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ElectrocauteryElectrocautery & Basic& Basic Endoscopy ProceduresEndoscopy Procedures

St. James HealthcareSt. James HealthcareEndoscopy DepartmentEndoscopy Department

Butte, MontanaButte, Montana20122012

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ELECTROCAUTERY SAFETY: ELECTROCAUTERY SAFETY: LEARNING MODULE GOALSLEARNING MODULE GOALS

1.1. TO UNDERSTAND THE BASIC PRINCIPLES OF TO UNDERSTAND THE BASIC PRINCIPLES OF

ELECTROCAUTERY SAFETY. ELECTROCAUTERY SAFETY.

2. BE ABLE TO EXPLAIN THE CORRECT APPLICATION OF 2. BE ABLE TO EXPLAIN THE CORRECT APPLICATION OF AN ELECTROCAUTERY PAD, EQUIPMENT SET UP AND AN ELECTROCAUTERY PAD, EQUIPMENT SET UP AND COMMUNICATION WITH ALL TEAM MEMBERS. COMMUNICATION WITH ALL TEAM MEMBERS.

3. BE ABLE TO IDENTIFY THREE THINGS THAT WILL 3. BE ABLE TO IDENTIFY THREE THINGS THAT WILL CHANGE YOUR EVERYDAY PRACICE.CHANGE YOUR EVERYDAY PRACICE.

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ELECTROCAUTERY SAFETY:ELECTROCAUTERY SAFETY: TEST YOUR KNOWLEDGE TEST YOUR KNOWLEDGE (TRUE/FALSE)(TRUE/FALSE)

An important step during any An important step during any electrocauteryelectrocautery procedure is to procedure is to verbalize to the MD completion of important verbalize to the MD completion of important electrocauteryelectrocautery safety safety checks.checks.

Application of the grounding pad needs to face the Application of the grounding pad needs to face the cauterycautery field.field.

The heater probe is safe in an The heater probe is safe in an unpreppedunprepped bowel and does not bowel and does not require a require a cauterycautery pad.pad.

In CUT Mode the tissue heats slowly with the effect of fluid losIn CUT Mode the tissue heats slowly with the effect of fluid loss, s, steam release with cooling, and then coagulation = HEMOSTASIS.steam release with cooling, and then coagulation = HEMOSTASIS.

In the COAG Mode there is highIn the COAG Mode there is high--continuous energy 60continuous energy 60--100 Watts.100 Watts.

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EquipmentEquipment

Electrosurgical GeneratorElectrosurgical Generator

Power CordPower Cord

Active CordActive Cord

Foot Pedal (remote control)Foot Pedal (remote control)

Grounding (skin) padGrounding (skin) pad

Instrument Instrument –– i.e. snare, bipolar probe or APCi.e. snare, bipolar probe or APC

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Electrosurgical Units:Electrosurgical Units: Settings and Modes Settings and Modes

Power settings = Watts or Joules;Power settings = Watts or Joules;

CUT CUT –– tissue heats and cells explode;tissue heats and cells explode;

COAGULATION COAGULATION –– tissue dehydrates and fulgurates;tissue dehydrates and fulgurates;

Blended Current Blended Current –– a combination of both (usually the case in a combination of both (usually the case in Endoscopy);Endoscopy);

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Patient Safety:Patient Safety: Best PracticesBest Practices

Attach the Active Cord to the active instrument Attach the Active Cord to the active instrument when MD is ready to initiate therapy;when MD is ready to initiate therapy;

VerbalizeVerbalize to the MD the important safety checks, i.e. to the MD the important safety checks, i.e. patient grounded, patient grounded, cauterycautery settingssettings and and active cord active cord connectedconnected to the instrument;to the instrument;

Be fastidious in the management of active cords, pad Be fastidious in the management of active cords, pad connections and instruments, i.e. avoid proximity to connections and instruments, i.e. avoid proximity to the patient of any coiled instrument and/or active and the patient of any coiled instrument and/or active and cauterycautery pad cord;pad cord;

