Air pollution in the operating room: A case study of characteristics of airborne particles, PAHs and environmentally persistent free radicals

https://doi.org/10.1016/j.apr.2021.101257Get rights and content

Highlights

  • High levels of fine particles and PAHs were found in laminar flow operating rooms.

  • First report of EPFRs in an operating room, present mainly as carbon-centered persistent radicals.

  • Fine particles in the operating room were dominantly calcareous, metal and organic-related particles.

Abstract

Air quality in the microenvironment of operating rooms (ORs) has attracted much attention as surgical smoke may pose health risks. We investigated air pollution in the operating room with a laminar flow system by examining the number and size distribution of airborne particles, the chemical composition and morphology of single particles, and polycyclic aromatic hydrocarbons (PAHs). In addition, environmentally persistent free radicals (EPFRs) in ORs are reported for the first time. The results showed that there were high levels of fine particles, EPFRs, and PAHs in laminar flow operating rooms during surgical procedures. PM2.5 is the dominant particle in ORs (accounting for >90%), consisting mainly of calcareous and metal-related particles based on the morphology and chemical analysis of single particles. In addition, anesthetic gas-related particles were found in the fine particles, and their toxicology requires more attention. EPFRs in the ORs were mainly carbon-centered radicals that may be reactive to cells. The concentrations of EPFRs and PAHs in ORs were higher than in the outside environment and present a potential health risk to surgeons and anesthetists. Hence, effective filtration and evacuation of surgical smoke are necessary.

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)

  • N. Massarotti et al.

    Air contamination inside an actual operating room due to ultrafine particles: an experimental-numerical thermo-fluid dynamic study

    Atmos. Environ.

    (2021)
  • B. Pan et al.

    Environmentally persistent free radicals: occurrence, formation mechanisms and implications

    Environ. Pollut.

    (2019)
  • P. Sanderson et al.

    A review of chemical and physical characterisation of atmospheric metallic nanoparticles

    Atmos. Environ.

    (2014)
  • B.C. Ulmer

    The hazards of surgical smoke

    AORN J.

    (2008)
  • E.A.F. Van Gestel et al.

    Assessment of the absorbed dose after exposure to surgical smoke in an operating room

    Toxicol. Lett.

    (2020)
  • X. Wang et al.

    Polycyclic aromatic hydrocarbons, polychlorinated biphenyls and legacy and current pesticides in indoor environment in Australia – occurrence, sources and exposure risks

    Sci. Total Environ.

    (2019)
  • X. Wu et al.

    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

    (2019)
  • A. Agirman et al.

    Effect of air exhaust location on surgical site particle distribution in an operating room

    Building Simulation

    (2020)
  • S.N. Andreasson et al.

    Polycyclic aromatic hydrocarbons in electrocautery smoke during peritonectomy procedures

    J. Environ. Public Health

    (2012)
  • A.M. Arangio et al.

    Quantification of environmentally persistent free radicals and reactive oxygen species in atmospheric aerosol particles

    Atmos. Chem. Phys.

    (2016)
  • W.L. Barrett et al.

    Surgical smoke: a review of the literature

    Surg. Endosc.

    (2003)
  • A. Błażewicz et al.

    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.

    (2013)
  • H. Born et al.

    How should we safely handle surgical smoke?

    Laryngoscope

    (2014)
  • A. Chen et al.

    Volatilization of polycyclic aromatic hydrocarbons (PAHs) over the North Pacific and adjacent Arctic Ocean: the impact of offshore oil drilling

    Environ. Pollut.

    (2021)
  • Q. Chen et al.

    Size-resolved exposure risk of persistent free radicals (PFRs) in atmospheric aerosols and their potential sources

    Atmos. Chem. Phys.

    (2020)
  • Y.J. Chen et al.

    Polycyclic aromatic hydrocarbons in the atmosphere of Shanghai, China

    Environ. Monit. Assess.

    (2011)
  • Zhiqin Chu et al.

    Unambiguous observation of shape effects on cellular fate of nanoparticles

    Sci. Rep.

    (2014)
  • G.B. Forbes

    Human Body Composition: Growth, Aging, Nutrition, and Activity

    (2012)
  • Cited by (5)

    • Indoor air particles in research vessel from Shanghai to Antarctic: Characteristics, influencing factors, and potential controlling pathway

      2023, Journal of Environmental Sciences (China)
      Citation Excerpt :

      Fig. 2 shows that the particle mass concentration distribution in most rooms peaked at 1-4 µm. Many studies have been conducted on the distribution of indoor particle mass concentration, and most findings have shown that the particle mass concentration increases with an increase in particle size (Chen and Li, 2015; Yu et al., 2021). We found that the mass concentration peaked at 1-4 µm, which may have been due to the presence of indoor emission sources of fine particle size segments or hygroscopic growth in the size fractions with smaller particles.

    Peer review under responsibility of Turkish National Committee for Air Pollution Research and Control.

    1

    These authors have contributed to this work equally.

    View full text