PROPER PRECAUTION When surgeons employ electrosurgery, be sure they follow protocols to minimize risks of accidental burns.
Electrosurgery units can be one of the most dangerous pieces of equipment in your OR, mostly because many surgeons and staff members don't understand the basic principles of electrosurgery and the best ways to avoid burns. Use this short quiz to refresh their memories so they can better protect themselves and your patients.
1. Electricity follows the path of least resistance.
a. trueb. false
Show Answer
Answer: a
Electrosurgery uses a high-frequency current that's converted into heat as it passes through resistance. The patient's tissue is what provides resistance. Bone and fat have the greatest resistance, meaning they are the poorest conductors of electricity, while nerves and muscle have the least resistance. If the tissue is a good conductor, it will allow easy passage of the current and generate less heat. Resistance also depends on the path that electricity takes through the body. For example, if the electricity goes in the patient's left hand and out his right foot, the resistance will be much higher than it would if it went in and out of adjacent fingers.
2. As tissue is desiccated, its resistance increases and electricity seeks alternative routes.
a. trueb. false
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Answer: a
Tissue that is desiccated cannot conduct electrical current effectively. As water is removed from the tissue, its resistance to the current increases. Remember how current follows the path of least resistance? If tissue is desiccated and the resistance increases, the current may seek an alternative pathway that's more conducive to completing the electrical circuit.
3. Insulation integrity has no relation to thermal injuries and is not a patient safety issue.
a. trueb. false
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Answer: b
One factor that can lead to unintentional injuries is the breakdown of the ESU's insulation or cord. The insulation of a monopolar electrical handpiece is designed to protect the patient from unnecessary exposure to the metal internal portion of the surgical instrument. Inspect electrosurgery instruments before each use, especially because insulation defects can be caused by daily wear and tear and repeated sterilization. You can also perform an electrical insulation scan, although this should be used in addition to visual inspections.
On The Web:
SAGES has launched a new program — the Fundamental Use of Surgical Energy (FUSE) — to educate surgeons and staff on the proper use of electrosurgery devices in the OR. The web-based, interactive educational program is free:
fundamentals-didactics.com.
4. Insulation failure is one of the events that can lead to an electrosurgical burn. What are the others?
a. capacitive coupling and direct coupling
b. high current densities and capacitive coupling
c. open circuit activation and high current density
d. eschar development and open circuit activation
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Answer: a
Capacitance, or the ability of a body to store an electrical charge, is a normal dynamic of electrical current. Capacitive coupling is a leakage of current that occurs between 2 closely placed conductors, even insulated ones, and causes burns to adjacent tissue. Direct coupling happens when the active tip of the instrument comes in contact with another metal instrument and transfers the electrical current. That uninsulated metal object will conduct current to any tissue it touches, resulting in a burn. While this can be prevented with the obvious — surgeons keeping the tip away from metal instruments and implants — it's also important to ensure the patient's body isn't touching metal, including IV poles, carts or even gown fasteners.
5. Active electrode shielding prevents patient injuries from capacitive coupling and insulation failure.
a. trueb. false
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Answer: a
Active electrode shielding is a technology that takes the electrical current and safely delivers it back to the generator. If the device detects that less than 100% of the energy is returned to the generator, or if there's an insulation failure, the generator ceases to deliver power. It's important to note that active electrode shielding has the power to eliminate capacitive coupling and insulation failure during laparoscopic surgery, but does not protect against pilot error such as direct coupling.
6. Identify only one of the following precautions to take if a patient has a pacemaker or implantable cardioverter defibrillator (ICD).
a. Electrosurgery is contraindicated and not safe for any patient with a pacemaker or ICD.
b. ESU cords or cables are best placed closest to the devices.
c. Do not let the current transect the ICD or pacemaker, with placement as far as clinically possible.
d. Maintain the longest distance between the active electrode and the pad.
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Answer: c
When using electrosurgery on a patient with an ICD or pacemaker, it is generally suggested that bipolar electrosurgery is the better bet. Monopolar electrosurgery can interfere with ICD or pacemaker conductions. When using electrosurgery with these patients, avoid transecting the electrical current through the heart, and place the active electrode and plate as close as possible to each other to decrease the current flow through tissue.
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