Electrosurgery Saftey
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Electrosurgery Saftey

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This is a CEU talk that I gave to the nurses at St Joseph Health Center concerning electrosurgical safety.

This is a CEU talk that I gave to the nurses at St Joseph Health Center concerning electrosurgical safety.

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  • “ All matter is made up of atoms. Atoms consist of electrons (negatively charged), protons (positively charged), and neutrons (neutral) particles. Atoms that contain equal numbers of electrons and protons are charge neutral. When forces are introduced that cause electrons to leave their base atoms and move to other atoms, the charges of the atom are changed: those with fewer electrons than protons become positively charged, and atoms with more electrons than protons become negatively charged. During movement, like charges repel each other and unlike charges attract. This electron movement is termed electricity. There are two natural properties of electricity that can impact patient care in the operating room.” (1) Electricity always seeks ground (its source) and seeks the path of least resistance. Electrosurgery Continuing Education Module , www.valleylabeducation.org
  • Review definitions on slide. Additional commentary for each slide may include: Current is the flow of electrons during a period of time, measured in amperes. The generator is the source of the current. Circuit is the pathway for the uninterrupted flow of electrons (must be complete or closed to flow). Explain the difference between an open (broken or interrupted) and closed (completed or uninterrupted) circuit. Emphasize that the circuit must be closed or completed for the current to flow. Describe the flow of current in a monopolar electrosurgical circuit (i.e., generator . . . active electrode . . . patient . . . return electrode . . . generator). Impedance/Resistance is the obstacle to the flow of current, measured in ohms (impedance = resistance). The patient’s tissue provides the resistance to the flow of the current. When current overcomes resistance (patient’s tissue provides the resistance), heat is generated that does the work of electrosurgery. Voltage is the force pushing current through the resistance, measured in volts. Emphasize that as the voltage goes up, the surgeon’s control goes down. ____________________ Suggested DEMO: Illuminate the light bulb Using a 40 watt clear incandescent bulb and with the generator set at 40 watts in cut, illuminate the light bulb. Describe the circuit, the flow of electrons to the bulb, current overcoming the impedance of the filament, generating light and heat .
  • When current is concentrated, heat is produced. The amount of heat produced determines the extent of tissue effect. Current concentration or density depends on the size of the area through which the current flows. Hold up a pencil and a pad for the audience to see while asking the question: “ What’s the difference between these two electrodes?” Pause for audience response: The size or surface area. A small area that concentrates the current offers more resistance, which necessitates more force to push the current through the limited space and, therefore, generates more heat. Because the electrosurgical pencil is referred to as an active electrode, many people think of the return electrode as inactive, passive, or neutral. The determining factor of whether enough heat is generated to produce a burn is the size of the surface area through which the current flows. The more concentrated the energy, the greater the thermodynamic effect. There should be minimal temperature rise at the return electrode (pad) site, if it is applied correctly. A large area offers less resistance to the flow of current, reducing the amount of heat produced. _____________________________ Suggested DEMO: High Current Concentration/Low Current Concentration Wrap pad around orange/lemon. Key Coag to surface. (Low concentration on orange/lemon surface, high current concentration at electrode tip.) Impale orange/lemon with pencil, key Coag, and barely touch fruit to pad surface. Major sparking occurs (high concentration at pad site). Current entering or exiting the patient, anywhere in the circuit where current is concentrated, heat is generated.
  • Even though each waveform looks significantly different, each is set at 50 watts. Power is a derived number, calculated by multiplying current or amps by voltage. For example, 50 watts could be produced by 10 amps times 5 volts or, conversely 5 amps times 10 volts. While each variation would produce 50 watts, the tissue effect would be different. Note that the cutting waveform on your left is delivering electrons 100% of the time. This uninterrupted or constant waveform is described as a 100% duty cycle. The amperage is constant and, therefore, high, needing less voltage to produce 50 watts. This lower voltage is demonstrated by the lower peaks or spikes (peak-to-peak voltage) shown on the graph. The constant flow of electrons to the cells causes extensive heat to be produced. Cellular cooling does not occur. The coagulation waveform on the your right is producing current flow only about 6% of the time, meaning that electrons are being delivered to the tissue in intermittent bursts. This requires very high voltage, as shown by the higher spike (peak-to-peak voltage) on the graph. (To achieve 50 watts with less amperage requires higher voltage.) These intermittent bursts of current heat up the cells and are followed by the off time when no current is flowing. Moisture is driven from the cells, denaturing the protein, causing the cell walls to collapse and a coagulum to form. In the center of the graph is the blend waveform. It is an alteration of the Cut waveform and is not influenced by the Coag setting. Blend is NOT a combination of the Cut and Coag waveforms. The Blend waveform offers the surgeon cutting or tissue vaporization with more hemostasis when compared to pure cut. With Blend, the voltage is progressively increased to compensate for the reduced flow of electrons. This alteration of the duty cycle allows some cellular cooling and produces simultaneous hemostasis. The on-off percentages of the duty cycle in Blend will vary from generator to generator. Adjustments to the Coag setting have no effect on the Blend mode. “ Can you cut with the coagulation waveform?” This is a commonly employed technique used by many surgeons. This slide demonstrates that it is possible to cut with any of the waveforms. A standard blade electrode was used in all of these examples. In each the electrode was moved through the tissue at the same rate of speed and power setting. The only difference was the waveform selected. On your left is the cut created by the cut waveform. Pure cut was able to cut farther per increment of time. Note that there is minimal thermal effect and no carbonization or “charring”. This is a result of the 100% duty cycle which produces heat so rapidly and efficiently that instantaneous cellular explosions occur. These cellular explosions create the most effective cutting or vaporization. The extremely high heat dissipates in the steam from cellular explosion. This prevents most heat from spreading laterally into adjacent tissue. On your right is the cut created by the coag waveform. The 6% duty cycle is inefficient at heat production, greatly reducing the incidence of cellular explosions. Much of the heat produced spreads laterally to adjacent tissue, creating a carbonized and desiccated surface. Note that the length of the cut is shorter due to the drag resulting from the inefficient production of heat. The blended waveform as demonstrated by the center cut may be an appropriate intermediate selection. The changes in voltage and duty cycle affect the length of the cut and the amount of thermal spread.