Ensure the Skin Grounding pad is from a sealed package Ensure the Skin Grounding pad is from a sealed package (to avoid dried gel and to ensure good skin contact); (to avoid dried gel and to ensure good skin contact);

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Complete the Circuit: Complete the Circuit: Grounding (Skin) PadGrounding (Skin) Pad

Ensure proper adherence and connectivity of the Grounding Pad toEnsure proper adherence and connectivity of the Grounding Pad to avoid thermal injuryavoid thermal injury

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Correct Vs. Incorrect Skin Correct Vs. Incorrect Skin Grounding Pad ApplicationGrounding Pad Application

A GENERAL PRINCIPLE THAT DOES NOT NECESSARILY APPLY WITH ALL CAUTERY PADS. CHECK WITH THE MANUFACTURER. ERBE RECOMMENDS EXAMPLE A FOR CORRECT PLACEMENT.

A B

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Best Practices: Grounding PadBest Practices: Grounding Pad

Application:Application:

apply grounding pad according to manufacturer apply grounding pad according to manufacturer recommendations;recommendations;

apply the grounding pad to well apply the grounding pad to well vascularizedvascularized tissue;tissue;

avoid scar tissue or bony prominences;avoid scar tissue or bony prominences;

direct and secure skin pad to the patient;direct and secure skin pad to the patient;

ASGE recommendations for internal devices and pregnancy;ASGE recommendations for internal devices and pregnancy;

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OTHER BEST PRACTICES:OTHER BEST PRACTICES:

Rings and Body Jewelry Rings and Body Jewelry –– ask patient to leave these at ask patient to leave these at home or remove prior to procedure;home or remove prior to procedure;

Hair Clipping Hair Clipping –– follow manufacturer recommendation;follow manufacturer recommendation;

Tattoos Tattoos –– avoid application over a tattoo site;avoid application over a tattoo site;

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Types of InterventionsTypes of Interventions

MonopolarMonopolar Coagulation Coagulation –– may be nonmay be non--contact (i.e. Argon contact (i.e. Argon Plasma Coagulation) or contact (i.e. Hot Snare);Plasma Coagulation) or contact (i.e. Hot Snare);

MonopolarMonopolar Cut Cut –– usually blended (i.e. Cut 1/Coag 18);usually blended (i.e. Cut 1/Coag 18);

Bipolar Bipolar –– pure pure coagcoag

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CoagulationCoagulation

Tissue heats slowly with the effect of fluid loss, steam Tissue heats slowly with the effect of fluid loss, steam release with cooling, and then coagulation = HEMOSTASIS;release with cooling, and then coagulation = HEMOSTASIS;

•• Bipolar Bipolar –– effective effective tamponadetamponade and and hemostasishemostasis;;

•• MonopolarMonopolar –– not really not really ““pure pure coagcoag””;;

WATT settings depend on electrosurgical WATT settings depend on electrosurgical generator;generator;

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CuttingCutting

Works best in tissue with low resistance, i.e. GI mucosa;Works best in tissue with low resistance, i.e. GI mucosa;

Requires moist tissue (not Requires moist tissue (not fulgarizedfulgarized) and loose contact;) and loose contact;

Works better with highWorks better with high--continuous energy 60continuous energy 60--100 Watts 100 Watts (mimics the scalpel with minimal coagulation);(mimics the scalpel with minimal coagulation);

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BlendBlend--CutCut

Less cell explosion (cut) than pureLess cell explosion (cut) than pure--cut, and moderate cut, and moderate desiccation + fulguration (coagulation);desiccation + fulguration (coagulation);

Different levels of Different levels of ““blendblend”” are set by the manufacturer;are set by the manufacturer;

In ERBE: EffectIn ERBE: Effect--1= minimal 1= minimal coagcoag; Effect; Effect--4 = maximal 4 = maximal coagcoag; ; ENDOENDO--CUT uses EffectCUT uses Effect--3 (high 3 (high coagcoag blendblend--cut)cut)

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ERBE ICC ERBE ICC -- 200200

← AUTO COAGSetting

AUTO CUTSetting

↓

↑MonopolarCut/Coag

↑Grounding

Pad

Power ON ↑ ↑Bipolar

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ERBE: ERBE: Which Pedal Do I Use?Which Pedal Do I Use?

