critical (Disinfect)Semi-critical (Disinfect)Non-critical (Clean)Non-critical (Clean)

GlutaraldehydeGlutaraldehydeGlutaraldehydeGlutaraldehyde

Glut HistoryGlut HistoryGlut HistoryGlut HistoryTanning agent for leatherTanning agent for leatherTissue fixativeTissue fixativePreservative in cosmeticsPreservative in cosmeticsTherapeutic agent for warts & other Therapeutic agent for warts & other

infectionsinfectionsX-ray processing solution & film X-ray processing solution & film

emulsionemulsion

Glutaraldehyde DisinfectionGlutaraldehyde Disinfection

Broad spectrum antimicrobial “cold” disinfectantBroad spectrum antimicrobial “cold” disinfectant

Glut action – bonds proteinGlut action – bonds protein

Device preparation – thorough cleaning and rinsingDevice preparation – thorough cleaning and rinsing

Efficacy monitoringEfficacy monitoring

Soak time controversySoak time controversy

ControversyControversyFDAFDA

45 min soak45 min soak

25 degrees C.25 degrees C.

Prof. OrgProf. Org20 min soak20 min soak

Room temp.Room temp.

Glut HazardsGlut Hazards Skin & mucous membrane hazardsSkin & mucous membrane hazards Ingestion hazards Ingestion hazards Respiratory hazardsRespiratory hazards Chronic exposure hazardsChronic exposure hazards

Exposure LevelsExposure LevelsExposure LevelsExposure Levels 0.04 ppm Detect odor0.04 ppm Detect odor 0.2 ppm Exposure level0.2 ppm Exposure level 0.3 ppm Irritant0.3 ppm Irritant 0.4 ppm Pouring0.4 ppm Pouring

VentilationVentilation

Glut

Vent

Processing Area

Spill ProcedureSpill Procedure

AmmoniaAmmonia

AAMI DocumentAAMI DocumentAAMI DocumentAAMI Document

““Safe use and handling of Safe use and handling of glutaraldehyde-based products glutaraldehyde-based products

in health care facilities”in health care facilities”

Glut AdvantagesGlut AdvantagesGlut AdvantagesGlut Advantages Effective for HLDEffective for HLD Highly compatibleHighly compatible Sterilization with long soak timesSterilization with long soak times Low cost, convenientLow cost, convenient

Glut LimitationsGlut LimitationsGlut LimitationsGlut Limitations Unstable - Effective life 2-4 weeksUnstable - Effective life 2-4 weeks Thorough rinsing - mandatoryThorough rinsing - mandatory Skin, respiratory hazardsSkin, respiratory hazards Glut bonds proteinsGlut bonds proteins

Options for alternatives: Other soaking Options for alternatives: Other soaking solutions (Cidex OPA) or sterilization methodssolutions (Cidex OPA) or sterilization methods

Cidex - OPA Cidex - OPA ORTHO-PHTHALDEHYDEORTHO-PHTHALDEHYDE

Cidex - OPA Cidex - OPA ORTHO-PHTHALDEHYDEORTHO-PHTHALDEHYDE

HDL in 10 min at 20 degrees CHDL in 10 min at 20 degrees C Ortho-phthaldehyde (.55%) + insert Ortho-phthaldehyde (.55%) + insert

ingredents (99.45%)ingredents (99.45%) No sterilant claimsNo sterilant claims Reuse 14 days (test strip)Reuse 14 days (test strip) Endorsed by many manufacturersEndorsed by many manufacturers Stains skin, eye & resp irritant, causes Stains skin, eye & resp irritant, causes

headachesheadaches

Sterilization OptionsSterilization Options

SteamSteam Ethylene OxideEthylene Oxide Peracetic AcidPeracetic Acid Gas PlasmaGas Plasma OzoneOzone

Sterilize

The Effects ofThe Effects of

Miners – Air ProblemsMiners – Air ProblemsMiners – Air ProblemsMiners – Air Problems

OR Team Serving as the Biological Indicator for Poor Air QualityOR Team Serving as the Biological Indicator for Poor Air Quality

AORN RPAORN RPAORN RPAORN RP

Personnel working with an ESU or Personnel working with an ESU or laser should avoid exposure to laser should avoid exposure to smoke plume generated during smoke plume generated during tissue cutting and coagulation.tissue cutting and coagulation.

Surgical smoke causes headaches, watery eyes, Surgical smoke causes headaches, watery eyes, respiratory problems in healthcare workersrespiratory problems in healthcare workers

NIOSHNIOSHNIOSHNIOSH19881988““Smoke generated during laser Smoke generated during laser

surgery presents a potential surgery presents a potential health hazard.”health hazard.”

NIOSHNIOSHNIOSHNIOSH19851985““There’s a potential hazard from There’s a potential hazard from

smoke generated by smoke generated by electrosurgical knives.”electrosurgical knives.”

ResearchResearchTomita et al, 1989Tomita et al, 1989

Laser: 1gm tissue Laser: 1gm tissue

3 unfiltered cigarettes3 unfiltered cigarettes

ESU: 1gm tissueESU: 1gm tissue

6 unfiltered cigarettes6 unfiltered cigarettes

Laser and ESU smoke are very similar!Laser and ESU smoke are very similar!

