DOI: 10.33962/roneuro-2021-081 Surgical smoke, neurosurgical practice and coronavirus: a few words of caution Adesh Shrivastava, Noor-Ul-Huda Maria, Rakesh Mishra, William Florez-Perdomo, Amit Agrawal, Luis Rafael Moscote -Salazar Romanian Neurosurgery (2021) XXXV (4): pp. 478-482 DOI: 10.33962/roneuro-2021-081 www.journals.lapub.co.uk/index.php/roneurosurgery Surgical smoke, neurosurgical practice and coronavirus: a few words of caution Adesh Shrivastava3, Noor-Ul-Huda Maria2, Rakesh Mishra6, William Florez-Perdomo4,5, Amit Agrawal3, Luis Rafael Moscote-Salazar1 1 Centre of Biomedical Research (CIB) Faculty of Medicine University of Cartagena, COLOMBIA 2 Punjab Institute of Neurosciences, Lahore, PAKISTAN 3 All India Institute of Medical Sciences, Bhopal, INDIA 4 Latin-American Council of Neurocritical Care, COLOMBIA 5 South Colombian University, Neiva, COLOMBIA 6 National Institute of Mental Health and Neurosciences, Bengaluru, INDIA ABSTRACT Surgical smoke also referred to as cautery smoke is a gaseous mixture produced during surgical procedures where there is ablation, cutting, coagulation, desiccation or vaporization of the tissue. In a true sense “surgical smoke” refers to surgically generated gaseous contents. The surgical smoke results from the destruction of bones and tissues, causing microscopic particles to get suspended in the environment. Coagulation devices such as ultrasound, electrical instruments and laser generate nebulization of particles viral, carcinogens and toxic substances. [4, 6] The recent appearance of COVID19 infection has emerged as a risk factor for surgical practice. Surgical smoke contains particulate matter which passes the upper respiratory tract and gets deposited.7-9 The overall effect of surgical smoke is determined by the duration of the working hours in the operating room [5, 10] as well as safety measures adopted to protect from the surgical smoke. [5] The global pandemic of Covid-19 has made surgeons rethink their strategies to maximize the safety of treating personnel. Neurosurgery is not untouched by the current situation of this pandemic. There are many concerns including the safety of health care workers, poor availability of resources etc. Many of the elective surgical procedures a r e p o s t p o n e d a l l - r o u n d t h e g l o b e as a m e an s t o p r e v e n t transmission.[11] Since the majority of neurosurgical illness is progressive and can transform from elective to emergency with time. Also, like in other specialities, neurosurgery is benefitted with technological advances to maximize the efficacy and minimize Keywords surgical smoke, coronavirus, neurosurgical practice Corresponding author: Luis Rafael Moscote-Salazar Department of Neurosurgery, University of Cartagena, Colombia rafaelmoscote21@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published December 2021 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 479 Surgical smoke, neurosurgical practice and coronavirus the morbidity associated with neurosurgical procedures. There are concerns with the use of ultrasonic aspirator, drill system which potentially generates aerosols and surgical smoke. With ongoing pandemic, it is evident that these procedures cannot be postponed indefinitely and no alternative is yet available to ensure a better outcome. Even in neurosurgical emergencies and Neurooncological surgeries, it is of utmost importance to take cognizance of potential effects of surgical smoke and precautions while operating on patients who are suspected or proven Covid-19 positive. Neurological surgery comprises a versatile set of different surgical domains that include spinal surgery, cranial surgery, endoscopic surgery and minimally invasive surgical procedures which have their own biological and physical factors. Since the surgical smoke has heterogenous composition, it is not clear which surgical procedure has more potential to generate smoke containing viral products as particulate matter. The surgical smoke thus generated consists of 95% water and 5% particulate matter consisting of chemical compounds, cell particles, bacteria, viruses and even drugs are taken by patients.[10, 12-15] Several chemical compounds (≥ 80 different toxic chemicals) have been found in surgical smoke. [16, 17] which have the potential to cause cell damage. [1, 16] Prolonged exposure to surgical smoke (with cumulative dose effect0 can cause mild symptoms like headache, irritability, mood changes to severe injuries like an injury to the lungs and in long term infections and a certain type of malignancies. 