implementing aorn recommended practices for electrosurgery

7/25/2019 Implementing Aorn Recommended Practices for Electrosurgery

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Implementing AORN

Recommended Practicesfor ElectrosurgeryLISA SPRUCE, DNP, RN, ACNP-BC, ANP-BC, ACNS-BC, CNOR;

MELANIE L. BRASWELL, DNP, RN, CNS, CNOR

www.aorn.org/CE

2.8

ABSTRACT

Technology is constantly changing, and it is important for perioperative nurses to stay

current on new products and technologies in the perioperative setting. AORNs Rec-

ommended practices for electrosurgery addresses safety standards that all periop-

erative personnel should follow to minimize risks to both patients and staff members

during the use of electrosurgical devices. Recommendations include how to select

electrosurgical units and accessories for purchase, how to minimize the potential for

patient and staff member injuries, what precautions to take during minimally inva-

sive surgery, and how to avoid surgical smoke hazards. The recommendations also

address education/competency, documentation, policies and procedures, and quality

assurance/performance improvement. Perioperative nurses should consider the use of

checklists and safety posters to remind staff members of the dangers of electrosurgery

and the steps to take to minimize the risks for injury. AORN J95 (March 2012) 373-384.

AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.12.018

Key words: electrosurgery, electrosurgical unit, ESU, active electrode, bipolar

active electrode, dispersive electrode, monopolar electrosurgery, ultrasonic de-

vice, argon enhanced coagulation technology, surgical smoke, minimally invasive

surgery, MIS.

The AORN Recommended practices for

electrosurgery was published in July 2009

online in Perioperative Standards and

Recommended Practices. The purpose of the re-

vised recommended practices (RP) document is toprovide guidance to perioperative nurses in the

use and care of electrosurgical equipment, includ-

ing high frequency, ultrasound, and argon beam

modalities.1(p99) There are 14 practice recom-

mendations that represent what is believed to be

an optimal level of practice. Hospital and ambula-

tory patient scenarios representing possible patient

safety situations are provided here to exemplify

indicates that continuing education contact hours

are available for this activity. Earn the contact hours

by reading this article, reviewing the purpose/goal and

objectives, and completing the online Learner Evalua-

tion athttp://www.aorn.org/CE.The contact hours

for this article expire March 31, 2015.

RECOMMENDED PRACTICES

doi: 10.1016/j.aorn.2011.12.018

AORN, Inc, 2012 March 2012 Vol 95 No 3 AORN Journal 373
http://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CE


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ways that practice recommendations for electro-

surgery might be implemented.

WHATS NEW?

Electrosurgery was introduced in the 1920s and is

commonly used today. However, new safety fea-

tures have been incorporated into current electro-

surgical unit (ESU) and active and dispersive

electrode designs. Electrosurgical unit devices

present risks for patient injury; the most common

form of patient injury is a burn at the dispersive

electrode site.2 In addition to presenting a risk

for patient injury, these devices can cause fires,

electrical shock, or explosions and may inter-

fere with other critical implanted electronic

medical devices such as pacemakers. This RP

document updates perioperative nurses on safe

practices in electrosurgery.

RATIONALE

Patient safety is the number-one priority for

perioperative nurses, and keeping patients and

staff members safe during the use of ESUs is

essential. Electrosurgical technology poses a

very high risk to the patient and can cause

permanent disfiguring injuries or death.3 In

addition, there is a high degree of risk to

personnel, such as shocks and burns, in the

presence of this device.

The generator of the ESU is the electricity

source. The monopolar electrosurgery circuit is

composed of the generator, the active electrode,

the patient, and the patient dispersive electrode

(ie, return electrode) (Figure 1). The patients

tissue provides impedance, and heat is produced

as the electrodes overcome the impedance. In

ground-referenced generators, alternative path-

ways to the ground may include the OR bed,

stirrups, staff members, and equipment, provid-

ing a potential risk of alternate site injury.

Isololated generators minimize this risk for in-

jury because the preferred pathway return to the

ground is through the generator.

This RP document addresses the safety mea-

sures that all perioperative personnel should use

to minimize risk to both patients and staff

members. The Association for the Advancement

of Medical Instrumentation has established min-

imum safety and performance standards for us-

ing ESU systems, which have been approved by

the American National Standards Institute and

the International Electrotechnical Commission.4

Figure 1. The monopolar electrosurgical circuit is composed of the generator, the active electrode, the

patient, and the patient dispersive electrode.

