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RECOMMENDED PRACTICES
Implementing AORNRecommended Practicefor ElectrosurgeryLISA SPRUCE, DNP, RN, ACNP-BC, ANP-BC, ACNS-BC, CNOR;MELANIE L. BRASWELL, DNP, RN, CNS, CNORwww.aorn.org/CE
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ABSTRACTTechnology is constantly changing, and it is important for perioperative nurcurrent on new products and technologies in the perioperative setting. AORommended practices for electrosurgery” addresses safety standards thaterative personnel should follow to minimize risks to both patients and stafduring the use of electrosurgical devices. Recommendations include howelectrosurgical units and accessories for purchase, how to minimize the popatient and staff member injuries, what precautions to take during minimsive surgery, and how to avoid surgical smoke hazards. The recommendaddress education/competency, documentation, policies and procedures, aassurance/performance improvement. Perioperative nurses should considerchecklists and safety posters to remind staff members of the dangers of elecand the steps to take to minimize the risks for injury. AORN J 95 (March 2012© AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.12.018
Key words: electrosurgery, electrosurgical unit, ESU, active electrode,active electrode, dispersive electrode, monopolar electrosurgery, ultrasovice, argon enhanced coagulation technology, surgical smoke, minimallysurgery, MIS.
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The AORN “Recommended prelectrosurgery” was publishedonline in Perioperative Stand
indicates that continuing education co
are available for this activity. Earn the c
by reading this article, reviewing the pur
objectives, and completing the online Lea
tion at http://www.aorn.org/CE. The co
for this article expire March 31, 2015.
doi: 10.1016/j.aorn.2011.12.018
© AORN, Inc, 2012
s forly 2009nd
Recommended Practices. The purpos
vised recommended practices (RP) d
“provide guidance to perioperative nu
use and care of electrosurgical equip
ing high frequency, ultrasound, and a
modalities.”1(p99) There are 14 practi
mendations that represent what is bel
an optimal level of practice. Hospital
tory patient scenarios representing po
hours
hours
oal and
valua-
ours
safety situations are provided here to exemplify
March 2012 Vol 95 No 3 ● AORN Journal 373
for el
1920safe
rent eisperst devost cdisp
tingcaus
mayectros. Thses o
iorityatienf ES
y posn cauath.3
isk tos, in the
electricityry circuit isve electrode,ve electrodee patient’st is producededance. Inative path-OR bed,
ent, provid-injury.risk for in-return to the
safety mea-el should used staffdvancement
blished min-ards for us-approved bystitute andommission.4
e, the
March 2012 Vol 95 No 3 SPRUCE—BRASWELL
ways that practice recommendationssurgery might be implemented.
WHAT’S NEW?Electrosurgery was introduced in thecommonly used today. However, newtures have been incorporated into cursurgical unit (ESU) and active and delectrode designs. Electrosurgical unipresent risks for patient injury; the mform of patient injury is a burn at theelectrode site.2 In addition to presenfor patient injury, these devices canelectrical shock, or explosions andfere with other critical implanted elmedical devices such as pacemakerdocument updates perioperative nurpractices in electrosurgery.
RATIONALEPatient safety is the number-one prperioperative nurses, and keeping pstaff members safe during the use oessential. Electrosurgical technologvery high risk to the patient and capermanent disfiguring injuries or de
Figure 1. The monopolar electrosurgic
patient, and the patient dispersive electrode374 AORN Journal
ectro-
s and isty fea-lectro-iveicesommonersivea riske fires,
inter-nicis RPn safe
forts andUs ises aseIn
addition, there is a high degree of rpersonnel, such as shocks and burnpresence of this device.
The generator of the ESU is thesource. The monopolar electrosurgecomposed of the generator, the actithe patient, and the patient dispersi(ie, return electrode) (Figure 1). Thtissue provides impedance, and heaas the electrodes overcome the impground-referenced generators, alternways to the ground may include thestirrups, staff members, and equipming a potential risk of alternate siteIsololated generators minimize thisjury because the preferred pathwayground is through the generator.
This RP document addresses thesures that all perioperative personnto minimize risk to both patients anmembers. The Association for the Aof Medical Instrumentation has estaimum safety and performance standing ESU systems, which have beenthe American National Standards Inthe International Electrotechnical C
uit is composed of the generator, the active electrod
al circ .for ebeingand
klistsstep
s takefe. Elnd itols sup perionents this
ff meity.ander w
ies. PRN’
differe unare u
otocove sucauseedia
the use ofnitoring.2,5
ed explana-quipment
ask ques-nefits to pa-
e facility sowhich helpsd with theESU use.
er that mini-0) Patientcur. Periop-ble of andiples of ESUeak up andent safetyistently fol-nsider the
ectrosurgical
’s manual tosits.
