Injury resulting from stray electrosurgical current during electrosurgery provides a strong case for malpractice suits. In fact, despite recent advances in technology, more malpractice cases are filed as a result of electrosurgical burns than any other surgical mishap - which explains why some malpractice insurers have increased their rates by 15 to 20 percent for surgeons who perform monopolar electrosurgical procedures. The number of cases that have actually gone to trial is likely dwarfed by the number of cases in which surgeons and insurance companies have settled claims out of court.

Clearly, we have a strong incentive to protect ourselves and our institutions from the financial and legal risks associated with such injuries. We need to understand and account for the risks of electrosurgery, particularly since 90 percent of today's surgeries implement it in some way.

While some approaches and tools are widely considered safer than others, keep in mind that each choice you make could compromise safety if you don't understand the characteristics of the waveforms and the various delivery systems. In short, there are recommendations for electrosurgery safety, but the incorporation of procedures, delivery systems and equipment must be considered together to optimize a patient-safe environment.

Which type of pad?
Let's being by reviewing the types of pads.

• Capacitive return electrode. This creates a capacitive effect, where energy is dispensed evenly using the patient's body to dissipate the charge. Variables in pad placement, adhesiveness of the pad and overheating at the pad site aren't a concern with this type of pad system. However, there is a human error component. The operator still has to clean the pad properly, examine it and make sure there are no defects. Appropriate patient selection and recommendations from the original equipment manufacturer are also important in preventing a burn to the patient. Keep in mind that this pad is incompatible with active electrode monitoring, which, as we'll discuss later, is a desirable safety feature.
• Non-monitoring conductive return electrode. This is less expensive, but the plate can't monitor skin resistance, thus putting the patient at risk for potential site burns. If the contact of the plate doesn't adhere properly to the patient's skin, the electrical resistance increases and the electrosurgical system isn't notified that the plate has become detached. Unless you smell the burning, you might not realize you've burned the patient until the end of the procedure. These plates aren't used frequently and there's a reason. Imagine it as a car with no seat belt. Sure you can drive it, but would you want to? The majority of electrosurgical systems on the market today have software that is only compatible with a monitoring plate.
• Contact quality monitoring plate. Commonly referred to as split pad technology, this plate monitors the skin's surface and measures its resistance. If the plate detects situations such as too much hair on the pad site or if it detaches from the patient, an alarm will go off. Most ESU systems have the ability to only accept a split system, but buyer beware: Various types of radiofrequency generators don't have monitoring systems and are compatible with either type of plate. This variable in hookup can lead to human error with regard to a potential burn if you don't consider all variables for plate placement.

Don't skimp on your surgical pencil
Though the inclination is to be cost effective, you really should consider the quality of the surgical pencil, or active electrode. Especially when it comes to safety, cheaper doesn't mean better.

Its mechanism needs to be well designed so that you won't have to worry about the quality of the connection. Consider the use of Teflon ESU tips in cases where a lot of tissue can stick to the ESU pencil tip. This assists in reducing the buildup of eschar, which can cause spark jumps due to tissue resistance. Make sure that the electrode is interchangeable with all kinds of tip devices and has the ability to adapt to products that facilitate the removal of surgical smoke. The pen should fit well in the physician's hand and should have similar weight and size when the smoke evacuator adapter is connected. The physician will be more likely to use the pencil with this safety device attached. Most companies design smoke evacuator pencils, but they're not always the most user-friendly. Find a smoke evacuator attachment that doesn't reduce the physician's ability to perform surgery.

Bipolar or monopolar?
For bipolar electrosurgery, some generators have an amp meter with both visual and audible indicators. This feature notifies the surgeon that the tissue has been fully desiccated. This has become a standard of care when performing procedures such as tubal ligations. If the tubes aren't fully occluded, the patient could potentially still get pregnant or the procedure could result in a tubal pregnancy.

Bipolar mode has traditionally been thought of as safer than monopolar mode, which is true in terms of insulation failure and spark jump. However, when operating around areas where there is a concern of lateral thermal spread, the operator must be aware that tissue destruction can well exceed the indicated area of destruction. The results can lead to complications such as bowel perforations or inadvertent tissue destruction in other organs or structures. You have to be particularly careful of the depth at which you're cutting or coagulating. Monopolar energy delivery penetration is more superficial, but your considerations again would be capacitive coupling and insulation failure when performing laparoscopy. As a patient liaison, you don't want to trade one set of complications for another. Weigh and consider all areas of safety.

At Gwinnett Hospital here in Georgia, we've used active electrode monitoring (AEM) with our generators for more than seven years. During monopolar laparoscopic procedures, AEM detects primary insulation failure and shuts off the generator, protecting the patient from a burn. The generator also senses stray energy through any primary insulation defect to the protective shield. If capacitance is set up during the procedure, the capacitively coupled energy is continually drained safely back to the generator by the protective shield. One hundred percent of the power is delivered at the surgeon's intended site. AEM technology is compatible with most generators that have the quality pad-monitoring feature.

