Surgical smoke evacuators and inertia in the time of COVID [PODCAST]

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“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.”

Rene’ M. Gonzalez is an anesthesiologist.

He shares his story and discusses his KevinMD article, “Surgical smoke evacuators and inertia in the time of COVID.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Rene’ Gonzalez. He is an anesthesiologist, and he wrote the KevinMD article “Surgical smoke evacuators and inertia in the time of COVID.” Rene’, welcome to the show.

Rene’ M. Gonzalez: Thank you very much, Kevin. It’s really a pleasure to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Rene’ M. Gonzalez: Absolutely. So I am an anesthesiologist, and I’ve been practicing anesthesia for almost 35 years now. I live and practice in New Jersey, in southern New Jersey. On the afternoon of Saturday, April 4th, I remember that day very well because I had been in front of my computer reading up on all of the sad accounts, really heartbreaking accounts, of my colleagues throughout the world who were in hot zones with the COVID pandemic, and some of their attempts to deal with it and some of their failures, when I got an email from my medical center announcing that it would be honoring the recommended moratorium on elective surgical and medical procedures for the upcoming weeks, effective a couple of days later, on Monday of the following week, in order to try to conserve health care professionals and also critically short supply equipment such as surgical masks, N95s, rubber gloves, etc.

I think that was a great idea, but I continued to read on, trying to understand more about the mode of transmission of COVID, and I spent that evening watching YouTube videos on some of the innovative ideas that my colleagues were using around the world. One of these was what’s come to be known as intubation and extubation boxes. They were constructing clear Plexiglas boxes, cutting arm holes into them, and placing them over the patient’s head and torso in order to be able to manipulate their airway.

People like me, anesthesiologists, emergency room physicians, critical care docs, and frontline providers, don’t have the luxury of social distancing, and we also can’t practice the principle of source control by having patients wear surgical masks. We have to remove patients’ masks and be close and personal as we intubate them, as we extubate them, as we apply respiratory treatments. All of these are aerosol-generating procedures. That day, I also remember seeing some very well-made simulations on YouTube of the spread of the aerosol cloud produced by patients coughing, and how it could spread for meters, actually.

So I went to bed that night pretty troubled, honestly. As I was falling asleep, I had a recollection of something from my days when I was the chief anesthesiologist at the Eye and Ear Hospital at the University of Pittsburgh. That’s where we did all of the ENT cases at Pitt. We had the largest ENT department in the world at the time there, and I believe they still do. We also did all of the plastic and reconstructive surgeries there. This was in the 1990s.

I had noticed that some of the plastic surgeons were using a device called the surgical smoke evacuator when they were removing genital warts, papillomas, and I inquired about the reason. The reason was that there were case reports, quite a few of them, of surgeons developing genital papillomas around their faces, around their mask lines. That was because when they use the laser or the electrocautery, the Bovie, to excise those lesions, active papillomaviruses get released into the plume of smoke, and they contaminate surfaces, including personnel.

We were also doing a large number of excisions of laryngeal papillomas on the ENT service, and we were facing the same problems. So I got together with our hospital engineer and with the ENT leadership, and we created a protocol for that, as well as for all of the plastic excisions of genital papillomas, whereby we would simply place the surgical smoke evacuator near the patient’s airway for ENT excision of laryngeal papillomas, and it would dramatically capture all of the smoke coming out of the patient’s airway that was potentially contaminated with papillomavirus. This became protocol. We adopted it and used it on all of our cases, and this was the idea that came into my mind that Saturday night of April 4th.

These surgical smoke evacuators are FDA-approved devices. They are basically very simple devices, really. Very sophisticated, very simple. They consist of a very powerful negative pressure air pump that actually collects a minimum of 25 cubic feet per minute of air, and then it’s attached to a very effective filter, which many people in medicine have never heard of. It’s called an ULPA filter, that’s ULPA, for ultra-low particulate air filter. Most of us have heard of and use HEPA filters, high-efficiency particulate air filters. These ULPA filters are an order of magnitude more effective, especially against tiny particles in the 0.1-micron range, which is exactly where the coronavirus lives. Coronaviruses are approximately 0.1 to 0.12 microns in diameter. So it occurred to me that this could potentially be a great idea in the battle, in the war, against COVID in the operating room and in critical care areas.