Hazards of PlumeHazards of Plume

OdorOdorParticulate Matter SizeParticulate Matter SizeViabilityViabilityEndoscopy concernsEndoscopy concerns

Odor from Toxic GasesOdor from Toxic GasesOdor from Toxic GasesOdor from Toxic Gases

*Polycyclic aromatic hydrocarbons*Benzene*Toluene*Formaldehyde*Acrolein

ODORODOR

Toxic Fumes and VaporsToxic Fumes and VaporsToxic Fumes and VaporsToxic Fumes and Vapors

AcroleinAcrolein BenzeneBenzene FormaldehydeFormaldehyde

Possible carcinogens!!!!Possible carcinogens!!!!

Particulate MatterParticulate Matter American College of Surgeons: American College of Surgeons:

5 microns = bacterial colonization 5 microns = bacterial colonization Regular surgical mask: Regular surgical mask:

5 micron filtration 5 micron filtration Research - 77% of surgical smoke is 1.1 Research - 77% of surgical smoke is 1.1

microns in size and smaller microns in size and smaller (Mihashi et al., 1975)(Mihashi et al., 1975)

Particulate ends up in the alveoli of your Particulate ends up in the alveoli of your lungslungs

ResearchResearchBaggish et al, 1988Baggish et al, 1988

Rats breathed unfiltered & filtered plumeRats breathed unfiltered & filtered plume

Unfiltered plume: Rats developed hypoxia, Unfiltered plume: Rats developed hypoxia, pulmonary problemspulmonary problems

Filtered plume: No changesFiltered plume: No changes

Viability ResearchViability Research

Garden et al, 1988Garden et al, 1988• Used CO2 laser on cow papillomavirusUsed CO2 laser on cow papillomavirus• Found intact viral DNA in plumeFound intact viral DNA in plume• Injected viral DNA from plume into cowInjected viral DNA from plume into cow• Grew same viral lesionGrew same viral lesion• Potential of transmission of viable Potential of transmission of viable

viral contaminantsviral contaminants

Transmission of virus to Dr.Transmission of virus to Dr.

Hallmo et al, 1991Hallmo et al, 1991• 44yo laser Dr developed laryngeal 44yo laser Dr developed laryngeal

papillomatosispapillomatosis• Lesions show same DNA type as Lesions show same DNA type as

anogenital condyloma from patientsanogenital condyloma from patients

Endoscopy Endoscopy Ott et al, 1993Ott et al, 1993

• Laparoscopy & plumeLaparoscopy & plume• Increase methemoglobin & Increase methemoglobin &

carboxyhemoglobincarboxyhemoglobin• (methemoglobin-(methemoglobin-OO22 carrying carrying

• capacity of RBCs)capacity of RBCs)

• Delay in healing?Delay in healing?

RecommendationsRecommendationsRecommendationsRecommendations AORNAORN ANSIANSI NIOSHNIOSH CDCCDC OSHAOSHA Global recommendationsGlobal recommendations

All say to evacuate All say to evacuate surgical smoke!surgical smoke!

SolutionsSolutionsSolutionsSolutions

Appropriate smoke Appropriate smoke evacuation systemevacuation system

In-line FilterIn-line FilterIn-line FilterIn-line FilterFor small amounts of plume use For small amounts of plume use

in-line filterin-line filter

Correct positioning neededCorrect positioning needed

Patient

Wall Suction

AORN Pilot Survey: Most popular methodAORN Pilot Survey: Most popular method

Wall SuctionWall SuctionWall SuctionWall Suction Corrodes pipesCorrodes pipes Contaminates buildingContaminates building Flow may not be high enough Flow may not be high enough

to capture surgical smoketo capture surgical smokeWall suction 2 cfmWall suction 2 cfm

Evacuator 30-50 cfmEvacuator 30-50 cfm

Smoke EvacuatorSmoke EvacuatorSmoke EvacuatorSmoke Evacuator

Needed when larger amounts of Needed when larger amounts of smoke createdsmoke created

Critical FeaturesCritical Features Efficiency Efficiency

Filtering capabilityFiltering capability Charcoal filter – removes odorCharcoal filter – removes odor ULPA filter – removes small ULPA filter – removes small

particulate (.1 microns, 99.999% particulate (.1 microns, 99.999% efficiency)efficiency)

Suction powerSuction power

Filter ChangingFilter Changing

Follow manufacturer’s recommendations when

changing

Occupational Hazard NOT Occupational Hazard NOT Environmental HazardEnvironmental Hazard

SolutionsSolutionsPosition smoke tube close to the Position smoke tube close to the

tissue impact sitetissue impact site

Automatic Automatic On/Off On/Off SystemSystem

Evacuation during endoscopyEvacuation during endoscopy

ChoicesChoices

SolutionsSolutionsSolutionsSolutionsHigh Filtration MasksHigh Filtration Masks

0.1 micron

filtration

Not the first line of defenseNot the first line of defense

Questions???Questions???Questions???Questions???

www.becomenasti.comwww.becomenasti.com

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