About Surgical smoke: Risk assessment and mitigation strategies and chemical adsorption by activated carbon N95 masks

Transcription

1 Accepted Manuscript About Surgical smoke: Risk assessment and mitigation strategies and chemical adsorption by activated carbon N95 masks Carlos Gustavo Wambier, MD PhD, Kachiu Cecilia Lee, MD, MPH, Patrícia Botini de Oliviera, MD, Sarah Perillo de Farias Wambier, MD PhD, Flavio Luis Beltrame, PharmD, PhD PII: DOI: S (18) Reference: YMJD To appear in: Journal of the American Academy of Dermatology Received Date: 18 October 2018 Revised Date: 24 October 2018 Accepted Date: 27 October 2018 Please cite this article as: Wambier CG, Lee KC, Botini de Oliviera P, Perillo de Farias Wambier S, Beltrame FL, About Surgical smoke: Risk assessment and mitigation strategies and chemical adsorption by activated carbon N95 masks, Journal of the American Academy of Dermatology (2018), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 1 2 About Surgical smoke: Risk assessment and mitigation strategies and chemical adsorption by activated carbon N95 masks Carlos Gustavo Wambier, MD PhD, a,b Kachiu Cecilia Lee, MD, MPH, c Patrícia Botini de Oliviera, MD, d Sarah Perillo de Farias Wambier, MD PhD, b Flavio Luis Beltrame, PharmD, PhD. e a- Department of Dermatology, Yale University School of Medicine, New Haven, CT b- Department of Medicine, State University of Ponta Grossa, Brazil c- Department of Dermatology, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island d- Patrícia Botini Dermatology Clinic, Maringá, Brazil e- Department of Pharmacy, State University of Ponta Grossa, Brazil. Corresponding author / Reprint requests: Carlos Gustavo Wambier, MD, PhD Yale University Center for Clinical Investigations. Address: 2 Church St South, Suite 401 New Haven, CT, cwambier@usp.br Funding: none. Conflicts of interest statement: None declared. Manuscript word count: 412 References: 4 Figures: 1 Video: Key words: activated carbon; charcoal; electrosurgery; lasers; N95 mask; residency training; safety; smoke evacuator; surgical mask; surgical plume; surgical smoke; verruca; mask. 27

3 28 No abstract 29 Abbreviations and acronym list: 30 HEPA: High efficiency particulate air 31 HEGA: High efficiency gas adsorption

4 To the Editor: We have read with interest the review article by Georgesen and Lipner for implementation of respiratory safety standards in dermatologic surgery. 1 This article addresses important safety standards related to protection from the effects of surgical plume. Although standards for respiratory personal protection equipment are of general awareness for the chemical, pharmaceutical and painting industry, a large knowledge gap exists for physicians regarding standards of practice on air quality and safety in clinic and operating rooms. This knowledge and clinical gap usually starts in the medical schools, when students may be exposed to high concentration of formaldehyde in the anatomy laboratories, 2 without using proper masks for chemical protection. For specific respiratory protection against the chemicals present in the electrosurgical and laser smoke, high efficiency particulate air (HEPA) filters mentioned by Georgesen and Lipner indeed arrest fine particles effectively, but are not effective filters of chemical molecules. If the physician and his team has routine exposure to surgical smoke, which contain volatile organic compounds and chemical vapors, the mask should also contain a specific chemical filter, such as an activated carbon layer (Fig.1). The combination of HEPA filters with an extra layer of activated carbon is sometimes called high efficiency gas adsorption (HEGA) filters. Cartridges in gas masks are necessary for adsorption of higher volumes. Although reusable masks (gas masks) with disposable cartridge filters exist, they tend to be heavier and interfere with head movement and voice communication. Thus, they are not practical for the nuisance chemical levels seen in the operating room. Although aspirators with chemical filters are available and removal of fumes may be assisted with ventilator exhausters, the surgeon is very close to the site of smoke production, and masks with activated carbon are still needed as personal protection equipment.

5 The use of disposable activated carbon masks is a simple procedure, that could be adopted by all medical personnel to avoid the risks of chemical inhalation during brief nuisance exposure to chemicals and volatile organic compounds 3 such as exposure to laser and electrosurgical smoke. The same masks may be used for brief formaldehyde exposure during anatomy classes, and are currently recommended for phenol-croton oil peels. 4 Further application includes surgeries of necrotic wounds and during examination of infected wounds, miiasis infestations, among other exposures to noxious odors. In addition to use of a fine particle filter mask, we aim to bring awareness to the necessity of using a chemical filter for protection against volatile molecules present in surgical plume.

6 66 REFERENCES Georgesen C, Lipner SR. Surgical smoke: Risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79(4): doi: /j.jaad de M. Ochs S, de O. Grotz L, Factorine LS, Rodrigues MR, Netto ADP. Occupational exposure to formaldehyde in an institute of morphology in Brazil: a comparison of area and personal sampling. Environ Sci Pollut Res. 2012;19(7): doi: /s Rozzi T, Snyder J, Novak D. Pilot Study of Aromatic Hydrocarbon Adsorption Characteristics of Disposable Filtering Facepiece Respirators that Contain Activated Carbon. J Occup Environ Hyg. 2012;9(11): doi: / Wambier CG, Beltrame FL. Air Safety and Personal Protective Equipment for Phenol Croton Oil Peels. Dermatologic Surg. 2018;44(7): doi: /dss

7 82 FIGURES/ LEGENDS Fig.1. Disposable activated carbon N95 mask with exhalation valve. The exhalation valve avoids respiratory vapors to condense and blurry the surgeon glasses, 85 personal protection eyewear and/or laser safety eyewear.

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