Historical Perspective

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1 THE ROLE OF THE PERIOPERATIVE NURSE IN ELECTRO-SURGICAL SAFETY Anna-Marie McCarthy

2 Electrosurgery The term electrosurgery refers to the passage of high-frequency electrical current through the tissue in order to achieve a specific surgical effect i.e. cutting, coagulation, desiccation or fulguration for the destruction or manipulation of the tissue.

3 Historical Perspective The use of cautery dates back as far as prehistoric times when heated stones were used to obtain haemostasis. The use of electricity in medicine coincided with the earliest scientific discoveries beginning in the 17th Century Joseph Rivere-First True use of Electricity in Surgery However many people credit William T Bovie as being the father of electrosurgical devices.

4 Guidelines for Quality and Safety The Framework for Improving Quality in our Health Service was published in April Within this document quality is defined by the four quality domains set out in Safer Better Healthcare Standards (2012). Person Centred Care & Support Effective Care & Support Safe Care & Support Better Health and Wellbeing

5 Is Electrosurgery Really a Quality Issue? A 55 year old male admitted to hospital with acute chest pain and dyspnoea due to a ruptured aortic aneurysm. He arrested and was resuscitated intraoperatively. The surgery was completed. After this operation burns on the anterior surface of the right hand, elbow and the distal forearm were noticed. He was right handed and there was a 57% loss of his complete ability.

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7 Types of Diathermy MONOPOLAR BIPOLAR Current flows in a closed loop- from device Current only flows in the defined tissue to instrument, through the patient s body to the patient plate and from there back to the device. region between both poles and not through the patient s body.

8 Preoperative Responsibilities Check the electrosurgical unit is clean and in working order. Patient s skin integrity is to be evaluated. Check if patient has a pacemaker, internal cardioverter defibrillator or other electrical implant. Ensure patient is in the desired position for surgery. Prepare site for application of dispersive electrode diathermy pad. Select a single use diathermy pad size appropriate to the patient size.

9 Preoperative Responsibilities Continued Apply the diathermy pad to ensure firm skin contact and check all attachments are secure. Document in the perioperative care plan the dispersive electrode diathermy pad position and site preparation. Ensure patients skin is not in contact with any metal interface. Metal jewellery should be removed. Ensure fluids do not come in contact with the diathermy pad. Position cables safely to prevent trips or falls and place foot pedals within appropriate site for surgeons use.

10 Intraoperative Responsibilities Once the patient s surgical site has been prepped and draped the active electrode lead is connected to the designated receptacle on the ESU by the circulating nurse. The active electrode is inspected before use. Ensure surgical site is fully dry and vapours evaporated prior to using the active electrode. Verify power settings. Store active electrodes in a dry well insulated safety holster when not in use at the surgical field.

11 Intraoperative Responsibilities Continued Document in perioperative care plan the type of diathermy used. The activated electrode should be cleaned regularly. Sponges close to the active electrode should be kept moist. Caution when using the active electrode in the presence of intestinal gases, oxygen enriched environments and fluid filled cavities. If the patient is repositioned during surgery check the position and contact of the dispersive electrode diathermy pad with the patients skin surface.

12 Postoperative Responsibilities Remove the dispersive electrode diathermy pad carefully. Check the patient s skin integrity. Turn off the ESU at the power switch. Clean ESU, power cord and foot pedal. Discard all disposable items and check reusable accessories prior to reprocessing.

13 Special Considerations Special precautions must be put in place for patients with pacemakers, internal cardioverter defibrillators or other electrical implants. A preoperative cardiology consult may be necessary. An ICD will need to be DEACTIVATED prior to surgery. Bipolar electrosurgery should be used wherever possible. All electrosurgical cords and cables and the diathermy pad should be placed on the opposite side as far as possible from the pacemaker/icd. pacemaker/icd The defibrillator should be kept on standby in the theatre at all times. Continuous monitoring must be in place. Patient should be reviewed by relevant personnel postoperatively.