ce &nav�
w Tech-
.org/n_
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
DISCUSSIONMost perioperative nursing strategiespatient safety while electrosurgery isare task oriented. Working as a teaming patient safety protocols and chechelp remind staff members of the keyelectrosurgical safety. At times, nursegranted that patients are going to be sasurgery is used every day in the OR, ato let one’s guard down. The use of topatient safety poster (Figure 2) can heltive personnel remember the key compelectrosurgery. Developing tools such aindividual practice settings reminds stathat patient safety is a team responsibil
Developing standardized protocolslists for each operating arena is anothreinforce all of the key safety strategand checklists should be based on AOommended practices. An example ofprotocols might be for patients who aing general surgery versus those whogoing minimally invasive surgery. Prpatients undergoing minimally invasiwould have additional safety steps berisks involved with using distention m
Recommendation I“Personnel selecting newand refurbished [ESUs] andaccessories for purchase oruse should make decisionsbased on safety features tominimize risks to patients andpersonnel.”1(p99) Personnelinvolved in purchasing deci-sions should considerthe following:
� The most frequently re-ported injury to patientsis a burn at the site ofthe dispersive electrode.2
Look for a dispersive
E
�
�
�
�
W
electrode that will
nsuringused
follow-wills forfor
ectro-is easych as aopera-s ofone in
mbers
check-ay torotocolss rec-rentdergo-nder-ls forrgery
of the.
minimize this risk, such as throughreturn electrode contact quality mo
� Speak to vendors and get a detailtion of the safety features of the ebeing considered for purchase.
� Form an interdisciplinary group totions and discuss the risks and betients of this type of equipment.
� Standardize equipment across ththere is no variation in practice,ensure that all patients are treatesame safety standards related to
Recommendation II“The ESU should be used in a mannmizes the potential for injuries.”1(p10
injuries, user injuries, and fires do ocerative nurses should be knowledgeadiligent in adhering to the basic princsafety. Perioperative nurses should spchallenge other team members if patiissues arise or strategies are not conslowed. Perioperative nurses should cofollowing steps for creating a safe elenvironment:
� Read and attach the manufacturerthe unit or cart on which the ESU
cational Resources
iop Modules: Electrosurgery. http://www.aorn.org/ucation/Specialty_Education/Periop_Modules.aspx.RN Video Library: Electrosurgery: Function, Practiety. http://cine-med.com/index.php?nav�nursing&subn&id�1937.ioperative Management Resources: Evaluation of Neogy. http://www.aornbookstore.org/.gical Smoke Evacuation Tool Kit. http://www.aornnical_Practice/ToolKits/Surgical_Smoke_EvacuatiolKit/Download_the_Surgical_Smoke_Evacuation_l_Kit.aspx.
te access verified December 12, 2011.
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PerEdAOSafaorPernolSurCliTooToo
eb si
AORN Journal 375
er when
surgical ent it-stand
at patients wrong.”
oper ac-
he pa-
March 2012 Vol 95 No 3 SPRUCE—BRASWELL
Electrosurgical Safety
It Takes a TEAM to:
Know how to:
Check the machine and accessories before use.
Avoid risks to patient and staff.
Solve simple problems.
Prepare the patient safely.
Assess the patient’s skin before and after elec-trosurgery use.
Understand:
What equipment you are using.
How to minimize risk.
Electrosurgery principles
Importance of letting the prep dry!
Why the active electrode is stored in a holstnot in use.
Every year patients and members of the surgery team are injured during cases where electrotechnology is used. Often times injuries occur due to operator error and not from the equipmself. It takes a team to assure patients and staff are safe from injury! Everyone should underthe risks and take action to prevent a mishap from occurring.
“We want to make surgical procedures around the world something thand surgeons quickly forget because they have gone right rather than
~Sir Liam Donaldson
Consider:
The patient’s weight, fat distribution, and age.
Active implants such as a pacemaker or ICD-patient cleared by cardiology.
Allergies.
The position of the return electrode and metal implants, patient position, operating site, scars and tattoos.
Be aware of:
The ESU has had proper maintenance, is in good working order with prcessories.
The lowest power setting is being used.
The alarms, never silence them!
The potential for injury due to direct or capacitive coupling.
The correct accessories go with the correct machine.
How to report events and near misses.
The danger of activating the ESU while staff are in direct contact with ttient.
Special precautions with argon enhanced coagulation.
Safety doesn’t happen by accident!
Figure 2. A patient safety poster can remind staff members of precautions to take during electrosurgery.
376 AORN Journal
on atected
s anationis ea
enceaccebe d
l humrds ahas ophenong pa
the ouse ttiss
ts ashou
orieslacemther
wer,blemplaceould
properly,r broken,
survey ofakes a min-reparation forurse shouldsurvey andtect patients
and maket use exten-
eld; the cordithoutffic path.10
s in the cord.removing
or cracksor replace-
in a manneries”1(p101)
ive electrode
l_
-6300,
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http://
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
� Ensure that the ESU is mountedresistant cart or shelf and is proliquids.
� Do not silence alarms—all alarmvation indicators should be operdible, and visible at all times. Itbecome distracted and to experimalization of deviation” (eg, theof activities that would normallyunacceptable). There is a naturatendency to ignore safety standaalarms over time when no eventNurses should be aware of thisand always be diligent in ensurisafety.
� Confirm the power settings withbefore the ESU is activated andest setting to achieve the desiredeffect.2,6-9 If the operator requesued increase in power, the nursecheck the entire ESU and accesscord connections and adequate pthe dispersive electrode.6,10,11 Ifcontinued request to increase pocould indicate that there is a prothe unit, the connections, or theof the grounding pad. Nurses shsume that it is okay toincrease power withoutstopping the procedureand checking the ma-chine and the patient.Surgery should not con-tinue if there is a con-cern that the machine isnot working properly.
Recommendation III“The electrical cords andplugs of the ESU should behandled in a manner thatminimizes the potential forinjury and subsequent patient
R
�
�
�
�
�
W
and user injuries.”1(p101)
tip-from
d acti-al, au-sy to“nor-ptanceeemedanndccurred.menontient
peratorhe low-uecontin-ldforent of
e is athiswithmentnot as-
When cords and plugs are handled imthe insulation can become frayed owhich presents an electrical hazard. Athe ESU physical environment only tute and should be a part of routine pevery procedure. The perioperative ntake the time to perform this criticalconsider the following actions to proand staff members:
� Do not place tension on the cordsure the length is adequate; do nosion cords.10
� Place the ESU near the sterile fishould reach the wall or outlet wstress and without blocking a tra
� Do not allow kinks, knots, or bend� Hold the plug, not the cord, when
the ESU from the outlet.� Keep the cord dry.10
� Check the cord for breaks, nicks,and remove it from use for repairment if needed.10
Recommendation IV“The active electrode should be usedthat minimizes the potential for injur(Figure 3). Incompatibility of the act
ources for Implementation
RN Clinical Answers. http://www.aorn.org/Clinicactice/Clinical_Answers/Clinical_Answers.aspx.RN Nurse Consult Line. 800-755-2676 or 303-755ion 1.R Perioperative Framework. http://www.aorn.org/Cctice/EHR_Periop_Framework/EHR_Perioperativemework.aspx.NurseLink. http://www.aorn.org/ORNurseLink/.ioperative Job Descriptions and Evaluation Tools.w.aorn.org/Secondary.aspx?id�20740&terms�ioperative%20competencies.
te access verified December 12, 2011.
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AORN Journal 377
l acti
hazar
perat
ng fo
with
ould
It is
be us12,14-1
-21 C
activ
gion
tic g
as f
. Peri
ction
ofessi
n.
electro
ility of the
ESU is in
the surgeon,
tive elec-
nductive
e.2,9,14,22
of the active
intentional
.8,14
the active
on.12,18
consider
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March 2012 Vol 95 No 3 SPRUCE—BRASWELL
with the ESU as well as unintentiona
and incomplete circuitry pose safety
patients and staff members.12,13 Perio
nurses should be diligent in monitori
tentional activation, problems arising
ESU, or unsafe practices, and they sh
up when patient safety is threatened.
tant to ensure that electrosurgery not
the presence of gastrointestinal gases
an oxygen-enriched environment.14,18
should be used when activating the
electrode near the head and neck re
the presence of combustible anesthe
The active electrode should be used
as possible from the oxygen source
tive nurses can take the following a
lessen risks:
� Coordinate with the anesthesia pr
minimize the oxygen concentratio
� Always visually inspect the active
Figure 3. The active electrode should b
at the field before use. Look for cord or
378 AORN Journal
vation
ds to
ive
r unin-
the
speak
impor-
ed in7 or in
aution
e
or in
ases.
ar away
opera-
s to
onal to
de
handpiece damage and incompatib
accessories with the ESU.
� Observe the sterile field when the
use and, when necessary, remind
technician, or assistant that the ac
trode should be placed in a nonco
safety holster when it is not in us
� Place the foot pedal near the user
electrode to reduce the risk of un
activation by other team members
� Remove accumulated eschar from
electrode tip away from the incisi
� Follow fire safety measures,23 and
using a checklist to make sure no
following steps are accidentally m
� Do not activate the active elec
presence of flammable agents.
� Time alcohol-based prep age
minimum dry time recommen
manufacturer is allowed to p
d in a manner that minimizes the potential for injurie
not allow the surgical technologist or
until
ing a
s pos
near
imiz
en, ni
line,
ld to
tingu
used
a ma
ries.
ure th
ct wi
sho
the
or sh
uch
ep so
ering
trode
he n
ersiv
patie
as th
ety st
from
is be
shou
des s
ical
ode,
in p
to pr
he following
nd after ESU
sure there is’s tissue.6 IfU alarm willtioning, thus
should bethe elec-
ositioning isuse a newosition a
of dispersivehere aret be folded,
gle-use dis-ening it and
acturer’s expi-he productdamage, dis-
ss, becausect.6,8,11,27
well-perfusedor of elec-, place thet skin on thelose as possi-
bony promi-earing sur-ttoos, or aiquet; or near
the patientnt is reposi-the electrodes skin.
de is a non-
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
surgeon to drape the patient
prep agent has dried.
� Remove suture packets contain
from the sterile field as soon a
� Moisten sponges that are used
tive electrode tip.18,24,25
� Arrange surgical drapes to min
buildup of oxidizers (eg, oxyg
oxide).
� Always have a wet towel, sa
ter available on the sterile fie
guish a fire.
� Be prepared to immediately ex
flames should they occur.
Recommendation V“When monopolar electrosurgery is
persive electrode should be used in
that minimizes the potential for inju
It is extremely important to make s
persive electrode has uniform conta
patient’s skin. The perioperative RN
verify this before surgery begins. If
notes that there is poor contact, he
should institute corrective actions, s
moving any oil, lotion, moisture, pr
or excessive hair that may be interf
contact; moving the dispersive elec
other site; or applying a new pad. T
should not use tape to hold the disp
trode in place.