COAGULATION (Blue) unit is completely independent of CUT COAGULATION (Blue) unit is completely independent of CUT (Yellow) unit; Power setting in one side does not affect the (Yellow) unit; Power setting in one side does not affect the other;other;

BLENDBLEND--CUT current is a feature of the CUT (Yellow) unit. CUT current is a feature of the CUT (Yellow) unit. The degree of The degree of ““blendingblending”” depends on the chosen mode depends on the chosen mode (Endo(Endo--Cut); Cut);

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Snare Snare PolypectomyPolypectomy

Higher risk of perforation in right colon or small bowel;Higher risk of perforation in right colon or small bowel;

Saline Saline ““pillowpillow”” or lift may be used for flat polyps;or lift may be used for flat polyps;

Settings depend on type of generator Settings depend on type of generator

Close snare with mild to moderate pressure during Close snare with mild to moderate pressure during electrocauteryelectrocautery or to or to ““cut throughcut through””;;

Some MDSome MD’’s will shake the polyp or lift it from the tissue wall s will shake the polyp or lift it from the tissue wall to avoid burning or contact injury;to avoid burning or contact injury;

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PolypectomyPolypectomy

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MonopolarMonopolar ElectrocauteryElectrocautery

Skin Pad Required Skin Pad Required –– good contact and best applied near to site of good contact and best applied near to site of the active electrode or instrument;the active electrode or instrument;

Instrument Examples: hot snare, hot biopsy, bipolar probe (Instrument Examples: hot snare, hot biopsy, bipolar probe (““Gold Gold ProbeProbe””), Argon Plasma Coagulator (APC) probe, ), Argon Plasma Coagulator (APC) probe, sphincterotomesphincterotome

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ElectrocauteryElectrocautery: The Risk of : The Risk of Current DivisionCurrent Division

The current may split (or divide) and follow more than one path The current may split (or divide) and follow more than one path to to ground causing patient exposure to the risk of alternate site buground causing patient exposure to the risk of alternate site burns rns because:because:

(1) current follows the easiest, most conductive path; (1) current follows the easiest, most conductive path;

(2) any grounded object, not just the generator, can complet(2) any grounded object, not just the generator, can complete the e the circuit; circuit;

(3) the surgical environment offers many alternative routes to(3) the surgical environment offers many alternative routes to ground; ground;

(4) if the resistance of the alternate path is low enough and (4) if the resistance of the alternate path is low enough and the current the current flowing to ground in that path is sufficiently concentrated, an flowing to ground in that path is sufficiently concentrated, an unintended burn may be produced at the alternate grounding site.unintended burn may be produced at the alternate grounding site.

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Argon Plasma Coagulation Argon Plasma Coagulation (APC)(APC)

Argon gas flows inside a hollow catheter;Argon gas flows inside a hollow catheter;

Skin Grounding Pad;Skin Grounding Pad;

NonNon--contact, coagulation effect (contact, coagulation effect (monopolarmonopolar current in a wire inside current in a wire inside the catheter); the catheter);

Short bursts (tap) or continuous movement Short bursts (tap) or continuous movement ““paintingpainting”” is done to is done to avoid deep tissue injury; avoid deep tissue injury;

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APCAPC

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Bipolar Electrocautery

Two or more small active electrodes very close to each other (thTwo or more small active electrodes very close to each other (the e active and return electrode);active and return electrode);

Does not require a skin grounding pad;Does not require a skin grounding pad;

Colon Prep required (if lower GI bleed);Colon Prep required (if lower GI bleed);

Good coagulation at low settings;Good coagulation at low settings;

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Bipolar Electrocautery

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ElectrocauteryElectrocautery ComplicationsComplications

Skin Burn Skin Burn –– avoid by ensuring appropriate grounding;avoid by ensuring appropriate grounding;

Implantable device Implantable device –– avoid interference or device damage; by avoid interference or device damage; by following prefollowing pre--procedure guidelines to screen forprocedure guidelines to screen for

Bowel Explosion Bowel Explosion –– avoid by assessing quality of bowel prep;avoid by assessing quality of bowel prep;

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ElectrocauteryElectrocautery: Skin Burn: Skin Burn

Alternate site burn due to a grounded electrosurgical generator and a ground referenced ECG device. The ECG electrode

provided the path of least resistance to ground with not enough current dispersal over a large enough area. The heat produced an alternate site burn under the ECG electrode due to current

concentration.