  • It is common knowledge that if an individual sticks his or her finger into an electrical outlet, there will immediately be a shock, leading to a burn, and ultimately death by electrocution. The current coming from an electrical outlet is 110 volts traveling at 60 Hertz, or cycles, per second from negative to positive poles causing neuromuscular stimulation. If an electrosurgical generator can produce as much as 10,000 volts, why isn’t the patient electrocuted during its use? (Pause and encourage audience response) Radio frequency current is electrical current that oscillates between negative and positive poles at over 100,000 times per second. This frequency results in little or no neuromuscular stimulation occurs. Frequencies above this range could be safely used to heat tissue with no danger of electrocution. These frequencies also happen to be in the range of AM radio transmission and with sufficient amplitude, can interfere with other electrical devices. This interference is called radio frequency leakage. Today’s electrosurgical generators operate safely at radio frequencies of 200 KHz to over 3 MHz .
  • Many electrosurgical units have two modes of functioning: monopolar (also called unipolar) and bipolar. This slide shows a monopolar circuit. In the monopolar mode, only the active electrode is in the operative wound. The return electrode is placed at some other location on the patient’s body. Current flows through the patient’s body, between the active electrode and the return electrode. Monopolar electrosurgery is used for tissue cutting, fulguration, and desiccation. Monopolar electrosurgery uses high voltage with voltage between 3,000 volts and 9,000 volts in coag and 1,350 volts and 4,000 volts in cut.
  • With the bipolar mode there are still two electrodes, an active and a return electrode. They are both incorporated into the same instrument. In this example, the current flows between the tips (simplistically, one is the active and the other is the return) of the bipolar forceps that are grasping tissue. Because the current flows from one tip (electrode), through tissue, to the other tip (electrode) the circuit is completed without current traveling through any other part of the patient’s body. A return electrode (pad) is not needed for a bipolar procedure. The tissue effect of bipolar electrosurgery, when forceps are used, is desiccation, because the tines of the forceps are in direct contact with the tissue. Other instrumentation is available that allows cutting during bipolar procedures. A benefit of bipolar electrosurgery is the use of lower voltage to push the current through the tissue. Because the forceps grasp only a small amount of tissue, the resistance is low. Consequently, the amount of voltage required will be low.
  • Electrosurgical devices have changed and evolved over the years. It has been a journey of safety with each technological innovations making the generators safer and more effective.
  • “ The introduction of the electrosurgery unit contributed to the provision of larger and more extensive exposures; allowed for longer operating times in which greater care could be taken to identify, dissect tumors; and led to a reduction in infection rates and anesthesia risks……” Vender, J.R., Miller, J., Rekito, A. and McConell, D.E. (2005). Effect of hemostasis and electrosurgery on the development and evolution of brain tumor surgery in the late 19 th and early 20 th centuries. Neurosurgery Focus, 18(4); 1 – 7. In a 1927 lecture in Glasgow, Scotland, Harvey Cushing said, “ When I first had the good fortune to see this loop being used bloodlessly to scoop out bits of tissue from a malignant tumour for the purposes of biopsy, I foresaw that a new tool had been put into our hands to facilitate the piecemeal removal of tumours. With Dr. Bovie’s co-operation, during the past few months I have gained sufficient familiarity with the instrument to realize that it holds out untold possibilities for the future of neurosurgery.” From 1927 lecture in Glasgow, Scotland. Horrax, G. (1981). Some of Harvey Cushing’s contributions to neurological surgery. Journal of Neurosurgery, Vol 54, April, 1981; 436-447. This slide depicts a ground referenced generator. This type of generator significantly increases the patient’s risk for burn injury at the return electrode site or at alternate pathway sites. As shown in this slide, the intended circuit is: from wall outlet  generator  active electrode  surgical site  return electrode  generator  through wall outlet to earth ground. However, the current does not have to follow this pathway (circuit). Any pathway to earth ground is a potential avenue. When the return electrode is placed on a patient, it is hoped and assumed that the return electrode will be the most conductive pathway for the current to exit and return to ground. If the current does exit at the return electrode site, there will most likely not be a burn because the current has been safely dispersed over a wide contact area (low current concentration). However, if the current does find an additional pathway of lower resistance, it may exit the patient at an alternate site. A burn could occur if the exit site is small (high current concentration). It is also possible for an alternate site burn to occur even if the return electrode is placed on the patient. If there is a problem with the quality or quantity of contact at the return electrode/patient interface, or if the return electrode site is not the pathway of least resistance, then a portion or all of the current could potentially exit at a more conductive site. If current concentration is high enough at the exit point, a burn could occur. An alternate pathway could be a result of current division (part of the current exits at some site other than the return electrode). Once again, if the current exits the body at a site that has a small surface area, such as the tip of a finger touching a conductive surface or an electrocardiograph lead, the current will concentrate and a burn may result. Consequently, always use ground referenced generators with extreme caution. Most ground referenced generators used return electrodes that had a single plate configuration.
