Surgical smoke evacuators and inertia in the time of COVID

As an anesthesiologist, I fully understand that providers in my specialty, along with emergency room and intensive care providers, must care for patients with COVID-19 at close physical range during aerosol-generating procedures (AGPs) such as tracheal intubation and extubation, without the option of “social distancing.”  Consequently, we currently rely on personal protective equipment (PPE), operating room ventilation systems, preoperative COVID testing, and hopefully, in the future, on vaccination and herd immunity, to protect our loved ones and us from COVID-19.  But unfortunately, it is well documented that none of these strategies are 100 percent effective.

Since the start of the pandemic, I have read, with great sadness, the tales of fear, anxiety, frustration, depression, and burnout from colleagues around the world, who are justifiably concerned that they might contract COVID on any given day at work, and then take it home to their loved ones.  A recent article on this website by an anesthesiologist was entitled “Will women in medicine survive COVID-19?”  Other very recent articles include: “Doctors are calling it quits under stress of the coronavirus” and “’We are drowning’: Doctor begs Manitobans to obey health orders, take burden off hospitals.” As an experienced health care provider who has spent much of my career studying human factors and human errors, I can assure you that it is disquieting and potentially very dangerous to have our critical care provider be anxious, preoccupied, distracted, or “burnt out” while attempting to take care of very sick patients during critical procedures.

Early in the pandemic, in thinking of and discussing possible solutions to help protect health care workers, two of my former colleagues and I recalled a device called the Surgical Smoke Evacuator (SSE), which we used extensively since the 1990s when we worked together at the University of Pittsburgh to collect and safely dispose of the papillomavirus-containing smoke and aerosol cloud generated during the laser or electrocautery removal of laryngeal, cutaneous, and genital warts (papillomas).  These FDA-approved air suction devices are still in routine use today in operating rooms around the world. They have been vigorously advocated by organizations such as the Centers for Disease Control (CDC), the Association of periOperative Registered Nurses (AORN), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

SSEs utilize a very powerful suction pump and the most effective small-particle filter, the ultra-low particulate air (“ULPA” filter) used in clinical medicine.  ULPA filters are much more effective at trapping particles the size of coronavirus (which are only approximately 0.1-0.12 microns in diameter) than are the better-known and more commonly-used and better-known “HEPA” filters.

And, unbeknownst to many critical care and emergency room personnel who never work in the operating room, and even under-appreciated by many anesthesiologists (since SSEs are traditionally considered “surgical” devices), these SSEs are sitting in many, if not most, operating rooms in the U.S. as I write this piece.  For example, my two colleagues and I realized that we all have an SSE in every one of our operating rooms in each of our three current hospitals in three different states.  Also, all of our SSEs are on carts with wheels; also, many manufacturers’ SSEs are small and portable, and could therefore be transported or even placed in other units in the hospital where AGPs are performed, such as the recovery room, emergency department, ICUs, or “COVID units.” SSEs are simple to use, and the disposables (plastic suction tubing, which is single-patient use only, and the ULPA filters, many of which have run-times of 80 hours) are inexpensive.

The concept is very simple: similarly to placing the patient end of the SSE suction hose near the surgical field to collect, trap, and safely dispose of the papillomavirus aerosol and smoke cloud as the surgeon vaporizes a papilloma with a laser or electorocautery, the suction hose is placed near the patient’s airway during tracheal intubation and extubation to collect much of the aerosolized, potentially coronavirus-containing cloud generated by coughing and airway management.  Thus, the SSE can be a shared resource utilized by both the surgical team and the airway management team to help reduce the aerosolized viral load and thus provide a cleaner operating room air environment for all of the personnel, including housekeeping.

We have attempted to communicate this simple, inexpensive concept to our colleagues in the U.S. and worldwide using traditional medical specialty journals and notifying our state and national specialty societies.  Yet, the response has been perplexingly lukewarm.  Perhaps burnout, COVID literature overload, practice finance, and departmental management concerns, lack of knowledge of the existence and potential uses and benefits of SSEs and ULPA filters, and other factors contribute to this inertia.

But one thing does seem certain as we face another wave of the pandemic sweeping the nation and the world: None of the current strategies (PPE, pre-op COVID testing, operating room ventilation systems, vaccines, herd immunity, etc.) do or will provide 100 percent protection to our health care workers during this or future respiratory pandemics.  Another wave could once again overwhelm our resources and PPE supplies.  Therefore, it seems prudent that we give very serious consideration to any simple, inexpensive, and already widely available technique, such as the use of SSEs, that can be used in addition to our current strategies to reduce the risk of transmission to our valuable health care workers.

If anybody wants to learn more about this proposed use of SSEs, here are a few publications.  Of note, I have no financial or other disclosures or conflicts of interest whatsoever to report.

Rene’ M. Gonzalez is an anesthesiologist.

Image credit:

View 1 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories