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Proposed Recommended Practices
JULY 1993, VOL 58, NO 1
AORN JOURNAL
Proposed Recommended Practices ELEC‘ROSURGERY
T
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Committee (RPC) is interested in receiving comments on this proposal from members and others. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect varia tions in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, emergency departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by RPC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to Recommended Practices Committee AORN, Inc 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Attention: Mary O’Neale, RN, BS, CNOR
The deadline for comments is Aug 6 , 1993. Purpose. These recommended practices provide guidelines to assist perioperative personnel in the use of electrosurgical equipment in their practice settings. Proper care and handling of electrosurgical equipment is essential to patient and personnel safety. Electrosurgery is used routinely to cut and coagulate body tissue with high radiofrequency electrical current. These recommended practices do not endorse any specific product. Biomedical services in practice settings should develop detailed, routine safety and preventive maintenance inspections and maintain records.
Recommended Practice I The electrosurgical unit (ESU), dispersive electrode, and active electrode selected for use should meet performance and safety criteria established by the practice setting. Interpretive statement 1 : Information regarding adequate safety margins, in-factory testing methods, warranties, and a manual for maintenance and inspections should be obtained from the manufacturer. Rationale: Equipment manuals assist in developing operational, safety, and maintenance guidelines.’ The ESU should be used according to the manufacturer’s written instructions.2 Interpretive statement 2: The ESU should be designed to minimize unintentional acf ivation. Rationale: 131
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Unintentional activation may result in patient and personnel injury.3 Interpretive statement 3: The ESU cord should be of adequate length and flexibility to reach the outlet without stress or use of an extension cord. Kinks, knots, and curls should be removed from the ESU cord before it is plugged into the wall outlet. Rationale: Tension increases the risk that the cord will become disconnected or frayed, which may result in injury to patients and per~onnel.~ Use of extension cords may result in macroshock or micro~hock.~ Cords that do not lie flat on the floor produce a potential for tripping and/or accidental unplugging.(j Interpretive statement 4: The ESU plug, not the cord, should be held when it is inserted into or removed from an electrical outlet. Rationale: Pulling on the ESU cord may cause it to break at the point where the wire is attached to the plug.7 Cord breakage is dangerous to patients and personnel and is inconvenient, and replacements are costly.* Interpretive statement 5: The ESU should be inspected before each use. An ESU that is not working properly or is damaged should be reported, labeled, and removed immediately to be checked by the biomedical department. Rationale: Equipment is checked to ensure it is in good working order.9 The manufacturer's written safety precautions are followed for the wellbeing of the patient and personnel involved with the procedure.'O Interpretive statement 6: The ESU should be grounded properly. Rationale: Proper grounding reduces the risk of electrical shock to the patient and perioperative personnel.'' Interpretive statement 7: The ESU should be mounted on a movable stand that will not tip. Rationale: 132
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Safety measures for perioperative personnel and patients to prevent injury and damage to the ESU require the stand to be tip resistant and moved carefully.12 Interpretive statement 8: The ESU and all reusable parts are cleaned with care following use according to the manufacturer's written instructions. Rationale: The ESU surface should not be saturated or have fluid poured over it because this could permit chemical germicide into the generator and cause malfunction.13 Interpretive statement 9: When the ESU foot switch is used, perioperative personnel should cover it with a clear, impervious cover if recommended by the manufacturer. Rationale: Placement in a clear, impervious cover protects the foot switch from fluid ~pi1lage.l~ Interpretive statement 10: During the procedure, perioperative personnel should check the entire circuit if higherthan-normal power settings are requested by the operator. Rationale: The dispersive electrode, generator, or connecting cords may be at fault and should be checked for any possible malfunction or hazard. Shock to those touching the patient may result. The patient and/or perioperative personnel may be burned.15 Interpretive statement 11 : Each ESU should be assigned an identification number/serial number. Rationale: An identification number/serial number allows for documentation of inspections, routine preventive maintenance, and tracking of equipment function and problems.16
Recommended Practice II Perioperative personnel should demonstrate competency in the use of the ESU in the practice setting. Interpretive statement 1:
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Perioperative personnel should be instructead in the proper operation, care, and handling of the ESU before use.
Rationale: Instruction and return demonstration in proper usage helps prevent injury and extends th’e life of the ESU.17 Interpretive statement 2: A detailed manual of operating instructions should be obtained from the manufacturer and be available in the practice setting. A brief set of operational directions should be on or attached to the ESU.
Rationale: Each type of ESU has specific manufacturer’s written operating instructions that should be followed for the safe operation of the unit.’*
Recommended Practice III The ESU, active electrode, and dispersive electrode should be used in a manner that reduces the potential for injury. Interpretive statement 1: The ESU should not be used in the presence of flammable agents (eg, alcohol, tincture-based agents); have safety features (eg, lights, activation sound) and be tested before each use; have the cord, plug, and foot switch cord checked for exposed wires or frays in the insu1ation ; have power settings confirmed orally with the operator before activation and determined in conjunction with the manufacturer’s recommendations; be protected from spills; and be operated at the lowest effective power settings for coagulation and/or cutting. Rationale: Inspections of the ESU and all safety features should be performed before each use because of potential hazards.I9 The volume of the activation indicator should be adjusted to an audible level to alert perioperative personnel immediately when an ESU is activated inadvertently.20 Ignition of flammable agents by the active electrode has resulted in patient and peri-
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operative personnel injury.21Fluids should not be placed on top of the ESU, because unintentional activation or device failure may occur if liquids enter the ESU generator.22 Interpretive statement 2: The active electrode should fasten directly into the ESU in a labeled, stress-resistant receptacle (if an adapter is used, it should be one that is approved by the manufacturer and does not compromise the generator’s safety features); be inspected at the field for damage before use; be placed in a clean, dry, well-insulated safety holster (ie, recommended by the manufacturer for use with the ESU) in a highly visible area when not in use during a procedure; be impervious to fluids; be disconnected from the ESU if allowed to drop below the sterile field; and have a tip that is secure and easy to clean of charred tissue.
Rationale: Incomplete circuitry, unintentional activation, and incompatibility of the active electrode with the generator may result in patient injury.23
Interpretive statement 3: The dispersive electrode should be inspected before each use for wire breakage or fraying; be the appropriate size for the patient (ie, neonate/infant, pediatric, adult) and never be cut to reduce size; be placed on the positioned patient on a clean, dry skin surface, over a large muscle mass, and as close to the operative site as possible (ie, bony prominences, scar tissue, skin over an implanted metal prosthesis, hairy surfaces, pressure points should be avoided); fasten directly into the ESU in a labeled, stress-resistant receptacle if an adapter, which is approved by the manufacturer and does not compromise the generator’s safety features, is used; have connections that are intact, clean, and make effective contact; and 133
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maintain uniform body contact (potential problems include tenting, gaping, and liquids that interfere with adhesion). Perioperative personnel should check the status of the dispersive electrode and connection of the cable if any tension is applied to the cord or if the surgical team repositions the patient. If reusable, the electrode should have periodic inspections by the biomedical service for electrical integrity and as recommended by the manufacturer. Rationale: Wire breakage and frays can deviate current Incomplete circuitry may lead to patient i n j ~ r y . ~Adequate 5 tissue perfusion promotes electrical conductivity in the area and dissipates heat at the electrode contact surface.z6 Hair should be removed before applying the dispersive electrode according to the manufacturer’s written instructions. Hairy surfaces have poor adhesion and tend to insulate.27 There is potential for superheating if a dispersive electrode is placed on the skin over an implanted metal prosthesis. The important factor in the dispersive electrode is the actual surface area in contact with the patient. The amount of surface area affects heat buildup at the dispersive site.** Discussion: During some surgical procedures, it may be desirable to use two ESUs simultaneously on the same patient. Perioperative personnel should place each dispersive electrode as close as possible to the respective surgical sites and ensure that there is no possibility of the two dispersive electrodes touching. The two ESUs must be of the same technology (eg, both grounded ESUs, both isolated ESUs). The biomedical service should test ESUs to ensure that simultaneous operation will not create any microshock hazards. Interpretive statement 4: The bipolar ESU should be used with its foot switch or a hand switching forceps according to the manufacturer’s written instructions. Discussion: In bipolar electrosurgery, a forceps is used for the coagulation of body tissue. One side of 134
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the forceps is the active electrode and the other side is the inactive electrode or ground. A dispersive electrode is not needed because current flows between the tips of the forceps rather than through the patient. The operator uses a foot switch to control the bipolar unit to provide precise hemostasis without stimulation or current spread to nearby s t r ~ c t u r e s . ~ ~ Interpretive statement 5: Patients with pacemakers should have continous electrocardiogram (ECG) monitoring when an ESU is being used. Rationale: Use of the ESU may interfere with pacemaker circuitry. The bipolar unit may be used when operating on a patient with a pacemaker.30 Discussion: Modern pacemakers are subject to interference; most are designed to be shielded from radiofrequency current during ESU use. Perioperative personnel should implement additional actions for the pacemaker patient that include, but are not limited to, making the distance between the active and dispersive electrodes as short as possible and placing both as far from the pacemaker as possible, ensuring that the current path from the surgical site to the dispersive electrode does not pass through the vicinity of the heart, keeping all ESU cords and cables away from the pacemaker and the leads, having a defibrillator available in the room, checking with the pacemaker’s manufacturer regarding its function during use of ESUs, and evaluating the pacemaker postoperatively for proper function.?’ Interpretive statement 6: A patient with an automatic implantable cardioverter defibrillator (AICD) should have the device deactivated before the procedure and have his or her ECG monitored continuously if an ESU will be used. Rationale: Electrosurgery must not be used on a patient
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with an activated AICD because it may trigger the device to s h o ~ k . 3 ~ Interpretive statement 7: The patient’s skin integrity should be evaloated and documented before and after ESU use. Particular areas to observe are under the dispersive electrode, under ECG leads, and at temperature probe entry sites.
Rationale: Assessment will allow evaluation of skin condition for possible injury. Alternate-pathway bums have been reported at ECG electrode sites and temperature probe entry sites.33
Interpretive statement 8: If an adverse skin reaction or injury occurs, the ESU and active and dispersive electrodes should be sent with their packages to the biomedical service for a full investigation. Device identification, maintenance/service information, and event information should be included in the report from the practice setting.
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tion and selection for patient care in the practice setting” and AORN “Recommended practices for laser safety in the practice setting” to assist in selecting a smoke evacuation system. When the evacuation system is used for the filtration of electrosurgical smoke, placement of the evacuator suction tubing should be as close to the source of the smoke as possible. This will maximize smoke capture and enhance visibility at the surgical site. Research findings suggest that there is little difference between the smoke generated from electrosurgery and from lasers. There is an undefined potential for bacterial and viral contamination of smoke. Toxicity and mutagenicity of the gaseous by-products exist.37High-filtration surgical masks may be worn by perioperative personnel during procedures that generate surgical smoke.
Recommended Practice V
Rationale: Retaining the ESU and electrodes allows for a complete systems check to determine system integrity.34
Recommended Practice IV Patients and perioperative personnel should be protected from inhaling the smoke generated during electrosurgery. Interpretive statement I : An evacuation system should be used to remove surgical smoke. Discussion: There may be a potential hazard from exposure to smoke generated during electrosurgery.35Further research must be performed to determine the actual magnitude of smokle exposure under practical electrosurgical condition~.~~ Interpretive statement 2: Smoke evacuation systems should be used according to manufacturers’ written instructions. Discussion: Health care facilities may use the AORN “Recommended practices for product evalua-
Policies and procedures for electrosurgery should be developed, reviewed annually, and available within the practice setting. Discussion: These policies and procedures should include, but are not limited to, equipment maintenance programs; reporting of injuries; sanitation of ESU; and documentation of the ESU brand name, ESU identification numberherial number, settings used, dispersive electrode and ECG pad placement, patient skin condition before and after electrosurgery, and other electrical devices used. These recommended practices should be used as guidelines for the development of policies and procedures in the practice setting. Policies and procedures establish authority, responsibility, and accountability. They also serve as operational guidelines. An introduction and review of policies and procedures should be included in orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient outcomes. Policies and 135
procedures also assist in the development of quality assessment and improvement activities.
Glossary Active electrode: The accessory that directs current flow to the operative site. Examples include pencils with various tips, resectoscopes, and fulguration tips. Current: A movement of electricity analogous to the flow of a stream of water. Dispersive electrode: The accessory that directs current flow from the patient back to the generator (often called the patient plate, return electrode, inactive electrode, or grounding plate/pad). Electrosurgery: The cutting and coagulation of body tissue with a high radiofrequency current. Electrosurgical unit (ESU): For the purposes of this document, the ESU is defined as the generator, the foot switch and cord (if applicable), and the electrical plug, cord, and connections. Generator: The machine that produces radiofrequency waves (often called a cautery unit, power unit, or Bovie). Grounded electrosurgery: The dispersive electrode is grounded to the metal chassis of the generator. Current will flow from the active electrode when it touches any grounded object in the room. Isolated electrosurgery: No reference to ground. For current to flow, there must be a complete circuit path from the active terminal to the patient terminal. Macroshock: Occurs when current flows through a large skin surface, as during inadvertent contact with moderately high voltage sources, such as electrical wiring failures, that allow skin contact with a live wire or surface at full voltage. Microshock: Occurs when current is applied to a small area of skin, as when current from an exterior source flows through the cardiac catheter or conductor. Notes I. M J Shaffer, M R Gordon, “Clinical engineer136
ing standards, obligations, and accountability,” Medical Instrumentation 13 (July/August 1979) 209215. 2. L J Atkinson, Berry and Kohn’s Operating Room Technique, seventh ed (St Louis: MosbyYearBook, Inc, 1992) 253. 3. Emergency Care Research Institute, “Electrosurgical units,” Technology for Surgery 8 (November 1987) 3; E Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” AORN Journal 53 (March 1991) 745. 4. L K Groah, Operating Room Nursing: Perioperative Practice, second ed (Norwalk, Conn: Appleton & Lange, 1990) 299. 5. M E Moser, “Electrical shock: An orientation study guide,” Point of View 23 (May I, 1986) 4-5. 6. Groah, Operating Room Nursing: Perioperative Practice, 299. 7. M H Meeker; J C Rothrock, Alexander’s Care of the Patient in Surgery, ninth ed (St Louis: MosbyYearBook, Inc, 1991) 43; Atkinson, Berry and Kohn’s Operating Room Technique, 253. 8. Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 43. 9. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Jones and Bartlett Publishers, 1991) 382. 10. Ibid. 1 1 . P F Schellhammer, “Electrosurgery: Principles, hazards, and precautions,” Urology 3 (March 1974) 261-267. 12. Atkinson, Berry and Kohn’s Operating Room Technique, 170. 13. Ibid, 232; Groah, Operating Room Nursing: Perioperative Practice, 300. 14. Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746. 15. Atkinson, Berry and Kohn’s Operating Room Technique, 172; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746; Groah, Operating Room Nursing: Perioperative Practice, 300. 16. Shaffer, Gordon, “Clinical engineering standards, obligations, and accountability,” 2 14; Atkinson, Berry and K ohn’s Operating Room Technique, 170-171. 17. J J Skreenock, “Electrosurgical quality assurance: The view from the OR table,” Medical Instrumentation 14 (September/October 1980) 261263; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 43. 18. Skreenock, “Electrosurgical quality aprance: The view from the OR table,” 261-263; Atkinson, Berry and Kohn’s Operating Room Technique, 170. 19. Skreenock, “Electrosurgical quality assurance: The view from the OR table,” 261-263. 20. Emergency Care Research Institute, “Update:
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Recommended Practices Comment Form AORN recommended practices represent what is believed to be an achievable and optimal level of practice. Because of differences in practice settings, recommended practices are necessarily broad to meet the needs of the membership. Recommended practices are meant to serve as guidelines to develop policies and procedures. The Recommended Practices Committee highly values all comments from the AORN membership regarding these proposed recommended practices. Please complete this comment form and return it to AORN Headquarters at the address below by Aug 6, 1993. Please attach additional pages of comments and/or suggestions as needed. All comments will be considered. Proposed recommended practices: 1. What is your overall opinion of these recomlended practices? Explain:
Excellent
Fair
Good
2. Will these recommended practices be useful UI your practice setting? Yes Explain:
No
Poor
~
3. Do these recommended practices address the major elements of this practice? Yes No Explain:
4.Please comment on particular areas of concernl in these recommended practices and submit supporting documentation.
