Surgical Smoke – Is Your Operating Room Safe For Your Staff and Patients?

The Association of periOperative Registered Nurses (AORN) is leading efforts to make smoke evacuation the law across the country. Fifteen states have enacted surgical smoke evacuation legislation, including Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island, and Washington. What are you doing about surgical smoke evacuation at your organization?

What Is Surgical Smoke?

Surgical smoke is a gaseous by-product produced by electrosurgery, laser tissue ablation, ultrasonic scalpel dissection, high-speed drilling or burring, or any procedure done by means of a surgical device that is used to ablate, cut, coagulate, desiccate, fulgurate, or vaporize tissue. It is also defined as "a visible plume of aerosolized combustion by-products produced by heat-generating surgical instruments". Approximately 90% of all surgical procedures generate surgical smoke, and an estimated 500,000 healthcare workers are exposed to surgical smoke each year. The average daily impact of surgical smoke on the surgical team is the equivalent of inhaling the smoke of 27-30 unfiltered cigarettes.

What Are The Hazards Of Surgical Smoke?  Why Is It Important to Minimize Exposure?

  • Surgical smoke contains over 150 hazardous chemicals and carcinogenic and mutagenic cells. It contains toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material, blood fragments, and viruses. It remains unknown whether COVID-19 may be transmitted to the surgical team by inhalation of surgical smoke, but research confirms other viruses can be transmitted through this smoke. In addition to the danger to healthcare workers, surgical smoke can cause cancer cells to metastasize in the incision site of patients having cancer removal surgery. Babies born by C-section breathe in their mother’s surgical smoke at birth.
  • Inhalation of Toxic Substance Prolonged exposure can lead to respiratory issues, eye irritation, and headaches.
  • Infection Transmission: Healthcare workers inhaling the smoke could be at risk of infection.
  • Eye Irritation: Smoke's chemical composition can cause eye discomfort, redness, and irritation.
  • Odor and Visibility: Surgical smoke has an unpleasant odor and can reduce visibility during procedures, affecting surgical precision.

What Are The Regulations Regarding Surgical Smoke In Healthcare Facilities?

The National Fire Protection Association (NFPA) requires healthcare facilities to capture surgical smoke plumes as close as possible to the point of generation in operating rooms (ORs) nationwide. This ensures that hazardous smoke is effectively removed. Several states have enacted laws to protect healthcare workers from surgical smoke. For example: Rhode Island and Colorado require hospitals and ambulatory surgery centers (ASCs) to use smoke evacuation systems for relevant surgical procedures. California mandates the use of surgical smoke plume scavenging systems in certain healthcare settings.

Facilities seeking to fulfill the updated requirements of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, can do so by following a step-by-step process:

  1. Secure commitment of facility executives, leaders, and teams working in clinical care environments where medical plume/surgical smoke is generated.
  2. Identify an interdisciplinary team that will hold the responsibility and authority to develop and implement policies and procedures requiring evacuation of all medical plume/surgical smoke.
  3. Develop an action plan, including adopting a facility-wide policy and procedure for medical plume/surgical smoke evacuation; determining resources needed (e.g., point-of-generation surgical smoke evacuation equipment and supplies); identifying barriers and planning for overcoming them during implementation; agreeing on a timeline for implementation; and determining how success will be measured and maintained (e.g., compliance metrics and an audit strategy).
  4. Implement the action plan by identifying and including all members of the affected teams (e.g., perioperative health care workers and teams working in other departments where medical plume/surgical smoke is generated), providing education about the dangers of medical plume/surgical smoke, and providing details about the facility’s action plan and each team member’s role in implementation.
  5. Audit and monitor compliance and celebrate successes.

OSHA Surgical Smoke Evacuation Guidelines

  • Use portable local smoke evacuators and room suction systems with in-line filters. For example, an ultra-low particulate air (ULPA) and an activated carbon filter.
  • Keep the smoke evacuator or room suction hose nozzle inlet within 2 inches of the surgical site to effectively capture airborne contaminants.
  • Have a smoke evacuator available for every operating room where plume is generated.
  • Evacuate all smoke, no matter how much is generated.
  • Keep the smoke evacuator "ON" (activated) at all times when airborne particles are produced during all surgical or other procedures.
  • Consider all tubing, filters, and absorbers infectious waste and dispose of them appropriately (biohazardous waste). When contaminated with blood or other potentially infectious materials, use universal precautions as required by the OSHA Bloodborne Pathogens Standard.
  • Use new tubing before each procedure and replace the smoke evacuator filter as recommended by the manufacturer’s information for use.
  • Inspect smoke evacuator systems regularly to ensure proper functioning.
  • Evaluating automatic activation capability when selecting smoke evacuation devices.
  • Using high-filtration masks.


Surgical smoke should not be taken casually. The exposure to and hazards involved with failing to eliminate surgical smoke can be significant not only for the patients but also for the staff. Organizations need to ensure that the evacuation systems in the building are maintained and staff are competent in using them. Make sure that you are following the manufacturer’s information for use. Treat surgical smoke like secondhand smoke. Keep the environment safe for all of your staff and patients!


  • Association of periOperative Registered Nurses (AORN)
  • Occupational Safety and Health Administration, 2023
  • Protection from Surgical Smoke, SB 410 by Senator Ileana Garcia, HB63 by Representative Marie Woodson & Co-Sponsored by Representative Alina Garcia and Representative Anna Eskamani, Florida Nurses Association.
  • National Fire Protection Association, Health Care Facilities Code 99, 2024.
  • Clearing the Air in Operating Rooms, Health Facilities Management, April 4, 2024

For questions or to learn more contact the C&A team at 704-573-4535 or email us at

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