The nurse should ensure that the
not contact any metal devices such
stirrups, positioning devices, or saf
buckles to prevent a possible burn
rected current. Patient jewelry that
the active and dispersive electrodes
removed. Electrocardiogram electro
be placed as far away from the surg
possible. When removing the electr
nurse should hold the adjacent skin
and peel the electrode back slowly
denuding the skin.
the
lcohol
sible.
the ac-
e the
trous
or wa-
extin-
ish
, a dis-
nner
”1(p104)
e dis-
th the
uld
nurse
e
as re-
lution,
with
to an-
urse
e elec-
nt does
e bed,
rap
di-
tween
ld be
hould
site as
the
lace
event
The nurse also should implement tas part of routine patient care:
� Assess the patient’s skin before ause to assess for any injuries.
� Use dual-foil electrodes to makeno impedance through the patientthe impedance is too high, the ESsound and the ESU will stop funcprotecting the patient from harm.2
� A single-use dispersive electrodecompatible with the ESU. Discardtrode after it has been used. If repneeded, discard the electrode andsingle-use product.11,26 Never repused electrode.
� Make sure to use the correct sizeelectrode for individual patients. Tdifferent sizes, and they should nocut, or altered in any way.
� Identify the expiration date on a sinpersive electrode package before opdo not use it if it is past the manufration date. Check the integrity of tand do not use it if there are flaws,coloration, poor adhesive, or drynethese could prevent adequate conta
� Place the dispersive electrode onmuscle, which is a better conducttricity than adipose tissue.11 Alsoelectrode on clean, dry, and intacsame side as the surgery and as cble to the site.
� Do not place the electrodes overnences, scar tissue, hair, weight-bfaces, potential pressure points, tametal prosthesis; distal to a tourna warming device.
� Place the dispersive electrode onafter final positioning. If the patietioned during surgery, verify thatis still in contact with the patient’
A capacitive coupled return electro
adhesive return electrode that is placed close toAORN Journal 379
h theatienad isis there isno m
linen,
cautinimalatientatione RNimp
n eneal insn oc
entallode isergizathwt patsfere thro
ve itebina
sed.2
nductseek
its wa
impoMIS:
ation
r syscurreand
(ie, c
IS for insu-ot intact, an
d and can-36 There arensulationerent colorsation is af which theisible if the
ive electrodeuous moni-on methodlation failure
atically shut
s of elec-minal pain,them thatge from the
g vessel oc-a mannerries.”1(p108)
ar electrodesetween thethere is noure 4). Onlyelectricaly current orve nurseand bipolar
that properrect cord is. Bipolarostasis be-o tines of
ient.
in a mannerp109) Ultra-al energy. A
March 2012 Vol 95 No 3 SPRUCE—BRASWELL
the patient and forms a capacitor witreturning electrical current from the pto the ESU. If a capacitive coupled pthe nurse should ensure that the padpriate size for the patient and that thequate contact by confirming there areals, such as foam, gel pads, or extrabetween the patient and the pad.
Recommendation VI“Personnel should take additional prewhen using electrosurgery during misive surgery (MIS).”1(p107) Specific pcan occur from direct coupling, insuland capacitive coupling.6 Perioperativshould understand these concepts andprecautions to prevent patient injury.
Direct coupling is the contact of aactive electrode tip with another metor object in the surgical field. This cawhen the surgeon or other user accidvates the ESU when the active electring another metal instrument, thus eninstrument. This energy will seek a pthe ground and can cause a significaninjury. Capacitive coupling is the trantrical current from the active electrodintact insulation to adjacent conductitissue, trocars). This occurs when complastic and metal trocar systems are ucurrent can be generated from the cothe nonconductor and the current canway through the patient’s tissues onreturn electrode.
The following safety measures areincorporate into nursing practice for
� Make sure the gas used for insufflflammable (eg, carbon dioxide).
� Make sure that conductive trocaare being used. This allows theflow safely between the cannuladominal wall.
� Do not use hybrid trocar systems
nation plastic and metal).380 AORN Journal
patient,t backused,appro-ade-ateri-
onsly inva-injury
failure,s
lement
rgizedtrumentcury acti-touch-
ing thatay toientof elec-ugh
ms (eg,tion8-30 Aor toa path-y to the
rtant to
is non-
temsnt tothe ab-
ombi-
� Examine the electrodes used in Mlation failure. If the insulation is nalternative pathway can be formecause serious patient injuries.28,31
multiple methods used to detect ifailure. One is the use of two diffon the active electrode. The insuldifferent color than the material oactive electrode is made, so it is vinsulation fails, indicating the actshould not be used. Active contintoring systems are another detectithat continuously monitor for insuor capacitive coupling and automdown when a breach is detected.
� Instruct patients to report symptomtrosurgical injury (eg, fever, abdovomiting) after MIS, and remindsymptoms can occur after discharpostanesthesia care unit.