March 2012 Vol 95 No 3 SPRUCEBRASWELL

374 AORN Journal


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DISCUSSION

Most perioperative nursing strategies for ensuring

patient safety while electrosurgery is being used

are task oriented. Working as a team and follow-

ing patient safety protocols and checklists will

help remind staff members of the key steps for

electrosurgical safety. At times, nurses take for

granted that patients are going to be safe. Electro-

surgery is used every day in the OR, and it is easy

to let ones guard down. The use of tools such as a

patient safety poster (Figure 2)can help periopera-

tive personnel remember the key components of

electrosurgery. Developing tools such as this one in

individual practice settings reminds staff members

that patient safety is a team responsibility.

Developing standardized protocols and check-

lists for each operating arena is another way to

reinforce all of the key safety strategies. Protocols

and checklists should be based on AORNs rec-

ommended practices. An example of different

protocols might be for patients who are undergo-

ing general surgery versus those who are under-

going minimally invasive surgery. Protocols for

patients undergoing minimally invasive surgery

would have additional safety steps because of the

risks involved with using distention media.

Recommendation I

Personnel selecting new

and refurbished [ESUs] and

accessories for purchase or

use should make decisions

based on safety features to

minimize risks to patients and

personnel.1(p99) Personnel

involved in purchasing deci-sions should consider

the following:

The most frequently re-

ported injury to patients

is a burn at the site of

the dispersive electrode.2

Look for a dispersive

electrode that will

minimize this risk, such as through the use of

return electrode contact quality monitoring.2,5

Speak to vendors and get a detailed explana-

tion of the safety features of the equipment

being considered for purchase.

Form an interdisciplinary group to ask ques-

tions and discuss the risks and benefits to pa-

tients of this type of equipment.

Standardize equipment across the facility so

there is no variation in practice, which helps

ensure that all patients are treated with the

same safety standards related to ESU use.

Recommendation II

The ESU should be used in a manner that mini-

mizes the potential for injuries.1(p100) Patientinjuries, user injuries, and fires do occur. Periop-

erative nurses should be knowledgeable of and

diligent in adhering to the basic principles of ESU

safety. Perioperative nurses should speak up and

challenge other team members if patient safety

issues arise or strategies are not consistently fol-

lowed. Perioperative nurses should consider the

following steps for creating a safe electrosurgical

environment:

Read and attach the manufacturers manual tothe unit or cart on which the ESU sits.

Educational Resources

Periop Modules: Electrosurgery. http://www.aorn.org/

Education/Specialty_Education/Periop_Modules.aspx.

AORN Video Library:Electrosurgery: Function, Practice &

Safety. http://cine-med.com/index.php?navnursing&subnav

aorn&id

1937. Perioperative Management Resources: Evaluation of New Tech-

nology. http://www.aornbookstore.org/.

Surgical Smoke Evacuation Tool Kit.http://www.aorn.org/

Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_

ToolKit/Download_the_Surgical_Smoke_Evacuation_

Tool_Kit.aspx.

Web site access verified December 12, 2011.

RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

AORN Journal 375
http://www.aorn.org/Education/Specialty_Education/Periop_Modules.aspxhttp://www.aorn.org/Education/Specialty_Education/Periop_Modules.aspxhttp://www.aorn.org/Education/Specialty_Education/Periop_Modules.aspxhttp://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://www.aornbookstore.org/http://www.aornbookstore.org/http://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Download_the_Surgical_Smoke_Evacuation_Tool_Kit.aspxhttp://www.aornbookstore.org/http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://cine-med.com/index.php?nav=nursing%26subnav=aorn%26id=1937http://www.aorn.org/Education/Specialty_Education/Periop_Modules.aspxhttp://www.aorn.org/Education/Specialty_Education/Periop_Modules.aspx


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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 patients 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 holster when

not in use.

Every year patients and members of the surgery team are injured during cases where electrosurgical

technology is used. Often times injuries occur due to operator error and not from the equipment it-

self. It takes a team to assure patients and staff are safe from injury! Everyone should understand

the risks and take action to prevent a mishap from occurring.

We want to make surgical procedures around the world something that patients

and surgeons quickly forget because they have gone right rather than wrong.

~Sir Liam Donaldson

Consider:

The patients 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 proper ac-

cessories.

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 the pa-

tient.

Special precautions with argon enhanced coagulation.

Safety doesnt happen by accident!

Figure 2. A patient safety poster can remind staff members of precautions to take during electrosurgery.


376 AORN Journal


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Ensure that the ESU is mounted on a tip-

resistant cart or shelf and is protected from

liquids.

Do not silence alarmsall alarms and acti-

vation indicators should be operational, au-

dible, and visible at all times. It is easy to

become distracted and to experience nor-

malization of deviation (eg, the acceptance

of activities that would normally be deemed

unacceptable). There is a natural human

tendency to ignore safety standards and

alarms over time when no event has occurred.