  • Note the possible paths to ground in the operating room, as shown in this illustration. The potential alternate ground paths are designated by the symbol for universal ground. Anyone or anything that touches the patient and is in contact with ground could become a pathway, enabling the current to complete its circuit. In 1995 ECRI published a Health Devices notice that ground referenced generators were unsafe and should not be used. ECRI (1995). Are Bovie CSV and other spark-gap electrosurgical units safe to use? Health Devices, Vol. 24, No. 7; 293-294
  • The alternate site injury shown here happened because the current exited the patient someplace other than the return electrode site. The current exited the patient’s body through an electrocardiograph lead, concentrating the current and resulting in a burn. The use of a ground referenced system greatly increases the patient’s risk of experiencing this type of injury. The use of isolated electrosurgery generators has minimized this risk (1). (1) Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO
  • Solid-state generators were introduced in 1968. The units were much smaller and used “isolated” circuitry. In isolated units, the electrical current produced by the generator is referenced to the generator and will ignore all grounded objects that may touch the patient except the return electrode. With isolated generators current division cannot occur and there is no possibility of alternate site burns. An isolated generator will not work unless the patient return electrode is applied to the patient. However, without additional safety features, the generator cannot determine the status of the contact at the pad/patient interface. Should the patient return electrode be compromised in the quantity or quality of the pad/patient interface in some way during surgery, a return electrode burn could occur. The perioperative nurse must be certain that the patient return electrode is in good contact with the patient throughout the surgical procedure. (1) ( Electrosurgery Continuing Education Module ) The diagram on this slide depicts an isolated generator. Note how the current from the wall outlet enters the generator and then returns to ground. As it passes through the generator, an isolated current is generated. It is this second current that is delivered to the patient. This current recognizes only the generator as ground. If it does not have a pathway back to the generator, the current will not flow. In other words, if the circuit from the generator to the patient and back to the generator through a return electrode is not complete or closed, the current will not flow. Electrosurgery Continuing Education Module , www.valleylabeducation.org ECRI (1995). Are Bovie CSV and other spark-gap electrosurgical units safe to use? Health Devices, Vol. 24, No. 7; 293-294 _____________________ Suggested Demo: Isolation – Light the light bulb with pad on arm. Remove pad and attempt to light the bulb. When this fails, firmly place flat side of blade on tongue and key cut. This type of generator significantly reduces the patient’s risk for an alternate site burn secondary to current division, because the current is referenced back to the generator. Isolation does not prevent pad site burns. If an isolated generator is not equipped with a contact quality monitoring system, a burn at the return electrode site may occur because of insufficient return electrode contact or conductivity.
  • This slide shows a return electrode site burn that occurred using a noncontact quality monitoring (split) PRE because of a compromised return electrode-patient interface. 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. (1) (1) Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO.
  • “ Patient return electrodes employing a contact quality monitoring system were introduced in 1981. Contact quality monitoring uses a split pad system whereby an interrogation current constantly monitors the quality of the contact between the patient and the patient return electrode. If a condition develops at the patient return electrode site that could result in a patient burn, the system deactivates the generator while giving audible and visual alarm signals. This represents a major safety device for patients and perioperative personnel since return electrode burns account for a majority of patient burns during electrosurgery. According to ECRI many electrosurgery burns could be eliminated by a patient return electrode quality contact monitoring system (ECRI, 1999).” (1) Pad site burns are a result of increased resistance and heat in the tissue under the patient return electrode. There are many factors that contribute to a rise in resistance and heat production at the pad site including (but not limited to): Excessive hair Adipose tissue Bony prominences Gel dry out Irregular body contours Partial removal of the return electrode A contact quality monitoring system measures the resistance under the patient return electrode and allows the generator to operate only within the preset safe parameters. The generator sends out a low voltage interrogation current through the return electrode cable. The current passes from one side of the split pad, through the patient’s tissue to the other side of the pad, and then back to the generator. Should the resistance at the pad site deviate from the safe range, the generator will alarm (both visually and audibly) and shut down, no longer delivering therapeutic current to the patient. Electrosurgery Continuing Education Module , www.valleylabeducation.org , accessed 20070608. ECRI (1995). Are Bovie CSV and other spark-gap electrosurgical units safe to use? Health Devices, Vol. 24, No. 7; 293-294 ____________________ Suggested DEMO : REM — Light a standard light bulb with the contact quality monitoring pad attached to your arm. Slowly pull the pad off of your arm by stepping on the cord and gently pulling upward with your arm. As the pad becomes dislodged, the generator will alarm and shut down.