One of the problems was access to these devices, and I woke up the next morning and remembered that in my current operating room, we have a surgical suction device. There are many manufacturers of surgical smoke evacuators, but our surgical fluid suction device, which the surgeon uses for suctioning blood and fluids from the field, actually, they all contain a surgical smoke evacuator. These are devices that are on wheels and portable, and we have one in every single operating room, and they’re relatively underutilized. They’re used by the surgeons as they Bovie.

Now, many organizations, including the CDC and the American Association of OR Nurses, have recommended the routine use of these surgical smoke evacuators for several decades now, not only for capturing viruses that could be released into the air, but also for capturing chemical substances that result from the burning of human flesh by electrocautery and laser, which can be quite toxic and have ill health effects. I think there have been estimates that working in an operating room is tantamount to smoking something like multiple packs of cigarettes a day, and if you’ve ever gone into an operating room, you know that there’s often the smell of burning flesh.

So my idea was pretty simple. I called a couple of former colleagues from the University of Pittsburgh who had gone elsewhere, and I asked them about their institutions, and they had these smoke evacuators built into their surgical blood suction units in every single one of their operating rooms. Three different institutions, three different states. So these devices are out there. They’re FDA-approved, the capital expenditure is already made, and they’re being relatively underutilized. They’re only used during the surgical part of the procedure, but they’re considered surgical devices. They are purchased under the surgeons’ departmental budgets, and they’re managed by the operating room nurses.

It’s very, very interesting that in April, the Society of Gastroenterologic Surgeons came out with a paper recommending their use, because COVID can also exist in the alimentary tract, in the GI tract, and in feces. So they were recommending the routine use of this for all endoscopic surgery, to try to prevent COVID from spreading, aerosolizing into the air, and being transmitted to health care workers.

So that was the crux of the idea, to use surgical smoke evacuators basically as a personal air-scrubbing system. The way to do it is very, very simple. It can be simply held by an assistant, or by a stand such as the one that we use for our anesthesia breathing circuit tubing, or by a clamp device near the patient’s airway during intubation and extubation, while the patient is coughing, to reduce the viral load that can contaminate not only the anesthesiologist but also the surgeon, the scrub nurse, the circulator, and the housekeeping people who are charged with cleaning up after the patient leaves the room. We often see, particularly after endotracheal extubation, patients cough for prolonged periods of time, and they are generating these aerosol clouds, which can be very effectively swept up and safely controlled by the use of a surgical smoke evacuator.

Kevin Pho: Now, are these surgical smoke evacuators routinely used in your medical institution?

Rene’ M. Gonzalez: Well, I retired from clinical practice this summer, coincidentally. I’ve been advocating them, and some of my colleagues are using them routinely. There’s been a little bit of inertia regarding the adoption of this, and that’s one of the reasons I wrote the article. It’s been a little bit surprising, but I call it a COVID-related inertia to the adoption of a new idea.

Kevin Pho: Now, what are the sources of pushback against this idea? Why aren’t more institutions implementing it?

Rene’ M. Gonzalez: You know, Kevin, that’s a fascinating question. I think a large part of it is simple lack of awareness of these devices. As I said, they’re considered surgical devices that are managed by the operating room nurses, and many anesthesiologists therefore don’t really involve themselves very much with the use of these. They are used by the surgeons and by the nurses, and I guess it hasn’t occurred to them, maybe, that these could be placed near the airway and used as air cleaners to control the aerosol cloud. I think that’s an important one. As far as emergency room docs and critical care, who face the same problems that we do with managing airways in close proximity to the patient’s airway, I think since they spend little or no time in the operating room, they’re simply unaware of the existence of these devices.