Nurses should be aware of this phenomenon

and always be diligent in ensuring patient

safety.

Confirm the power settings with the operator

before the ESU is activated and use the low-

est setting to achieve the desired tissue

effect.2,6-9 If the operator requests a contin-

ued increase in power, the nurse should

check the entire ESU and accessories for

cord connections and adequate placement of

the dispersive electrode.6,10,11 If there is a

continued request to increase power, this

could indicate that there is a problem with

the unit, the connections, or the placement

of the grounding pad. Nurses should not as-

sume that it is okay to

increase power without

stopping the procedure

and checking the ma-

chine and the patient.

Surgery should not con-

tinue if there is a con-

cern that the machine is

not working properly.

Recommendation III

The electrical cords and

plugs of the ESU should be

handled in a manner that

minimizes the potential for

injury and subsequent patient

and user injuries.1(p101)

When cords and plugs are handled improperly,

the insulation can become frayed or broken,

which presents an electrical hazard. A survey of

the ESU physical environment only takes a min-

ute and should be a part of routine preparation for

every procedure. The perioperative nurse should

take the time to perform this critical survey and

consider the following actions to protect patients

and staff members:

Do not place tension on the cord and make

sure the length is adequate; do not use exten-

sion cords.10

Place the ESU near the sterile field; the cord

should reach the wall or outlet without

stress and without blocking a traffic path.10

Do not allow kinks, knots, or bends in the cord.

Hold the plug, not the cord, when removing

the ESU from the outlet.

Keep the cord dry.10

Check the cord for breaks, nicks, or cracks

and remove it from use for repair or replace-

ment if needed.10

Recommendation IV

The active electrode should be used in a manner

that minimizes the potential for injuries1(p101)

(Figure 3). Incompatibility of the active electrode

Resources for Implementation

AORN Clinical Answers. http://www.aorn.org/Clinical_

Practice/Clinical_Answers/Clinical_Answers.aspx.

AORN Nurse Consult Line. 800-755-2676 or 303-755-6300,

option 1.

EHR Perioperative Framework.http://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_

Framework.aspx.

ORNurseLink. http://www.aorn.org/ORNurseLink/.

Perioperative Job Descriptions and Evaluation Tools.http://

www.aorn.org/Secondary.aspx?id20740&terms

perioperative%20competencies.

Web site access verified December 12, 2011.


AORN Journal 377
http://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspxhttp://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspxhttp://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/ORNurseLink/http://www.aorn.org/ORNurseLink/http://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/Secondary.aspx?id=20740%26terms=perioperative%20competencieshttp://www.aorn.org/ORNurseLink/http://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/EHR_Periop_Framework/EHR_Perioperative_Framework.aspxhttp://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspxhttp://www.aorn.org/Clinical_Practice/Clinical_Answers/Clinical_Answers.aspx


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with the ESU as well as unintentional activation

and incomplete circuitry pose safety hazards to

patients and staff members.12,13 Perioperative

nurses should be diligent in monitoring for unin-

tentional activation, problems arising with the

ESU, or unsafe practices, and they should speak

up when patient safety is threatened. It is impor-

tant to ensure that electrosurgery not be used in

the presence of gastrointestinal gases12,14-17 or in

an oxygen-enriched environment.14,18-21 Caution

should be used when activating the active

electrode near the head and neck region or in

the presence of combustible anesthetic gases.

The active electrode should be used as far away

as possible from the oxygen source. Periopera-

tive nurses can take the following actions to

lessen risks:

Coordinate with the anesthesia professional to

minimize the oxygen concentration.

Always visually inspect the active electrode

at the field before use. Look for cord or

handpiece damage and incompatibility of the

accessories with the ESU.

Observe the sterile field when the ESU is in

use and, when necessary, remind the surgeon,

technician, or assistant that the active elec-

trode should be placed in a nonconductive

safety holster when it is not in use.2,9,14,22

Place the foot pedal near the user of the active

electrode to reduce the risk of unintentional

activation by other team members.8,14

Remove accumulated eschar from the active

electrode tip away from the incision.12,18

Follow fire safety measures,23 and consider

using a checklist to make sure none of the

following steps are accidentally missed:

Do not activate the active electrode in the

presence of flammable agents.

Time alcohol-based prep agents so the

minimum dry time recommended by the

manufacturer is allowed to pass, and do

not allow the surgical technologist or

Figure 3. The active electrode should be used in a manner that minimizes the potential for injuries.


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surgeon to drape the patient until the

prep agent has dried.

Remove suture packets containing alcohol

from the sterile field as soon as possible.

