No group of surgical instruments is used so frequently and understood so poorly as electrosurgery units. To wit: According to a Feb. 2005 survey by ECRI, 30 percent of its facility members reported that their patients had suffered electrosurgical burns - and 30 percent of those respondents didn't know how the injuries had occurred. To help you better understand your ESU - and to help make your electrosurgical practice safer - here are seven concerns and challenges of electrosurgery, and what you can do to meet them.

Performing a technology assessment
The first thing to check is generator compatibility. Try to standardize ESUs throughout your facility; if a surgeon asks you to bring two generators into the same room, they must be of the same technology. Putting two different models of generator in the same room needlessly puts the patient at risk for an electrosurgical burn.

Evaluate your ESU's safety technologies. I highly recommend that, if you don't already have them, you use the following in conjunction with your unit:

• Tissue-resistance sensor. If the surgeon activates the foot pedal before touching the instrument tip to tissue, the generator will detect an increase in resistance, and the unit will automatically drop the voltage.
• Active electrode shielding. This prevents electrical energy from leaking out of an active electrode with compromised insulation and eliminates capacitive coupling during the procedure. If you don't use active electrode shielding, consider such devices as InsulScan to supplement visual between-case electrode inspection.
• Return electrode contact quality monitoring. RECQM provides a better level of protection than continuity monitoring by ensuring that good contact exists between the dispersive electrode and patient. It uses interrogation current through patient tissues to verify acceptable impedance level and is used with a dual-foil dispersive electrode.

Thoroughly check that your ESU is in good working order before a procedure, just as you would with a surgical laser. Turn the circuit breaker off, plug it in, flip it on, make sure all the indicators work and make sure all the alarms are audible.

The average life expectancy of a reusable device is one year. I'm not telling you to throw all your trays away, though. If it were up to me, I'd have totally disposable trays all the time and just throw everything away after a case. Of course, that's not realistic. But you must monitor high-risk reusable devices such as electrodes. Document the number of reprocessing cycles they go through, and document your visual and mechanical inspections to ensure they're safe, undamaged and in working order.

To get a handle on the waveform variations of your ESUs, make model-specific charts of the wattage parameters and voltage-per-watt delivery. That will help staff know that, for example, if the ESU is in coagulation mode, the safe wattage/voltage parameters change significantly. We've laminated index-card-sized charts for staff to carry with them.

Preventing electrosurgical fires
ESU devices start more airway fires than lasers do. ESU devices don't need flammable anesthetics to start a fire, so you must take extra precautions.

• Don't use the ESU in the presence of flammable agents. Adhere to manufacturer recommendations for drying time, and document it.
• Check your adapters for compatibility. A fire can occur at the adaptor if it's used to attach the wrong kind of pencil tip.
• Visually inspect the electrode and cord for damage, as they can set the drape on fire.
• Secure the electrode cord to the drape with non-conductive material. If you wrap it around something metal, it can become just as hot as the electrosurgical pencil tip and can create a fire.
• Put an active electrode in an insulated holster when not in use.
• Frequently clean the active tip of eschar to prevent spark jump.
• Moisten or remove sponges close to the active tip to prevent accidental ignition.
• Don't use an active electrode in the presence of intestinal gases. Put a wet towel over the rectum if you're doing lower-tract procedures.
• Keep a CO2 fire extinguisher readily available.
• In case of a fire, do not use a fire blanket, which can actually spread a fire.
• Before and after use, remove the batteries from battery-powered electrocautery devices. Properly dispose of batteries when you're through with them.
• Don't use nitrous oxide during activation of the ESU. Nitrous with oxygen presents as if 100 percent oxygen is being delivered. Turn off oxygen 60 seconds before activating the ESU.
• Use the lowest possible watts and voltage.
• Use water-soluble lubricant for the eye and on hair near the surgical area.
• Keep a basin of H2O/saline on the sterile field and give a bottle of H2O to the anesthesia provider.
• Place suction tubing under the drapes, close to the anesthetic gases and oxygen delivery system.

Grounding pad issues
Grounding pads can burn patients if you don't pay close attention to the potential risk areas.

You should be using RECQM. I can't believe any facilities are compromising patient safety for the price difference between monitored and non-monitored pads.

