Surgical smoke refers to the smoke generated in the operating room due to surgical equipment and special equipment. Such as high-frequency electric knife, laser, ultrasonic equipment, high-speed drill, cutting drill, etc. used in surgery, surgical smoke generated during surgery on human tissue (for example, hemostasis, tissue dissection). In recent years, the harmful components of surgical smog have continued to grow. Most hospitals only use certain protective measures for the safety of patients. However, the protection of medical personnel has not received any attention and no measures have been taken.
Main source of surgical smoke
1, high frequency electric knife
High-frequency electric knives are the most common heat-generating equipment. It uses two basic waveforms for cutting and coagulation. The cutting waveform is a continuous low-voltage wave mode. The continuous current heats the cells to a boiling point of 100 ° C, causing the cell wall to rupture. The cytosol is released by evaporation into vapor, and the intracellular material is diffused into the air to form surgical smog. The solidification waveform is an interrupt (suppression) high voltage mode. The transfer of current causes the temperature of the cell fluid to gradually rise to 90 ° C, the cell liquid evaporates, the protein denatures, and finally loses structural integrity. When the temperature reaches 200 ° C, the structure will be carbonized. The necrotic tissue floats on the surface layer and contacts the positive electrode for drying and coagulation. This method of current conduction results in a large thermal tissue effect, and carbonized tissue will facilitate the release of cellular debris into the air.
2, laser
The laser is the second common heat generating device used by surgeons. Different from ordinary beams, it is monochromatic, parallel, and coherent. Thermal effects vary with wavelength, light intensity (ie, energy density), spectrum, and water content. The high temperature (100 ° C to 212 ° C) generated by the laser causes the cells adjacent to the tissue to boil and explode. Evaporation of the cells releases the water vapor and cytoplasm therein. The nature of the cytoplasm depends on the type of laser used and the type of tissue being treated. Both the laser and the high-frequency electrosurgery work with high thermal energy and release the contents of the cells. The laser and electrosurgical particles are compared and the two are very similar. Because of these similarities, the smoke emission measures used by lasers and high-frequency electrosurgical knives should be the same.
3, ultrasound equipment
Ultrasound equipment is commonly used in incision and hemostasis. Ultrasonic cutting does not produce audible sound waves. It is called ultrasound because it produces vibration frequencies that exceed the human hearing range. The ultrasonic aspirator has a vacuum function. Since the generated heat is conducted out through the rinsing liquid, the thermal damage of the ultrasonic waves is small. The tip spray produces a small mist, but the surgical site is always clean by the suction of the tip. Ultrasonic scalpels have strong tips and blades. When the tip vibrates, heat is generated by the edge of the blade. This technique allows the surgeon to coagulate and divide the tissue. The tip vibrates at a frequency of 55,000 times per second, stimulating collagen denaturation and forming a clot. The movement of the tip produces steam, which can carry away infectious aerosols due to the lower temperature of the tip.
4, high-speed electronic equipment
Often in the operating room, bone saws, drill bits and other high-speed electronic devices that cut tissue structures produce contaminated gases that are often overlooked. These tools generate heat by rapidly rotating and cutting, destroying the structure of the tissue. Heat generated by saw blades, drill bits, etc. Operators often use flushing fluids to avoid heat buildup. The mechanical movement of the saw blade, drill bit, etc. is combined with the rinsing fluid to spread the aerosol in the form of a water mist to the surgical field. Researchers have shown that blood clotting aerosols are likely to be inhaled by health care workers when using power tools. The question that arises is whether the aerosol carried in the power tool contains blood pathogens, which will cause harm to the health of the medical staff.
Surgical smoke components and potential health hazards
The amount of smoke in the tissue of the surgery varies greatly depending on the surgical procedure applied. All in all, the biggest component is water vapor (up to 95%), followed by harmful organic and inorganic components, fine particles and harmful microorganisms.
1, particle size
Surgical smoke produces particles of different sizes depending on the type of heating device. The smaller the particle size, the faster the swimming. This may affect the health of the surgeon and the auxiliary surgery team members (such as roving nurses, anesthesiologists) during the procedure. It is very important to determine the size of the atomized particles. Particles less than 100 microns in air, 5 microns or larger will deposit on the nose, pharynx, trachea and bronchial wall; particles smaller than 2 microns will enter the bronchial and alveolar, the gas exchange area of ​​the lung; virus It is the smallest in morphology, ranging from 0.01 to 0.3 microns.
2, chemical composition
Surgical smoke contains a long list of chemicals. Two chemical substances worth noting are acrylonitrile and hydrogen cyanide. Acrylonitrile is an unstable, colorless chemical that is absorbed through the skin and lungs. Acrylonitrile releases hydrogen cyanide. Hydrogen cyanide is a toxic and colorless substance that can also enter the lungs through the skin and gastrointestinal tract.
Benzene in surgical smog is another chemical that needs to be identified. OSHA specifies benzene limit values ​​(PELs) to prevent medical personnel from injuring benzene. Since benzene is a cause of leukemia, the protective measures for benzene inhalation are enforced by OSHA.