Moisten sponges that are used near the ac-

tive electrode tip.18,24,25

Arrange surgical drapes to minimize the

buildup of oxidizers (eg, oxygen, nitrous

oxide).

Always have a wet towel, saline, or wa-

ter available on the sterile field to extin-

guish a fire.

Be prepared to immediately extinguish

flames should they occur.

Recommendation V

When monopolar electrosurgery is used, a dis-

persive electrode should be used in a manner

that minimizes the potential for injuries.1(p104)

It is extremely important to make sure the dis-

persive electrode has uniform contact with the

patients skin. The perioperative RN should

verify this before surgery begins. If the nurse

notes that there is poor contact, he or she

should institute corrective actions, such as re-moving any oil, lotion, moisture, prep solution,

or excessive hair that may be interfering with

contact; moving the dispersive electrode to an-

other site; or applying a new pad. The nurse

should not use tape to hold the dispersive elec-

trode in place.

The nurse should ensure that the patient does

not contact any metal devices such as the bed,

stirrups, positioning devices, or safety strap

buckles to prevent a possible burn from di-rected current. Patient jewelry that is between

the active and dispersive electrodes should be

removed. Electrocardiogram electrodes should

be placed as far away from the surgical site as

possible. When removing the electrode, the

nurse should hold the adjacent skin in place

and peel the electrode back slowly to prevent

denuding the skin.

The nurse also should implement the following

as part of routine patient care:

Assess the patients skin before and after ESU

use to assess for any injuries.

Use dual-foil electrodes to make sure there isno impedance through the patients tissue.6 If

the impedance is too high, the ESU alarm will

sound and the ESU will stop functioning, thus

protecting the patient from harm.2

A single-use dispersive electrode should be

compatible with the ESU. Discard the elec-

trode after it has been used. If repositioning is

needed, discard the electrode and use a new

single-use product.11,26 Never reposition a

used electrode. Make sure to use the correct size of dispersive

electrode for individual patients. There are

different sizes, and they should not be folded,

cut, or altered in any way.

Identify the expiration date on a single-use dis-

persive electrode package before opening it and

do not use it if it is past the manufacturers expi-

ration date. Check the integrity of the product

and do not use it if there are flaws, damage, dis-

coloration, poor adhesive, or dryness, becausethese could prevent adequate contact.6,8,11,27

Place the dispersive electrode on well-perfused

muscle, which is a better conductor of elec-

tricity than adipose tissue.11 Also, place the

electrode on clean, dry, and intact skin on the

same side as the surgery and as close as possi-

ble to the site.

Do not place the electrodes over bony promi-

nences, scar tissue, hair, weight-bearing sur-

faces, potential pressure points, tattoos, or ametal prosthesis; distal to a tourniquet; or near

a warming device.

Place the dispersive electrode on the patient

after final positioning. If the patient is reposi-

tioned during surgery, verify that the electrode

is still in contact with the patients skin.

A capacitive coupled return electrode is a non-

adhesive return electrode that is placed close to


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the patient and forms a capacitor with the patient,

returning electrical current from the patient back

to the ESU. If a capacitive coupled pad is used,

the nurse should ensure that the pad is the appro-

priate size for the patient and that there is ade-

quate contact by confirming there are no materi-

als, such as foam, gel pads, or extra linen,

between the patient and the pad.

Recommendation VI

Personnel should take additional precautions

when using electrosurgery during minimally inva-

sive surgery (MIS).1(p107) Specific patient injury

can occur from direct coupling, insulation failure,

and capacitive coupling.6 Perioperative RNs

should understand these concepts and implementprecautions to prevent patient injury.

Direct coupling is the contact of an energized

active electrode tip with another metal instrument

or object in the surgical field. This can occur

when the surgeon or other user accidentally acti-

vates the ESU when the active electrode is touch-

ing another metal instrument, thus energizing that

instrument. This energy will seek a pathway to

the ground and can cause a significant patient

injury. Capacitive coupling is the transfer of elec-trical current from the active electrode through

intact insulation to adjacent conductive items (eg,

tissue, trocars). This occurs when combination

plastic and metal trocar systems are used.28-30 A

current can be generated from the conductor to

the nonconductor and the current can seek a path-

way through the patients tissues on its way to the

return electrode.

The following safety measures are important to

incorporate into nursing practice for MIS:

Make sure the gas used for insufflation is non-

flammable (eg, carbon dioxide).

Make sure that conductive trocar systems

are being used. This allows the current to

flow safely between the cannula and the ab-

dominal wall.

Do not use hybrid trocar systems (ie, combi-

nation plastic and metal).