  • In 1995 tissue response technology was made available to the clinical practitioner. This technology uses a computer-controlled tissue feedback system that senses tissue impedance (resistance) at the active electrode site. The generator automatically adjusts the current and output voltage 200 times per second in the cut and blend modes to maintain a consistent surgical effect. This results in the use of lower power setting and voltages in the cut and blend modes, which helps to reduce the risk of patient injury. (1) Electrosurgery Continuing Education Module , www.valleylabeducation.org , Eggleston, J.L., Kennedy, J.S. Platt, R.C., and Taylor, K.D. (1997). ‘Instant Response’ electrosurgery generator for laparoscopy and endoscopy. Minimally Invasive Therapy & Allied Technology, Vol 5. No 6: 491-495
  • The clinical benefits of tissue response technology includes: Reduced lateral thermal spread Reduced need to adjust power settings Reduced video interference Minimized sparking Electrosurgery Continuing Education Module , www.valleylabeducation.org , There is obviously less thermal spread and tissue destruction when using tissue response electrosurgery generators but when introduced it was only available in the cut (yellow) mode. Pollinger, H.S., Mostafa, G., Harold, K.L., Austin, C.E., Kercher, K.W., Matthews, B.D. (2003). Comparison of wound-haling characteristics with feedback circuit elecrosurgical generators in a porcine model. The American Surgeon, Vol. 69; 1054 – 1060. Additionally, the power curve of tissue response generators remains constant over tissues of varying ohms of resistance.
  • Tissue fusion is a technology uses a unique combination of pressure and low voltage energy (180 volts with first generation and 120 volts with second generation) to permanently fuse tissue and vessels up to and including 7 mm in diameter without clips, sutures, or other mechanical ligation devices. The photographs show an example of a tissue fusion sealed vessel. “ The LS has the highest burst pressure and fastest sealing time and was the highest rated overall. The HS produced the lowest thermal spread and smoke but had the lowest mean burst pressure. The GP had the highest smoke production, and variable burst pressures. Despite employing nanotechnology, the ES device was the slowest and had variable burst pressures.” Lamberton, G.R., His, R.S., Jin, D. H., Linder, T. U., Jellison, F. C., and Bladwin, D. D. (2008). Prospective comparison of four laparoscopic vessel ligation devices. Journal of Endourology, 22 (1); 2307-2312. Verhoeff Van Gieson elastic stain of an artery from a porcine kidney. The black fishnet patters are the elastin fibers. They show a long and connected pattern. The red is collagen, and the black dots are the nuclei. The yellow is background stain which stains the muscle and connective tissues.
  • Radiofrequency energy generates heat within the tissue to drive out water and denature proteins. When pressure is added, the opposing layers of the denatured proteins fuse together.
  • Clinical benefits of tissue fusion include: The possibility of reduced blood loss in some surgical procedures Reduced risk of retained needles and needlestick injuries No dislodged clips Reduced lateral thermal spread, sticking, and charring No foreign material left behind Leaves tissue in its normal anatomical position The tissue fusion technology has further reduced thermal spread increasing patient safety. Experience with a New Energy Source for Tissue Fusion in Pediatric Patients Ponsky TA1, Rothenberg SS2. 1University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA; 2Presbyterian/St. Luke’s Medical Center, Denver, Colorado, USA Introduction: Options for effective techniques for vessel and tissue sealing in infants and children are limited because of the size and limited intracorporeal space of many pediatric patients. We evaluated a new energy source, The ForceTriad™ (Covidien Energy-Based Devices, (formerly Valleylab, Boulder, CO) LigaSure, which delivers both monopolar and bipolar energy in a 5 mm format, that allows for tissue fusion and vessel sealing and division. This report documents our experience with this device. Methods: A database review was performed looking for all cases that were performed in children using the ForceTriad LigaSure as the main source of homeostasis and tissue fusion. Two different handpieces were used: a fine Maryland Dissector type instrument with no cutting blade (LigaSure Lap), and a sealer/cutter (LigaSure V), both in a 5mm format. Results: A total of 60 cases were performed in children from September, 2006 to September, 2007 using the ForceTriad. The two most common cases were Nissen fundoplication (40) and lung lobectomy (11). Other procedures included, excision of choledochal cyst (3), aortopexy, closure of bronchopleural fistula, resection of a giant thymic cyst (1), thymectomy (1), parathyroid adenoma excision (1), total colectomy (2), and intestinal duplication resection (2). There were no failures of vessel or tissue fusion and no operative complications. A delayed hydropneumothorax developed in one lung resection and spontaneously resolved. Conclusion: The ForceTriad provides a safe and effective energy source in a 5 mm format. As compared to previous versions of the LigaSure there is less sticking, a quicker seal, and no tissue fusion failures. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Annual Meeting. Philadelphia, Pennsylvania; April 9-12, 2008. Program Number ETP005.
