CNA754 Foundations of Perioperative Nursing Practice

Perioperative nursing is specifically responsible for the patients who are having several invasive and/or nursing procedures (Spry 2016). Perioperative nurses are known to work with different medical professionals including nurse practitioners, surgeons, nurse anesthetists, anesthesiologists and surgical technologists (Spry 2016). Their main role is centralized within the postoperative, pre-operative, and intraoperative care processes (Spry 2016). In Australia, many registered nurses pursue further studies for becoming pre-operative nurses, and the Australian College of Operating Room Nurses (ACORN) provides recommended standards of practice and professional guidelines to the peri-operative nurses to ensure the best practice standard for them. However several risks are there for perioperative nurses who work in operation theatre including both direct and indirect hazards (Ralph and Viljoen 2018). Operating room nurses most often suffer from scratches, stabs, and cuts. Exposure to drugs, radiation, and anesthetic gases also enhances their risk within operation theatre (Ghosh 2013). Currently, many energy-based devices and surgical apparatus are been used in the operation theatre. Along with many advantages, they are also associated and/or responsible for many perioperative hazards. For example, it can be stated that every year more than thousands of healthcare professionals throughout the world are exposed to surgical smoke that has a potential biological impact. Therefore, in this study, the author is going to critically analyse and evaluate several resources on the mentioned topic including ACORN standards and guidelines for perioperative staff and current peer-reviewed articles. All the findings will also be discussed and analysed in relation to the practice setting of the author.

Several evidences are there that the smoke used in the surgical unit contains pathogens, toxic gases and particulate matter; hence, considered a hazard for both the perioperative team as well as the patient. Surgical smoke is also known as surgical plume. Different energy-based devices are considered the major sources of surgical plume. Some examples of the devices include ultrasonic instruments, diathermy, burs and saws, and high-speed drills (Schultz 2014). A surgical plume is considered to be created by the cellular fluid as steam, thermal damage of tissue, and spews cell contents into the air (Schultz 2014). The surgical plume comprises almost 95 percent water vapor and the rest 5 percent of cellular fragments and other chemical components (Schultz 2014). It is already known that health professionals including perioperative nurses are routinely exposed to surgical plume, bio-aerosols, smoke in the surgical unit produced by apparatus utilized to identify tissue and provide homeostasis (Schultz 2014). However, Potential health risks are directly associated with the imposition of surgical plume mostly for anaesthetists and nurses who spend a long time in the operation theatre than ancillary workers including surgeons, orderlies due to the surgical unit protocol and work schedules. Different strategies are currently been followed in order to evacuate the smoke from the surgical unit for developed health outcomes. Modern research has elicited that surgical smoke is harmful to the personnel who are exposed to it regularly. The cytotoxic and mutagenic properties of the substances from all the mentioned apparatus are raising several questions. Surgical plume in surgical theatre is classified as the biological, physical, and chemical subclass. As mentioned above that surgical plume comprises 5 percent chemical substances along with 95 percent water. The 5 percent chemical substances include both dead and live cellular ingredients (eg., blood cells, tissue fragments, viruses, extracellular and intracellular bacteria, vapors, and toxic gases) (Schultz 2014). Researchers state that surgical plume contains several toxic gases including hydrogen cyanide, formaldehyde, benzene and benzene-associated components that have adverse effects on perioperative staff as well as patients when coming into contact (Schultz 2014). Some known chemical components of surgical plume include acetonitrile, acrolein, acetylene, acrylonitrile, benzene, ethane, creosols, carbon monoxide, free radicals, formaldehyde, methane, isobutene, phenol, acetylene, alkylbenzenes, propene, and polycyclin aromatic hydrocarbons (Schultz 2014). Hydrogen cyanide is considered a cardio-toxic substance, whereas substances like benzene, butadiene and acrolein are considered potent carcinogens that can cause cancer (Fortin et al. 2015). Long-term exposure to acrylonitrile may also cause cancer. Some chemical substances are also responsible for developing major respiratory symptoms and breathing shortages.  On the other hand, the physical substance comprises particles that range in size from less than 0.01 micron to greater than 200 microns (Palmerton and Lynch 2009). Particles of different sizes are produced by laser ablation and ultrasonic devices (Palmerton and Lynch 2009).  Very fine dust is been created by the ultrafine particles. Anything less than 30 nanometers can bypass the normal filtration mechanism of the lungs and ultimately block the alveolar region. Substances that deposit in the small air sacs (alveoli) most commonly induce inflammatory interactions, chronic obstructive pulmonary diseases, and other chronic respiratory illnesses. Pneumonia, congestion, emphysematous, and bronchiolitis can also be caused after repeated inhalation of the surgical plume. Apart from chemical and physical substances, the biological components present in bio plume include potentially infectious bacteria and viruses (eg., human papillomavirus, human immunodeficiency virus, bovine papillomavirus, and hepatitis virus) (Ulmer 2008). Therefore, exposure to surgical plume in surgical unit increases the risk of transmissible disease from one person to another mostly in the immune-compromised patients as well as in the perioperative staff that is also considered a potential hazard associated with the utilization of energy-based device in the operation theatre (Ulmer 2008). In the next section of this study, the author is going to review the risks associated with the exposure of bio-plume in the surgical unit.

In the previous section of the study, the author discussed the components of bio-plume in detail. Biological impacts of individual chemical substances have also been discussed. However, several research has been performed in order to investigate the health impacts associated with exposure to surgical smoke (Ulmer 2008). Surgical smoke is been considered carcinogenic (Mowbray et al. 2013). Apart from that the generation and release of carbon monoxide in time of electrocautery can cause nausea and respiratory complications, headaches, burning, and watery eyes (Mowbray et al. 2013). It is considered that the carcinogenicity of surgical plumes is almost very similar to cigarette smoke (Lewin, Brauer and Ostad 2011). Recently published quantitative studies have elicited that the average daily exposure of surgical plume in the surgical unit is almost very equivalent to 27 to 30 cigarettes. It is also been considered that the ablation of one gram of tissue as generating surgical plume with the carcinogenic impact of inhaling approximately six unfiltered cigarettes. Any particles less than 5 microns are identified as lung-damaging; hence can result in chronic as well as acute respiratory alterations that include asthma, emphysema, and chronic bronchitis (Fan, Chan and Chu 2009). Poorly maintained surgical environments result in an enhance in staff absenteeism and reduction in productivity due to chronic and acute respiratory complications (Fan, Chan and Chu 2009). Long-term exposure to the substances is considered very harmful for the nurses as they have to spend a longer time in surgical unit. Apart from nurse, it also has been shown the surgical plume is hazardous for patients in the time of laparoscopic surgery and endoscopic procedures because of the absorbance of the surgical smoke contaminants into the vascular system of the patient (Fan, Chan and Chu 2009).  However, the complications and concerns about the potential risks and threats of surgical plume are not new. An increase in carboxyhemoglobin and methaemoglobin in the bloodstream was been observed due to the absorbance of surgical smoke through the peritoneal membrane 22 years ago. This effect decreases the oxygen-carrying capacity of red blood cells; hence results in a false elevation in oxygen readings that might result in unidentified patient hypoxia. Comparison of ultrasonic, bipolar, and monopolar apparatus found that the highest production of the surgical plume is associated with monopolar devices. Lasers and electrocautery devices heat the target tissues and target cells at boiling point ultimately result in the rupture of the cells and dispersion of thin and ultra-thin particles into the air atmosphere (Fan, Chan and Chu 2009). Surgical plume produced from electrosurgical surgery and laser surgery comprises HIV, HPV and hepatitis B virus, and many other infectious agents (Fan, Chan and Chu 2009). Studies have elicited that the infectious agents can be transmitted to the upper respiratory tract through the inspiration of surgical smoke. Different case studies and reports are there; for example, after utilizing a laser devise to vaporize condyloma, a surgeon had developed laryngeal papillomatosis (Liu et al. 2019). Development and progression of tonsillar cancer is also been associated with the disclosure of surgical plume comprising HPV 16 cells (Neumann et al. 2019). Therefore, evacuate of the surgical plume is highly recommended in surgical settings along with the application of different preventive measures. In the next section of this study, the author is going to discuss the ACORN standards in view of the mentioned hazard.

The Australian College of Operating Room Nurses is there in Australia for representing professionals interests of the nurses who work in the surgical setting. The main objective of ACORN is to flourish excellence in perioperative nursing care. Specific recommended standards of practice and professional guidelines are been provided by the ACORN standards for ensuring the best care standard of the perioperative staff and the developed treatment and/or surgical outcome of the patients (Holmes 2016). ACORN standard publication of the year 2014-2015 cited the surgical smoke issues within its document. The documentation was mostly oriented to the clinical management of surgical plumes. The ACORN standard encompasses three different recommendations and standard statements focusing on the precise utilization of the surgical smoke evacuation devices in the operation unit, that there is a mandatory requirement of containing and confining surgical plume at the time of its’ production and different policies and strategies are to be taken and implemented by healthcare facilities in order to fix the issues with surgical plume generation. Surgical plume evacuation devices are currently been considered one of the most conventional solutions for surgical plume-associated complications (Holmes 2016). A work health and safety guideline was been issued by the Australian Ministry of Health in January of 2015 in correlation to this to be followed in Australia within every health district. However, still, no mandate is not there to be used in the surgical unit to evacuate surgical plume but a guideline for managing and/or controlling the mentioned issue. In the next paragraph of the study, the author is going to discuss the standard and the guidelines in more detail.

It is already mentioned that ACORN provided three different standards to be followed in the surgical unit in order to mitigate the exposure of surgical plume. Standard statement 1 states that health personnel has to be responsible and careful to utilize appropriate apparatus and procedures to prohibit exposure to surgical plumes (endovision.com 2016). To justify and support standard statement 1 the rationale was also been provided (see appendix 1 for details). However, all the personnel of the surgical unit has a duty to utilize plume evacuation systems with ultra-low penetrating air (ULPA) filters and the efficacy of the filters have to be not less than 99.999 percent.  Between the suction canister and the wall outlet, in-line filters are to be placed to prohibit contamination of the wall suction (central vacuum system) (endovision.com 2016).  The decision is to be made by the personnel to utilize wall suction with in-line filters based on a risk assessment to incorporate plume volume, the term of the procedure, and instrumentation. Last but not least 0.1-micron filtration masks are not to be utilized as the first line of protection against the exposure of bio-aerosol and surgical smoke. However, for secondary protection, the masks can be utilized.  Standard statement 2 states that the surgical plume is to be contained and confined in time of its’ generation and/ or development (See appendix 2 for rationale section). In order to maintain standard 2 in the surgical unit, all the personnel have the responsibility to properly test and evaluate the surgical equipment to ensure the working efficacy and to assemble needed capture devices before the initiation of a clinical procedure (endovision.com 2016). In operation theatre, the plume evacuation system is to be positioned for every procedure that incorporate the utilization of any energy-based surgical devices (endovision.com 2016). The closed-loop filtration system is to be used in the time of any invasive surgical procedures and laparoscopy to vent all surgical plumes. Filters of a plume evacuation system are to be utilized and changed following proper timing in accordance with the instruction of manufacturers (endovision.com 2016). All the accessories of the plume evacuation instruments including adapters, filters, connectors, tubing are to be properly disposed of in accordance with safety standards and guidelines in order to reduce the chances of contamination and transmission of blood-borne pathogens. Standard statement 3 states that the procedures and policies shall be improved and implemented in a health service organization that utilizes energy-based devices. (see appendix 3 for rationale). ACORN standard mentioned several responsibilities of a health service organization in accordance with standard statement 3 including the maintenance of a high level of dedication and commitment to mitigate the exposure of surgical plume, appropriate delivery and implantation of plume evacuation apparatus within the surgical unit to meet procedural requirements and promoting proper staff education (endovision.com 2016). Appropriate education in the potential risks of the surgical plume and the utilization of plume evacuation equipment is to be provided to the health-personnel (endovision.com 2016). Peri-operative nurses are to be properly guided with the negative health impact of long-term exposure to bio-aerosols and surgical plumes. The competence of personnel in the utilization of plume evacuation instruments is to be assessed and developed gradually to ensure both the wellbeing of patients and perioperative professionals. Health service organization also has to provide the personnel with risk assessment tools, competency validation, and proper training (endovision.com 2016). Last but not least current standards and policies are to be developed in order to provide personnel with guidance for restricting exposure to the surgical plume hazard (endovision.com 2016). In the next segment of this study, the author is going to align own experience and working site environment in accordance with the ACORN peri-operative standards and guidelines.  

Therefore, it can be stated in conclusion that surgical plume is increasing the risk of surgical unit gradually. Despite the awareness and innovation of different apparatus for mitigating the risk of it, not every healthcare sector is prepared enough for implanting all the devices. Complete management of the surgical plume has not yet been possible, hence, in Australia, many healthcare personnel and staff suffer from the physiological complications caused by exposure to surgical plume every year. However, constantly healthcare organizations are trying their best for developing a safe clinical environment to cut out the potential risks and hazards by providing efficient and safe care to their patients through professional turbulences. In my unit, proper education is given to all the personnel as well as the patients. All perioperative nurses along with healthcare professionals try to properly maintain all the mentioned equipment used for eliminating surgical smoke produced due to the utilization of energy-based surgical apparatus. Healthcare authorities give priority to all the standards and guidelines set by ACORN. Therefore, it can be presumed that within the next few years the utilization of evacuation devices will become mandatory in the surgical unit and it will be possible to restrict the exposure of surgical plume in operation theatre to both the patients and health personnel and the associated hazards.

Reference

endovision.com.au, 2016. Standards for perioperative nurses in Australia. [online] Endovision.com.au. Available at: <https://www.endovision.com.au/wp-content/uploads/2019/03/ACORN-Surgical-Plume-Edition-14-11-10-2016.pdf> [Accessed 9 March 2021].

Fan, J.K.M., Chan, F.S.Y. and Chu, K.M., 2009. Surgical smoke. Asian Journal of surgery, 32(4), pp.253-257.

Fortin, J.L., Desmettre, T., Luporsi, P. and Capellier, G., 2015. Cyanides and cardiotoxicity. Toxicology of Cyanides and Cyanogens: Experimental, applied and clinical aspects, pp.224-231.

Ghosh, T., 2013. Occupational health and hazards among health care workers. International Journal of Occupational Safety and Health, 3(1), pp.1-4.

Holmes, S., 2016. Factors affecting surgical plume evacuation compliance. ACORN: The Journal of Perioperative Nursing in Australia, 29(4), p.39.

Lewin, J.M., Brauer, J.A. and Ostad, A., 2011. Surgical smoke and the dermatologist. Journal of the American Academy of Dermatology, 65(3), pp.636-641.

Liu, Y., Song, Y., Hu, X., Yan, L. and Zhu, X., 2019. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. Journal of Cancer, 10(12), p.2788.

Mowbray, N., Ansell, J., Warren, N., Wall, P. and Torkington, J., 2013. Is surgical smoke harmful to theater staff? A systematic review. Surgical endoscopy, 27(9), pp.3100-3107.

Neumann, K., Cavalar, M., Rody, A., Friemert, L. and Beyer, D.A., 2018. Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments. Archives of gynecology and obstetrics, 297(2), pp.421-424.

Palmerton, D. and Lynch, J., 2009, March. Lasers in medicine–Rules, regulations, and practices in managing laser plume. In International Laser Safety Conference (Vol. 2009, No. 1, pp. 307-313). Laser Institute of America.

Ralph, N. and Viljoen, B., 2018. Fundamentals of missed care: Implications for the perioperative environment. Journal of Perioperative Nursing, 31(3), pp.3-4.

Schultz, L., 2014. An analysis of surgical smoke plume components, capture, and evacuation. AORN journal, 99(2), pp.289-298.

Spry, C., 2016. Essentials of perioperative nursing. Jones & Bartlett Publishers.

Ulmer, B.C., 2008. The hazards of surgical smoke. AORN journal, 87(4), pp.721-738.

Looking for affordable assignment help online? Need someone to offer you prices that would go easy on your pocketbook? Bothered, “Can I pay someone to do my assignment at the best industry price?” Of course, you can. MyAssignmenthelp.co.uk has the finest paper writers. They are dedicatedly available to back you up with well-knit assignment papers at the best industry price. 

Sign up for finance assignment help or management assignment help and enjoy a flat 20% off along with an additional $20 sign-up bonus. How cool is that? So, think no more and count on our expertise for affordable assignment help in the UK.