March, 2007

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SURGICAL SAFETY
Your Refresher on ESU Safety

Four tried and true steps to prevent laparoscopic electrosurgical burns.
Vangie Dennis, RN, CNOR, CMLSO
Lawrenceville, Ga.

The possibility of potentially fatal stray electrosurgical burns exists every time one of your surgeons opts for the versatility and efficacy of monopolar electrosurgery. It shouldn’t happen, but too many patients suffer each year from complications ranging from pain to death (see “Statistics That May Shock You”). But it’s easy sometimes to forget just how dangerous routinely used equipment can be. With that in mind, here’s a refresher on safe electrosurgery.

PROTECT YOURSELF
It’s common sense to standardize laparoscopic electrosurgical safety, just as you have with pre-op timeouts and post-op sponge counts.

1. Watch for breakdowns.
Insulation failure is one of the two phenomena (that aren’t pilot error) that may transfer electrical current to non-target tissue. In order to preserve the insulation, therefore, you should assess processing methods that may limit degradation of monopolar instrumentation. EtO sterilization will be less detrimental to your electrosurgical instruments than harsh steam, which can quickly break down insulation. Visually inspect insulation, looking closely for any cracks or tears before and after processing, preoperatively, perioperatively and on a schedule determined by the manufacturer’s written instructions. Immediately dispose of and replace worn out instruments.

To make it easier to spot breaks in the insulation, you might consider instruments with brightly colored inner layers of insulation along the electrode shaft. This makes it easier to spot breaks in the insulation; however, they’re not all visible to the naked eye. In fact, the majority are not, and the smallest defects tend to concentrate leaked current, which can cause a deeper burn and result in the perforation of an organ.

1. Perform an electrical insulation scan.
Another way to assess insulation breaks you can’t see is performing an electrical scan on instruments before and after each procedure. However, this test doesn’t detect breaks in the insulation contiguously, so a breakdown in the insulation intraoperatively won’t be prevented. Further, scanners can’t prevent capacitive coupling, so you should only use this method to enhance visual inspections.

3. Use active electrode shielding technology.
This is crucial, because it’s the only technology that prevents insulation failure and capacitive coupling (a leakage of current that happens when a capacitor is present and two conductors are separated by an insulator). In capacitive coupling, current passes through intact insulation. Many factors set up this phenomenon, including patient tissue, trocar type and placement of monopolar instrumentation. The patient’s bowel may be close to the leaked current, which will take the path of least resistance to the return electrode. Active electrode shielding continuously monitors instruments and returns all current safely to the generator through the protective shield. It automatically alarms and doesn’t allow activation of monopolar energy if insulation fails or capacitive coupling occurs. Because the safer instruments look and function like conventional instruments, the transition in our 28 ORs seven years ago was seamless. We’ve eliminated duty cycles on those devices, because active shielding catches instrument failure. Best of all, we’ve actually saved money.

4. Take intraoperative precautions.
Four other steps that decrease (but don’t eliminate) the chance of capacitive coupling:
• Activate the electrode when touching tissue.
• Clean the active tip routinely during surgery to prevent eschar buildup, which can cause tissue to stick and set up resistance to current flow.
• Don’t use a hybrid system of reusable and single-use trocars.
• Visually inspect instruments throughout each procedure.

Ms. Dennis (vdennis@ghsnet.org) is the advanced technology coordinator for Promina Gwinnett Health System in Georgia.

Statistics That May Shock You

• A study by the Physicians Insurer Association of America in 2000 that examined 1,426 claims addressing devices causing injury found that the cause in 5.38 percent was listed as electrosurgery.
• When patients are burned, they usually don’t present with symptoms until three to five days post-op.
• Even with antibiotic therapy, about 25 percent of patients who develop peritonitis die.
• Only about one in 20 hospitals nationwide takes advantage of AEM technology, which prevents capacitive coupling and insulation failure.

— Vangie Dennis, RN, CNOR, CMLSO