Recommendation VII“Bipolar active electrodes, includincluding devices, should be used inthat minimizes the potential for injuUnlike monopolar electrodes, bipolhave two poles. The current flows btwo poles and back to the ESU, soneed for a dispersive electrode (Figthe tissue grasped is included in thecurrent and there is no chance of straalternative pathways. The perioperatishould make sure that the monopolarplugs on the ESU are differentiated,accessories are used, and that the corplugged in to the correct bipolar plugactive electrodes provide precise hemcause the current runs between the twthe electrode and not through the pat
Recommendation VIII“Ultrasonic devices should be usedthat minimizes potential injuries.”1(
sonic devices do not create electric
generator is used to produce ultrasonic energyand cand
no nerisk wsonneof ae
ouldmoke
th anlter.
logy (sonneminimype oy thaESUent thgas
to thectuallseful
acture
opolar sur-implementent safety:
line by acti-after moder-d betweenzes the riskould be lim-at achieves
in directfrom patient
re is directforced into
ich could be
or death asology, thefollowing
ufflators haveurizationated. Thef gas inside
urgery unitrode.
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
and mechanical vibrations that cutlate, causing denaturation of proteinformation of a coagulum. There isa dispersive electrode. The biggestultrasonic devices is the risk to perare operating the device. Inhalationgenerated by the ultrasonic ESU shimized by using measures such as suation systems and wall suction wiultra-low penetration air (ULPA) fi
Recommendation IX“Argon enhanced coagulation technoposes unique risks to patient and perand should be used in a manner thatthe potential for injury.”1(p109) This ttechnology is a form of electrosurgerradio-frequency coagulation from ancapable of delivering monopolar currflow of ionized argon gas. The argonthe current from the active electrodeso the active electrode never has to ainto contact with the tissue. This is uhard-to-reach places.
During the use of AEC, all manuf
Figure 4. In bipolar electrosurgery, curwithout the need for a dispersive elect
written instructions should be followed in
oagu-theed forith
l whorosols
be min-evac-
in-line
AEC)l safetyizes
ft usesthat isrough a
carriestissue
y comefor
rs’
to all of the safety measures for mongery. The perioperative nurse shouldthe following actions to promote pati
� Purge the air from the argon gasvating the system before use andate delays between activations anuses. Purging the gas line minimiof gas embolism. The gas flow shited to the lowest level possible ththe desired effect.
� Do not place the active electrodecontact with tissue and remove ittissue after each activation. If thecontact with tissue, the gas can bea vessel and cause gas emboli, whfatal to the patient.
� To prevent potential patient injurya complication of argon gas technperioperative RN should take thesteps as part of care:� Make sure that endoscopic ins
audible and visual over-pressalarms that cannot be deactivAEC is a secondary source o
ows between the two poles and back to the electros
rent fladdition the patient and can cause a rapid rise in
AORN Journal 381
ibly c
li, spedurin
ical sbe idhe N
ealthto redoke totilatioh in-li
aryd of tr thanurses
heir pe type safsurguse rcal Nltrati
ch Aetencand qThes
tion orsonnucatioto theaffordate c
AORdeveltionssist ptency
ld includeg diagnosis,and interven-atient’s re-pdated RPse relevanty.developed,essary, andg. New or
nity for col-sonnel from
evelopdures thatnd Proce-es a collec-izable tem-
ve Standardsr quality im-prove patientFor details ons that are spe-this article,ocument.
RIOnderwent ar her leftly 40 min-settingsispersiveleft lateral
on requestedof an inade-
peatedlyed, and thefter the pro-that the dis-ntact with theo be intact
n check, theg in the pa-
March 2012 Vol 95 No 3 SPRUCE—BRASWELL
intra-abdominal pressure, possgas emboli to form.
� Monitor patients for gas embocally end-tidal carbon dioxide,procedure.
Recommendation X“Potential hazards associated with surggenerated in the practice setting shouldand safe practices established.”1(p110) TInstitute of Occupational Safety and Hmends that smoke evacuators be usedpotential adverse effects of surgical smsonnel and patients. Local exhaust ven(eg, smoke evacuator, wall suction witULPA filter) should be used as the primof smoke evacuation. The suction wansmoke evacuation should not be fartheinches from the source of the smoke. Nevaluate the type of LEV needed in tsettings for surgical procedures. ThLEV is based on adequacy to ensurmoval of the anticipated amount ofsmoke. Perioperative nurses shouldtory protection (ie, a fit-tested surgitering facepiece respirator or high-fimask) as secondary protection.