Examine the electrodes used in MIS for insu-

lation failure. If the insulation is not intact, an

alternative pathway can be formed and can

cause serious patient injuries.28,31-36 There are

multiple methods used to detect insulation

failure. One is the use of two different colors

on the active electrode. The insulation is a

different color than the material of which the

active electrode is made, so it is visible if the

insulation fails, indicating the active electrode

should not be used. Active continuous moni-

toring systems are another detection method

that continuously monitor for insulation failure

or capacitive coupling and automatically shut

down when a breach is detected.

Instruct patients to report symptoms of elec-

trosurgical injury (eg, fever, abdominal pain,

vomiting) after MIS, and remind them that

symptoms can occur after discharge from the

postanesthesia care unit.

Recommendation VII

Bipolar active electrodes, including vessel oc-

cluding devices, should be used in a manner

that minimizes the potential for injuries.1(p108)

Unlike monopolar electrodes, bipolar electrodeshave two poles. The current flows between the

two poles and back to the ESU, so there is no

need for a dispersive electrode (Figure 4). Only

the tissue grasped is included in the electrical

current and there is no chance of stray current or

alternative pathways. The perioperative nurse

should make sure that the monopolar and bipolar

plugs on the ESU are differentiated, that proper

accessories are used, and that the correct cord is

plugged in to the correct bipolar plug. Bipolaractive electrodes provide precise hemostasis be-

cause the current runs between the two tines of

the electrode and not through the patient.

Recommendation VIII

Ultrasonic devices should be used in a manner

that minimizes potential injuries.1(p109) Ultra-

sonic devices do not create electrical energy. A

generator is used to produce ultrasonic energy


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and mechanical vibrations that cut and coagu-

late, causing denaturation of protein and the

formation of a coagulum. There is no need for

a dispersive electrode. The biggest risk with

ultrasonic devices is the risk to personnel who

are operating the device. Inhalation of aerosols

generated by the ultrasonic ESU should be min-

imized by using measures such as smoke evac-

uation systems and wall suction with an in-line

ultra-low penetration air (ULPA) filter.

Recommendation IX

Argon enhanced coagulation technology (AEC)

poses unique risks to patient and personnel safety

and should be used in a manner that minimizes

the potential for injury.1(p109) This type of

technology is a form of electrosurgery that uses

radio-frequency coagulation from an ESU that is

capable of delivering monopolar current through a

flow of ionized argon gas. The argon gas carries

the current from the active electrode to the tissue

so the active electrode never has to actually come

into contact with the tissue. This is useful for

hard-to-reach places.

During the use of AEC, all manufacturers

written instructions should be followed in addition

to all of the safety measures for monopolar sur-

gery. The perioperative nurse should implement

the following actions to promote patient safety:

Purge the air from the argon gas line by acti-

vating the system before use and after moder-

ate delays between activations and between

uses. Purging the gas line minimizes the riskof gas embolism. The gas flow should be lim-

ited to the lowest level possible that achieves

the desired effect.

Do not place the active electrode in direct

contact with tissue and remove it from patient

tissue after each activation. If there is direct

contact with tissue, the gas can be forced into

a vessel and cause gas emboli, which could be

fatal to the patient.

To prevent potential patient injury or death asa complication of argon gas technology, the

perioperative RN should take the following

steps as part of care:

Make sure that endoscopic insufflators have

audible and visual over-pressurization

alarms that cannot be deactivated. The

AEC is a secondary source of gas inside

the patient and can cause a rapid rise in

Figure 4. In bipolar electrosurgery, current flows between the two poles and back to the electrosurgery unit

without the need for a dispersive electrode.


AORN Journal 381


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intra-abdominal pressure, possibly causing

gas emboli to form.

Monitor patients for gas emboli, specifi-

cally end-tidal carbon dioxide, during the

procedure.

Recommendation X

Potential hazards associated with surgical smoke

generated in the practice setting should be identified,

and safe practices established.1(p110) The National

Institute of Occupational Safety and Health recom-

mends that smoke evacuators be used to reduce the

potential adverse effects of surgical smoke to per-

sonnel and patients. Local exhaust ventilation (LEV)

(eg, smoke evacuator, wall suction with in-line

ULPA filter) should be used as the primary methodof smoke evacuation. The suction wand of the

smoke evacuation should not be farther than two

inches from the source of the smoke. Nurses should

evaluate the type of LEV needed in their practice

settings for surgical procedures. The type of

LEV is based on adequacy to ensure safe re-

moval of the anticipated amount of surgical

smoke. Perioperative nurses should use respira-

tory protection (ie, a fit-tested surgical N95 fil-

tering facepiece respirator or high-filtrationmask) as secondary protection.

