Electrosurgery Saftey

Evidence-Based
Recommended Practices
for Electrosurgery

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Program Content

- Principles of electricity and electrosurgery

- Electrosurgical safety innovations

- Innovations in hemostasis and tissue division

- Best practices for patient safety

COVIDIEN, COVIDIEN with Logo andand ™ marked brands are trademarksCovidien AG or its affiliate. ©2008 Covidien or itsor its affiliate. All rights reserved. CONFIDENTIAL. Not for
COVIDIEN, COVIDIEN with Logo ™ marked brands are trademarks of of Covidien or its affiliate. ©2008 Covidien AG affiliate. All rights reserved. R0005658
further distribution or reproduction. R000658

Universal Properties of Electricity
Electricity always . . .
- Seeks ground (its source)
- Seeks path of least resistance


Properties of Electricity

Current Flow of electrons during a period of Impedance Obstacle to the flow of current
time, measured in amperes measured in ohms

Circuit Pathway for the uninterrupted flow of Voltage Force pushing current through the
electrons (must be complete/closed to flow) resistance, measured in volts


Current Concentration/Dispersal


Waveforms


Frequency Spectrum


Monopolar
Return electrode at another site
Active electrode at surgical site

High voltage
Current flows through the body Coag – 3,000-9,000
Cut – 1,350-4,000


Bipolar
Active and return electrodes within the
instrument

Current flow confined to tissue between
electrodes


Electrosurgery Safety Innovations

1968 – Solid state 1995 – Tissue response 2006 – Tissue sensing

1999 – Tissue fusion

1926 RF ESU 1981 – Return electrode
monitoring


Grounded System
“Revolutionized surgery—
blood loss could be
controlled.”
Vender, 2005

“…holds untold possibilities
for the future…”
Cushing, 1927

However…..

Current referenced to earth ground could seek alternate pathway.


Pathways to Ground

Ground-referenced ESUs increase safety risks to patients
and are not recommended for use.
ECRI, 1995


Alternate Site Injury

Alternate site injury resulted from the use
on a ground reference generator.

The use of isolated generators has
minimized this risk.

Still a risk when using large capacitive
patient return electrodes.

AORN Recommended Practices 2008


Isolated System

Isolated ESUs decrease the risk of patient burns and are safer to use
ECRI, 1995


Return Electrode Site Injury

Historically the most common injury has
been a skin injury at the patient return
electrode site.

This risk has been minimized through
advances in patient return electrode design
and the use of return electrode contact
quality monitoring


Non CQM (split) PREs


Contact Quality Monitoring

Return electrode contact quality monitors help prevent patient burns.
ECRI, 1995


Tissue Response Technology
Computer-controlled system senses impedance at active electrode.

Adjust output voltage 200 times per second
(cut and blend) to maintain consistent surgical effect
Eggleston et al, 1997


Clinical Benefits of Tissue Response
Reduced lateral thermal spread
Fewer power setting changes
Less video interference
Minimized sparking
“Consistent/precise tissue effect”
Pollinger et al, 2003
#1 #3

Cut at 30 watts


Tissue Sealing/Fusion Technology

- Controlled combination of pressure
and radiofrequency bipolar energy
- Low voltage
- High current

- Fuses tissue bundles, lymphatics and vessels
up to 7 mm in diameter

- Clips, sutures, mechanical ligation devices NOT
required

- Superior clinical performance when compared
to ultrasonic scalpel, plasma bipolar
coagulator, and nano ES device
Lamberton et al, 2008

Microscopic stain of artery

Tissue Effect of Fusion

Uses energy to denature the collagen and elastin in vessel walls and rearrange the
collagen and elastin into a permanent seal


Clinical Results of Tissue Fusion

Reduced thermal spread
Can reduce blood loss
Less risk of retained needles
Fewer needlestick injuries
No dislodged clips
No foreign material left behind
Tissue in normal anatomical position

“Less sticking, quicker seal and no tissue fusion failures.”
Ponsky et al, 2008


Tissue Sensing Technology

- Senses tissue impedance

- Decisions about tissue and output made
every 300 milliseconds, or
3,333 times per second

- Lower power settings and voltages in all
modes reduces patient injury risk

- Closed-loop control coag


Three Mode Device

Three distinct output modes:

BLUE Coagulation

Cuts faster, bleeds less Clear Dissection with hemostasis

Yellow Cut


Evidence-Based Practices
For Electrosurgery Patient Safety


Follow Manufacturer’s Written Instructions

ESU and accessories should be used
according to the manufacturer’s written
instructions


Instructions are on package
inserts and on package wrappers!


