Awareness of Surgical Smoke Risks and Assessment of Safety Practices During Electrosurgery Among US Dermatology Residents

Abstract

This study assessed clinician awareness of surgical smoke risks and current safety practices during active electrosurgery among dermatology residents.

Electrosurgery is a modality often used in surgical procedures to achieve intraoperative hemostasis. Surgical smoke poses a significant health risk as a carcinogen, pulmonary irritant, and vector for transmitting infectious particles. Lewin et al conducted a review on the hazards of surgical smoke, concluding that high-filtration masks and smoke evacuation systems should be used during electrosurgery. A subsequent study by Oganesyan et al quantified the amount and chemical composition of surgical smoke, revealing a significant increase in fine particulates during active electrosurgery and an increased concentration of 2 commonly found carcinogens in cigarette smoke (1,3 butadiene and benzene). Interestingly, only 10% of dermatologic surgeons reported consistent use of smoke management modalities during surgery.

Standards of care relating to protective measures during electrosurgery are not yet rigorous in dermatology. Given the objective data confirming surgical smoke hazards, our study aimed to assess provider awareness and current safety practices. We selected dermatology residents as our study population because these physicians are beginning their careers, and safety practices adopted now have the potential to have a positive impact on their health and future.

Methods

The study protocol received institutional review board approval by the University of California–Irvine Human Research Protection Program. An anonymous online survey through the Research Electronic Data Capture (REDCap) survey tool was sent to program directors at Accreditation Council for Graduate Medical Education–approved dermatology residency programs in the United States. The survey was open from February 10, 2016, through June 30, 2016. Respondents were surveyed on questions relating to surgical smoke risks, whether they received education on the hazards of surgical smoke, and if they felt that adequate precautions were being taken to protect them from surgical smoke. They were not compensated for their participation.

Results

A total of 153 dermatology residents responded (Table 1), a 61.2% response rate. A total of 110 residents (71.9%) did not receive any formal education on the hazards of electrosurgery smoke from their program. One hundred six (69.2%) reported sometimes or never wearing a surgical mask during electrosurgery, and 135 (88.2%) reported never wearing a high-filtration mask (N95). In terms of smoke management, 69 residents (45.1%) did not know if a smoke evacuation system was available in rooms where electrosurgery was performed. Despite the low reported use of protective equipment, 117 residents (76.5%) were concerned about transmission of infectious diseases via surgical smoke, and 110 (71.9%) indicated concern that carcinogens are present in surgical smoke. Finally, almost three-fourths of residents (112) reported that adequate precautions were not being taken to protect them from surgical smoke (Table 2).

Table 1. Characteristics of 153 Responding Dermatology Residents.

Characteristic	Respondents, No. (%)
Residency program level
PGY-2	52 (34.0)
PGY-3	53 (34.6)
PGY-4	48 (31.4)
Geographic location of residency
West	35 (22.9)
Northeast	47 (30.7)
South	41 (26.8)
Midwest	30 (19.6)
Sex
Male	68 (44.4)
Female	85 (55.6)
Residency class size per year
1-2 Residents	21 (13.7)
3-4 Residents	68 (44.4)
5-6 Resident	40 (26.1)
>6 Residents	24 (15.7)

Abbreviation: PGY, postgraduate year.

Table 2. Survey Responses of 153 Dermatology Residents.

Survey Question	No. (%)
Do you wear a surgical mask during electrosurgery (ie, hyfrecator use)?
Always	19 (12.4)
Often	28 (18.3)
Sometimes	88 (57.5)
Never	18 (11.8)
Do you wear a high-filtration mask (N95) during electrosurgery (hyfrecator use)?
Always	1 (0.7)
Often	1 (0.7)
Sometimes	16 (10.5)
Never	135 (88.2)
Did you receive education on the hazards of electrosurgery smoke from your program?
Yes	43 (28.1)
No	110 (71.9)
Is there a smoke evacuation system available in all the rooms where electrosurgery is performed?
Yes	42 (27.5)
No	42 (27.5)
I don’t know	69 (45.1)
Is there a high-efficiency particulate air filter in all the rooms where electrosurgery is performed?
Yes	3 (2.0)
No	22 (14.4)
I don’t know	128 (83.7)
Are you concerned about transmission of infectious diseases via surgical smoke?
Yes	117 (76.5)
No	36 (23.5)
Are you concerned that carcinogens are present in surgical smoke?
Yes	110 (71.9)
No	43 (28.1)
Are you concerned that surgical smoke may cause adverse pulmonary effects in the long term?
Yes	104 (68)
No	49 (32)
Do you feel like adequate precautions are being taken to protect you from surgical smoke?
Yes	41 (26.8)
No	112 (73.2)

Discussion

Surgical smoke contains toxic organic compounds and carcinogens and can transmit live viruses, such as human papillomavirus. Therefore, prevention of smoke inhalation should be a health consideration for dermatologists. First, a smoke evacuation system is highly recommended. Our study revealed that almost half of dermatology residents did not know if there was a smoke evacuation system available. Second, high-filtration N95 surgical masks are recommended to prevent inhalation of most particulate matter. Most dermatology residents denied wearing these masks. Notably, the cost of both N95 grade masks and smoke evacuation systems are obstacles to promoting surgical smoke safety. For instance, a 3M National Institute of Occupational Safety and Health–approved N95 surgical respirator costs about $1 compared with $0.08 per standard surgical mask, a significant cost difference. Surgical smoke evacuators typically cost more than $1500 per unit plus lifetime maintenance costs, and an assistant might be required to operate the unit. A dual-purpose hyfrecator/evacuation tubing system allows single-operator use. Finally, reducing the production of intraoperative surgical smoke via knowledge of optimal time spent to achieve hemostasis should be promoted and taught to residents early in their training.

Our study demonstrates a significant disconnect between awareness of surgical smoke hazards and a clear lack of protective measures. These data can serve as a foundation to help inform safety guidelines in electrosurgery, ensuring the availability of smoke management devices and N95 masks and requiring formal dermatology resident education on the hazards of surgical smoke and recommended protective measures.