Some other interesting factors: I’ve given a lot of deep thought to some of this inertia. I think another one is the fact that there is an overload of COVID-related information, not only in the medical journals and the online journals, but also in social media and in the mass media, and it’s a lot to take in and absorb. I think there are also other very, very significant and very legitimate COVID-related distractions. A lot of anesthesiologists right now are very concerned about their practice finances, because that long moratorium that we had on elective surgery and on elective procedures really created some significant financial problems for groups, and they’re scrambling to try to deal with all of that. So I think those are some of the reasons.

Kevin Pho: And as far as you know, are any physicians or institutions in the world using surgical smoke evacuators in the way that you describe?

Rene’ M. Gonzalez: Well, like I said, ENT programs are probably using them for laryngeal papillomas the way that I described. I was using them, and some of my colleagues in a couple of other institutions are using them. I have no way of knowing who is actually using them now. I have tried to get the word out there.

Some of the other interesting reasons, possibly, for this inertial phenomenon that we’ve seen: So I had my idea on a Saturday evening, April 4th. I wrote my first paper on it that Monday, actually started Sunday, and submitted it, and actually submitted two papers on the topic to one of our specialty journals that is very much concerned with patient safety. After editing, they accepted them about a week later, so we’re talking the middle of April. They didn’t wind up getting published until August or early September, and I believe that is again because of the COVID information overload. A lot of the editors on staff are also clinicians themselves, and were in big cities, and were facing the same COVID crisis that the rest of us are facing.

So the traditional medical journals, I don’t think, have been able to catch up, especially in the early phases of the pandemic. I think they’re still moving pretty slowly and haven’t been able to catch up. Some of the journals want prospective randomized controlled studies, you know, full scientific method, and I am completely in favor of rigid scientific methodology and evidence-based medicine. However, observation and inferential logic, I think, can also go a long way, especially in the middle of a pandemic. We don’t exactly have the resources or manpower to be conducting a lot of clinical studies as we’re suffering with this pandemic. And again, I go back to what this is based on: personal experience using it for ENT purposes, back when I was at the University of Pittsburgh, and also the hard specifications, the specs that the FDA has approved, that these manufacturers rigidly adhere to for these machines.

Kevin Pho: And to be clear, the majority of medical institutions today in the United States, they have these surgical smoke evacuators in pretty much all their facilities?

Rene’ M. Gonzalez: I’m thinking that’s probably the case, certainly based on sampling my colleagues and my own personal experience, because just about every operating room has a surgical blood and fluid suction device, and as I said, many of them have devices with built-in SSEs.

One of the other functionalities of this idea is that they’re also small, very portable. The surgical smoke evacuators that I mentioned in my operating rooms are in a larger unit that is on wheels and can be transported to the recovery room if a patient is coughing or needs to be reintubated, and could even conceivably be transported to, or placed in, an emergency room, an ICU, or a COVID unit that a hospital has to set up. But there are even smaller devices by other manufacturers that are very portable and can be used for the same reason.

And I think, Kevin, I also think that perhaps people are misunderstanding my idea here, in that this is not meant to be a substitute for N95 masks or proper respirator systems or eye protection or the operating room ventilation system. It really should be viewed as an additional, adjunctive, one more.

Some of the other lines of defense that we use are pre-op COVID testing. But interestingly enough, for elective procedures, initially a lot of institutions were saying, “Well, we’ll demand that every patient get tested for COVID before elective surgery, one to two days before their procedure.” Then they realized they couldn’t get the results back in time, so they pushed it back. They loosened that standard to two to four days before. Some institutions are doing five days pre-procedure. Well, we also know that there’s a 10 to 30 percent rate of false negatives with COVID testing, so certainly not a hundred. And the farther out in advance of the procedure that a patient is tested, they have many days to potentially become COVID-infected.

