Celebrating Nurses’ Monumental Impact
There is a myriad of ways to participate in National Nurses Week, which is celebrated May 6-12, from honoring your staff RNs with a gift or event to taking steps to let...
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By: Dianne Taylor
Published: 10/10/2007
You're in the middle of a laparoscopic procedure. Suddenly, the picture is flickering, and the screen goes blank. Now what?
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Problems such as flickering, blurring, distortion, fog and blank monitors not only delay surgery, extend anesthesia time and increase stress but also, in the worst of cases, can lead to iatrogenic injury. Almost half (48 percent) of the responders to an Outpatient Surgery survey (n=60) say they experience laparoscopy problems "occasionally" and another 11 percent say they deal with them "regularly." We asked a panel of our readers to share their best troubleshooting tips.
Preventive maintenance
The best way to deal with most common laparoscopy problems? Prevent them by thoroughly inspecting your set-up and equipment pre-operatively.
"Perform a complete check of all areas (electrical cords, suction, lights) before you use the equipment and supplies," says a nurse manager. "This eliminates or allows time to correct 99 percent of potential problems."
For example, fogging and blurring - the two most common hitches reported by our responders - can result from condensation on the surfaces of the eyepiece, coupler lens and camera lens.
Look through the scope before surgery. If you see problems, detach the camera and clean the lenses. The Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) Laparoscopy Troubleshooting Guide recommends checking to be sure a cracked lens isn't the cause of the gathered moisture.
To facilitate this pre-flighting, some panelists use simple but effective communication.
At the Upland, Calif.-based San Antonio Ambulatory Surgical Center, director of nursing Susan Dievendorf, RN, color-codes ports to respective cables. "We used to have problems like the screen blanking out or an inability to take pictures," she says. "Now we can immediately look to see if the cables are in the right ports."
Carol M. Gerisch, RN, BSN, MBA, director of surgical services with St. Luke Community Hospital in Saint Ignatius, Mont., posts instructions for slaving the monitors to each other and says this simple step has made set-up easier and reduced operator error.
Getting the fog out
Even the best preparation won't eliminate all problems. According to our survey, fog, blurring/distortion and flickering are the three most common.
Nearly two-thirds (64 percent) of responders deal with lens fogging at least occasionally. Fog usually forms when the surgeon removes the laparoscope from the body, the scope cools down and humidity inside the body condenses on the lens upon reinsertion. Subsequent injection of cold CO2 causes more temperature instability and worsens the problem. Here are four fixes.
Many panelists also use anti-fog solutions and scope warmers. Although most are disappointed in their results, those who say they rarely or never experience fogging (n=11) report using anti-fog solutions liberally - before every case and throughout surgery as needed. In addition, the way you use the solutions may influence their efficacy. The SAGES manual recommends cleaning the eyepiece with irrigation on the inside and wiping it with cotton soaked in warm, non-saline water externally, then wiping with dry gauze before applying anti-fog solution. Adds one panelist: "Clean laparoscope lenses with alcohol after decontamination to prevent anti-fog buildup."
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Clearing up the picture
Thirty-two percent of responders experience blurring or distortion at least occasionally. While experts say motion of tissue and instruments as well as patient movements like pulsation, respiration and intestinal peristalsis influence image quality, blurring and distortion can also be fog- or equipment-related. Once you've ruled out fog, consider these equipment-troubleshooting measures:
Stopping the flicker
"Flickering can result in momentary loss of landmarks, unplanned dissection of tissue, or worse," says Jennifer Misajet, director of surgical services with North Colorado Medical Center in Greeley, Colo. More than one-fourth (27 percent) of our panelists experience flickering at least occasionally. This problem typically results from inadequate electrical connections, and responders suggest first checking to ensure that they are secure.
"Check the camera head wire, check the video cable connection at each monitor and check the adapter that plugs into the CCU to see if it is dry," recommends one California-based equipment administrator. Indeed, the SAGES guide says flickering can result from moisture in the camera-cable connecting plug and recommends using suction or compressed air (but not cotton-tip applicators) to dry it. Pam Kendrick with the Cumberland Medical Center in Crossville, Tenn., says that flickering can result from radiofrequency interference from the cautery unit and, as such, is difficult to completely eliminate.
Other less-common but potentially significant trouble spots include lighting problems, inadequate insufflation/loss of pneumoperitoneum and suddenly blank monitors.
"With a blank monitor, trying to troubleshoot video equipment in the middle of a case is very frustrating. You also have an upset surgeon who has no visual field at all now," says Denise Lamberton, director of the Welborn Clinic Surgery Center in Evansville, Ind. "This could be dangerous for the patient, especially if any bleeding was evident before loss of the picture."
Too many cooks
Laparoscopic equipment is complex and sensitive - and prone to operator error, especially when there are too many cooks in a rushed kitchen. The experience of Lisa Didier, clinical director with Davis Surgical Center in Layton, Utah, is typical of many responders. "We have a problem with too many experts. Everyone has an opinion about how the system works best," she says. "The reps come and adjust the systems so everything is working well, then one little thing happens and the fingers start flying to adjust the camera box, move the lines, etcetera."
Ultimately, agree many of our panelists, the most important troubleshooting rule of thumb is to stay calm and approach problems very deliberately. One nurse manager in California restricts troubleshooting responsibilities to one helper and the primary circulator. "A calm circulator who can block out an irritated physician and focus on troubleshooting is wonderful," she says.
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