The Final FourThe final four recommendations in eaRP document discuss education/compumentation, policies and procedures,assurance/performance improvement.topics are integral to the implementaAORN practice recommendations. Peshould receive initial and ongoing edcompetency validation as applicableImplementing new and updated RPsexcellent opportunity to create or updtency materials and validation tools.perioperative competencies team hasthe AORN Perioperative Job DescripCompetency Evaluation Tools37 to asative personnel in developing compe
tion tools and job descriptions.382 AORN Journal
ausing
cifi-g the
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ORNy, doc-ualitye fourfeln andir roles.s anompe-N’sopedand
erioper-evalua-
Documentation of nursing care shoupatient assessment, plan of care, nursinand identification of desired outcomestions, as well as an evaluation of the psponse to care. Implementing new or umay warrant a review or revision of thdocumentation being used in the facilit
Policies and procedures should bereviewed periodically, revised as necreadily available in the practice settinupdated RPs may present an opportulaborative efforts with nurses and perother departments in the facility to dorganization-wide policies and procesupport the RPs. The AORN Policy adure Templates, 2nd edition,38 providtion of 15 sample policies and customplates based on AORN’s Perioperatiand Recommended Practices. Regulaprovement projects are necessary to imsafety and to ensure safe, quality care.the final four practice recommendationcific to the RP document discussed inplease refer to the full text of the RP d
AMBULATORY PATIENT SCENAMs P, a 20-year-old female patient, uroutine excision of a large mass undearm. The procedure took approximateutes. The ESU was in use and initialwere cut/coagulate at 30 watts. The delectrode was placed on the patient’sthigh. During the procedure, the surgethat the settings be increased becausequate desired effect. The physician rerequested that the settings be increaslast setting recorded was 70 watts. Acedure, the circulating nurse noticedpersive electrode was not in good copatient’s skin but the skin appeared tand free of injury.
During a routine postoperative skipostanesthesia care nurse noted a rin
tient’s navel that had not been removed beforeinjurreveto di
cume
settindyingmon
teps asuch
ase, bapprot sougnd thurn.r analtednectiooblemom thunitto r
ents w
er ofital re
an eng ante cand laph nodless thinimalogyperat
singlew sigbdomnds. Harrheapain,
d an atypicalcess.ascular col-fter surgery.t was deter-laparoscopicnsulated cov-eated a ther-that was un-
ccur in asopic thermalch can occur
reached.40 At of this tis-ccur if therelativelying central
s, surgicalresponsible
l instruments.a defect, it
l it can be.
re in ae technologyative RNsof electrosur-tients andand imple-ntly reducediligentat safetyented in ev-e.
ery. In: Periop-actices. Denver,
Control Riska 16).sks. Perioper
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
surgery and a bright red area of skinaround the ring. Further investigationthat the preoperative nurse had failedthe navel ring even though it was dothat all jewelry had been removed.
Preoperative care in the ambulatorybecome a familiar routine, with the reatients, use of checklists, and use of comment such as the ESU. Often, simple squiries are overlooked because they areof the routine care of patients. In this cthe dispersive electrode did not adhereto the patient’s skin, the electric currenalternate pathway through the patient athe metal on her skin, thus causing a b
When a surgeon repeatedly asks foin settings, the procedure should be hthe circulating nurse inspects the conelectrodes. If all are intact and the prtinues, the unit should be removed frand tagged for inspection, and a newbe brought in for use. It is imperativeber that nurses are advocates for patiunable to speak for themselves.
HOSPITAL PATIENT SCENARIOMr D, a 74-year-old married man, fathand grandfather of 11, underwent a digexam during a routine physical and hadprostate-specific antigen (PSA) screenitive needle biopsy that indicated prostasubsequently underwent a video-assistescopic prostatectomy with pelvic lympsection. His surgery was completed inhours. His estimated blood loss was moperatively, he was admitted to the urofloor to advance to discharge. On postoone, Mr D reported pain at one of theincision sites. This incision did not shoerythematic or purulent drainage. His adistended. He had persistent bowel souported nausea and had vomiting and diever, he did not experience abdominal
white blood count was within normal limits,yaledscovernted
g canof pa-equip-nd in-a part
ecausepriatelyht an
rough
increasewhilens andcon-
e roomshouldemem-
ho are
four,ctallevatedd a posi-cer. He
aro-e dis-an four
l. Post-unitive daytrocar
ns ofen wase re-. How-his
did not have a fever. Overall, Mr D hapresentation for an intra-abdominal absHowever, Mr D experienced a cardiovlapse from sepsis and died four days a
After an autopsy was performed, imined that during Mr D’s surgery, ainstrument for which the protective iering had worn off was used. This crmal injury to a portion of his boweldetected during the surgery.
A laparoscopic thermal injury may olittle as two seconds.28,39,40 A laparoscinjury is the result of tissue death, whiif a temperature differential of 30° C islaparoscopic thermal injury is the resulsue death. Thermal injuries also may oinsulated covering on an instrument isthin. All perioperative personnel, includsterile supply department staff membertechnologists, surgeons, and nurses, arefor maintaining the integrity of surgicaIf an instrument is suspected of havingmust be removed from circulation untirepaired or replaced to prevent injuries
CONCLUSIONPatients in the perioperative setting ahighly technical, high-risk area. As thevolves, it is imperative that perioperunderstand not only the componentsgery but also the potential risks to papersonnel. Understanding these risksmenting safety practices can significathe chance of injury. Nurses must beabout patient safety and make sure thprecautions and practices are implemery case, for every patient, every tim
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4. ANSI/AAMI HF18:2001. ElectrosurgicaArlington, VA: Association for the AdMedical Instrumentation; 2001.