5. Is the format workable and easy to understand?Yes
No
Explain:
6. What is your general impression of AORN Standards and Recommended Practices?
7. How could the Recommended Practices Cormnittee further assist you?
8. Please list suggestions for future recommended practices. Thank you for your assistance. Return to: Recommended Practices Committee AORN, Inc 2170 S Parker Rd, Suite 300, Denver, CO 80231-5711 Attn: Mary O’Neale, RN, BS, CNClR Name (optional): Address: City: State:
Zip: 137
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Controlling the risks of electrosurgery,” Health Devices 18 (December 1989) 431. 21. T A Bowdle et al, “Fire following use of electrocautery during emergency percutaneous transtracheal ventilation,” Anesthesiology 66 (May 1987) 697-698; P R Freund, H M Radke, “Intraoperative explosion: Methane gas and diet,” Anesthesiology 55 (December 1981) 700-701. 22. Skreenock, “Electrosurgical quality assurance: The view from the OR table,” 262; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746; Groah, Operating Room Nursing: Perioperative Practice, 300. 23. A K Reeter, “Bipolar forceps misconnection hazardous,” OR Manager 6 (February 1990) 13; Atkinson, Berry and Kohn’s Operating Room Technique, 172. 24. Emergency Care Research Institute, “Electrosurgical units,” 3. 25. Ibid. 26. G R Neufeld, K R Foster, “Electrical impedance properties of the body and the problem of alternate-site bums during electrosurgery,” Medical Instrumentation 19 (March/April 1985) 83-87. 27. Groah, Operating Room Nursing: Perioperative Practice, 300; Atkinson, Berry and Kohn’s Operating Room Technique, 171. 28. Emergency Care Research Institute, “Update: Controlling the risks of electrosurgery,” 430-431. 29. Groah, Operating Room Nursing: Perioperative Practice, 301. 30. Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 748. 3 1. Groah, Operating Room Nursing: Perioperative Practice, 30 1. 32. B L Lee, G Mirabal, “Automatic implantable cardioverter defibrillator: Interpreting, treating ventricular fibrillation,” AORN Journal 50 (December 1989) 1226; S A Moser, D Crawford, A Thomas, “Updated care guidelines for patients with automatic implantable cardioverter defibrillators,” Critical Care Nurse 13 (April 1993) 70. 33. A J L Schneider, H P Apple, R T Braun, “Electrical burns at skin temperature probes,” Anesthesiology 47 (July 1977) 72-74; B Finley et al, “Electrosurgical bums resulting from use of miniature ECG electrodes,” Anesthesiology 41 (September 1974) 263-269; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 748-749; Groah, Operating Room Nursing: Perioperative Practice, 299. 34. F Gendron, “ ‘Bums’ occurring during lengthy s u r g ic a1 procedures ,” J o u r n a 1 of C 1in ica 1 Engineering 5 (January-March 1980) 19-26; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 749,752. 35. Emergency Care Research Institute, “ESU
138
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smoke-should it be evacuated?” Health Devices 19 (January 1990) 12. 36. Ibid. 37. M S Baggish et al, “Presence of human immunodeficiency virus DNA in laser smoke,” Lasers in Surgery and Medicine 11 (1991) 202-203; Y Tomita et al, “Mutagenicity of smoke condensates induced by CO, laser irradiation and electrocauterization,” Mutation Research 89 (1981) 145; W S Sawchuk et al, “Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: Detection and protection,” Journal of the American Academy of Dermatology 21 (July 1989) 41. Suggested reading Becker, C M; Malhotra, I V; Hedley-Whyte, J. “The distribution of radiofrequency current and bums.” Anesthesiology 38 (February 1973) 106-122. Buczko, G B; McKay, W P S. “Electrical safety in the operating room.” Canadian Journal of Anesthesia 34 no 3 (1987) 315-322. Emergency Care Research Institute. “ESU monitoring systems.” Technology f o r Surgery 8 (December 1987) 1-3. Gatti, J E, et al. “The mutagenicity of electrocautery smoke.” Plastic and Reconstructive Surgery 89 (May 1992) 781-784. National Institute for Occupational Safety and Health. Health Hazard Evaluation Report. pub1 no HETA 85-126-1932. Washington, DC: US Department of Health and Human Services, 1988. Pearce, J. “Current electrosurgical practice hazards.” Journal of Medical Engineering and Technology 9 (May/June 1985) 107-111. Soderstrom, R M. “Electrosurgery’s advantages and disadvantages.” Contemporary OBIGYN 35 (Oct 15, 1990) 35-47. Tucker, R D; Ferguson, S . “Do surgical gloves protect staff during electrosurgical procedures?” Surgery 110 (November 1991) 892-895. Voyles, C R,Tucker, R D. “Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery.” American Journal of Surgery 164 (July 1992) 57-62.
