best practice nurse

7/29/2019 best practice nurse

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Best Practices forElectrosurgery


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3

Potential Adverse Outcomes


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Potential Electrosurgery Injuries

Laparoscopic Injuries

Alternate Site Injuries Return Electrode Site Injuries

Fire Injuries


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5

Basic Principles of Electrosurgery


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Basic Principles of Electricity

Electricity always . . .

Seeks ground (its source)

Seeks the path of least

resistance


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Properties of Electricity

Current Flow of electrons during a

period of time, measured in

amperes

Circuit Pathway for the

uninterrupted flow of

electrons (must be

complete/ closed to flow)

Impedance Obstacle to the flow of

current measured in ohms

Voltage Force pushing current

through the resistance,

measured in volts


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Frequency Spectrum


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The more concentrated the current,

the greater the potential for a burn.

Current Concentration/Dispersal


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Monopolar

Active electrode at surgical site Return electrode at another site Current flows through the body

between the electrodes High voltage

Coag 3000 9000

Cut 1350 - 4000


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Bipolar

Active and return electrodes in theinstrument

Current flow confined to tissuebetween electrodes

Low Voltage (320 - 1200 volts)


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Electrosurgical Technologies


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Patient Burns

Pad site burn


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Therapeutic current

Interrogation current

Contact Quality Monitoring


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Contact Quality Monitoring

The most frequently reportedpatient injury has been a skin injury

at the patient return electrode site

The risk of this type of injury has

been minimized through advancesin patient return electrode design

Nondrying conductive material

Use of return electrode contact

quality monitoring

AORN Recommended Practices, 2009


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20

Best Practices to Achieve Favorable PatientOutcomes Related to Electrosurgery


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Follow Manufacturers Written Instructions

The ESU and accessories shouldbe used according to the

manufacturers written instructions.

Each type of ESU has specificmanufacturers written operating

instructions to be followed for safeoperation of the unit

Accessories should be used,handled, cleaned, and processed

according to manufacturers

instructions



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General Safety Precautions

Test alarm systems Set activation tone to audible level


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General Safety Precautions

Confirm Power SettingsPlug Accessories into Correct Receptacles


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Selecting the Patient Return Electrode

Patient return electrodes should becompatible with the ESU

Do not attempt to use return

electrodes that disable the contact

quality monitoring system

Verify that the: Electrode is intact

Conductive gel, if present, is moist

Manufacturers expiration date has

not been reach

Do not reuse patient returnelectrode


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Selecting the Patient Return Electrode Site

Follow manufacturers writteninstructions

The conductive and adhesivesurfaces of the electrode should be

placed on:

Clean, dry skin

Over a large, well-perfused

muscle mass of the surgical

side

Close to the surgical site

Convex area


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Avoid Patient Return Electrode Sites High

in Resistance

Prostheses

Hair

Bony prominences

Scar tissue


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Preparing the Patient Return Electrode Site

Follow manufacturers

instructions for hairremoval, cleaning, and

drying site

Protect return

electrode from fluidinvasion

Do not use flammable

agents for PRE sitepreparation


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Patient Return Electrode Guidelines

Do not overlap edges

of return electrodeDo not cut or modify

return electrode


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Patient Return Electrode Guidelines

Do not warm return electrode Apply return electrode after

positioning

Place return electrode proximal totourniquet, preferably on operative

side


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Follow Manufacturer Instructions When

Using Different Sizes of Patient Electrodes

Select patient electrode accordingto patient weight

Infant patient return electrode

Do not exceed 120 watts of power Use short activations

Neonatal patient return electrode

Do not exceed 300 milliamps of

power

Do not activate active electrode

longer than 30 seconds

For neonates < .45 kg, use of

bipolar electrosurgery


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Compression Stockings and Patient Return

Electrodes

Compression stocking maycause

Increased temperature at the

pad site

Increased impedance at padsite

Current concentration with

resultant heat build up

Do not apply the patient returnelectrode to areas wherepressure is applied to the

patient

ECRI


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Warming Devices and the Patient Return

Electrode

Always follow manufacturersinstructions when using a warming

device

Avoid close contact with warmingblanket

A towel, blanket, or folded sheetmay be placed between the patient

return electrode and the warming

blanket to distance the heating

source from the patient return

electrode

Covidien Clinical Information Hotline


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Reducing the Potential for Alternate Site

Burns

Avoid skin-to-skin contact, such asfingers touching leg or knee

touching knee when positioning the

patient

Use non-conductive dry padding toprevent skin-to-skin contact

Position the return electrode toprovide a direct current route


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When to Use Two Patient Return

Electrodes

Placement of additional PREs

increases the dispersion of

electrosurgical current and heat at

the pad-to-patient interface

Obesity

Emaciation

Fluid environment

Long duty cycles



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Removing the Patient Return Electrode

Remove return electrode slowly,supporting the tissue underneath

Observe skin under pad Chart appearance of site


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Active Electrodes

When not in use, always placeactive electrodes in a non-

conductive holster

Electrodes that do not fit in theholster should be placed in a

designated location with tips away

from flammable material

Active electrode tips should besecurely seated into the hand

piece



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Active Electrodes

Do not use suctioncoagulator as a retractor

Avoid tissue contact withshaft during activation

Ensure that the outside ofthe suction coagulatorremains free of fluids and

mucus which may conduct

electrical current

Unintended activation mayresult if the suction

coagulator handswitch isimmersed in saline solution

or other conductive fluids

Covidien Instructions for Use, Suction Coagulator


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Active Electrodes

Build-up of eschar increasesresistance at the active electrode

and may require the use of higher

power setting

Eschar debris may ignite

Use a coated electrode to easilyremove eschar buildup onelectrode tip


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Active Electrodes

Do not use red rubber catheters or

other materials as a sheath

Red rubber or plastic materials

may ignite

Use manufacturer approvedinsulated tips

ERCI, 2006


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Radio Frequency Current Leakage

