Best Practices for Electrosurgery

Potential Adverse Outcomes

Potential Electrosurgery Injuries

Alternate Site Injuries

Return Electrode Site Injuries

Laparoscopic Injuries

Fire Injuries

Basic Principles of Electrosurgery

Basic Principles of Electricity

Electricity always . . .

Seeks ground (its source) Seeks the path of least resistance

Properties of Electricity
Current Flow of electrons during a period of time, measured in amperes Pathway for the uninterrupted flow of electrons (must be complete/ closed to flow)

Circuit

Impedance Obstacle to the flow of current measured in ohms Voltage Force pushing current through the resistance, measured in volts

Frequency Spectrum

Current Concentration/Dispersal

The more concentrated the current, the greater the potential for a burn.

Monopolar

Active electrode at surgical site Return electrode at another site Current flows through the body between the electrodes High voltage Coag 3000 9000 Cut 1350 - 4000

Bipolar

Active and return electrodes in the

instrument
Current flow confined to tissue between electrodes Low Voltage (320 - 1200 volts)

Electrosurgical Technologies

Patient Burns

Pad site burn

Contact Quality Monitoring

Therapeutic current

Interrogation current

Contact Quality Monitoring

The most frequently reported patient injury has been a skin injury at the patient return electrode site The risk of this type of injury has been minimized through advances in patient return electrode design

Nondrying conductive material Use of return electrode contact quality monitoring

AORN Recommended Practices, 2009

Best Practices to Achieve Favorable Patient Outcomes Related to Electrosurgery

20

Follow Manufacturers Written Instructions

The ESU and accessories should be used according to the manufacturers written instructions. Each type of ESU has specific manufacturers written operating instructions to be followed for safe operation of the unit Accessories should be used, handled, cleaned, and processed according to manufacturers instructions

AORN Recommended Practices, 2009

General Safety Precautions

Test alarm systems

Set activation tone to audible level

General Safety Precautions

Plug Accessories into Correct Receptacles

Confirm Power Settings

Selecting the Patient Return Electrode

Patient return electrodes should be compatible with the ESU

Do not attempt to use return electrodes that disable the contact quality monitoring system Electrode is intact Conductive gel, if present, is moist Manufacturers expiration date has not been reach

Verify that the:

Do not reuse patient return electrode

Selecting the Patient Return Electrode Site

Follow manufacturers written instructions The conductive and adhesive surfaces of the electrode should be placed on:

Clean, dry skin Over a large, well-perfused muscle mass of the surgical side Close to the surgical site

Convex area

Avoid Patient Return Electrode Sites High in Resistance

Prostheses

Bony prominences

Scar tissue

Hair

Preparing the Patient Return Electrode Site

Follow manufacturers instructions for hair removal, cleaning, and drying site

Protect return electrode from fluid invasion

Do not use flammable agents for PRE site preparation

Patient Return Electrode Guidelines

Do not overlap edges of return electrode

Do not cut or modify return electrode

Patient Return Electrode Guidelines

Do not warm return electrode Apply return electrode after positioning Place return electrode proximal to tourniquet, preferably on operative side

Follow Manufacturer Instructions When Using Different Sizes of Patient Electrodes

Select patient electrode according to patient weight Infant patient return electrode

Do not exceed 120 watts of power Use short activations

Neonatal patient return electrode

Do not exceed 300 milliamps of power Do not activate active electrode longer than 30 seconds For neonates < .45 kg, use of bipolar electrosurgery

Compression Stockings and Patient Return Electrodes

Compression stocking may cause

Increased temperature at the pad site Increased impedance at pad site Current concentration with resultant heat build up

Do not apply the patient return electrode to areas where pressure is applied to the patient

ECRI

Warming Devices and the Patient Return Electrode

Always follow manufacturers instructions when using a warming device Avoid close contact with warming blanket A towel, blanket, or folded sheet may be placed between the patient return electrode and the warming blanket to distance the heating source from the patient return electrode

Covidien Clinical Information Hotline

Reducing the Potential for Alternate Site Burns

Avoid skin-to-skin contact, such as fingers touching leg or knee touching knee when positioning the patient Use non-conductive dry padding to prevent skin-to-skin contact Position the return electrode to provide a direct current route

When to Use Two Patient Return Electrodes

Placement of additional PREs increases the dispersion of electrosurgical current and heat at the pad-to-patient interface

Obesity Emaciation Fluid environment Long duty cycles

AORN Recommended Practices, 2009

Removing the Patient Return Electrode

Remove return electrode slowly, supporting the tissue underneath Observe skin under pad Chart appearance of site

Active Electrodes

When not in use, always place active electrodes in a nonconductive holster Electrodes that do not fit in the holster should be placed in a designated location with tips away from flammable material Active electrode tips should be securely seated into the hand piece

AORN Recommended Practices, 2009

Active Electrodes

Do not use suction coagulator as a retractor Avoid tissue contact with shaft during activation Ensure that the outside of the suction coagulator remains free of fluids and mucus which may conduct electrical current Unintended activation may result if the suction coagulator handswitch is immersed in saline solution or other conductive fluids

Covidien Instructions for Use, Suction Coagulator

Active Electrodes

Build-up of eschar increases resistance at the active electrode and may require the use of higher power setting Eschar debris may ignite Use a coated electrode to easily remove eschar buildup on electrode tip

Active Electrodes
Do not use red rubber catheters or other materials as a sheath

Red rubber or plastic materials may ignite Use manufacturer approved insulated tips