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Devices. 2005;34(12):414-420.7. De Marco M, Maggi S. Evaluation of s
frequency radiation emitted by electrosuPhys Med Biol. 2006;51(14):3347-3358
8. ECRI Institute. Electrosurgery checklistRoom Risk Management. 2007;2(Surger
9. Massarweh NN, Cosgriff N, Slakey DPhistory, principles, and current and futuColl Surg. 2006;202(3):520-530.
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11. ESU burns from poor dispersive electrotion. Health Devices. 1993;22(8-9):422-
12. The patient is on fire! A surgical fires phttp://www.mdsr.ecri.org/summary/detai8197. Accessed November 29, 2011.
13. Misconnection of bipolar electrosurgicaHealth Devices. 1995;24(1):34-35.
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15. Beesley J, Taylor L. Reducing the riskare you assessing the risk? J Perioper P16(12):591-597.
16. Soussan EB, Mathieu N, Roque I, Antoexplosion with colonic perforation durincoagulation for hemorrhagic radiation-inGastrointest Endosc. 2003;57(3):412-41
17. Smith C. Surgical fires—learn not to bu2004;80(1):23-34.
18. Ignition of debris on active electrosurgiHealth Devices. 1998;27(9-10):367-370
19. Smith TL, Smith JM. Electrosurgery inhead and neck surgery: principles, advaplications. Laryngoscope. 2001;111(5):7
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24. A report by the American Society of ATask Force on Operating Room Fires. Pfor the prevention and management of ofires. Anesthesiology. 2008;108(5):786-8
25. ECRI Institute. Surgical fires. OperatingManagement. 2006;2(Safety 1):1-18.
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(MAUDE) Database. http://www.accessscripts/cdrh/cfdocs/cfMAUDE/Detail.CFMID�767284. Accessed November 29, 201
27. Demir E, O’Dey DM, Pallua N. Accideing surgery. J Burn Care Res. 2006;27(
28. Wu MP, Ou CS, Chen SL, Yen EYT, RoComplications and recommended practicegery in laparoscopy. Am J Surg. 2000;179
29. Tucker RD, Voyles CR, Silvis SE. Capstray currents during laparoscopic and etrosurgical procedures. Biomed Instrum26(4):303-311.
30. Wang K, Advincula AP. “Current thoughgery. Int J Gynaecol Obstet. 2007;97(3):2
31. Odell RC. Pearls, pitfalls, and advancemlivery of electrosurgical energy during lProblems Gen Surg. 2002;19(2):5-17.
32. Guidance section: ensuring monopolar esafety during laparoscopy. Health Devic20-26.
33. ECRI. Safety technologies for laparoscoelectrosurgery; devices for managing buDevices. 2005;34(8):259-272.
34. Evaluation of electroscope electroshieldDevices. 1995;24(1):11-19.
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36. Yazdani A, Krause H. Laparoscopic instion failure: the hidden hazard. J Minimcol. 2007;14(2):228-232.
37. Perioperative Job Descriptions and Comption Tools [CD-ROM]. Denver, CO: AOR
38. Policy and Procedure Templates, 2nd eDenver, CO: AORN, Inc; 2010.
39. Shirk GJ, Johns A, Redwine DB. Compliscopic surgery: how to avoid them and hothem. J Minim Invasive Gynecol. 2006;13
40. Saye WB, Miller W, Hertzmann P. Elecmal injury. Myth or misconception? SurEndosc. 1991;1(4):223-228.
Lisa Spruce, DNP, RN, ACNP-BC,ACNS-BC, CNOR, was the corporatemanager of surgical services, UHS ofInc, King of Prussia, PA, at the timewas written. Dr Spruce has no declarthat could be perceived as posing a pconflict of interest in the publication
Melanie L. Braswell, DNP, RN, CNan advanced practice nurse, Sinai HoBaltimore, MD. Dr Braswell has no daffiliation that could be perceived aspotential conflict of interest in the puthis article.
ence
.8.aorn.org/CE
EXAMINATION
CONTINUING EDUCATION PROGRAM2wwwImplementing AORN Recommended
Practices for Electrosurgery
mmended
lectrosurgi-
s for
ur conve-e Exami-
PURPOSE/GOAL
To educate perioperative nurses about how to implement the AORN “Recopractices for electrosurgery” in inpatient and ambulatory settings.
OBJECTIVES
1. Identify potential risks involved with the use of electrosurgery.2. Discuss AORN’s practice recommendations for the use and care of e
cal equipment.3. Discuss methods for implementing AORN’s practice recommendation
electrosurgery.
The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.
injury
e site.
gical
ury, rclude
makend 42, 3, a
f members ofety includepatient safety
afety protocols.
nd 42, 3, and 4
or refurbishedperioperative
atures.ode contact
QUESTIONS
1. The most common form of patientthe use of electrosurgery isa. a burn at the dispersive electrodb. a positioning injury.c. a capacitive-coupling injury.d. an injury related to an electrosur
2. In addition to the risk of patient injvolved with using electrosurgery in1. electrical shock.2. explosion.3. fire.4. interference with a patient’s pace
a. 1 and 2 b. 3 ac. 1, 2, and 3 d. 1,
© AORN, Inc, 2012
during
fire.
isks in-
r.
nd 4
3. Activities that can help remind stafthe key steps for electrosurgical saf1. posting an electrosurgery-related
poster.2. developing standardized patient s3. using checklists.4. working as a team.
a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,
4. In considering the purchase of newelectrosurgical units or accessories,nurses should1. speak to vendors about safety fe2. avoid products with return electr
quality monitoring.
