The high-frequency current used during electrosurgery can burn and it can kill. Think that statement's over the top? Assume your ORs are immune to adverse events? Read on. You're one of the non-believers we're targeting with this quiz of electrosurgery's hard and fast rules. It's based on our experiences and on the official word of AORN's Recommended Practices for Electrosurgery. Use it to reinforce the importance of maintaining basic safety measures during every minute of every case.

1. One difference between monopolar and bipolar electrosurgery is:
a. only one has an active electrode
b. the placement of the dispersive electrode
c. only one provides hemostasis
d. only one uses a handpiece

Answer: b

• The reason. Monopolar electrosurgery involves placing the active electrode (pencils and tips, for example) in the surgical site and the dispersive electrode close by on the patient's skin, which sends current through the patient. Bipolar electrosurgery involves placing forceps containing the active and dispersive electrodes in its tip around the targeted tissue. Here the current is contained and doesn't flow through the patient's body.
• The official word. Personnel working with electrosurgical equipment should be knowledgeable about principles of electrosurgery, risks to patients and personnel, measures to minimize these risks and corrective actions to employ in the event of a fire or injury.
• Insider's tip. Schedule regular in-services with your staff to review the difference between active electrodes (they direct current to the surgical site) and dispersive electrodes (they return current to the ESU). Make sure they can distinguish between monopolar and bipolar electrosurgery.

2. The following should not come in contact with the patient during electrosurgery:
a. OR bed
b. Mayo stand
c. IV pole
d. all of the above

Answer: d

• The reason. Conductors of electricity can interrupt the intended electrosurgery circuit, creating alternative or secondary pathways for the current to follow and causing harm to the patient.
• The official word. Personnel should verify that no small metal materials (snaps on gowns, for example) are in contact with the patient's skin.
• Insider's tip. Ensure patients don't contact metal objects during initial positioning and throughout surgery. Place a draw sheet over patients' hands to ensure they don't accidentally touch the OR table's metal frame. Metal surfaces on patient positioning devices should be covered and well padded.

3. After prepping and before you activate the ESU, you should always wait:
a. 2 minutes
b. 4 minutes
c. 8 minutes
d. Follow the prep manufacturer's specific directions

Answer: d

• The reason. Drying times depend on a prep's active ingredients.
• The official word. Ignition of flammable substances by active electrodes has caused fires and patient injuries. Alcohol-based skin prep agents are particularly hazardous because the surrounding hair or fabric can become saturated.
• Insider's tip. Circulators should communicate required drying times to the surgical team. Apply just enough prep so that it doesn't pool under the patient. Take care that the solution doesn't collect in crevices on the patient's body.

4. The following should guide the placement of the dispersive electrode during monopolar electrosurgery, except:
a. surgeon preference
b. proximity to the surgical site
c. presence of metal implants
d. skin integrity

Answer: a

• The reason. Placing the dispersive electrode close to the surgical site decreases the chance of current seeking an alternative pathway during its expected circuit.
• The official word. Place the conductive and adhesive surfaces of the active and dispersive electrode(s) on clean, dry skin over a large, well-perfused muscle mass on the surgical side and close to the surgical site. Don't place pads over bony prominences, scar tissue or metal implants.
• Insider's tip. Aim for highly vascular areas of the body like the thighs or buttocks. Avoid scars, which may indicate the presence of metal implants below the skin's surface.

5. The ESU's power setting should primarily be based on:
a. the procedure being performed
b. the operating surgeon's preference card
c. the lowest effective voltage
d. the case's duration

Answer: c

• The reason. Using voltage settings in excess of what's needed to effectively cut or coagulate tissue increases the risk of collateral damage.
• The official word. After considering the manufacturer's written recommendations and the patient's size, the operator and the user should verbally confirm power settings before activation.
• Insider's tip. Start low and move higher to find the appropriate voltage for each case. The power setting might be too high if you notice a greater-than-normal amount of smoke generated at the surgical site. Excess smoke might also tip off your staff to clean scar tissue off the active electrode's tip.

6. When not in use, the active electrode should be kept:
a. on the Mayo stand
b. on the patient
c. on the OR table
d. in a safety holster

Answer: d

• The reason. Careless handling and storage of the active electrode between uses can result in injuries to your staff or patients and the accidental ignition of flammable materials.
• The official word. Place the active electrode in a clean, dry, well-insulated safety holster when not in use.
• Insider's tip. Be prepared to face efficiency-minded surgeons who don't want to remove electrodes from the surgical site. Stand your ground, refer to AORN's recommendations and emphasize the danger of laying the active electrode on flammable drapes.

7. ESU cords are insulated, so scrub techs can wrap them around metal clamps.
a. true
b. false

Answer: b

• The reason. Wrapping cords around conductive materials creates an alternative pathway for the current to follow on its expected circuit between the ESU and electrodes.
• The official word. When securing the active electrode cord to the drapes, use plastic or another nonconductive material. Don't let the cord coil. This minimizes the risk of injury from conduction of stray current.
• Insider's tip. Use plastic towel clips to attach cords to surgical drapes. Consider using drapes with built-in Velcro straps designed for securing cords safely and efficiently.

8. The following should be used to extinguish an OR fire, except:
a. water
b. fire blanket
c. saline
d. carbon dioxide fire extinguisher

Answer: b

• The reason. Fire blankets actually trap fire around the patient.
• The official word. Exercise caution during surgery on the head and neck near combustible anesthetic gases. Keep the active electrode as far from the oxygen source as possible and use the lowest practical level of oxygen.
• Insider's tip. Ask anesthesia providers to lower or eliminate oxygen flow when surgeons activate electrodes around the head or neck. Tent drapes around the head to prevent oxygen buildup.

9. During monopolar electrosurgery, dispersive electrodes should be placed on patients:
a. in pre-op
b. in the OR, before patients are positioned
c. in the OR, after patients are positioned

Answer: c

• The reason. The most frequently reported patient injury from electrosurgery is tissue damage at the dispersive electrode site, says AORN.
• The official word. Place dispersive electrodes on the patient after final positioning to prevent buckling and to maintain good skin contact with the electrode.
• Insider's tip. When repositioning patients, check the integrity of the dispersive electrode. Look for tenting, gapping or liquid interference.

10. The following members of the surgical team should control the ESU foot pedal (if one is used) during surgery:
a. circulator
b. scrub nurse
c. surgeon
d. anesthesia provider

Answer: c

• The reason. Whoever controls the active electrode must also control the foot pedal that activates it. Surgeons sometimes put their assistants on pedal duty, which increases the likelihood of accidental firing of the electrode.
• The official word. The active electrode should not be activated until it's in close proximity to the tissue; this minimizes the risk of contacting unintended tissue.
• Insider's tip. Keep ESU activation alarms set loud enough to hear over all other sounds in the OR — particularly noisy surgical smoke evacuation systems used during electrosurgery — even if they annoy surgeons or staff. You need to know when the active electrode is fired and locate it quickly if the activation was unintentional.