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Proposed Recommended Practices ELEC‘ROSURGERY
T
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Committee (RPC) is interested in receiving comments on this proposal from members and others. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect varia tions in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, emergency departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by RPC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to Recommended Practices Committee AORN, Inc 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Attention: Mary O’Neale, RN, BS, CNOR
The deadline for comments is Aug 6 , 1993. Purpose. These recommended practices provide guidelines to assist perioperative personnel in the use of electrosurgical equipment in their practice settings. Proper care and handling of electrosurgical equipment is essential to patient and personnel safety. Electrosurgery is used routinely to cut and coagulate body tissue with high radiofrequency electrical current. These recommended practices do not endorse any specific product. Biomedical services in practice settings should develop detailed, routine safety and preventive maintenance inspections and maintain records.
Recommended Practice I The electrosurgical unit (ESU), dispersive electrode, and active electrode selected for use should meet performance and safety criteria established by the practice setting. Interpretive statement 1 : Information regarding adequate safety margins, in-factory testing methods, warranties, and a manual for maintenance and inspections should be obtained from the manufacturer. Rationale: Equipment manuals assist in developing operational, safety, and maintenance guidelines.’ The ESU should be used according to the manufacturer’s written instructions.2 Interpretive statement 2: The ESU should be designed to minimize unintentional acf ivation. Rationale: 131
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Unintentional activation may result in patient and personnel injury.3 Interpretive statement 3: The ESU cord should be of adequate length and flexibility to reach the outlet without stress or use of an extension cord. Kinks, knots, and curls should be removed from the ESU cord before it is plugged into the wall outlet. Rationale: Tension increases the risk that the cord will become disconnected or frayed, which may result in injury to patients and per~onnel.~ Use of extension cords may result in macroshock or micro~hock.~ Cords that do not lie flat on the floor produce a potential for tripping and/or accidental unplugging.(j Interpretive statement 4: The ESU plug, not the cord, should be held when it is inserted into or removed from an electrical outlet. Rationale: Pulling on the ESU cord may cause it to break at the point where the wire is attached to the plug.7 Cord breakage is dangerous to patients and personnel and is inconvenient, and replacements are costly.* Interpretive statement 5: The ESU should be inspected before each use. An ESU that is not working properly or is damaged should be reported, labeled, and removed immediately to be checked by the biomedical department. Rationale: Equipment is checked to ensure it is in good working order.9 The manufacturer's written safety precautions are followed for the wellbeing of the patient and personnel involved with the procedure.'O Interpretive statement 6: The ESU should be grounded properly. Rationale: Proper grounding reduces the risk of electrical shock to the patient and perioperative personnel.'' Interpretive statement 7: The ESU should be mounted on a movable stand that will not tip. Rationale: 132
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Safety measures for perioperative personnel and patients to prevent injury and damage to the ESU require the stand to be tip resistant and moved carefully.12 Interpretive statement 8: The ESU and all reusable parts are cleaned with care following use according to the manufacturer's written instructions. Rationale: The ESU surface should not be saturated or have fluid poured over it because this could permit chemical germicide into the generator and cause malfunction.13 Interpretive statement 9: When the ESU foot switch is used, perioperative personnel should cover it with a clear, impervious cover if recommended by the manufacturer. Rationale: Placement in a clear, impervious cover protects the foot switch from fluid ~pi1lage.l~ Interpretive statement 10: During the procedure, perioperative personnel should check the entire circuit if higherthan-normal power settings are requested by the operator. Rationale: The dispersive electrode, generator, or connecting cords may be at fault and should be checked for any possible malfunction or hazard. Shock to those touching the patient may result. The patient and/or perioperative personnel may be burned.15 Interpretive statement 11 : Each ESU should be assigned an identification number/serial number. Rationale: An identification number/serial number allows for documentation of inspections, routine preventive maintenance, and tracking of equipment function and problems.16
Recommended Practice II Perioperative personnel should demonstrate competency in the use of the ESU in the practice setting. Interpretive statement 1:
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Perioperative personnel should be instructead in the proper operation, care, and handling of the ESU before use.
Rationale: Instruction and return demonstration in proper usage helps prevent injury and extends th’e life of the ESU.17 Interpretive statement 2: A detailed manual of operating instructions should be obtained from the manufacturer and be available in the practice setting. A brief set of operational directions should be on or attached to the ESU.
Rationale: Each type of ESU has specific manufacturer’s written operating instructions that should be followed for the safe operation of the unit.’*
Recommended Practice III The ESU, active electrode, and dispersive electrode should be used in a manner that reduces the potential for injury. Interpretive statement 1: The ESU should not be used in the presence of flammable agents (eg, alcohol, tincture-based agents); have safety features (eg, lights, activation sound) and be tested before each use; have the cord, plug, and foot switch cord checked for exposed wires or frays in the insu1ation ; have power settings confirmed orally with the operator before activation and determined in conjunction with the manufacturer’s recommendations; be protected from spills; and be operated at the lowest effective power settings for coagulation and/or cutting. Rationale: Inspections of the ESU and all safety features should be performed before each use because of potential hazards.I9 The volume of the activation indicator should be adjusted to an audible level to alert perioperative personnel immediately when an ESU is activated inadvertently.20 Ignition of flammable agents by the active electrode has resulted in patient and peri-
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operative personnel injury.21Fluids should not be placed on top of the ESU, because unintentional activation or device failure may occur if liquids enter the ESU generator.22 Interpretive statement 2: The active electrode should fasten directly into the ESU in a labeled, stress-resistant receptacle (if an adapter is used, it should be one that is approved by the manufacturer and does not compromise the generator’s safety features); be inspected at the field for damage before use; be placed in a clean, dry, well-insulated safety holster (ie, recommended by the manufacturer for use with the ESU) in a highly visible area when not in use during a procedure; be impervious to fluids; be disconnected from the ESU if allowed to drop below the sterile field; and have a tip that is secure and easy to clean of charred tissue.
Rationale: Incomplete circuitry, unintentional activation, and incompatibility of the active electrode with the generator may result in patient injury.23
Interpretive statement 3: The dispersive electrode should be inspected before each use for wire breakage or fraying; be the appropriate size for the patient (ie, neonate/infant, pediatric, adult) and never be cut to reduce size; be placed on the positioned patient on a clean, dry skin surface, over a large muscle mass, and as close to the operative site as possible (ie, bony prominences, scar tissue, skin over an implanted metal prosthesis, hairy surfaces, pressure points should be avoided); fasten directly into the ESU in a labeled, stress-resistant receptacle if an adapter, which is approved by the manufacturer and does not compromise the generator’s safety features, is used; have connections that are intact, clean, and make effective contact; and 133
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maintain uniform body contact (potential problems include tenting, gaping, and liquids that interfere with adhesion). Perioperative personnel should check the status of the dispersive electrode and connection of the cable if any tension is applied to the cord or if the surgical team repositions the patient. If reusable, the electrode should have periodic inspections by the biomedical service for electrical integrity and as recommended by the manufacturer. Rationale: Wire breakage and frays can deviate current Incomplete circuitry may lead to patient i n j ~ r y . ~Adequate 5 tissue perfusion promotes electrical conductivity in the area and dissipates heat at the electrode contact surface.z6 Hair should be removed before applying the dispersive electrode according to the manufacturer’s written instructions. Hairy surfaces have poor adhesion and tend to insulate.27 There is potential for superheating if a dispersive electrode is placed on the skin over an implanted metal prosthesis. The important factor in the dispersive electrode is the actual surface area in contact with the patient. The amount of surface area affects heat buildup at the dispersive site.** Discussion: During some surgical procedures, it may be desirable to use two ESUs simultaneously on the same patient. Perioperative personnel should place each dispersive electrode as close as possible to the respective surgical sites and ensure that there is no possibility of the two dispersive electrodes touching. The two ESUs must be of the same technology (eg, both grounded ESUs, both isolated ESUs). The biomedical service should test ESUs to ensure that simultaneous operation will not create any microshock hazards. Interpretive statement 4: The bipolar ESU should be used with its foot switch or a hand switching forceps according to the manufacturer’s written instructions. Discussion: In bipolar electrosurgery, a forceps is used for the coagulation of body tissue. One side of 134
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the forceps is the active electrode and the other side is the inactive electrode or ground. A dispersive electrode is not needed because current flows between the tips of the forceps rather than through the patient. The operator uses a foot switch to control the bipolar unit to provide precise hemostasis without stimulation or current spread to nearby s t r ~ c t u r e s . ~ ~ Interpretive statement 5: Patients with pacemakers should have continous electrocardiogram (ECG) monitoring when an ESU is being used. Rationale: Use of the ESU may interfere with pacemaker circuitry. The bipolar unit may be used when operating on a patient with a pacemaker.30 Discussion: Modern pacemakers are subject to interference; most are designed to be shielded from radiofrequency current during ESU use. Perioperative personnel should implement additional actions for the pacemaker patient that include, but are not limited to, making the distance between the active and dispersive electrodes as short as possible and placing both as far from the pacemaker as possible, ensuring that the current path from the surgical site to the dispersive electrode does not pass through the vicinity of the heart, keeping all ESU cords and cables away from the pacemaker and the leads, having a defibrillator available in the room, checking with the pacemaker’s manufacturer regarding its function during use of ESUs, and evaluating the pacemaker postoperatively for proper function.?’ Interpretive statement 6: A patient with an automatic implantable cardioverter defibrillator (AICD) should have the device deactivated before the procedure and have his or her ECG monitored continuously if an ESU will be used. Rationale: Electrosurgery must not be used on a patient
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with an activated AICD because it may trigger the device to s h o ~ k . 3 ~ Interpretive statement 7: The patient’s skin integrity should be evaloated and documented before and after ESU use. Particular areas to observe are under the dispersive electrode, under ECG leads, and at temperature probe entry sites.
Rationale: Assessment will allow evaluation of skin condition for possible injury. Alternate-pathway bums have been reported at ECG electrode sites and temperature probe entry sites.33
Interpretive statement 8: If an adverse skin reaction or injury occurs, the ESU and active and dispersive electrodes should be sent with their packages to the biomedical service for a full investigation. Device identification, maintenance/service information, and event information should be included in the report from the practice setting.
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tion and selection for patient care in the practice setting” and AORN “Recommended practices for laser safety in the practice setting” to assist in selecting a smoke evacuation system. When the evacuation system is used for the filtration of electrosurgical smoke, placement of the evacuator suction tubing should be as close to the source of the smoke as possible. This will maximize smoke capture and enhance visibility at the surgical site. Research findings suggest that there is little difference between the smoke generated from electrosurgery and from lasers. There is an undefined potential for bacterial and viral contamination of smoke. Toxicity and mutagenicity of the gaseous by-products exist.37High-filtration surgical masks may be worn by perioperative personnel during procedures that generate surgical smoke.