General Safety Precautions

Test alarm systems Set activation tone
to audible level

Plug accessories into correct
receptacles Confirm power settings


Patient Return Electrode Site Selection

- Follow manufacturer’s written
instructions
- Well vascularized
muscle mass
- Convex area
- Close to surgical site

Hotline News, 2000


Patient Return Electrodes Site Selection

Prostheses Bony prominences

Avoid sites high
in resistance

Ball, 2004

Scar tissue Hair


Patient Return Electrode Site Preparation

Follow manufacturer’s Protect return electrode Do not use flammable
instructions for hair from fluid invasion agents for PRE site
removal, cleaning, and preparation
drying site



Active Electrode

Active electrode MUST be in a non-conductive
holster when not in use

Electrode that does not fit holster should be placed
in a designated site with tip away from flammable
material

Active electrode tips should be securely seated
into the hand piece



Active Electrodes

“Frequent cleaning of the
electrode tip is recommended.”
Massarweh, 2006

Use a coated electrode to easily remove
eschar buildup on electrode tip.


Active Electrodes

Do not use red rubber catheters or other
materials as a sheath.

- Red rubber or plastic materials
may ignite

- Use manufacturer approved
insulated tips


Radiofrequency Current Leakage

- Active electrode cords should not
be wrapped around metal
instruments

- Active electrode and other
electrical cords should not be
bundled together


Electrosurgery During Pregnancy

No evidence to contraindicate use

Dispersive amniotic fluid protects fetus
from concentration of electrical current

No neuromuscular stimulation above 100
kHz — radiofrequency range

Leonardo da Vinci
c. 1510 - 1512

Te Linde's Operative Gynecology Text, 8th Edition


Pacemakers

- Consult pacemaker manufacturer
- Use ESU with care
- Use bipolar
- Use low power setting (cut)
- Avoid current flow through heart and pacemaker
- Keep cords away from pacemaker and leads

Heart with Leads and Pacemaker



Implantable Cardioverter Defibrillator (ICD)

- Cardiology consult to evaluate ICD
function and risk

- Defibrillator available

- Deactivate ICD before ESU use
- ECG and peripheral pulse monitoring

- Use bipolar

- If monopolar used place PRE close to
surgical site

- Avoid current flow through heart and ICD

- Check ICD post-op by a trained person
Donnelly, 2007

Jewelry

- Jewelry should be removed if it is within the
activation range of the active electrode

- When using a reusable, capacitive-coupled
return electrode, all of the patient’s metal
jewelry should be removed



Tattoos

Avoid placing the patient return electrode
over a tattoo.


Inks (red in particular) contain metals
which could serve as a heat or electrical
conductor
Clinical Hotline


Hearing Aids

Best to remove before surgery.

Radiofrequency leakage may cause interference.

Radiofrequency current may damage two-piece
wireless devices. They should not be worn when
electrosurgery is used.

ECRI, 2003
Hotline News, 2005


Avoid Hemostat Burns

- Use lowest power setting
- Activate low voltage (cut)
- Avoid touching patient
- Hold hemostat with full grip
- Do not open circuit activate
- Avoid metal to metal arcing

Note: Surgical gloves do not insulate against RF current


What is Surgical Smoke?

The gaseous byproducts of the disruption and vaporization of tissue
protein and fat.


Smoke Chemical Soup

xylene
benzene
ile

e
nitr

en
to
ace

yr
St
xide
ca rbon mono

ne
metha ac
et
yle
form ne
alde
hyde

cyanide
l etha
eno ne
ph

tol
al ue
furfur ne


Chemicals and Health Effects
Chemical Health Effects

Acetaldehyde Eye, skin, respiratory irritant; causes
erythema, coughing, pulmonary edema;
may be teratogenic

Acrolein Eye, skin, respiratory irritant; liver kidney
damage; increased clotting time

Acetonitrile Nose irritant, throat asphyxiant; liver and
kidney damage in animal models

Benzene Headache, fatigue, weakness; bone marrow
damage; trigger for leukemia

Styrene Respiratory irritant; vapors cause nose
lining damage in animal models

Toluene Eye, respiratory irritant; CNS function;
teratogenesis with high inhalation levels

Xylene Respiratory irritant; chronic exposure
associated with changes in blood cells


Evacuate and Filter Smoke

Evacuation System Components

- Capture device

- Vacuum source

- Filtration system


Promote Patient and Staff Safety Through
Best Practices

“An educated perioperative staff is the
patient’s best advocate”


Program Summary

- Principles of electricity and electrosurgery

- Electrosurgical safety innovations

- Innovations in hemostasis and tissue division

- Best practices for patient safety

Prior to use, clinicians should review the Instructions for
Use package inserts and/or User’s Guide provided by the
manufacturer to ensure safe and appropriate utilization of
electrosurgical devices.


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