Use the right pads for the equipment. If you are going to switch pad manufacturers, check and double-check compatibility. Further, use the appropriate-sized pad for the patient. Some companies have one-size-fits-all pads. Others have a variety of sizes, such as smaller pads for pediatric patients 30 pounds and less. Never cut or modify a pad.

Evaluate the skin before and after applying the pad. Document excessive adipose, bony prominences, adhesive failure, metal prosthesis, scar tissue and fluid invasion, even on a monitored pad. Note tattoos, as there may be metal in the ink, and they compromise circulation. Pick a large area with muscle mass that's clean, dry and shaven as the application site. The thigh, abdomen, upper arm and buttocks work fine; the arm is good for procedures on the upper chest.

Assess the gel before you apply the pad. If it dries out, you're putting the patient at risk for a dispersive pad burn.

Make sure the pad adheres fully. If it buckles, replace it - it's only $2.50. Orient the long axis of the pad toward the operative site to optimize return-current flow.

Use a capacitive pad - an alternative to conventional conductive return electrodes - while in contact with fluids and on patients with prosthetics, pacemakers or body jewelry. Capacitive pads are large, foldable, padded return electrodes the patient lies on. The reusable pads are compatible with RECQM but cannot be used on pediatrics or with active electrode shielding.

Jewelry and body piercings
Your best bet is to remove the jewelry altogether, especially if it transects the current. If you absolutely cannot remove it, you must be extra cautious about preventing a burn.

A capacitive pad might be a good choice. Or you can use an isolated generator, which, because it returns energy from the active electrode only to the dispersive pad - and not to alternate ground points on the patient - decreases the chance of a burn due to radiofrequency leakage.

Ensure the integrity of the electrode insulation. Insulation failure is the No. 1 cause of injuries associated with electrosurgical current. It happens when electrodes are damaged via normal wear, use and reprocessing. All can cause cuts, nicks and abrasions to the insulation - and at high-voltage waveforms, you'll quickly blow a hole in the insulation.

Laparoscopy instruments
You need to take special precautions with laparoscopy. Ensure a proper connection and multi-foot-pedal access, use a low-voltage cutting waveform when possible, avoid open-circuit activation and document instrument reprocessing cycles. Most important: Check the electrode insulation, as insulation failure is high in laparoscopic procedures, and about 90 percent of the electrode shaft is out of view of the laparoscope during the procedure.

The first step is visual inspection. But let's face it: The average age of the OR nurse is 49, and you have a hard time reading the newspaper with your glasses on, let alone detecting tiny breaks in insulation. Visual inspection is better than nothing, but let me suggest you go a bit further.

Perform electrical testing before and after each procedure with a scanner. However, these insulation-integrity testers can't detect non-full-thickness breaks and can't test or detect capacitively coupled leakage current. They're a supplement to - not a replacement for - visual inspections.

At my facility, we have converted to active electrode shielding/monitoring in all 28 of our ORs. We deemed active electrode shielding safest because it addresses capacitive leakage, insulation failures and trocar insertion-site injury. It's not perfect; it won't address inadvertent active electrode contact, the active electrode on the patient, return-electrode-related problems or external cable failures. But the technology is compatible with a majority of the ESUs that have RECQM.

Patients with pacemakers
A patient with a pacemaker, neurotransmitter or automatic internal cardiac defibrillator poses yet another danger. The first thing you should do is check with the pacemaker manufacturer for its recommendations. Intraoperatively, use active electrode shielding and preferably bipolar energy. Most important, place the grounding or capacitive pad so it doesn't transect the heart in close proximity to the active tip. Have a defibrillator available. Use the lowest possible voltage settings.

Keep a pacemaker magnet in the OR; it can be used to assess the pacemaker (which you should do continually during the surgery), check battery life and treat pacemaker-induced tachycardia. Have the resource number for the pacemaker manufacturer on hand.

Clearing the smoke
There's no such thing as safe surgical smoke. It's vaporized human body parts with the potential to transmit viral and bacterial matter, and it can remain in the air up to 10 minutes andtravel in the air currents throughout the OR. Train staff to use and check your smoke evacuator and to replace the filters. It should go without saying that smoke evacuator will be in use when the ESU is.