In fact, one of my colleagues, shortly after they reinstituted elective surgery with mandatory COVID testing for all patients, one of his colleagues and the anesthesia resident who were assigned to a particular case both came down with COVID. The patient had tested negative preoperatively, had his surgery, and a few days later presented to the ER with severe respiratory symptoms, COVID-positive. Both the anesthesiologist and the resident caring for that patient wound up converting to COVID-positive. Anecdotal, but again, not surprising.

N95 masks are not 100 percent effective. None of the measures that we use, you know, even the promising vaccines that are on the horizon. We’re excited when we hear they’re 90 to 95 percent effective; that’s also 5 to 10 percent lack of effectiveness. So I think the more layers of defense that we have, say, for our personnel, are going to be.

Kevin Pho: We’re talking to Rene’ Gonzalez. He’s an anesthesiologist, and he wrote the KevinMD article “Surgical smoke evacuators and inertia in the time of COVID.” Rene’, you said that a lot of procedure-based physicians may not be aware of surgical smoke evacuators. Now, where can they find out more information about them? Who can they go to in the hospital to learn more?

Rene’ M. Gonzalez: OK, well, I would start by going to the operating room nurse manager in the hospital and asking which units they currently have in their operating rooms. And then you can contact the local reps. You can research this online very easily. As I mentioned, there are multiple manufacturers of surgical smoke evacuators in the United States, and I think these devices are used worldwide, especially in the more developed nations. So again, I think they’re sitting right there in front of our eyes, and we don’t realize they’re there.

Another concern: People said, “Well, what about the expense?” And I say, well, if your hospital has these devices, the only expense is the disposable suction tubing. What I recommend is the 7/8-inch tubing, which is the widest diameter, like more of the aerosolized contaminants, and that’s about four or five dollars per use with the system I use. So the way I envision it is that anesthesia providers can use the SSE in the beginning of the case, during intubation, until the airway is secure. They can turn it over to the surgeon to use during the duration of the case for surgical purposes, and the surgeon hands it back to the anesthesiologist to use at the end of the case, peri-extubation.

Another concern: The only other cost of disposables is the ULPA filters, and in the Neptune, the Stryker Neptune units that we use in my operating rooms, these have 80-hour run times, and the ULPA filter canisters are only about each, and that’s 80 hours of continuous run time. That’s a lot of cases. So really, the expenses are very, very minimal compared to the expense of getting a provider or a housekeeping person or a nurse sick, taking it home to the family, spreading the virus.

The other concern that I think people may have is that this is some complicated piece of equipment that they don’t know how to use. Again, it is literally as simple as plugging in the disposable tubing, turning the machine on, holding the end near the patient’s airway, and then turning it off at the end of the case, and of course, disposing of the disposable tubing in an appropriate manner so that you don’t contaminate the environment.

Kevin Pho: And my final question, Rene’. What’s your take-home message that you want to leave with the KevinMD audience?

Rene’ M. Gonzalez: I would say that in this war against this invisible enemy, which creates these invisible clouds every time a patient coughs or every time we perform an aerosol-generating procedure, first of all, we should be open-minded. Second of all, we have equipment sitting in our midst that’s already paid for, with very little additional expense in terms of disposables, that can help us as an additional line of defense as health care providers who cannot social distance, and we should seriously consider using this as an adjunct. None of the current personal protective strategies, such as preoperative or pre-procedure COVID testing, N95 masks, PAPR respirators, eye protection, and even the vaccination that’s coming down the pike, none of those are 100 percent effective.

If you imagine yourself as a soldier going to war, and I give you one more piece of equipment that can help you save your life or save the life of your buddies or your loved ones, I think it makes sense to pay attention. And again, these are already FDA-approved devices. They have been in use for decades. They are tried and true. And I think, until the studies are done, they could be very, very useful adjuncts to our current strategies against COVID.

Kevin Pho: Rene’, thank you so much for your time and insight, and thanks again for being on the show.

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