The Final Four

The final four recommendations in each AORN

RP document discuss education/competency, doc-

umentation, policies and procedures, and quality

assurance/performance improvement. These four

topics are integral to the implementation of

AORN practice recommendations. Personnel

should receive initial and ongoing education and

competency validation as applicable to their roles.

Implementing new and updated RPs affords an

excellent opportunity to create or update compe-

tency materials and validation tools. AORNs

perioperative competencies team has developed

the AORN Perioperative Job Descriptions and

Competency Evaluation Tools37 to assist perioper-

ative personnel in developing competency evalua-

tion tools and job descriptions.

Documentation of nursing care should include

patient assessment, plan of care, nursing diagnosis,

and identification of desired outcomes and interven-

tions, as well as an evaluation of the patients re-

sponse to care. Implementing new or updated RPs

may warrant a review or revision of the relevant

documentation being used in the facility.

Policies and procedures should be developed,

reviewed periodically, revised as necessary, and

readily available in the practice setting. New or

updated RPs may present an opportunity for col-

laborative efforts with nurses and personnel from

other departments in the facility to develop

organization-wide policies and procedures that

support the RPs. The AORN Policy and Proce-

dure Templates, 2nd edition,38 provides a collec-

tion of 15 sample policies and customizable tem-

plates based on AORNs Perioperative Standards

and Recommended Practices. Regular quality im-

provement projects are necessary to improve patient

safety and to ensure safe, quality care. For details on

the final four practice recommendations that are spe-

cific to the RP document discussed in this article,

please refer to the full text of the RP document.

AMBULATORY PATIENT SCENARIOMs P, a 20-year-old female patient, underwent a

routine excision of a large mass under her left

arm. The procedure took approximately 40 min-

utes. The ESU was in use and initial settings

were cut/coagulate at 30 watts. The dispersive

electrode was placed on the patients left lateral

thigh. During the procedure, the surgeon requested

that the settings be increased because of an inade-

quate desired effect. The physician repeatedly

requested that the settings be increased, and the

last setting recorded was 70 watts. After the pro-

cedure, the circulating nurse noticed that the dis-

persive electrode was not in good contact with the

patients skin but the skin appeared to be intact

and free of injury.

During a routine postoperative skin check, the

postanesthesia care nurse noted a ring in the pa-

tients navel that had not been removed before


382 AORN Journal


11/15

surgery and a bright red area of skin injury

around the ring. Further investigation revealed

that the preoperative nurse had failed to discover

the navel ring even though it was documented

that all jewelry had been removed.

Preoperative care in the ambulatory setting can

become a familiar routine, with the readying of pa-

tients, use of checklists, and use of common equip-

ment such as the ESU. Often, simple steps and in-

quiries are overlooked because they are such a part

of the routine care of patients. In this case, because

the dispersive electrode did not adhere appropriately

to the patients skin, the electric current sought an

alternate pathway through the patient and through

the metal on her skin, thus causing a burn.

When a surgeon repeatedly asks for an increase

in settings, the procedure should be halted while

the circulating nurse inspects the connections and

electrodes. If all are intact and the problem con-

tinues, the unit should be removed from the room

and tagged for inspection, and a new unit should

be brought in for use. It is imperative to remem-

ber that nurses are advocates for patients who are

unable to speak for themselves.

HOSPITAL PATIENT SCENARIOMr D, a 74-year-old married man, father of four,

and grandfather of 11, underwent a digital rectal

exam during a routine physical and had an elevated

prostate-specific antigen (PSA) screening and a posi-

tive needle biopsy that indicated prostate cancer. He

subsequently underwent a video-assisted laparo-

scopic prostatectomy with pelvic lymph node dis-

section. His surgery was completed in less than four

hours. His estimated blood loss was minimal. Post-

operatively, he was admitted to the urology unit

floor to advance to discharge. On postoperative day

one, Mr D reported pain at one of the single trocar

incision sites. This incision did not show signs of

erythematic or purulent drainage. His abdomen was

distended. He had persistent bowel sounds. He re-

ported nausea and had vomiting and diarrhea. How-

ever, he did not experience abdominal pain, his

white blood count was within normal limits, and he

did not have a fever. Overall, Mr D had an atypical

presentation for an intra-abdominal abscess.

However, Mr D experienced a cardiovascular col-

lapse from sepsis and died four days after surgery.

After an autopsy was performed, it was deter-

mined that during Mr Ds surgery, a laparoscopic

instrument for which the protective insulated cov-

ering had worn off was used. This created a ther-

mal injury to a portion of his bowel that was un-

detected during the surgery.