Active electrode cords should notbe wrapped around metal

instruments

Active electrode and otherelectrical device cords should not

be bundled together

Phippen, Ulmer, & Wells, 2009


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Avoiding Hemostat Burns

Do not buzz the hemostat with a needle

electrode

Do not lean on the patient, the table, or the

retractors while buzzing the hemostat

Activate cut rather than coag

Firmly grasp as much of the hemostat as

possible before activating

Buzz the hemostat below hand level

Activate the generator after the instrument

makes contact with the hemostat

When using a coated or nonstick blade

electrode, place the edge of the electrode

against the hemostat Note: Surgical gloves do not insulate

against RF current

Ulmer, 2008


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Pacemakers

Consult pacemaker manufacturer Use

electrosurgery with care

Use bipolar

Use low power setting

Avoid current flow through heart and

pacemaker

Keep cords away from pacemaker

and leads

Postoperatively have the device

checked by a trained individual

Phippen, Ulmer, & Wells, 2009


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Internal Cardioverter-Defibrillators

Obtain preoperative cardiology consult toevaluate correct functioning and determine

risks

Have defibrillator immediately available

Deactivation of ICD by trained personnel

before ESU use

Continuous ECG and peripheral pulse

monitoring

Use bipolar

If monopolar used ensure distance between

the active and patient return electrode is as

short as possible

Avoid current flow through heart and ICD

Postoperatively have the device checked by

a trained individual



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Hearing Aids

Best practice is to remove hearingaids prior to surgery

RF leakage may causeinterference to the hearing aid

reception

RF current may damage two piecewireless hearing aids, thus theyshould not be worn when

electrosurgery is used



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Cochlear Implant

Do not use monopolar electrosurgery on

the head or neck of a cochlear implant

patient

Use bipolar electrosurgery on the head

and neck of patients with implants that do

not have extracochlear reference

electrodes

The bipolar electrode must not contact the

implant

If the implant has extracochlear reference

electrodes, bipolar may be used if the

electrode is kept more than 10 cm (4

inches) from the extracochlear electrodes

Postoperatively have the device checked

by a trained individual

AORN Recommended Practices, 2009; Hotline News, Vol 6, Number 4


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Dental Appliances

Avoid direct contact with any metaldental appliances

Cover braces with teeth guards(silicone or rubber) or use bipolar

energy when possible

Remove palate spreaders prior tosurgery if electrosurgery will beused in immediate area of the

device

Covidien Clinical Information Hotline


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Jewelry

Jewelry should be removed if it iswithin the activation range of the

active electrode.

When using a reusable, capacitive-coupled return electrode, all of the

patients metal jewelry should be

removed.



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Tattoos

Avoid placing the patient returnelectrode over tattoos

Inks (red in particular) containmetals which could serve as a heat

or electrical conductor

Valleylab Clinical Hotline



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Electrosurgery During Pregnancy

No evidence to contraindicate the use ofelectrosurgery during pregnancy

Amniotic fluid protects fetus from anyconcentration of electrical current owing

to the dispersion effect

Just as high frequency of electrosurgerycurrent above 100 kHz prevents

neuromuscular stimulation in adults,

children, and infants, the same is true

for the fetus Leonardo da Vincic. 1510 - 1512

Te Linde's Operative Gynecology Text, 8th Edition


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Electrosurgery During Cesarean Sections

If flammable prepping solutionused follow manufacturers

instructions

Apply the patient return electrodeto a site that will not be exposed to

pooling of amniotic fluid Activate electrosurgery pencil only

when in contact with intended

tissue

Place electrosurgery pencil in non-conductive safety holster when not

in use


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Pediatric Applications and Small Anatomic

Structures

Pediatric applications and/or proceduresperformed on small anatomic structures

may require reduced power settings

Potential for unintended thermal damageto tissue with high current flow and

longer activation

For procedures where the current couldflow though delicate parts of the body,

use of bipolar technique may be

desirable in order to avoid unwanted

coagulation

Covidien Electrosurgery Users Guide

Best Practices to Achieve Favorable Patient


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Best Practices to Achieve Favorable PatientOutcomes Related to Electrosurgery

1. Manufacturers Instructions

2. Safety Precautions (2)

3. Selecting the Patient ReturnElectrode

4. Selecting the Patient ReturnElectrode Site (2)

5. Preparing the Patient ReturnElectrode Site

6. Patient Return Electrode Guidelines

7. Different Sizes of Patient Electrodes

8. Compression Stockings and PatientReturn Electrodes

9. Warming Devices and the PatientReturn Electrode

10.Alternate Site Burns

11. Use Two Patient ReturnElectrodes

12.Active Electrodes (4)

13. RF Current Leakage

14.Avoiding Hemostat Burns

15. Pacemakers

16. Internal Cardioverter-Defibrillators

17. Hearing Aids

18. Cochlear Implant

19. Dental Appliances & Jewellery (2)

20. Tattoos

21. Electrosurgery During Pregnancy /Cesarean Sections (2)

22. Pediatric Applications and SmallAnatomic Structures


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Evaluate Patient After Surgery

Electrosurgery InjuryPressure InjuryChemical Injury


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Questions ???

Thank you !


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Program Summary

Potential adverse outcomes related to electrosurgery

Basic principles of electrosurgery

Best practices to achieve favorable patient outcomes related toelectrosurgery

Prior to use, clinicians should review the Instructions for Use product

inserts and/or Users Guide provided by the manufacturer to ensure

safe and appropriate utilization of electrosurgical devices.

best practice nurse

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