Implementing Aorn Recommended Practices for Electrosurgery
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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/CE7/25/2019 Implementing Aorn Recommended Practices for Electrosurgery
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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.
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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.aspx7/25/2019 Implementing Aorn Recommended Practices for Electrosurgery
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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.
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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.
RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org
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.aspx7/25/2019 Implementing Aorn Recommended Practices for Electrosurgery
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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.
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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
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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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36. Yazdani A, Krause H. Laparoscopic instrument insula-
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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.
March 2012 Vol 95 No 3 SPRUCEBRASWELL
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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
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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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