1, 9, 18 Particulate matter in surgical smoke is mostly less than 5 um in size. [12, 19] Although many regulatory bodies agree on the dangers of surgical smoke, the degree of hazard and methods to prevent is yet to be firmly established20. Electrocautery generates heat which damages the cell membranes and generates smoke containing mostly water vapour which gets aerosolized in the operating room. [2, 8, 21], In addition, it chars the neighbouring cells. This causes further thermal necrosis and releases carbonized cell fragments and gaseous hydrocarbons.[22] The byproduct of diathermy coagulation and biochemicals present in the smoke depends on the settings of diathermy and the tissue being burnt with the gray matter being low particulate matter tissues. [1, 18, 23-27] Similarly ultrasonic aspirators create aerosols by creating cavitation nuclei. The combined action of ultrasonic aspirators and diathermy electrocoagulation has potential to generate aerosols containing infective particulates. Electrocautery produces more particulate matter than lasers and ultrasonic devices, but because the smoke generated by lasers and ultrasonic devices is colder and has more biohazard with the risk of transmitting infection [1, 26, 27] as the smoke and aerosols can be inhaled and gets deposited in the respiratory system.28 Though, there is insufficient evidence for COVID-19 transmission through surgical smoke, data, existing studies and expert opinion suggests it a theoretical risk.29, 30 A review was done based on the existing studies suggested the methods to mitigate the potential risk of surgical smoke and COVID-19 transmission to OR personnel. [29] The composition of this hazardous surgical smoke depends much on the type of surgical procedure, the duration, the devices/instruments used, the structure of the operating theatre, the expertise of the surgeon, the pathology operated upon and the precautionary measures taken during surgery. It is not hard to imagine that such surgical procedures carry the potential of a generation of heavy and potentially hazardous surgical smoke. While on the other hand, for brain surgery, a use of bipolar cautery, CUSA, ultrasonic probe, generation of biological particle including tumours and again infectious matter, bone dust because of bone drilling and craniotomy flap elevation, neuronavigation and laser contribute in the generation of the Surgical Smoke. Studies on biohazards of surgical smoke have shown the presence of viral DNA, activated Corynebacterium, Hepatitis B, Human papillomavirus. [1, 31-38] In a few studies, 80% of the surgical smoke from infected patients contained viral particles suggesting the potential risk of transmission to personnel in OR. [39-41] Bacteria and viruses can survive in the surgical smoke for up to 72 hours’[19] It has been shown that in aerosols SARS-CoV-2 can survive up to 3 hours and on the surfaces up to 72 hours.38 However, no data is yet available for transmission of SARS-CoV-2 through smoke produced in a surgical procedure. Majority of the literature available is related to laparoscopic surgeries. [11, 42] Even the biohazard potential is not very well established in other surgical specialities [42-44] SARS-CoV-2 has shown transmission potential through aerosols and fomites similar to SARS-CoV-1 in experimental conditions [38]. 480 Adesh Shrivastava, Noor-Ul-Huda Maria, Rakesh Mishra et al. To reduce the risk of transmission of SARS-CoV-2 through surgical smoke, preventive strategies suggested by Zheng et al. seems appropriate and worth considering in neurosurgical patients.[11] Chow et al have mentioned the method to convert existing OR into negative pressure OR.45 Unilaminar airflow in OR is effective in removing 97% of particulate matter of size more than or equal to 0.3 um.46 Various filters can be used along with smoke evacuators in the OR like, charcoal filters, coconut shell charcoal, ultralow particulate air (ULPA) filters.29 these filters can retain particles up to 0.1 um in size. Different surgical societies all around the world have published guidelines involving comprehensive measures, changes in OR and filtration systems aimed to prevent the established and hypothetical risk of transmission. [47-49] Neurosurgical procedures are not immune to the production of surgical smoke given the usage of ultrasonic aspirators, high-speed pneumatic drills. In parallel to other surgical association, the neurosurgical community should assess the size of the risk to provide quality surgery to the patient and protection of the surgical team. The American National Standards Institute (ANSI) has established strategies for smoke reduction during laser surgery. 50 In the current pandemic of COVID-19, health care worker needs to have PPE and N95 masks. Available masks to prevent inhalation of surgical masks and its health hazards include Surgical mask, N85 masks and High filter masks.