September 28, 2023

These commonly used devices can be powerful in both good and bad ways in the OR.

FRAYED AND DANGEROUS The most common safety issue with electrosurgical laparoscopic instruments is breached insulation, which isn't always this obviously identifiable.

Electrosurgery is a widespread practice that nevertheless is poorly understood by some surgeons and OR teams. For example, when performing procedures with electrosurgical tools, some surgeons always employ the same energy level when they and the patient would be better served with knowledge about how to achieve the desired tissue effect using the least amount of energy. To provide safer patient care, surgeons and OR staff need to be aware of numerous potential electrosurgery complications and how to avoid them.

Direct application. The most common type of electrosurgery injury often involves thermal burns to tissue, critical structures and blood vessels. Surgeons should keep the tips of electrosurgical devices away from vital structures and use short bursts of energy.

Inadvertent activation. When devices are not in use, surgeons should remove them from the surgical field and store them in a rigid plastic holder. To remove any ambiguity, many electrosurgical devices feature audible activation tones that alert surgeons and members of the surgical team when they have been activated.

Residual heat. The tips of electrosurgical devices remain hot for periods of time after they are deactivated.

Insulation failure. The insulation that surrounds active electrodes in electrosurgical instruments can break down. These small insultation imperfections are nearly impossible to identify with the naked eye. To increase patient and provider safety, some electrosurgical instruments feature double layers of different colored insulation, on the premise that defects in the outer layer are easier to notice. It’s a similar concept to double-gloving to avoid sharps injuries.

Direct coupling. When active electrodes of electrosurgical devices accidentally touch nearby metal instruments, often due to surgeon error, the current that flows to the instruments can burn tissue it touches.

Capacitive coupling. This occurs when current is transferred from the active electrode through intact insulation to adjacent conductive material. To combat capacitive coupling, surgeons should use lower power settings and short activation bursts, as well as avoid maneuvering the instruments close to metal objects in the surgical field.

Mohsen El-Sayed, MD, FRCOG, a gynecologic surgeon at Darent Hospital in Kent, England, says monopolar devices present the risk of lateral thermal spread, direct coupling, insulation failure and capacitive coupling. He adds that although bipolar devices are associated with less risk of lateral thermal spread and eliminate risks of direct coupling and capacitive coupling, they can still cause complications resulting from insulation failure and inadvertent activation.

“Comprehensive knowledge about surgical energy and developing technology ultimately contributes to increased electrosurgical safety,” says Dr. El-Sayed.

Testing and confirming the integrity of the surgical tools that utilize electric current is an everyday safety consideration in the ASC.

Healthmark
The McGan Insulation Tester.

In the busy ambulatory surgery center environment, safety is critically important for the well-being of the surgeons as well as the OR staff who work together to keep caseloads moving and their patients experiencing safe and positive outcomes.

One of the focal areas that deserves special attention is the integrity and performance of the electrosurgical instruments used in many surgeries that utilize electric current to heat and cut tissue with great precision. Any defects or concerns with these instruments can cause harm to the healthcare workers who use them each day – and possibly harm patients as well.

The solution is a tool that can verify the insulation integrity of electrosurgical equipment and keep surgeons as well as patients safe from unintended tissue burns. Fortunately, such a tool exists in the McGan Insulation Tester by Healthmark. Designed for electrically testing electrosurgical instruments, the low frequency high voltage McGan Insulation Tester is used to detect and locate defects such as pinholes, cracks and bare spots in the jacket or coating of laparoscopic and bi-polar electrosurgical instruments.

It’s a convenient way to track the safety of the specific instruments being used and discover flaws that are not always visible. As far as how it is used, the McGan Insulation Tester is a handheld, portable unit so it is easy to manipulate. Under the supervision of OR team members, it can test the insulation integrity of electrosurgical equipment for flaws in protective coatings applied over conductive instrument surfaces to prevent inadvertent tissue burns, which may occur during electrosurgical instrument procedures.

Electrosurgical procedures are a staple in the ambulatory surgery setting, and the types of instruments that are typically employed need to be utilized in the safest manner possible. The AAMI ST79 rule specifically states that “Instrumentation intended for use with electric current should be tested for integrity each time it is processed.” Meeting this standard with the easy-to-use McGan Insulation Tester, which is specifically designed to detect and locate defects in the coating of electrosurgical instruments, will help healthcare professions adhere to the highest standard of safety.