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Heater ProbeHeater Probe

Coagulates and Irrigates;Coagulates and Irrigates;

Is not Is not electrocauteryelectrocautery (no sparks); safe in (no sparks); safe in unprepared bowel.unprepared bowel.

Has an electrically heated coil inside a Has an electrically heated coil inside a TeflonTeflon--covered insulated cylinder; covered insulated cylinder;

Power setting in Joules (Watts x Sec);Power setting in Joules (Watts x Sec);

Heater Probe Unit decides time needed to Heater Probe Unit decides time needed to deliver the required energy;deliver the required energy;

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Bleed Site Control: Bleed Site Control: Other methodsOther methods

PrepPrep-- saline lift / saline lift / chromoendoscopychromoendoscopy to visualize polyp border (helps to visualize polyp border (helps to prevent a bleeding complication);to prevent a bleeding complication);

HemoclipsHemoclips

ScleroSclero Injection Injection –– Epinephrine 1:10,000Epinephrine 1:10,000

Band Band LigatorLigator

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ELECTROCAUTERY SAFETY:ELECTROCAUTERY SAFETY: POST QUESTIONS (TRUE/FALSE)POST QUESTIONS (TRUE/FALSE)

An important step during any An important step during any electrocauteryelectrocautery procedure is to procedure is to verbalize to the MD completion of important verbalize to the MD completion of important electrocauteryelectrocautery safety safety checks;checks;

Application of the grounding pad needs to face the Application of the grounding pad needs to face the cauterycautery field;field;

The heater probe is safe in an The heater probe is safe in an unpreppedunprepped bowel and does not bowel and does not require a require a cauterycautery pad;pad;

In CUT Mode the tissue heats slowly with the effect of fluid losIn CUT Mode the tissue heats slowly with the effect of fluid loss, s, steam release with cooling, and then coagulation = HEMOSTASIS;steam release with cooling, and then coagulation = HEMOSTASIS;

In the COAG Mode there is highIn the COAG Mode there is high--continuous energy 60continuous energy 60--100 Watts;100 Watts;

Identify three things that will change your everyday practice.Identify three things that will change your everyday practice.

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ReferencesReferences

ERBE (2008). Retrieved online atERBE (2008). Retrieved online at www.www.erbeerbe--usa.comusa.com;;

Valley Lab (2009). Retrieved online at Valley Lab (2009). Retrieved online at www.valleylab.comwww.valleylab.com. .

Olympus America (2009). Retrieved online at Olympus America (2009). Retrieved online at www.olympus.comwww.olympus.com. .

ASGE (2003). Electrosurgical generators. Retrieved online atASGE (2003). Electrosurgical generators. Retrieved online at www.asge.orgwww.asge.org;;

Morris, M. (2006) Morris, M. (2006) ElectrosurgeryElectrosurgery in the Gastroenterology Suite: Principles, in the Gastroenterology Suite: Principles, Practice and Safety. SGNA Journal. Retrieved online at Practice and Safety. SGNA Journal. Retrieved online at www.sgna.orgwww.sgna.org;;

EndoNurseEndoNurse (2002). (2002). ElectrocauteryElectrocautery: Sacred Cow or Valuable Asset. Retrieved : Sacred Cow or Valuable Asset. Retrieved online atonline at www.www.endonurseendonurse.com.com;;

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THE ENDTHE END

A Healthy Sea Polyp

Susan DePasquale, CGRN, MSN (2009, Rev. 2012)