14 Laparoscopic Surgery The dangers of electrosurgery are increased by the confined, enclosed conditions that apply in a laparoscopic procedure. Vision is limited to the immediate operating area and much of the length of the instrument may be outside the surgeons field of vision. Patient injury can occur through direct coupling or capacitative coupling. However insulation failure is thought to be the main cause of electrosurgical complications. Every laparoscopic instrument set likely has one or more reusable instruments with an insulation defect.

15 In Conclusion The safe use of electrosurgical equipment will have a positive influence on the patient s surgical outcome and protect perioperative personnel. It is essential to have a basic knowledge and understanding of electricity and the risks associated with electrosurgical equipment. Australian College of Operating Room Nurses Standards for Perioperative Nursing

16 QUALITY MEANS DOING IT RIGHT WHEN NO ONE IS LOOKING Henry Ford

17 References AORN (2014) Perioperative standards and recommended practices, Denver:AORN Carlson, J. and Rice, S. (2014) 'All of a sudden, there was fire', Modern Healthcare, 44(28), 8-9. CUH (2015) Policy and procedure for the safe use of electrosurgical diathermy in the operating theatre departments in Cork University Hospital Group, CUH: PPG-CUH-CUH-226. Demircin, S., Aslan, F., Karagoz, Y. and Atilgan, M. (2013) Medicolegal aspects of surgical diathermy burns: A case report and review of the literature, Romanian Journal of Legal Medicine, 21, EORNA (2015) Position statements and guidelines for perioperative nursing practice Part I, Belgium: EORNA Garcia-Bracamonte, B., Rodriguez, J., Casado, R., and Vanaclocha, F. (2013). Electrosurgery in patients with implantable electronic cardiac devices (Pacemakers and Defibbrillators), Actas Dermo-Sifiliográficas (English Edition), 104(2), Hay, D. (2005) Electrosurgery, Surgery (Oxford), 23(2), Huang, H., Yen, C. and Wu, M. (2014) Complications of electrosurgery in laparoscopy, Gynecology and Minimally Invasive Therapy, 3(2), Liodaki, E., Stang, F. H., Lohmeyer, J. A., Bergmann, P. A., Mailänder, P. and Siemers, F. (2013) 'Noncontact electrosurgical grounding - A useful and safe tool in the initial surgical management of thermal injuries', Burns ( ), 39(1),

18 References Continued.. Massarweh, N., Cosgriff, N. and Slakey, D. (2006) Electrosurgery: History, principles and current and future uses, Journal of the American College of Surgeons. 202(3), Montero, P. N., Robinson, T. N., Weaver, J. S. and Stiegmann, G. V. (2010) 'Insulation failure in laparoscopic instruments', Surgical Endoscopy,24(2), Potty, A., Khan, W. and Tailor, H. (2010) Diathermy in perioperative practice, British Journal of Perioperative Nursing, 20(11), Sankaranarayanan, G., Resapu, R. R., Jones, D. B., Schwaitzberg, S. and De, S. (2013) 'Common uses and cited complications of energy in surgery', Surgical Endoscopy, 27(9), Seifert, P. C., Peterson, E. and Graham, K. (2015) 'Crisis Management of Fire in the OR', AORN Journal, 101(2), Taheiri, A., Mansoori, P., Sandoval, L., Feldman, S., Pearce, D. and Williford, M. (2014). Electrosurgery Part I: Basics and principles, Journal of the American Academy of Dermatology, 70(4), 591.e1-591.e14. Taheiri, A., Mansoori, P., Sandoval, L., Feldman, S., Pearce, D. and Williford, M. (2014). Electrosurgery:Part II. Technology, applications and safety of electrosurgical devices, Journal of the American Academy of Dermatology, 70(4), 607.e1-607.e12. Watanabe, Y., Kurashima, Y., Madani, A., Feldman, L., Ishida, M., Oshita, A., Naitoh, T., Noma, K., Yasumasa, K., Nagata, H., Nakamura, F., Ono, K., Suzuki, Y., Matsuhashi, N., Shichinohe, T., Hirano, S. and Feldman, L. S. (2016) 'Surgeons have knowledge gaps in the safe use of energy devices: a multicenter cross-sectional study', Surgical Endoscopy, 30(2), Wood, E. (2015) 'New curriculum aims to reduce hazards of energy devices in the OR', OR Manager, 1-1.