  • In 2006 tissue sensing energy technology was made available to the clinical practitioner. The tissue sensing energy system communicates information about the patient’s tissues back to the platform making each surgical procedure custom and specific to each patient. It senses tissue resistance and adjusts output voltage, current, and power every 300 microseconds or 3,333 times per second in all modes to maintain a consistent surgical effect. Human perception starts at 150 milliseconds—in that time the tissue sensing technology has made 483 decisions. This technology uses lower power settings and voltages in all modes, which helps to reduce the risk of patient injury.
  • The electrosurgery mode device has a clear button that activates the new tissue sensing energy platform. The clear third button which allows the surgeon to make full use of the capabilities of the energy platform by activating a special electrosurgery mode that provides hemostasis with tissue dissection at the same time. Hemostasis with division mode provides a unique combination of monopolar hemostasis and dissection while using a lower power setting resulting in less char, less thermal spread, less arcing and smoother passage through tissue than a traditional coagulation mode. There is a difference in the waveforms generated by the different technologies. The more controlled wave form of tissue sensing provides the surgeon with a better tissue effect that includes less thermal spread, lower power settings, and consistent tissue effect.
  • According to AORN Recommended Practices for Electrosurgery, Recommended Practice III, the ESU and accessories should be used according to manufacturer’s written instructions. Each type of ESU has specific manufacturer’s written operating instructions to be followed for safe operation of the unit. For all products and devices used in the operating room instructions for use can be found not only in the Users Guide, but also on package wrappers and on instructions in the shipping carton or package. All are important for the safe use of the product. (1) Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO.
  • Prior to generator use, set the activation tone to an audible level and test the alarm systems to ensure that the tones can be heard. All alarms should be tested to assure the ESU is functioning appropriately. The activation tone alerts the surgical team when the generator is delivering RF energy. (1) When plugging accessories into the bipolar and monopolar receptacles, ensure that the accessory is plugged into the correct receptacle. Plugging an accessory into the wrong receptacle can result in patient injury, staff injury, as well as damage to the instrument. Also, examine all instruments and connections to the system before using. Ensure that the instruments function as intended. Improper connection may result in arcs, sparks, instruments malfunction, or unintended surgical effects. (2) Confirm proper power settings before proceeding with surgery. If the proper power settings are not know, set the power to a low setting and cautiously increase the power until the desired effect is achieved. If increased power settings are requested, check the patient return electrode and all instrument connections before major power setting adjustments. (3) (1) Valleylab Force Triad User’s Guide, 2006, Boulder: CO, p. 2-3 (2) Ibid, p, 2-3 3) Ibid, p. 2.2
  • Always follow the manufacturer’s written instructions that are found on patient return electrode packaging and in package inserts. When choosing a patient return electrode site, look for a well vascularized muscle mass and a convex area. Apply the patient return electrode close to the surgical site. Hotline News (September, 2000). Patient Return Electrode Lesions ; Boulder, CO: Valleylab Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO.
  • Always assess the patient for the presence of a metal prosthesis and other types of implants. It is important to determine the exact implant site. The presence of scar tissue around prosthesis creates an area of increased resistance. Also, scar tissue is high resistance tissue and may cause current to concentrate at adjacent points of low resistance tissue. Like internal scar tissue, skin surface scar tissue is high in resistance and, therefore, should be identified prior to placing the return electrode. Avoid bony prominences because these sites are high in resistance and may cause a pressure point at the patient return electrode-patient interface. Excessive hair affects the patient’s resistance and interferes with the ability of the return electrode to adhere to the patient. The decision to remove hair must be based on the amount of hair at the site and the manufacturer’s instructions concerning hair removal. “ Sites with excellive hair, bony prominences, excessively dry skin, or excellive adipose tissue must be avoided because they provide resistance to the flow of electrons. After a pad is placed on the patient, the patient should not be repositioned.” [Ball, K.A. (2004). Lasers: The Perioperative Challenge, 3 rd Ed. Denver, CO: AORN; pg 23. Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO.
  • Always follow the manufacturer’s instructions for hair removal, cleaning, and drying the patient return electrode site. Hair removal may be necessary to ensure a quality patient return electrode-patient interface, particularly when using a non-contact quality monitoring system. During skin preparation, exercise extreme care to prevent fluid invasion of the return electrode. When preparing the patient return electrode site, do not use flammable agents, such as acetone or alcohol to degrease the skin when you are concerned about the ability of the PRE to adhere to the skin. Use of these products could contribute to an ignition incident if not completely evaporated prior to attaching the PRE or draping the patient. Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO.
