Air pollution in the operating room: A case study of characteristics of airborne particles, PAHs and environmentally persistent free radicals
Introduction
The air quality in the operating room (OR) needs to meet certain standards and provide a controllable and safe operating environment. With the use of the laminar flow system, the air cleanliness level of ORs is generally very high. However, previous studies found that surgical smoke can cause air pollution in the OR (Massarotti et al., 2021; Ulmer, 2008). The Occupational Safety and Health Administration lists surgical smoke as a potential occupational hazard with potential health risks to the surgeon. Several studies have found that the number and prevalence of respiratory problems reported by nurses in the OR are higher than the average prevalence rate in the general population (Ball, 2010).
Surgical smoke is generated during tissue cutting and coagulating blood vessels, when using electrocautery, lasers, and ultrasonic scalpels (Buonanno et al., 2019). There are more than 150 substances in surgical smoke, including gaseous and solid compounds, such as CO, hydrocarbons, nitrile and amines, which are produced by the burning of protein and fatty tissue, and the particles of surgical smoke also contain viable or non-viable cells, bacteria, viruses, tissue, or cell fragments (Barrett and Garber, 2003; Fan et al., 2009; Francke et al., 1995; Weber and Spleiss, 1995). The compounds in surgical smoke vary according to the type of surgery and the surgical technique (Buonanno et al., 2019).
As important air pollutants, much of the research on surgical smoke has focused on particle concentration and polycyclic aromatic hydrocarbons (PAHs) (Andreasson et al., 2012; Born and Ivey, 2014; Buonanno et al., 2019; Fan et al., 2009; Li et al., 2020; Murr et al., 2020). Particle concentrations can be increased by more than 16 times above the baseline when using electrocautery (Born and Ivey, 2014), and can be much higher than in the environment outside the OR (Li et al., 2020; Murr et al., 2020). PAHs in surgical smoke were several times higher than those in engine exhaust (Yang et al., 2018), and the metabolites of PAHs were detected in the urine of medical staff in ORs (Van Gestel et al., 2020). In addition, environmentally persistent free radicals (EPFRs), as a new pollutant type, can induce the production of reactive oxygen species (ROS), causing oxidative stress and thereby threatening human health (Chen et al., 2020; Sly et al., 2019). Atmospheric EPFRs exist mainly in fine particles (Arangio et al., 2016), and high concentrations of ROS in the ambient atmospheric environment have been found (Chen et al., 2020; Fuller et al., 2014), however, there are few studies of their occurrence in ORs.
There are differences in the particle and chemical composition of surgical smoke produced by different types of surgery. Particle size is an important factor influencing particle deposition in the human respiratory tract. Coarse particles (>2.5 μm) are mainly deposited in the upper respiratory tract, and fine particles (<2.5 μm) can reach the alveoli and bronchi; the deposited fraction also varies with particle size (Hofmann, 2011).The size of surgical smoke particle varies according to the type of surgery and surgical equipment (Fan et al., 2009), and the toxicity of surgical smoke is related to its chemical composition (Park et al., 2018; Sanderson et al., 2014). Not all surgical smoke was found to contain PAHs (Yang et al., 2018; Yeganeh et al., 2020). Previous animal exposure experiments have shown that iron-soot aerosols have an oxidative stress effect, whereas iron or soot alone do not (Jung et al., 2004). Yang et al., using a field emission scanning electron microscope (FE-SEM), found metal elements in ORs, and suggested that the composition of surgical smoke particles varies according to the emission sources of various surgical procedures (Yang et al., 2018). Therefore, the chemical composition and size distribution of surgical smoke particles need to be considered in various type of surgery when considering their health effects. Overall, it is clear that further research is needed on the characterization of surgical smoke.
Previous studies have focused separately on the concentration and size distribution of surgical smoke particles and the gas composition (Andreasson et al., 2012; Buonanno et al., 2019; Li et al., 2020; Tseng et al., 2014; Wang et al., 2015; Yeganeh et al., 2020). The present research is concerned with spinal surgery cases in laminar flow ORs. The surgical smoke compositions of spinal surgeries was analyzed comprehensively from the perspective of gaseous and particulate matter, including the characteristics of single particles of surgical smoke, and the gaseous and particle phase of PAHs, while EPFRs were also analyzed.