[51-53] Surgical mask doesn’t provide tight face seal, positive pressure inside the facepiece and filter particulate matter less than 5 um in size and therefore may fail to protect from transmission of infective pathogens through surgical smoke.[21, 54] Surgical masks my provide > 90% protection and has been in use for a century and N95 mask may not offer adequate protection in these potential contagious procedures and activated carbon filters in addition to N95 may be more appropriate. [21, 55-58] However, N95 masks have their own challenges which includes CO2 build up, difficulty in breathing after a certain time and subjective symptoms of headache, light headedness etc. [59] In summary, there is an increased need to create awareness regarding the side effect of surgical smoke, to train an individual to minimize the exposure and develop facilities for the safe evacuation of the surgical smoke in the operation theatre and thus to safeguard the personnel’s in the operating theatre. [21] REFERENCES 1. Barrett WL, Garber SM. Surgical smoke: a review of the literature. Is this just a lot of hot air? Surgical endoscopy 2003;17:979-987. 2. Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? a systematic review. Surgical endoscopy 2013;27:3100-3107. 3. Waddell AW. Cultivating quality: implementing surgical smoke evacuation in the operating room. The American journal of nursing 2010;110:54-58. 4. Carbajo-Rodríguez H, Aguayo-Albasini JL, Soria-Aledo V, García-López C. Surgical smoke: risks and preventive measures. Cirugía Española (English Edition) 2009;85:274-279. 5. Van Giersbergen MY, Alcan AO, Kaymakci S. Investigation of Surgical Smoke Symptoms and Preventive Measures in Turkish Operating Rooms. International Journal of Health Sciences and Research 2019;9:138-144. 6. Marsh S. The smoke factor: things you should know. J Perioper Pract 2012;22:91-94. 7. Michaelis M, Hofmann FM, Nienhaus A, Eickmann U. Surgical Smoke-Hazard Perceptions and Protective Measures in German Operating Rooms. Int J Environ Res Public Health 2020;17:515. 8. Fitzgerald JE, Malik M, Ahmed I. A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery. Surgical endoscopy 2012;26:337-342. 9. Liu N, Filipp N, Wood KB. The utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery: a prospective self-controlled study. The spine journal : official journal of the North American Spine Society 2020;20:166-173. 10. Ünver S, Topçu SY, Findik ÜY. Surgical smoke, me and my circle. International Journal of Caring Sciences 2016;9:697-703. 11. Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy. Annals of Surgery 2020;Publish Ahead of Print. 12. Ulmer BC. The hazards of surgical smoke. AORN journal 2008;87:721-734; quiz 735-728. 13. Fencl JL. Guideline Implementation: Surgical Smoke Safety. AORN journal 2017;105:488-497. 14. Tramontini CC, Galvão CM, Claudio CV, Ribeiro RP, Martins JT. [Composition of the electrocautery smoke: integrative literature review]. Rev Esc Enferm USP 2016;50:148-157. 15. Gianella M, Hahnloser D, Rey JM, Sigrist MW. Quantitative chemical analysis of surgical smoke generated during laparoscopic surgery with a vessel-sealing device. Surg Innov 2014;21:170-179. 16. Sisler JD, Shaffer J, Soo J-C, et al. In vitro toxicological 481 Surgical smoke, neurosurgical practice and coronavirus evaluation of surgical smoke from human tissue. J Occup Med Toxicol 2018;13:12-12. 17. King B, McCullough J. NIOSH health hazard evaluation report. HETA# 2000-0402-3021. Inova Fairfax Hospital, Falls Church, Virginia 2006. 18. Okoshi K, Kobayashi K, Kinoshita K, Tomizawa Y, Hasegawa S, Sakai Y. Health risks associated with exposure to surgical smoke for surgeons and operation room personnel. Surgery today 2015;45:957-965. 19. Benson SM, Novak DA, Ogg MJ. Proper use of surgical n95 respirators and surgical masks in the OR. AORN journal 2013;97:457-467; quiz 468-470. 20. York K, Autry M. Surgical Smoke: Putting the Pieces Together to Become Smoke-Free: 1.6 www.aornjournal.org/content/cme. AORN journal 2018;107:692-703. 21. Liu Y, Song Y, Hu X, Yan L, Zhu X. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. Journal of Cancer 2019;10:2788-2799. 22. Pollock L. Hazards of Electrosurgical Smoke. Perioperative Nursing Clinics 2007;2:127-138. 23. Ott DE, Moss E, Martinez K. Aerosol exposure from an ultrasonically activated (Harmonic) device. J Am Assoc Gynecol Laparosc 1998;5:29-32. 24. Karjalainen M, Kontunen A, Saari S, et al. The characterization of surgical smoke from various tissues and its implications for occupational safety. PLoS One 2018;13:e0195274. 