  • The active electrode should be placed in a clean, dry, well-insulated safety holster when not in use to minimize the risk of injury from unintentional activation. Injuries have resulted when the active electrode has been left lying on the patient between uses. Electrodes that do not fit in the holster should be placed in a designated location with tips away from flammable material (eg, drapes). The active electrode tips should be securely seated into the hand piece. A loose tip may cause a spark or burn to tissue contracting the exposed, noninsulated section of the tip. Recommended Practices for Electrosurgery, AORN Standards, Recommended Practices and Guidelines , 2008
  • “ Frequent cleaning of the electrode tip is recommended. As eschar builds up on the tip, impedance increases and can cause arcing, sparking or ignition and flaming of the eschar. When cleaning the electrode, the eschar should be wiped away using a sponge rather than the common scratch pad, because these pads will scratch grooves into the electrode tip, increasing eschar buildup.” Massarweh, N.N., Cosgriff, N. & Slakey, D.P. (2006). Electrosurgery: history, principles, and current and future uses. J Am Coll Surg, 202(3) ; 520-530. Excessive eschar buildup at the operative site and on the active electrode tip greatly increases resistance. Also, the accumulation of eschar on the active electrode presents a significant fire hazard. With sufficient heating, eschar can become a glowing ember and pose a fire hazard both as an ignition source and as a fuel. If eschar is present, the scrub person should remove it according to the manufacturer’s recommendations. Scratch pads are used to remove this eschar buildup, but with each scratch micro grooves are left behind. The use of a nonstick active electrode tip facilitates the removal of eschar, however, it does not eliminate the need for frequent cleaning. Tips made of material such as elastomeric silicone that can be wiped off with a damp sponge are preferable. Electrodes can be heated to extremely high temperatures immediately after activation. Using a damp sponge will reduce the risk of accidental ignition of the sponge. Note the picture of a stainless steel blade after two minutes of use in Cut. The eschar remains on the blade after cleaning with a scratch pad.
  • Surgeons worry about accidental burns to tissue edges from the noninsulated portion of the shaft of the active electrode tip. In order to prevent this from happening it is a common practice to shield the tip with a piece of red rubber or other material such as steri-strips or needle electrode plastic covers. The ECRI warns against this practice. Besides altering a medical device, sheathing materials can serve as a fuel source and may ignite during the procedure. Electrodes that come pre-shielded are available from ESU manufacturers. Manufacturer insulated electrodes must be kept free of eschar build-up and used according to the manufacturers instructions.
  • Radiofrequency current, unlike the 60 cycle current from the wall outlet, can and does “leak” through the insulation on the cord or electrode. No matter how thick the layer of insulation is, there will be some current leakage with the use of this high frequency current. The higher the voltage, the more insulation it can overcome, resulting in a higher amount of leakage current. Consequently, avoid wrapping active electrode cords around metal instruments and bundling cords together. ____________________ Suggested DEMOS: Wrap ES pencil cord around fluorescent light and activate Coag to illuminate light bulb or wrap ES pencil cord around a hemostat and activate Coag while having the tip of the hemostat in contact with a piece of fruit, such as an orange.
  • No data indicate that using electrosurgical techniques in the pregnant patient has any untoward effect on the fetus at any stage of development. The fetus, bathed in electrolyte-rich amniotic fluid, is protected from any concentration of electrical current owing to the dispersion effect bathed in electrolyte-rich amniotic fluid, is protected from any concentration of electrical current owing to the dispersion effect. Just as the radio wave frequency of all generators is above the cardiac effect (the level that stimulates muscle contraction) for adult electrosurgery, the same is true for the fetus. Te Linde's Operative Gynecology Text, Eighth Edition, Chapter 16, page 330
  • If the patient has an external or internal pacemaker, use electrosurgery with extreme caution. The electrosurgery generator can cause pacemakers “to enter an asynchronous mode or can block the pacemaker effect entirely.” Before using electrosurgery on a patient with a pacemaker, consult with the pacemaker manufacturer or facility cardiology department. Bipolar electrosurgery is the preferred modality for the patient with a pacemaker, because of lower voltages needed to push the bipolar current through the patient’s tissue. Apply the return electrode so that the current will flow between the active electrode site to the return electrode without passing through the area of the heart or pacemaker implantation site. Ensure that the distance between the active and return electrode sites is as short as possible, but as far as possible from the pacemaker site. Do not lay the active electrode or cord across the pacemaker. When activated, leakage current may inadvertently cause the pacemaker to activate.
  • Preoperative cardiology consult to evaluate correct functioning and determine risks Defibrillator immediately available Deactivate the ICD before ESU use. Using electrosurgery on a patient with an activated ICD may trigger an electrical shock to the patient. Continuous ECG and peripheral pulse monitoring. Use bipolar as an alternative whenever possible. If monopolar used, ensure distance between the active and patient return electrode is as short as possible. Avoid current flow through heart and ICD. AORN, Standards, Recommended Practices, and Guidelines, 2008 Edition, Denver, CO: AORN Donnelly, P.Pal, N.Herity, N.( 2007). Perioperative Management of Patients with Implantable Cardioverter Defibrillators. N.Ulster Med J. 76(2): 66–67
  • With the increase of body piercing, this has become an issue facing many perioperative nurses. Both the AORN Recommended Practices 2008 and AORN Journal in July 1999 have reinforced their current stance that all jewelry should be removed. Even with the use of an isolated ESU, it would be possible for current to concentrate at the site of the jewelry or body piercing metal as it travels through the patient’s body from the surgical site to the PRE. If jewelry cannot be easily removed and will not physically interfere with surgical procedures: Optimize the skin-to-jewelry interface by covering the item with gauze (a small 2x2) and taping it into place. Remove any jewelry that is in the direct path of the current from the active electrode to the return electrode. Avoid direct contact to the jewelry item with the activated electrode tip. Avoid direct contact to metal jewelry with a deactivated electrode to prevent conduction of residual heat. Clinical Information Hotline News, June 2000
  • Avoid placing the dispersive electrode over a tattoos. (1) Inks (red in particular) contain metals which could serve as a heat or electrical conductor. (2) Although there have been no reported electrosurgery injuries from patient return electrodes placed over tattoos, superheating of the tissue has occurred during magnetic resonance imaging, therefore, it is prudent to avoid this site when possible. 3(1), (2) Recommended Practices for Electrosurgery, Standards, Recommended Practices, and Guidelines (2008). AORN. Denver: CO. Valleylab Clinical Hotline Form Letter to Customer concerning placement of patient return electrode over tattoos (3) AORN, Ibid.