March 2012 Vol 95 No 3 ● AORN Journal 385
o discnt.dized
nd 42, 3, a
tivatit is in’s dire
(ESUeriope
e stertlet w
the c
cord
e ESU
the acnde at
ofession.r assinductse.
surgeon andate the device
ar the active
2, and 52, 3, 4, and 5
osurgery, ifn the patient’se periopera-
electrode to
re, or prepwith contact.y be interfer-
electrode in
3, and 42, 3, 4, and 5
id trocar sys-minimally
cts of surgical_________od of
acepiece
with consulta-
e Education.
of interest in
March 2012 Vol 95 No 3 CE EXAMINATION
3. form an interdisciplinary group trisks and benefits of the equipme
4. help ensure equipment is standarthe facility.a. 1 and 2 b. 3 ac. 1, 3, and 4 d. 1,
5. It is permissible to disengage the accator on the electrosurgical unit if iwith the ability to hear the surgeonduring surgery.a. true b. false
6. In handling the electrosurgical unitimize the potential for injury, the pnurse shoulda. place the ESU near enough to th
that the cord reaches the wall oustress.
b. tape down any kinks or knots inprevent trips and falls.
c. use an extension cord if the ESUlong enough.
d. hold the cord when removing ththe outlet.
7. To minimize injuries during use ofelectrode, the perioperative nurse ca1. visually inspect the active electro
before it is used.2. coordinate with the anesthesia pr
minimize the oxygen concentrati3. remind the surgeon, technician, o
place the active electrode in a cosafety holster when it is not in u
The behavioral objectives and examination fo
tion from Rebecca Holm, MSN, RN, CNOR,
Ms Retzlaff, Ms Holm, and Ms Bakewell hav
the publication of this article.
386 AORN Journal
uss the
across
nd 4
on indi-terferingctions
) to min-rative
ile fieldithout
ord to
is not
from
tive
the field
onal to
stant toive
4. place the foot pedal between theassistant so that either may activas needed.
5. moisten sponges that are used neelectrode tip.a. 1 and 2 b. 1,c. 3, 4, and 5 d. 1,
8. During the use of monopolar electrthere is not uniform contact betweeskin and the dispersive electrode, thtive nurse should consider1. applying a new pad.2. repositioning the used dispersive
another site.3. removing any oil, lotion, moistu
solution that may be interfering4. removing excessive hair that ma
ing with contact.5. using tape to hold the dispersive
place.a. 3 and 5 b. 1,c. 1, 2, 3, and 4 d. 1,
9. Conductive trocar systems and hybrtems are equally safe for use duringinvasive surgery.a. true b. false
10. To reduce the potential adverse effesmoke to personnel and patients, __should be used as the primary methprotection.a. local exhaust ventilationb. fit-tested surgical N95 filtering f
respiratorsc. high-filtration masks
program were prepared by Kimberly Retzlaff, editor/team lead,
editor, and Susan Bakewell, MS, RN-BC, director, Perioperativ
eclared affiliations that could be perceived as potential conflicts
r this
clinical
e no d
.8.aorn.org/CE
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM2wwwImplementing AORN Recommended
Practices for Electrosurgeryne theon proe item
tives o
the u. 5.dation
elec. 5.ORNery.
se yo
objechion fr
2. Nesulttion #
e? (Select all
team regard-
to change/ure.
eeting withand acceptance
evaluate ther intervals
ted as best
e as a resultt all that
t relevant to
teach othersded change.port to make
t we verifythe 2.8 con-68-minute)
This evaluation is used to determito which this continuing educatimet your learning needs. Rate th
described below.
OBJECTIVES
To what extent were the following objeccontinuing education program achieved?
1. Identify potential risks involved withelectrosurgery. Low 1. 2. 3. 4
2. Discuss AORN’s practice recommenthe use and care ofcal equipment. Low 1. 2. 3. 4
3. Discuss methods for implementing Atice recommendations for electrosurgLow 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increaknowledge of the subject matter?Low 1. 2. 3. 4. 5. High
5. To what extent were your individualmet? Low 1. 2. 3. 4. 5. Hig
6. Will you be able to use the informatarticle in your work setting? 1. Yes
7. Will you change your practice as a ring this article? (If yes, answer ques
applicant who successfully completes this program
© AORN, Inc, 2012
extentgrams as
f this
se ofHighs fortrosurgi-High
’s prac-
ur
tives
om thiso
of read-7A. If
7A. How will you change your practicthat apply)1. I will provide education to my
ing why change is needed.2. I will work with management
implement a policy and proced3. I will plan an informational m
physicians to seek their inputof the need for change.
4. I will implement change andeffect of the change at regulauntil the change is incorporapractice.
5. Other:7B. If you will not change your practic
of reading this article, why? (Selecapply)1. The content of the article is no
my practice.2. I do not have enough time to
about the purpose of the nee3. I do not have management sup
a change.4. Other:
8. Our accrediting body requires thathe time you needed to completetinuing education contact hour (1
dentialing Center
eptance of this
ers. Each
no, answer question #7B.) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.
Event: #12507; Session: #0001; Fee: Members $14, Nonmembers $28
The deadline for this program is March 31, 2015.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answ
can immediately print a certificate of completion.March 2012 Vol 95 No 3 ● AORN Journal 387