A Preliminary Study Of The Effect Of Surgical Smoke To Occupational Exposed Population

Background:Electrosurgical devices, such as electrocautery、laser and ultrasonic scalpel, can rapidly cut tissues and electrohemostasis by burning tissue with high temperature. In surgery using electrosurgical facilities, the bleeding amount、the tissue touched and the time span of the surgery is much more less than ordinary surgery. In the same times, the cutting wound is much more even and the effect of electrohemostasis is much more thorough. Due to all these characteristic,the electrosurgical facilities were widely used in therapy of benign and malignant diseases of dermatological department、gynecology and obstetrics、surgical department、intestinal tract and ENT, especially in therapy of body cavity such as nasal cavity、throat、external auditory canal、vocal cord vaginal、anus、rectum、thoracic cavity、abdominal cavity and brain. While the electrocautery、,laser and ultrasonic scalpel burn the tissues with high temperature, the protein and fluid of tissue is incomplete combusted and aerosolize to create a mixture:surgical smoke. The form of surgical smoke is a plume of gaseous material that is expelled into the environment; it can be seen and be inhaled by human. It is also called Laser Generated Airborne Contaminants (LGAC)、surgical plume、 laser plume.Researches have been hold and standards have been put into place by many regulatory organizations in the United States and worldwide. National Institute for Occupational Safety and Health (NIOSH) issued a hazard alert for the "Control of Smoke from Laser/Electric Surgical Procedures." in1996.This document states that smoke plume generated from laser and electrosurgical tools contain toxic gases and cellular material and have a mutagenic potential. NIOSH issues that the hazard should be evacuated through the use of portable smoke evacuators and room suction systems, the capture velocity of the suction unit and the distance between the suction hose nozzle inlet and the surgical site is suggested in the alert. A High Efficiency Particulate Air (HEPA) filter or equivalent is recommended for trapping particulates. American National Standards Institute (ANSI) states that Laser Generated Airborne Contaminants (LGAC) is a resulting hazard and the electrosurgical devices produce the same type of airborne contaminants. ANSI states that Laser Generated Airborne Contaminants (LGAC) must be evacuated and can be reduced through the use of smoke evacuators and wall suction systems. ANSI states that surgical masks are not designed to provide protection from plume contents, so masks cannot provide proper protection. The Canadian Standards Association (CSA) released a standards relating to the management of surgical plume and its inherent hazards in2009:entitled "Plume scavenging in surgical, diagnostic, therapeutic, and aesthetic settings."This standard details a comprehensive approach to managing plume and extends its mandates to all surgical settings, based on risk assessment. Association of perioperative Registered Nurses (AORN) recognizes that exposure to surgical smoke and bio-aerosols pose a hazard to perioperative professionals and the safe practices should be established. AORN publishes Perioperative Standards and Recommended Practices and emphasizes that detectable odor during the use of a smoke evacuation system is a signal that the smoke is not efficiently controlled, The AORN also demand to use local exhaust ventilation as central smoke evacuation systems, portable smoke evacuation units, wall suction with inline filter and laparoscopic evacuation/filtration systems. The personal protective equipment such as high filtration surgical masks worn properly, protective eye wear and Skin protection (eg, gloves) are also requested. The AORN also request to educate staff such as to develop and implement training programs, demonstrate competencies on equipment and supplies, to comply with regulations and standards and document and maintain educational activities. There is no such standards and alerts in Chinese.Aerodynamic size of77%surgical smoke particles is less than1.1μm, belongs to the particles that injury lungs (0.5-5.0μm). Surgical masks can only filter particles bigger than5.0μm, so the masks cannot separate the surgical smoke effetely. The bigger particle crashed the air tube before it reached the alveoli, and was stickled to the mucosa and deleted by cough. Due to its aerodynamic size, surgical smoke can reach the alveoli rapidly and enter the circulation through the abundant capillary network of alveoli. Baggiest’s research has been shown clearly that when exposed to a relatively large quantity of surgical smoke, laboratory rats develop small particles in alveoli which causes pulmonary congestion and lung abnormalities.The usual content of surgical smoke including toxic chemical compounds, bio-aerosols, dead and live cellular material, viruses, and mutagenic agent. The potential hazards including the biological hazard of bio-aerosols, dead and live cellular material, viruses; the chemical hazard of toxic chemical compounds and the physical hazard of high temperature. We don’t discuss the biological and physical hazards in this research. Although the type and concentration of the chemical component differs according to the surgery type, surgery region, tissue type, the energy of devices, the age of patient, but the difference is much more slender. Hoglan’s research finds more than600kinds of chemical compounds in surgical smoke. The usual chemical contents including PolycyclicAromaticHydrocarbons (PAH), nitrile, fat acid, phenols, hydrogen cyanide, formaldehyde, benzene, and so on. Hydrogen cyanide, formaldehyde and benzene are toxic, colorless gases that are absorbed easily by the lungs, gastrointestinal tract and skin. Acrylonitrile is a colorless, volatile liquid that is absorbed easily