ERCI, 2006

Radio Frequency Current Leakage

Active electrode cords should not be wrapped around metal instruments Active electrode and other electrical device cords should not be bundled together

Phippen, Ulmer, & Wells, 2009

Avoiding Hemostat Burns

Do not buzz the hemostat with a needle electrode Do not lean on the patient, the table, or the retractors while buzzing the hemostat Activate cut rather than coag Firmly grasp as much of the hemostat as possible before activating Buzz the hemostat below hand level Activate the generator after the instrument makes contact with the hemostat When using a coated or nonstick blade electrode, place the edge of the electrode against the hemostat

Note: Surgical gloves do not insulate against RF current

Ulmer, 2008

Pacemakers

Consult pacemaker manufacturer Use electrosurgery with care Use bipolar Use low power setting Avoid current flow through heart and pacemaker Keep cords away from pacemaker and leads Postoperatively have the device checked by a trained individual

Phippen, Ulmer, & Wells, 2009

Internal Cardioverter-Defibrillators

Obtain preoperative cardiology consult to evaluate correct functioning and determine risks Have defibrillator immediately available Deactivation of ICD by trained personnel before ESU use Continuous ECG and peripheral pulse monitoring Use bipolar If monopolar used ensure distance between the active and patient return electrode is as short as possible Avoid current flow through heart and ICD Postoperatively have the device checked by a trained individual

AORN Recommended Practices, 2009

Hearing Aids

Best practice is to remove hearing aids prior to surgery RF leakage may cause interference to the hearing aid reception RF current may damage two piece wireless hearing aids, thus they should not be worn when electrosurgery is used

AORN Recommended Practices, 2009

Cochlear Implant

Do not use monopolar electrosurgery on the head or neck of a cochlear implant patient Use bipolar electrosurgery on the head and neck of patients with implants that do not have extracochlear reference electrodes
The bipolar electrode must not contact the implant

If the implant has extracochlear reference electrodes, bipolar may be used if the electrode is kept more than 10 cm (4 inches) from the extracochlear electrodes Postoperatively have the device checked by a trained individual

AORN Recommended Practices, 2009; Hotline News, Vol 6, Number 4

Dental Appliances

Avoid direct contact with any metal dental appliances Cover braces with teeth guards (silicone or rubber) or use bipolar energy when possible Remove palate spreaders prior to surgery if electrosurgery will be used in immediate area of the device

Covidien Clinical Information Hotline

Jewelry

Jewelry should be removed if it is within the activation range of the active electrode. When using a reusable, capacitivecoupled return electrode, all of the patients metal jewelry should be removed.

AORN Recommended Practices, 2009

Tattoos

Avoid placing the patient return electrode over tattoos Inks (red in particular) contain metals which could serve as a heat or electrical conductor

Valleylab Clinical Hotline

AORN Recommended Practices, 2009

Electrosurgery During Pregnancy

No evidence to contraindicate the use of electrosurgery during pregnancy
Amniotic fluid protects fetus from any concentration of electrical current owing to the dispersion effect Just as high frequency of electrosurgery current above 100 kHz prevents neuromuscular stimulation in adults, children, and infants, the same is true for the fetus

Leonardo da Vinci c. 1510 - 1512

Te Linde's Operative Gynecology Text, 8th Edition

Electrosurgery During Cesarean Sections

If flammable prepping solution used follow manufacturers instructions Apply the patient return electrode to a site that will not be exposed to pooling of amniotic fluid Activate electrosurgery pencil only when in contact with intended tissue Place electrosurgery pencil in nonconductive safety holster when not in use

Pediatric Applications and Small Anatomic Structures

Pediatric applications and/or procedures performed on small anatomic structures may require reduced power settings Potential for unintended thermal damage to tissue with high current flow and longer activation For procedures where the current could flow though delicate parts of the body, use of bipolar technique may be desirable in order to avoid unwanted coagulation

Covidien Electrosurgery Users Guide

Best Practices to Achieve Favorable Patient Outcomes Related to Electrosurgery

1. Manufacturers Instructions 2. Safety Precautions (2) 3. Selecting the Patient Return Electrode 4. Selecting the Patient Return Electrode Site (2) 5. Preparing the Patient Return Electrode Site 6. Patient Return Electrode Guidelines 7. Different Sizes of Patient Electrodes 8. Compression Stockings and Patient Return Electrodes 9. Warming Devices and the Patient Return Electrode 10. Alternate Site Burns 11. Use Two Patient Return Electrodes 12. Active Electrodes (4) 13. RF Current Leakage 14. Avoiding Hemostat Burns 15. Pacemakers 16. Internal Cardioverter-Defibrillators 17. Hearing Aids 18. Cochlear Implant 19. Dental Appliances & Jewellery (2) 20. Tattoos 21. Electrosurgery During Pregnancy / Cesarean Sections (2) 22. Pediatric Applications and Small Anatomic Structures

Evaluate Patient After Surgery

Chemical Injury

Pressure Injury

Electrosurgery Injury

Questions ???
Thank you !

Program Summary

Potential adverse outcomes related to electrosurgery Basic principles of electrosurgery Best practices to achieve favorable patient outcomes related to electrosurgery

Prior to use, clinicians should review the Instructions for Use product inserts and/or Users Guide provided by the manufacturer to ensure safe and appropriate utilization of electrosurgical devices.