A laparoscopic thermal injury may occur in as

little as two seconds.28,39,40 A laparoscopic thermal

injury is the result of tissue death, which can occur

if a temperature differential of 30 C is reached.40 A

laparoscopic thermal injury is the result of this tis-

sue death. Thermal injuries also may occur if the

insulated covering on an instrument is relatively

thin. All perioperative personnel, including central

sterile supply department staff members, surgical

technologists, surgeons, and nurses, are responsible

for maintaining the integrity of surgical instruments.

If an instrument is suspected of having a defect, it

must be removed from circulation until it can be

repaired or replaced to prevent injuries.

CONCLUSION

Patients in the perioperative setting are in a

highly technical, high-risk area. As the technology

evolves, it is imperative that perioperative RNs

understand not only the components of electrosur-

gery but also the potential risks to patients and

personnel. Understanding these risks and imple-

menting safety practices can significantly reduce

the chance of injury. Nurses must be diligent

about patient safety and make sure that safety

precautions and practices are implemented in ev-

ery case, for every patient, every time.

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Manufacturer and User Facility Device Experience

(MAUDE) Database.http://www.accessdata.fda.gov/

scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__

ID837984. Accessed November 29, 2011.

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Advisory. 2006;3(1):1-3.

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Practices. Denver, CO: AORN, Inc; 2011:215-236.

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Task Force on Operating Room Fires. Practice advisory

for the prevention and management of operating room

fires. Anesthesiology. 2008;108(5):786-801.

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Manufacturer and User Facility Device Experience

(MAUDE) Database.http://www.accessdata.fda.gov/

scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__

ID767284.Accessed November 29, 2011.

27. Demir E, ODey DM, Pallua N. Accidental burns dur-

ing surgery. J Burn Care Res. 2006;27(6):895-900.

28. Wu MP, Ou CS, Chen SL, Yen EYT, Rowbotham R.

Complications and recommended practices for electrosur-

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stray currents during laparoscopic and endoscopic elec-

trosurgical procedures. Biomed Instrum Technol. 1992;

26(4):303-311.

30. Wang K, Advincula AP. Current thoughts in electrosur-

gery.Int J Gynaecol Obstet. 2007;97(3):245-250.

31. Odell RC. Pearls, pitfalls, and advancements in the de-

livery of electrosurgical energy during laparoscopy.

Problems Gen Surg. 2002;19(2):5-17.

32. Guidance section: ensuring monopolar electrosurgical

safety during laparoscopy. Health Devices. 1995;24(1):

20-26.

33. ECRI. Safety technologies for laparoscopic monopolar

electrosurgery; devices for managing burn risks. HealthDevices. 2005;34(8):259-272.

34. Evaluation of electroscope electroshield system.Health

Devices. 1995;24(1):11-19.

35. Dennis V. Implementing active electrode monitoring: a

perioperative call. SSM. 2001;7(2):32-38.

36. Yazdani A, Krause H. Laparoscopic instrument insula-

tion failure: the hidden hazard. J Minim Invasive Gyne-

col. 2007;14(2):228-232.

37. Perioperative Job Descriptions and Competency Evalua-

tion Tools [CD-ROM]. Denver, CO: AORN, Inc. In press.

38. Policy and Procedure Templates, 2nd ed [CD-ROM].

Denver, CO: AORN, Inc; 2010.

39. Shirk GJ, Johns A, Redwine DB. Complications of laparo-

scopic surgery: how to avoid them and how to repair

them.J Minim Invasive Gynecol. 2006;13(4):352-359.

40. Saye WB, Miller W, Hertzmann P. Electrosurgery ther-

mal injury. Myth or misconception? Surg Laparosc

Endosc. 1991;1(4):223-228.

Lisa Spruce, DNP, RN, ACNP-BC, ANP-BC,

ACNS-BC, CNOR, was the corporate clinical

manager of surgical services, UHS of Delaware,

Inc, King of Prussia, PA, at the time this article

was written.Dr Spruce has no declared affiliation

that could be perceived as posing a potential

conflict of interest in the publication of this article.

Melanie L. Braswell,DNP, RN, CNS, CNOR, is

an advanced practice nurse, Sinai Hospital of

Baltimore, MD.Dr Braswell has no declared

affiliation that could be perceived as posing a

potential conflict of interest in the publication of

this article.


384 AORN Journal
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=767284http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=837984http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197


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CONTINUING EDUCATION PROGRAM

2.8

www.aorn.org/CEImplementing AORN RecommendedPractices for Electrosurgery

PURPOSE/GOAL

To educate perioperative nurses about how to implement the AORN Recommended

practices for electrosurgery in inpatient and ambulatory settings.

OBJECTIVES

1. Identify potential risks involved with the use of electrosurgery.

2. Discuss AORNs practice recommendations for the use and care of electrosurgi-

cal equipment.