Additionally, the McGan Insulation Tester is manufactured with a rechargeable battery and maintains applied test voltage with a constant current source. It also features full test current at low voltages, limited output current for operational safety, easy to read LED indicators, as well as an LED display of alarm and battery charge. The McGan Insulation Tester comes with the following reusable and interchangeable accessories: ground wire with alligator clip, ring electrode, tri-hole electrode, brush electrode, saddle and case. The Bi-Polar Fixture accessory that works in conjunction with the saddle, ground wire and brush electrode can be purchased separately. Additionally, an optional Wire Tester accessory used with an HV Red Lead Wire is available for testing wires by locating and identifying defects such as pinholes or cracks in the conductive core.

Healthmark is committed to offering a variety of innovative solutions to help the busy ambulatory surgery center staff meet industry standards and guidelines by offering user-friendly tools and complimentary support and education opportunities in the electrosurgical equipment arena, among other important infection control and safety solutions.

Note: For more information go to hmark.com.

A safety expert’s advice on preventing the incidents she sees time and time again.

One of the most effective ways to promote electrosurgical safety at your facility is to regularly review the most common mistakes surgeons make — and demonstrate the appropriate corrective action.

To that end, Julie Miller, MS, is a font of knowledge. Ms. Miller serves as a principal project engineer 1 at ECRI, a non-profit organization with global headquarters in Plymouth Meeting, Pa., that provides independent medical device evaluation — and she see a lot of incident reports related to electrosurgical safety. We caught up with Ms. Miller recently and asked her about the most common electrosurgical safety issues that still plague surgical facilities.

OSM: What is one electrosurgery safety risk you would always advise surgical leaders to watch for?

Ms. Miller: Burns from electrosurgical unit (ESU) pencils accidentally activating on the patient. A lot of times this happens when the ESU isn’t in use and is resting on the patient instead of being properly placed in its non-conductive safety holster. If the tip is hot due to buildup of eschar or it accidentally activates, patients can wind up with some nasty burns. The report comes in and says that the device misfired or was activated by itself, but through investigation we find out that somebody accidentally leaned on it or stepped on the foot switch while the pencil was resting on the patient. Patient harm is very commonly caused by user error with this technology.

OSM: Can you give us one more?

Ms. Miller: The fire risk in the OR where the energy devices serve as a common ignition source in the fire triangle that already has an oxidizer (oxygen) and fuel (prepping agents soaked into drapes). If you’re working on the patient’s face during head and neck procedures, that’s where the risk is at its highest, because the ignition source is working where there is open oxygen. If you’re placing a jugular catheter and a fire starts, it can be catastrophic.

The bottom line is that when staff are fully aware of the risks associated with electrosurgery, they’re more likely to take the necessary precautions to prevent them.

Is a RECQM system in place during electrosurgeries at your facility?

During monopolar electrosurgery, is a single-foil conductive return electrode sufficient to engage the safety functions of a generator’s return electrode contact quality monitoring (RECQM) system? The answer is that it isn’t, according to Julie Miller, MS, principal project engineer at ECRI, a non-profit organization with global headquarters in Plymouth Meeting, Pa., that provides independent medical device evaluation.

Ms. Miller says an OR team that is using a conductive return electrode (versus a large capacitive gel pad) requires a dual-foil (also known as split-foil) return electrode during monopolar electrosurgery for RECQM to occur.

A RECQM system is an important electrosurgery safety feature that halts activation of an electrosurgical device if its impedance is out of expected range or changes too much from its initial value, which can occur if the return electrode is not in good contact with the patient. According to Ms. Miller, this added safety capability has led to wider use of dual-foil return electrodes compared to single-foil return electrodes in ORs and procedure rooms.

Ms. Miller explains that the conductive surface of a dual-foil electrode is divided in two halves, each connected independently via the same cable to the electrosurgical unit. This split surface allows the electrosurgical device to sense impedance differences between the two halves of the conductive surface.

“For example, if the patient is shifted during surgery and their return electrode peels away, an alarm will activate if the RECQM detects a large enough change in impedance between the two foils of the electrode,” says Ms. Miller. “Clinical teams must address this issue before resuming the procedure. This ultimately minimizes the risk of a return electrode patient burn.”

Ms. Miller notes that a dual-foil conductive return electrode still requires appropriate sizing and placement depending on the patient and procedure. “Many general-purpose electrosurgical units do still accept single-foil return electrodes, which only engage a generator’s ‘continuity monitor, but this only alarms in the event that the return electrode or its cord is entirely disconnected,” she adds. OSM