Section snippets
ORs and sampling
Samples were collected from spinal surgical cases in two vertical laminar airflow ORs (OR3 and OR5) of the First Affiliated Hospital of the University of Science and Technology of China (see Figure S1 and Table S1 for detailed information). The air cleanliness in the ORs is Class 5 according to GB 50333–2013, similar to Class 5 of ISO14644-1, for which the maximum particle number concentration limits for particles equal to and larger than 0.5 μm and 5.0 μm are 3500 P m−3 and 0 P m−3,
Number and mass concentration of particles in the ORs
The results show that the aerosol particle number and mass concentration in the ORs varied substantially during operations (Fig. 1) and were much higher than in the CO-OR (P < 0.05), except for channel 0.3 (the particle number and mass concentration of channel 0.3 in ORs was at the same level as those for the CO-OR). The particle concentration decreased with increasing particle size, while the mass concentration showed the opposite trend. Particle sizes in the size channels of range of 0.3–0.5,
Potential sources of particles during surgical procedures in the ORs base on particle composition and morphological characteristics
The composition of calcareous particles in ORs is similar to mineral particles observed in the outside environment, usually containing Si, Ca and Fe (Li et al., 2016); however, a difference was that the calcareous particles found in the ORs rarely contained Al and usually contained O, K, Co, and S. The particle sources in ORs include preparatory processes before surgery (Noguchi et al., 2017), the surgery itself, and the post-operative cleaning process, which are different from other
Conclusion
The results of this study show that spinal surgery can produce significant levels of air pollution in ORs. High concentrations of airborne particles, PAHs and EPFRs were found in laminar flow ORs. PM2.5, accounting for >90% of the particles, dominated the spinal surgery smoke particles. EPFRs in the OR were found for the first time and showed a high ESR spectra signal compared with the outside environment. Compared with other operations, PAHs in spinal surgery smoke mainly gaseous phase PAHs
Credit author statement
Xiawei Yu, Hanyang Liu: Formal analysis, Investigation, Writing - original draft, Writing - review & editing, Visualization. Fang Kang: Methodology, Investigation, Resources, Writing - review & editing. Bingqing Zhu: Resources, Investigation. Xudong Wu, Chengge Hu, Xiang Huang, Longquan Wang, Youqun Chu: Investigation. Mingming Han: Writing - Review & Editing. Juan Li, Zhouqing Xie: Conceptualization, Methodology, Writing - review & editing, Supervision, Funding acquisition, Project
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
This work was supported by the National Key Project of Ministry ofScience and Technology of China (MOST) (2016YFC0203302) and the Fundamental Research Funds for the Central Universities (WK9110000059).
References (56)
Compliance with surgical smoke evacuation guidelines: implications for practice
AORN J.
(2010)- et al.
Exposure risk to carcinogenic PAHs in indoor-air during biomass combustion whilst cooking in rural India
Atmos. Environ.
(2004) - et al.
Airborne particle emission rates and doses received in operating rooms from surgical smoke
Build. Environ.
(2019) - et al.
Occurrence and exposure to polycyclic aromatic hydrocarbons and their derivatives in a rural Chinese home through biomass fuelled cooking
Environ. Pollut.
(2012) - et al.
Surgical smoke
Asian J. Surg.
(2009) - et al.
Comparison of on-line and off-line methods to quantify reactive oxygen species (ROS) in atmospheric aerosols
Atmos. Environ.
(2014) Modelling inhaled particle deposition in the human lung—a review
J. Aerosol Sci.
(2011)- et al.
Urinary levels of 1-hydroxypyrene in children residing near a coal-fired power plant
Environ. Res.
(2011) - et al.
Physiochemical characteristics of aerosol particles in the typical microenvironment of hospital in Shanghai, China
Sci. Total Environ.
(2017) - et al.
A review of single aerosol particle studies in the atmosphere of East Asia: morphology, mixing state, source, and heterogeneous reactions
J. Clean. Prod.
(2016)
Air contamination inside an actual operating room due to ultrafine particles: an experimental-numerical thermo-fluid dynamic study
Atmos. Environ.
Environmentally persistent free radicals: occurrence, formation mechanisms and implications
Environ. Pollut.
A review of chemical and physical characterisation of atmospheric metallic nanoparticles
Atmos. Environ.
The hazards of surgical smoke
AORN J.
Assessment of the absorbed dose after exposure to surgical smoke in an operating room
Toxicol. Lett.
Polycyclic aromatic hydrocarbons, polychlorinated biphenyls and legacy and current pesticides in indoor environment in Australia – occurrence, sources and exposure risks
Sci. Total Environ.
Concentration, exchange and source identification of polycyclic aromatic hydrocarbons in soil, air and tree bark from the Middle-Lower Yangtze Plain, China
Atmospheric Pollution Research
Effect of air exhaust location on surgical site particle distribution in an operating room
Building Simulation
Polycyclic aromatic hydrocarbons in electrocautery smoke during peritonectomy procedures
J. Environ. Public Health
Quantification of environmentally persistent free radicals and reactive oxygen species in atmospheric aerosol particles
Atmos. Chem. Phys.
Surgical smoke: a review of the literature
Surg. Endosc.
Differences in trace metal concentrations (Co, Cu, Fe, Mn, Zn, Cd, and Ni) in whole blood, plasma, and urine of obese and nonobese children
Biol. Trace Elem. Res.
How should we safely handle surgical smoke?
Laryngoscope
Volatilization of polycyclic aromatic hydrocarbons (PAHs) over the North Pacific and adjacent Arctic Ocean: the impact of offshore oil drilling
Environ. Pollut.
Size-resolved exposure risk of persistent free radicals (PFRs) in atmospheric aerosols and their potential sources
Atmos. Chem. Phys.
Polycyclic aromatic hydrocarbons in the atmosphere of Shanghai, China
Environ. Monit. Assess.
Unambiguous observation of shape effects on cellular fate of nanoparticles
Sci. Rep.
Human Body Composition: Growth, Aging, Nutrition, and Activity
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Peer review under responsibility of Turkish National Committee for Air Pollution Research and Control.
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These authors have contributed to this work equally.