3. Discuss methods for implementing AORNs practice recommendations for

electrosurgery.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. The most common form of patient injury during

the use of electrosurgery is

a. a burn at the dispersive electrode site.

b. a positioning injury.

c. a capacitive-coupling injury.

d. an injury related to an electrosurgical fire.

2. In addition to the risk of patient injury, risks in-

volved with using electrosurgery include

1. electrical shock.

2. explosion.

3. fire.

4. interference with a patients pacemaker.

a. 1 and 2 b. 3 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

3. Activities that can help remind staff members of

the key steps for electrosurgical safety include

1. posting an electrosurgery-related patient safety

poster.

2. developing standardized patient safety protocols.

3. using checklists.

4. working as a team.

a. 1 and 3 b. 2 and 4

c. 2, 3, and 4 d. 1, 2, 3, and 4

4. In considering the purchase of new or refurbished

electrosurgical units or accessories, perioperative

nurses should

1. speak to vendors about safety features.

2. avoid products with return electrode contact

quality monitoring.

EXAMINATION

AORN, Inc, 2012 March 2012 Vol 95 No 3 AORN Journal 385
http://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aorn.org/CE


14/15

3. form an interdisciplinary group to discuss the

risks and benefits of the equipment.

4. help ensure equipment is standardized across

the facility.

a. 1 and 2 b. 3 and 4

c. 1, 3, and 4 d. 1, 2, 3, and 4

5. It is permissible to disengage the activation indi-

cator on the electrosurgical unit if it is interfering

with the ability to hear the surgeons directions

during surgery.

a. true b. false

6. In handling the electrosurgical unit (ESU) to min-

imize the potential for injury, the perioperative

nurse should

a. place the ESU near enough to the sterile fieldthat the cord reaches the wall outlet without

stress.

b. tape down any kinks or knots in the cord to

prevent trips and falls.

c. use an extension cord if the ESU cord is not

long enough.

d. hold the cord when removing the ESU from

the outlet.

7. To minimize injuries during use of the active

electrode, the perioperative nurse can1. visually inspect the active electrode at the field

before it is used.

2. coordinate with the anesthesia professional to

minimize the oxygen concentration.

3. remind the surgeon, technician, or assistant to

place the active electrode in a conductive

safety holster when it is not in use.

4. place the foot pedal between the surgeon and

assistant so that either may activate the device

as needed.

5. moisten sponges that are used near the active

electrode tip.

a. 1 and 2 b. 1, 2, and 5

c. 3, 4, and 5 d. 1, 2, 3, 4, and 5

8. During the use of monopolar electrosurgery, if

there is not uniform contact between the patients

skin and the dispersive electrode, the periopera-

tive nurse should consider

1. applying a new pad.

2. repositioning the used dispersive electrode to

another site.

3. removing any oil, lotion, moisture, or prep

solution that may be interfering with contact.

4. removing excessive hair that may be interfer-ing with contact.

5. using tape to hold the dispersive electrode in

place.

a. 3 and 5 b. 1, 3, and 4

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

9. Conductive trocar systems and hybrid trocar sys-

tems are equally safe for use during minimally

invasive surgery.

a. true b. false

10. To reduce the potential adverse effects of surgicalsmoke to personnel and patients, ___________

should be used as the primary method of

protection.

a. local exhaust ventilation

b. fit-tested surgical N95 filtering facepiece

respirators

c. high-filtration masks

The behavioral objectives and examination for this program were prepared by Kimberly Retzlaff, editor/team lead, with consulta-

tion from Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Perioperative Education.

Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest inthe publication of this article.

March 2012 Vol 95 No 3 CE EXAMINATION

386 AORN Journal


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CONTINUING EDUCATION PROGRAM

2.8

www.aorn.org/CEImplementing AORN RecommendedPractices for Electrosurgery

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Identify potential risks involved with the use of

electrosurgery. Low 1. 2. 3. 4. 5. High

2. Discuss AORNs practice recommendations for

the use and care of electrosurgi-

cal equipment. Low 1. 2. 3. 4. 5. High

3. Discuss methods for implementing AORNs prac-

tice recommendations for electrosurgery.

Low 1. 2. 3. 4. 5. High

CONTENT

4. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

7. Will you change your practice as a result of read-

ing this article? (If yes, answer question #7A. If

no, answer question #7B.)

7A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regard-

ing why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptanceof the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals

until the change is incorporated as best

practice.

5. Other:

7B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to

my practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other:

8. Our accrediting body requires that we verify

the time you needed to complete the 2.8 con-

tinuing education contact hour (168-minute)

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 Centers Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center

approves 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 acceptance of this

activity 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 answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION
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implementing aorn recommended practices for electrosurgery

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