Recommended Practice V
Rationale: Retaining the ESU and electrodes allows for a complete systems check to determine system integrity.34
Recommended Practice IV Patients and perioperative personnel should be protected from inhaling the smoke generated during electrosurgery. Interpretive statement I : An evacuation system should be used to remove surgical smoke. Discussion: There may be a potential hazard from exposure to smoke generated during electrosurgery.35Further research must be performed to determine the actual magnitude of smokle exposure under practical electrosurgical condition~.~~ Interpretive statement 2: Smoke evacuation systems should be used according to manufacturers’ written instructions. Discussion: Health care facilities may use the AORN “Recommended practices for product evalua-
Policies and procedures for electrosurgery should be developed, reviewed annually, and available within the practice setting. Discussion: These policies and procedures should include, but are not limited to, equipment maintenance programs; reporting of injuries; sanitation of ESU; and documentation of the ESU brand name, ESU identification numberherial number, settings used, dispersive electrode and ECG pad placement, patient skin condition before and after electrosurgery, and other electrical devices used. These recommended practices should be used as guidelines for the development of policies and procedures in the practice setting. Policies and procedures establish authority, responsibility, and accountability. They also serve as operational guidelines. An introduction and review of policies and procedures should be included in orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient outcomes. Policies and 135
procedures also assist in the development of quality assessment and improvement activities.
Glossary Active electrode: The accessory that directs current flow to the operative site. Examples include pencils with various tips, resectoscopes, and fulguration tips. Current: A movement of electricity analogous to the flow of a stream of water. Dispersive electrode: The accessory that directs current flow from the patient back to the generator (often called the patient plate, return electrode, inactive electrode, or grounding plate/pad). Electrosurgery: The cutting and coagulation of body tissue with a high radiofrequency current. Electrosurgical unit (ESU): For the purposes of this document, the ESU is defined as the generator, the foot switch and cord (if applicable), and the electrical plug, cord, and connections. Generator: The machine that produces radiofrequency waves (often called a cautery unit, power unit, or Bovie). Grounded electrosurgery: The dispersive electrode is grounded to the metal chassis of the generator. Current will flow from the active electrode when it touches any grounded object in the room. Isolated electrosurgery: No reference to ground. For current to flow, there must be a complete circuit path from the active terminal to the patient terminal. Macroshock: Occurs when current flows through a large skin surface, as during inadvertent contact with moderately high voltage sources, such as electrical wiring failures, that allow skin contact with a live wire or surface at full voltage. Microshock: Occurs when current is applied to a small area of skin, as when current from an exterior source flows through the cardiac catheter or conductor. Notes I. M J Shaffer, M R Gordon, “Clinical engineer136
ing standards, obligations, and accountability,” Medical Instrumentation 13 (July/August 1979) 209215. 2. L J Atkinson, Berry and Kohn’s Operating Room Technique, seventh ed (St Louis: MosbyYearBook, Inc, 1992) 253. 3. Emergency Care Research Institute, “Electrosurgical units,” Technology for Surgery 8 (November 1987) 3; E Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” AORN Journal 53 (March 1991) 745. 4. L K Groah, Operating Room Nursing: Perioperative Practice, second ed (Norwalk, Conn: Appleton & Lange, 1990) 299. 5. M E Moser, “Electrical shock: An orientation study guide,” Point of View 23 (May I, 1986) 4-5. 6. Groah, Operating Room Nursing: Perioperative Practice, 299. 7. M H Meeker; J C Rothrock, Alexander’s Care of the Patient in Surgery, ninth ed (St Louis: MosbyYearBook, Inc, 1991) 43; Atkinson, Berry and Kohn’s Operating Room Technique, 253. 8. Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 43. 9. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Jones and Bartlett Publishers, 1991) 382. 10. Ibid. 1 1 . P F Schellhammer, “Electrosurgery: Principles, hazards, and precautions,” Urology 3 (March 1974) 261-267. 12. Atkinson, Berry and Kohn’s Operating Room Technique, 170. 13. Ibid, 232; Groah, Operating Room Nursing: Perioperative Practice, 300. 14. Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746. 15. Atkinson, Berry and Kohn’s Operating Room Technique, 172; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746; Groah, Operating Room Nursing: Perioperative Practice, 300. 16. Shaffer, Gordon, “Clinical engineering standards, obligations, and accountability,” 2 14; Atkinson, Berry and K ohn’s Operating Room Technique, 170-171. 17. J J Skreenock, “Electrosurgical quality assurance: The view from the OR table,” Medical Instrumentation 14 (September/October 1980) 261263; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 43. 18. Skreenock, “Electrosurgical quality aprance: The view from the OR table,” 261-263; Atkinson, Berry and Kohn’s Operating Room Technique, 170. 19. Skreenock, “Electrosurgical quality assurance: The view from the OR table,” 261-263. 20. Emergency Care Research Institute, “Update:
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Recommended Practices Comment Form AORN recommended practices represent what is believed to be an achievable and optimal level of practice. Because of differences in practice settings, recommended practices are necessarily broad to meet the needs of the membership. Recommended practices are meant to serve as guidelines to develop policies and procedures. The Recommended Practices Committee highly values all comments from the AORN membership regarding these proposed recommended practices. Please complete this comment form and return it to AORN Headquarters at the address below by Aug 6, 1993. Please attach additional pages of comments and/or suggestions as needed. All comments will be considered. Proposed recommended practices: 1. What is your overall opinion of these recomlended practices? Explain:
Excellent
Fair
Good
2. Will these recommended practices be useful UI your practice setting? Yes Explain:
No
Poor
~
3. Do these recommended practices address the major elements of this practice? Yes No Explain:
4.Please comment on particular areas of concernl in these recommended practices and submit supporting documentation.