  • Electrosurgical generators run at a radio frequency (RF) of 200 kHz to 3.3 MHz. There is always a certain amount of high and low RF leakage from all electrosurgery equipment in the market place. Therefore, there is concern about the effect of this leakage on any medical devices owned by or used on patients in surgery. Research shows that the only hearing aids that have been adversely affected by (RF) leakage have been exposed to radio frequencies much higher than electrosurgical units. The one documented event that was related to a security system that runs at a frequency of 900 MHz. Generally speaking, there are no safety dangers caused by RF leakage to hearing aids worn into surgery, as long as they do not interfere with the surgical procedure itself. However, it is recommended that a hearing is not worn during surgery when electrosurgery is used. The RF leakage will potentially cause some interference to the hearing aid reception and if the patient is awake and unable to make adjustments because of restraints, this could cause considerable irritation and/or discomfort to the patient. Such things as garage door openers, microwaves and cellular phones can also affect hearing aids. When interference does occur, the wearer must be able to adjust in order to eliminate the interference. Two piece hearing aids can be damaged by the radio frequencies of electrosurgical generators. These are not to be worn into any electrosurgical procedure. For electrosurgical safety, it is recommended all unnecessary items such as jewelry, glasses and hearing aids be removed. Per Telex, a hearing aid manufacture, hearing aids should be removed unless they are necessary for the successful completion of the procedure. (1), (2) (1) Telex Hearing Aid Manufacture (2) Valleylab Clinical Hotline Form Letter concerning hearing aids and electrosurgery, November 17, 2005 (3) ECRI (2003). Talk to the Specialist: Hearing aids and emi. Health Devices, 32(11). IMAGE: Accessed on 2/17/2007 from Micro-Sharp Hearing Centers Web Page, http://www.microsharphearingcenters.com/page2.html
  • Why do surgical team members sometimes get shocked while holding a hemostat? A hole in their glove, frequently blamed for this occurrence, is actually a result of the shock. The current applied to the hemostat that is clamped to the bleeding vessel will travel to the tissue, seeking the return electrode and thus attempting to complete the circuit. As the tissue is desiccated, the resistance rises. When the resistance reaches a point where the path of least resistance becomes the person holding the hemostat, the current will take that path. Scrubbed members of the surgical team frequently are touching the patient and are therefore putting themselves in circuit. The manufacturers of electrosurgical generators do not recommend that surgeons use the technique of “buzzing the hemostat”. However, it remains a commonly employed method of achieving hemostasis and there are techniques that can reduce the potential for being shocked. The techniques shown are for stainless steel electrodes. Helpful hints: Grasp the hemostat with a firm grip over a large surface Do not activate in open circuit – the pencil should be in contact with the hemostat before activating Use the cut waveform because it is low voltage and will not produce large bursts of energy Use the lowest power setting possible Do not put yourself in the circuit.
  • Surgical smoke is called by a variety of names, including cautery smoke, diathermy plume, plume, smoke-plume, aerosols, bio-aerosols, vapor, and air contaminants. It can be seen and smelled (Figure 2). Surgical smoke is the result of the interaction of tissue and mechanical tools and/or heat producing equipment such as those that are used for dissection and hemostasis. Both the visible and the odorous components of surgical smoke are the gaseous byproducts of the disruption and vaporization of tissue protein and fat (Ott, 1997). Ott DE. Smoke and particulate hazards during laparoscopy procedures. Surgical Services Management . 1997;3(3): 11-13.
  • Smoke has been described as part of the chemical soup that is present during the care of perioperative patients.
  • The chemical composition of surgical smoke has been well documented. Barrett and Garber identified a long list of chemicals present in surgical smoke (Table 3). Two of the chemicals of concern were acrylonitrile and hydrogen cyanide. Acrylonitrile is a volatile, colorless chemical that can be absorbed through the skin and lungs. Acrylonitrile liberates hydrogen cyanide. Hydrogen cyanide is toxic, colorless and can also be absorbed into the lungs, through the skin and via the gastrointestinal tract. (Barrett, 2004). Hollmann and colleagues in Switzerland conducted experiments to determine the chemical composition of surgical smoke. Using laser photoacoustic spectroscopy they identified 11 different gases that could be classified as toxic and mutagenic. Of concern in their study was the level of furfural present in surgical smoke, at a level of 12 times higher than recommended occupational exposure limits. Furfural is a solvent that acts as a strong irritant affecting the eyes, mucous membranes, lungs, and the central nervous system. Their conclusions note that the ,”potential danger from toxic and mutagen gas compounds, particulate material, and partly virulent virus DNA cannot be overemphasized.” (Hollmann, 2004). Benzene is another of the chemicals identified in surgical smoke. The OSHA sets permissible exposure limits (PELs) to protect workers from the hazards associated with inhaling benzene. Protection from inhaling benzene is mandated by OSHA because benzene is documented as being a trigger for leukemia (Ulmer, 1997). Awareness of some of the chemical components of smoke, recommended exposure limits, and the associated health effects is an important consideration in the education of surgical staff members. Barrett W L. Garber SM. Surgical smoke — a review of the literature. Business Briefing: Global Surgery; 2004:1-7. Hollmann, R., Hort, C. E., Kammer, E., Naegele, M., Sigrist, M. W. & Meuli-Simmen, C. (2004). Smoke in the operating theater: an unregarded source of danger. Plastic & Reconstructive Surgery, 114 (2): 458-463. Ulmer, B.C. (1997). Air quality in the operating room. Surgical Services Management, 3 (3): 18-21.