3, other ingredients
In addition to focusing on the chemical composition of surgical smoke, it is also important to focus on blood particles, viruses and bacteria in the smoke particles. Companies such as Plappert have designed a project to evaluate the cytotoxicity, genotoxicity, chromosomal breakage and mutagenicity of potential by-products of smoke generated by laser thermal decomposition of human tissue. (In this type of surgery, human tissue is exposed to very high temperatures). Through multiple tests of aerosols, the results of the research team's report indicate that surgical smog can be hazardous to health and that personnel in the operating room should be protected. In 1998, Capizzi et al. studied the viability of viruses in laser resurfacing operations. Of the 13 bacterial specimen tests, 5 had coagulase-negative staphylococci growth. Among the five, one has both Corynebacterium growth and one has Neisser growth. The researchers concluded that bacteria have potential transmission capacity between personnel and smoke, so appropriate dilution measures should be used.
Surgical smoke protection measures
Traditional protective measures----masks and suction equipment
To prevent cross-contamination between the patient and the medical staff, the medical staff wears a mask during the operation. However, ordinary masks can only filter out particles of about 5 microns, but most of the particulate matter contained in surgical smoke is much smaller than 0.1 micron. Even with imported high-efficiency filter masks, it is impossible to filter out harmful substances in surgical smoke. In addition, the wear of the mask during the wearing process also affects the filtering effect, so wearing the mask alone cannot protect the medical staff from the surgical smoke. In addition, surgical smog will not only potentially affect the surgeon's health, but also because a surgical smoke will affect the doctor's field of vision, so usually a set of suction equipment. It works like a vacuum cleaner, and once the suction port or tubing is blocked, the pumping efficiency is significantly reduced. And because most of them are integrated handheld, there are many inconveniences in actual use, which reduces the surgeon's goodness and acceptance. Traditional protection measures can only partially reduce the inhalation rate of surgical smoke, and cannot completely protect patients and medical personnel from surgical smog.
Latest surgical measures for surgical smog
To avoid exposure to surgical fumes, first avoid or reduce contact in the work area. Indoor ventilation is a commonly used protective measure at home and abroad. The operating room ventilation equipment must be able to reduce the number of bacteria and particles in the air while discharging the harmful substances and heat load outside the house. The above requirements can be achieved by different air supply systems, such as air supply ducts close to the ceiling, air outlets close to the ground, and laminar ceilings installed above the operating area.
Whether it is the "Technical Specification for Hospital Cleansing Department" GB50333[31] promulgated in China in 2014, or the relevant standards of foreign hospitals, the control of the surgical environment is paid extra attention, and the risk of injury to the patient during the operation is minimized. In recent years, the concept of “mainstream area†and “partial purification†developed at home and abroad, that is, all the air supply openings are arranged on the operating bed to form a blowing device. Due to its effectiveness, economy and energy efficiency have been greatly promoted and adopted by relevant hospital standards.
China's "Hospital Surgery Department Building Technical Specifications" stipulates that the air supply area of ​​the Class I operating room is not less than 2.4m*2.6m, which divides the operating room into "mainstream area" and "peripheral area". The protection performance of the “mainstream zone†mainly depends on the performance of the air supply device, which is mainly manifested by the anti-interference of the airflow, and a low-turbulence vertical displacement airflow must be formed. During the operation, with the activities of medical staff and the use of high-frequency electric knives, lasers and other surgical instruments, the content of harmful substances such as bacteria and particulate matter in the room is not fixed, and surgical smog is not only harmful to patients. More damage to medical staff. According to the above research, the various chemical substances contained in surgical smog are carcinogenic. In order to reduce the cancer risk of medical staff due to inhalation of surgical smog, the harmful gases in the protected area should be diluted as soon as possible to prevent harmful gas from rising. And being inhaled by the medical staff. Germany's Weiss Air Conditioning Technology Co., Ltd. combines a traditional laminar air supply system to transform a static air supply system into a dynamic monitoring self-cleaning system. The air cleanliness real-time monitoring self-cleaning system, referred to as CPM, monitors the air quality (particles, bacteria, bacteria content, etc. in the air) in real time. If the air quality is good, it will display green light; If the surgical smoke or personnel walking caused by electric knives and other equipment causes the air quality to drop, a yellow light or a red light will be displayed. At this time, the CPM will have an alarm signal to the automatic control system of the operating room air supply device, and the air supply volume will be diluted and eliminated. Harmful gases return air quality to standard values. The system will be monitored 24 hours a day, 7 days a week, which means that the air volume will be automatically adjusted according to the measurement results, whether it is used or not. When used in the operating room, the laminar air supply will reach approximately 0.25m/s to 0.38m/s; when the operating room is unoccupied, the air supply system will automatically shut down as long as the air quality is in the green area. In other words, the air quality in the operating room is monitored in real time and consistently meets the standard, and it has energy-saving benefits.
In summary, surgical smoke generated by lasers, high-frequency electrosurgical knives, etc. has become an invisible major pollutant in the operating room. Increased safety risks for perioperative care workers and patients. Most hospitals still lack effective protection for medical staff. The latest control to prevent smoke contamination in the operating room is dilution.
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