5. Is the format workable and easy to understand?Yes
No
Explain:
6. What is your general impression of AORN Standards and Recommended Practices?
7. How could the Recommended Practices Cormnittee further assist you?
8. Please list suggestions for future recommended practices. Thank you for your assistance. Return to: Recommended Practices Committee AORN, Inc 2170 S Parker Rd, Suite 300, Denver, CO 80231-5711 Attn: Mary O’Neale, RN, BS, CNClR Name (optional): Address: City: State:
Zip: 137
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Controlling the risks of electrosurgery,” Health Devices 18 (December 1989) 431. 21. T A Bowdle et al, “Fire following use of electrocautery during emergency percutaneous transtracheal ventilation,” Anesthesiology 66 (May 1987) 697-698; P R Freund, H M Radke, “Intraoperative explosion: Methane gas and diet,” Anesthesiology 55 (December 1981) 700-701. 22. Skreenock, “Electrosurgical quality assurance: The view from the OR table,” 262; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 746; Groah, Operating Room Nursing: Perioperative Practice, 300. 23. A K Reeter, “Bipolar forceps misconnection hazardous,” OR Manager 6 (February 1990) 13; Atkinson, Berry and Kohn’s Operating Room Technique, 172. 24. Emergency Care Research Institute, “Electrosurgical units,” 3. 25. Ibid. 26. G R Neufeld, K R Foster, “Electrical impedance properties of the body and the problem of alternate-site bums during electrosurgery,” Medical Instrumentation 19 (March/April 1985) 83-87. 27. Groah, Operating Room Nursing: Perioperative Practice, 300; Atkinson, Berry and Kohn’s Operating Room Technique, 171. 28. Emergency Care Research Institute, “Update: Controlling the risks of electrosurgery,” 430-431. 29. Groah, Operating Room Nursing: Perioperative Practice, 301. 30. Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 748. 3 1. Groah, Operating Room Nursing: Perioperative Practice, 30 1. 32. B L Lee, G Mirabal, “Automatic implantable cardioverter defibrillator: Interpreting, treating ventricular fibrillation,” AORN Journal 50 (December 1989) 1226; S A Moser, D Crawford, A Thomas, “Updated care guidelines for patients with automatic implantable cardioverter defibrillators,” Critical Care Nurse 13 (April 1993) 70. 33. A J L Schneider, H P Apple, R T Braun, “Electrical burns at skin temperature probes,” Anesthesiology 47 (July 1977) 72-74; B Finley et al, “Electrosurgical bums resulting from use of miniature ECG electrodes,” Anesthesiology 41 (September 1974) 263-269; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 748-749; Groah, Operating Room Nursing: Perioperative Practice, 299. 34. F Gendron, “ ‘Bums’ occurring during lengthy s u r g ic a1 procedures ,” J o u r n a 1 of C 1in ica 1 Engineering 5 (January-March 1980) 19-26; Moak, “Electrosurgical unit safety: The role of the perioperative nurse,” 749,752. 35. Emergency Care Research Institute, “ESU
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smoke-should it be evacuated?” Health Devices 19 (January 1990) 12. 36. Ibid. 37. M S Baggish et al, “Presence of human immunodeficiency virus DNA in laser smoke,” Lasers in Surgery and Medicine 11 (1991) 202-203; Y Tomita et al, “Mutagenicity of smoke condensates induced by CO, laser irradiation and electrocauterization,” Mutation Research 89 (1981) 145; W S Sawchuk et al, “Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: Detection and protection,” Journal of the American Academy of Dermatology 21 (July 1989) 41. Suggested reading Becker, C M; Malhotra, I V; Hedley-Whyte, J. “The distribution of radiofrequency current and bums.” Anesthesiology 38 (February 1973) 106-122. Buczko, G B; McKay, W P S. “Electrical safety in the operating room.” Canadian Journal of Anesthesia 34 no 3 (1987) 315-322. Emergency Care Research Institute. “ESU monitoring systems.” Technology f o r Surgery 8 (December 1987) 1-3. Gatti, J E, et al. “The mutagenicity of electrocautery smoke.” Plastic and Reconstructive Surgery 89 (May 1992) 781-784. National Institute for Occupational Safety and Health. Health Hazard Evaluation Report. pub1 no HETA 85-126-1932. Washington, DC: US Department of Health and Human Services, 1988. Pearce, J. “Current electrosurgical practice hazards.” Journal of Medical Engineering and Technology 9 (May/June 1985) 107-111. Soderstrom, R M. “Electrosurgery’s advantages and disadvantages.” Contemporary OBIGYN 35 (Oct 15, 1990) 35-47. Tucker, R D; Ferguson, S . “Do surgical gloves protect staff during electrosurgical procedures?” Surgery 110 (November 1991) 892-895. Voyles, C R,Tucker, R D. “Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery.” American Journal of Surgery 164 (July 1992) 57-62.