  • Our first two methods to reduce risk are limited in scope. The third and final option, to evacuate and filter smoke, is by far the best form of protection. Evacuation systems have three components: Capture device Vacuum source Filtration systems Point them out on the slide utilizing the picture of the smoke evacuator and capture device.

Electrosurgery Saftey Electrosurgery Saftey Presentation Transcript

  • Evidence-BasedRecommended Practicesfor Electrosurgery COVIDIEN, COVIDIEN with Logo and ™ marked brands are trademarks of Covidien or its affiliate. ©2008 Covidien or its affiliate. All rights reserved. R0005658
  • Program Content - Principles of electricity and electrosurgery - Electrosurgical safety innovations - Innovations in hemostasis and tissue division - Best practices for patient safetyCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Universal Properties of Electricity Electricity always . . . - Seeks ground (its source) - Seeks path of least resistanceCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 voltsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Current Concentration/DispersalCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • WaveformsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Frequency SpectrumCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Monopolar Return electrode at another site Active electrode at surgical site High voltage Current flows through the body Coag – 3,000-9,000 Cut – 1,350-4,000COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Bipolar Active and return electrodes within the instrument Current flow confined to tissue between electrodesCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Electrosurgery Safety Innovations 1968 – Solid state 1995 – Tissue response 2006 – Tissue sensing 1999 – Tissue fusion 1926 RF ESU 1981 – Return electrode monitoringCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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.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. R0005658further distribution or reproduction. R000658
  • Pathways to Ground Ground-referenced ESUs increase safety risks to patients and are not recommended for use. ECRI, 1995COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Isolated System Isolated ESUs decrease the risk of patient burns and are safer to use ECRI, 1995COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008 Non CQM (split) PREsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Contact Quality Monitoring Return electrode contact quality monitors help prevent patient burns. ECRI, 1995COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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, 1997COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 wattsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 arteryCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Tissue Effect of Fusion Uses energy to denature the collagen and elastin in vessel walls and rearrange the collagen and elastin into a permanent sealCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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, 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 coagCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Three Mode Device Three distinct output modes: BLUE Coagulation Cuts faster, bleeds less Clear Dissection with hemostasis Yellow CutCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Evidence-Based Practices For Electrosurgery Patient SafetyCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Follow Manufacturer’s Written Instructions ESU and accessories should be used according to the manufacturer’s written instructions AORN Recommended Practices 2008 Instructions are on package inserts and on package wrappers!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. R0005658further distribution or reproduction. R000658
  • General Safety Precautions Test alarm systems Set activation tone to audible level Plug accessories into correct receptacles Confirm power settingsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Patient Return Electrode Site Selection - Follow manufacturer’s written instructions - Well vascularized muscle mass - Convex area - Close to surgical site Hotline News, 2000COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Patient Return Electrodes Site Selection Prostheses Bony prominences Avoid sites high in resistance Ball, 2004 Scar tissue HairCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Active Electrodes “Frequent cleaning of the electrode tip is recommended.” Massarweh, 2006 Use a coated electrode to easily remove eschar buildup on electrode tip.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. R0005658further distribution or reproduction. R000658
  • 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 tipsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Radiofrequency Current Leakage - Active electrode cords should not be wrapped around metal instruments - Active electrode and other electrical cords should not be bundled togetherCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 Lindes Operative Gynecology Text, 8th EditionCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008 Donnelly, 2007COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 AORN Recommended Practices 2008COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Tattoos Avoid placing the patient return electrode over a tattoo. AORN Recommended Practices 2008 Inks (red in particular) contain metals which could serve as a heat or electrical conductor Clinical HotlineCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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, 2005COVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 currentCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • What is Surgical Smoke? The gaseous byproducts of the disruption and vaporization of tissue protein and fat.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. R0005658further distribution or reproduction. R000658
  • 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 neCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • 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 cellsCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Evacuate and Filter Smoke Evacuation System Components - Capture device - Vacuum source - Filtration systemCOVIDIEN, 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. R0005658further distribution or reproduction. R000658
  • Promote Patient and Staff Safety Through Best Practices “An educated perioperative staff is the patient’s best advocate”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. R0005658further distribution or reproduction. R000658
  • 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.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. R0005658further distribution or reproduction. R000658