25. PetrusM B, PatachiaM, DumitrasDC. Spectroscopic analysis of surgical smoke produced in vitro by laser vaporization of animal tissues in a closed gaseous environment. RomRepPhys 2015; 67(3):954-965. . 26. In SM, Park DY, Sohn IK, et al. Experimental study of the potential hazards of surgical smoke from powered instruments. Br J Surg 2015;102:1581-1586. 27. Weld KJ, Dryer S, Ames CD, et al. Analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility. J Endourol 2007;21:347-351. 28. Limchantra IV, Fong Y, Melstrom KA. Surgical Smoke Exposure in Operating Room Personnel: A Review. JAMA Surg 2019. 29. Mowbray NG, Ansell J, Horwood J, et al. Safe management of surgical smoke in the age of COVID-19. Br J Surg 2020. 30. de Leeuw RA, Burger NB, Ceccaroni M, et al. COVID-19 and laparoscopic surgery, a scoping review of current literature and local expertise. JMIR Public Health Surveill 2020. 31. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med 2016;73:857-863. 32. Gloster HM, Jr., Roenigk RK. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 1995;32:436-441. 33. Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surgical endoscopy 2014;28:2374-2380. 34. Capizzi PJ, Clay RP, Battey MJ. Microbiologic activity in laser resurfacing plume and debris. Lasers Surg Med 1998;23:172-174. 35. Hensman C, Baty D, Willis RG, Cuschieri A. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. An in vitro study. Surgical endoscopy 1998;12:1017-1019. 36. Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. J Med Virol 1991;33:47-50. 37. Zhou Q, Hu X, Zhou J, Zhao M, Zhu X, Zhu X. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Manag Res 2019;11:3643-3654. 38. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020;382:1564-1567. 39. Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med 1991;11:197-203. 40. Fletcher JN, Mew D, DesCoteaux JG. Dissemination of melanoma cells within electrocautery plume. American journal of surgery 1999;178:57-59. 41. Sood AK, Bahrani-Mostafavi Z, Stoerker J, Stone IK. Human papillomavirus DNA in LEEP plume. Infect Dis Obstet Gynecol 1994;2:167-170. 42. Pawar T, Pokharkar A, Gori J, et al. The Technique and Justification for Minimally Invasive Surgery in COVID-19 Pandemic: Laparoscopic Anterior Resection for Near Obstructed Rectal Carcinoma. J Laparoendosc Adv Surg Tech A 2020;30:485-487. 43. Ngaserin SH, Koh FH, Ong BC, Chew MH. COVID-19 not detected in peritoneal fluid: a case of laparoscopic appendicectomy for acute appendicitis in a COVID-19- infected patient. Langenbecks Arch Surg 2020:1-3. 44. Cicuttin E, Cobianchi L, Chiarugi M, Catena F, Coccolini F, Pietrabissa A. Detect to protect: pneumoperitoneum gas samples for SARS-CoV-2 and biohazard testing. Surgical endoscopy 2020. 45. Chow TT, Kwan A, Lin Z, Bai W. Conversion of operating theatre from positive to negative pressure environment. The Journal of hospital infection 2006;64:371-378. 46. Spagnolo AM, Ottria G, Amicizia D, Perdelli F, Cristina ML. Operating theatre quality and prevention of surgical site infections. J Prev Med Hyg 2013;54:131-137. 47. Mintz Y, Arezzo A, Boni L, Chand M, Brodie R, Fingerhut A. A Low Cost, Safe and Effective Method for Smoke Evacuation in Laparoscopic Surgery for Suspected Coronavirus Patients. Ann Surg 2020. 48. The American College of Surgeons. ACS COVID-19 and Surgery March 24 Aahwfoc-c-g. 49. https://www.sages.org/recommendations-surgical- response-covid-19/. TSoAGaESSRRSRtC-CAa. 482 Adesh Shrivastava, Noor-Ul-Huda Maria, Rakesh Mishra et al. 50. Bigony L. Risks associated with exposure to surgical smoke plume: a review of the literature. AORN journal 2007;86:1013-1020; quiz 1021-1014. 51. Coleman S. Protecting yourself against surgical smoke. Or Nurse 2014;8:40-46. 52. Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol 2011;65:636-641. 53. Fan JK, Chan FS, Chu KM. Surgical smoke. Asian journal of surgery 2009;32:253-257. 54. Bree K, Barnhill S, Rundell W. The Dangers of Electrosurgical Smoke to Operating Room Personnel: A Review. Workplace health & safety 2017;65:517-526. 55. Georgesen C, Lipner SR. Surgical smoke: Risk assessment and mitigation strategies. J Am Acad Dermatol 2018;79:746-755. 56. Jamal S, Hassan M, Farooqi M, Ali S. Surgical Smoke- Concern for Both Doctors and Patients. Indian J Surg 2015;77:1494-1495. 57. Oberg T, Brosseau LM. Surgical mask filter and fit performance. American journal of infection control 2008;36:276-282. 58. Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta- Analysis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2017;65:1934-1942. 59. Rebmann T, Carrico R, Wang J. Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses. American journal of infection control 2013;41:1218-1223.