through the skin and lungs and exerts its toxicity by liberating cyanide. The CO inhalated will elevate the carboxyhaemoglobin and methemoglobin, research has improved that the carboxyhaemoglobin and methemoglobin of patient and medical staff for several hours after they were exposed to surgical smoke. Xi ping Liu find that the PAH concentration on the surgical mask of medical staff who were exposed to surgical smoke is50times higher than that in the regular environment of Taipei, which further poses as a potential health threat to surgical staff.The occupational exposures concentration of surgical smoke is relatively lower and the duration is longer, and there is difference between the concentration, duration, protection measure, and individual physical condition. The research on the exposed individual is fewer:the research on the small particles in laboratory rats’alveoli; Xujun Zhang’s research about the genotoxicity of Fume extract by Electro-Surgical Units on strain. There is only one research about the affect of surgical smoke on human being:Douglas’research on the elevation of carboxyhaemoglobin and methemoglobin of patient and medical staff after they were exposed to surgical smoke. The component of surgical smoke is similar to other smoke, According to one report,1gram of ablated human tissue is equivalent to6cigarettes in terms of mutagenicity. The research of cigarette smoke and cooking oil fumes all show the effect of smoke on the blood lipid of exposed population:the blood lipid change of smoking population is high level of triglyceride and low-density lipoprotein cholesterol, on the other hand, the cholesterol, low-density lipoprotein cholesterol of occupational exposed group is higher than the control group.Because the effect of surgical smoke on exposed population cannot be showed rapidly, little attention was pay to the hazard of surgical smoke. Researches at home and abroad show that most of the occupation exposed population is uncertain about the hazard, and has no consciousness of occupational protection, the compliance to use the protection equipment is poor.In conclusion, surgical smoke is a hazard to health of occupational exposed population, but owing to the low dosage of the smoke, the effect of surgical smoke on exposed population cannot be showed rapidly. In order to make sure weather the surgical smoke has the monitorable and concrete effect to occupational exposed population, we decide to hold a preliminary study of the effect of surgical smoke to occupational exposed population refer to the index of other smoke’s effect on human. It is essential and necessary because this study can provide a foundation to further pertinent research and arise the attention of occupational exposed population on the hazard.Research purposesTo measure and analyze the routine blood test, blood lipids, kidney biochemical function result of the occupational population exposed to surgical smoke and to preliminarily investigate the influence effect of surgical smoke to on occupational exposed population. To investigate about their cognition of surgical smoke and present situation of occupational protection. To test the basic knowledge of occupational population and to design and execute different training program for doctor and nurse to promote the knowledge level。Objective and Methods1. The first part. Investigation of the epidemiology characteristic of the occupational exposed group and the control groupThe study subjects were medical staff in a hospital in Guangzhou, criteria of subject selection for investigation:without primary chronic disease, no factory discharging toxic material around one’s house, no high blood lipid, high blood pressure, high blood hemoglobin or anemia in family history. The exposed group is60health care workers who were exposed to surgical smoke more than five years,10times per week,10minutes per time; because this study uses group comparison, according to the principle of comparable to the exposed group and the amount of the sample of the exposed group, we choose the control group, the amount of the control group and the exposed group need not to be strict in proportion, but the amount of the control group should bigger than the amount of the exposed group. So we choose74health care workers who were never exposed to surgical smoke as the control group, the age, height, weight, dietary history, the alcohol history, and the smoking history of the control group is even with the exposed group. Self-designed questionnaires were applied to both groups. The questionnaires are divided into two sections:general information, diet and lifestyle questionnaires. General information includes:gender, age, height, weight. Eating habits and lifestyle questionnaires includes:dietary history, alcohol history, smoking history, physical excises history and cooking oil fumes history in recent5years. Drinking means drink alcohol more than2times per week; smoking means smoke more than20cigarettes per week; excising means excise more than3times regularly per week; high lipid diet means eat lard oil and fat more than10times per week; cooking oil fumes contacting means contact cooking oil fumes more than10times per week;2. The second part. Collecting and detecting blood of the occupational exposed group and the control groupThe peripheral blood was taken from both groups to test the routine blood test, blood lipids, and kidney function. The routine blood test is tested with SYSMEX X1000i,the biochemistry is tested with SHIMADZU CL-8000, the cholesterol is tested by GODPOD method, the level of low-density lipoprotein cholesterol and high-density lipoprotein cholesterol is tested with directly method, the creatinine is tested with sarcosine oxidase method.3. The third part. Investigation of the cognition of surgical smoke and present situation of occupational protection of the occupational exposed populationThe