Yet another option for reducing the risk of capacitive coupling is tissue-sensing response, sometimes known as leakage canceling. Keep in mind that unlike AEM technology, which completely prevents capacitive coupling and insulation failure, tissue sensing only reduces the potential for capacitance and insulation failure (which has a higher potential of occurrence with reusable monopolar instruments) to occur. New generators have microprocessors that can interface with the surgical site at thousands of cycles per second (depending on the company) and provide tissue impedance data to the generator. A newer generator can then adjust its energy output at cycles per second. It reads the voltage buildup and can pull back up to 80 percent of its energy to minimize the potential for capacitive coupling. A faster response also means smoother cutting and decreased tissue damage while eliminating manual power adjustments.

Though it's not a substitute for a Bovie pencil, the ligature system has caught on quickly as a safer alternative to active electrodes. Ligating shears use electricity to indirectly induce heat in coiled wires that can cut and coagulate. Ultrasonic scalpels, in which rapid vibration provides the heat, are also catching on quickly as safety-conscious implements.

Make safety job one
Sometimes companies overload nurses with too much information, which is not always conducive to our understanding. Sometimes we have too many options and can't make sense of our choices. As is the case with any surgical purchasing decision, evaluation and trials with safety considerations being the primary focus are crucial. Surgeons and nurses should know what they need before going shopping. The most effective safety device, after all, is an educated and well-trained staff.

Nikomed USA
Gallant Safety Prep Razors
(800) 355-NIKO
www.nikomedusa.com
Price: $0.50 or less each
FYI: Preparing the patient for the ground pad can help cut down on soreness and skin problems. These prep razors lift and separate hair for a closer cut. Since the handle comes before the blade, the shearer can shave without applying any pressure to the target area. Free samples are available, says the company.

Megadyne
EZ Pen
(800) 747-6110
www.megadyne.com
Price: Not disclosed
FYI: Most electrosurgical pencils are disposable, but the EZ Pen is reusable and features a green plug that pops out after 10 uses, preventing dialectic breakdown and current spray that can shock the surgeon, says the company.

Megadyne
Coated Blade Electrodes
(800) 747-6110
www.megadyne.com
Price: Not disclosed
FYI: Because buildup can misdirect the current and cause fires, these electrodes are made for easy cleaning. The company says they also cut down on the risk of collateral damage by letting the surgeon place the entire blade in the cavity.

Megadyne
Mega2000 Soft
(800) 747-6110
www.megadyne.com
Price: Not disclosed
FYI: Instead of using an adhesive to stick to the patient, this gel pad reduces pressure on the target area while providing a safe return, says the company, which reports more than 20 milllion procedures with no pad site burns. It has a return electrode contact quality monitoring and is reusable for two years.

Megadyne
E-Z Clean Resposable Laparoscopic Electrodes
(800) 747-6110
www.megadyne.com)
Price: Not disclosed
FYI: These feature two layers of insulation and an "indicator shaft" that reduce the risk of burns from the capacitor to minimize insulation failure and stray current, says the company. When the outer layer is breached, it peels back to expose the yellow underlayer, letting the surgeon know when to replace the electrode.

Bovie
New Icon GI Generator
(800) 537-2790
www.boviemedical.com
Price: $10,000
FYI: To keep the doctor's focus on the field and not looking for a foot pedal, this generator features an activation button on the endoscope handle. When the user tries to use a solid pad, a text box (not an error code) pops up on the touch screen with a reminder that split pads tend to be safer. If for some reason the snare is not properly hooked up to the generator, it senses that and emits an alert tone to prevent the guillotining of polyps.

3M
Universal Uncorded Split Electrosurgical Pad 9160
(888) 3M-HELPS
www.mmm.com
Price: Not disclosed
FYI: This grounding pad is just 15 square inches in surface area, making it easy to place on the patient while avoiding bony prominences. The patented 3M Green Safety Ring dispenses energy evenly over the pad to prevent burns. According to the company, the non-woven backing conducts heat 25 percent faster than foam.

Mectra Labs
Electrolube
(800) 323-3968
www.mectralabs.com
Price: $400 per case (20 uses per case)
FYI: This lubricant keeps tissue from sticking to the instrument, thus preventing charring, bleeding and tearing. A cleaner instrument also means less use of cautery cleaning pads, which can leave metal fragments on the instrument.

Starion Care Technology
TLS3 (Thermal Ligating Shears)
(800) STARION
www.starioninstruments.com
Price: $419
FYI: The Starion system uses pure heat instead of electricity to cut and seal. The wire in the jaw-shaped forceps clamps down on the target area and welds tissue together without the risk of collateral tissue damage, thermal spread or stray current. The company says the heat in its system is more highly focused and faster than bipolar electrocautery.

ERBE
VIO 300D Electrosurgical Generator
(800) 778-3723
www.erbe-usa.com
Price: Not disclosed
FYI: This generator features automatic dosing of power, meaning it determines how much power is needed and produces no more than that amount. It is programmable, so each doctor can have his own presets loaded into it. Its pulse settings allow expanded ranges of coag effects, greater control and a consistent, homogenous beam of coagulation, says the company. The pulse effect eliminates the need to use the foot pedal. Also, the generator won't engage if it detects that the pad isn't on the patient properly.

Utah Medical Products
Epitome Scalpel
(800) 533-4984
www.utahmed.com
Price: $7 to $14 each, 10 to 25 per box
FYI: These non-sharp scalpels cause minimal thermal injury to tissue, allowing healing and cosmetic results comparable a conventional sharp scalpel with less risk of harming the surgeon and technician, says the company.