questionnaires of the exposed group add the research about their cognition of surgical smoke and present situation of occupational protection:including weather they think the surgical do harm to human body, the concrete harm of the surgical smoke, which kind of mask they wear when exposed to surgical smoke, did they use suction system to clear the smoke.4. The test and the training of basic knowledge of the occupational exposed populationA test paper of7Dimensions/20items is designed to test the occupational exposed population, and the result is analyzed to plan a different training program for doctors and nurses. After the training, the occupational exposed population, were tested again for evaluate the affect of the training.All of the data were carefully checked and arranged before put into the computer, the data were analyzed with SPSS13.0software. Chi-square test and t test were used.Results 1. Investigation of the equilibrium of the occupational exposed group and the control groupThe investigation of the equilibrium of the occupational exposed group and the control group shows that the difference between the age, height, weight, dietary history,the alcohol history, and the smoking history of the two group was not significant.(P>0.05), this indicate that the two group were comparable.2. Compare the blood test result of the occupational exposed group and the control groupThe cholesterol, low-density lipoprotein cholesterol, the ratio of low-density lipoprotein cholesterol, hemoglobin, and hematocrit of the exposed group was higher than the control group, the ratio of high-density lipoprotein cholesterol was lower than the control group, the difference was significant (P<0.05), and the difference of red blood cell count, white blood cells count, platelet count, absolute lymphocyte, uric acid, urea and keratinize was not significant.(P>0.05).3. Investigation of the cognition of surgical smoke and present situation of occupational protection of the occupational exposed populationOnly35%of the occupational exposed population thought that the surgical smoke does harm to the human body, but none of them can name the type of its concrete harm. All of the occupational exposed population ware surgical masks which cannot protect them from the surgical smoke while exposed to surgical smoke,55%of the occupational exposed population used the suction system to clear the smoke.4. The result of the test and the effect of the training programThe level of the occupational exposed population’s basic knowledge about surgical smoke is very low and the lowest is the knowledge level of physical properties. It is necessary to held a training program to promote the basic knowledge of Surgical Smoke of the occupational exposed population. The score of doctor and nurse before training are different. The score of total and all dimensions except the combination of surgical smoke are elevated after training, the difference was significant (P<0.05). The score of doctor and nurse after training are different:the score of total, physical property, standard of authority organization, effect to human body and chemical property of doctor are higher than those of nurse, but the score of resource and composition of nurse are higher than those of doctor, the difference was significant (P <0.01).Conclusion1. Through the investigation and analyze of the blood test of the exposed group and the control group, this research find that the surgical smoke is a hazard to the health of the occupational exposed population. The level of cholesterol and low-density lipoprotein cholesterol of the exposed group rose which will elevate the risk of atherosclerosis and coronary heart disease of the exposed group. The constant elevation of carboxyhaemoglobin and methemoglobin caused the elevation of hemoglobin and hematocrit of the exposed group.2. Investigation of the cognition of surgical smoke and present situation of occupational protection of the occupational exposed population finds that the cognition of surgical smoke and present situation of occupational protection is insufficient. It is necessary to hold a comprehensive and deep study on the knowledge-belief-behavior model of the exposed group to investigate the exposed group’s degree of knowledge and cognition about the surgical smoke, the supply of needed equipment, the accurateness and the compliance to use these equipment. The study on the knowledge-belief-behavior model of the exposed group will help to get prepared to set an occupational protection training program and popularize the training program more pertinently.3. The occupational exposed population extremely lack knowledge of surgical smoke. Training can promote the knowledge level and the training effect of the doctor’s is better than the nurse’s.In this study, a series of investigation and blood test were carried out to know the effect of surgical smoke on the health of the occupational exposed population and the cognition of surgical smoke and present situation of occupational protection of the occupational exposed population. Our result indicate that surgical smoke has a certain impact on the blood lipids and hemoglobin of occupational exposed population and. the cognition of surgical smoke and present situation of occupational protection is insufficient. It is necessary to conduct a long-term tracking on occupational exposed population and search for sensitive indicators to provide a scientific evidence for the occupational protection. The research provide a direction to conduct a long-term tracking on occupational exposed population and to search for sensitive indicators to provide a scientific evidence for the occupational protection, it provide an evidence to hold an occupational safety protection training program for occupational exposed population about surgical smoke, and eventually protect the health of occupational exposed population.