Igniting up to 70% of surgical fires every year, electrosurgical units (ESUs) are some of the most common ignition sources in the operating room. In addition to fiber optic light cables accidents and on top of the fire risk, electrosurgical accidents can lead to painful burns and injuries. With this alarming statistic in mind, every member of the perioperative team needs to be educated on the dangers of electrosurgical units — and know how to prevent fires and burns.
What is Electrosurgery?
Electrosurgery is a practice that allows surgeons to use high-frequency electric currents to make precise incisions, remove abnormal tissue, cauterize wounds, and desiccate tissue. This practice is a staple of the operating suite, dating back to the first 19th-century use of electrocautery to achieve hemostasis. Since then, electrosurgery has evolved to now include the patient’s body as part of the electrical circuit, acting as the resistance to the current.
Potential Dangers of Electrosurgical Units
While electrosurgery can be useful, improper use can cause serious damage to patients. In up to 5 in 1,000 cases, patients experienced an injury, such as burns and unintended cuts, as a direct result of an inadvertent stray energy transfer.
Direct Application
It’s unfortunately easy to accidentally activate an electrosurgical unit. Many are controlled by pedals that could easily be activated by a surgical team member leaning on it or placing a heavy surgical instrument on it. Note, having a surgeon manipulate the electrosurgical instrument and another team member activate the unit (or vice versa), is risky and can also lead to an adverse event. If someone unintentionally activates the ESU, they could potentially cause injury by applying the electrode to the wrong site or anatomical area of the patient or shorting to another conductive instrument.
Direct Coupling
Remember, the patient’s tissue is part of the electrical circuit and is offering some resistance to the current. When an active electrode gets too close to another metal object, like a laparoscope, the current jumps from the resistant tissue into the metal conductor, resulting in high heat in an unintended part of the body. This has the potential to burn or damage organs and other tissue that was in contact with the secondary instrument.
Insulation Failure
Especially during laparoscopic procedures, insulation failure is one of the leading causes of electrosurgical injuries. The electrosurgical instrument is coated with insulation to ensure that the active electrode only comes in contact with the intended tissues, but when this insulation begins to break down there is nothing to protect other tissues from burns. Unfortunately, these types of injuries are very serious but also easy to miss.
Electrosurgical Safety Practices
Because ESUs can cause injury in so many different ways, you also need more than one approach to risk mitigation.
Alarms, Visuals, and Inspections
The straightforward answer to the risks involved with electrosurgery is to use risk mitigation devices, like alarms and cameras, and set safety protocols that require insulation inspections. There are several alarms or tones that can be used to alert the perioperative team that an ESU has been activated, which can reduce the number of direct application injuries. In cases of direct coupling, surgeons should keep the electrode in their line of sight and far away from any metal instruments.
To prevent insulation failure, the instrument should undergo extensive inspection prior to use, after use, before washing, and after sterilizing. This may seem like a tedious process, but at each step of the way, there is potential to compromise the insulation, especially during sterilization when steam and chemicals could cause holes or breaks.
Not only should insulation be inspected, the patient’s skin and tissue should be checked and logged as well. Prior to using an electrosurgical instrument, the perioperative team should check for any metal jewelry, tattoos, cuts, lesions, scars, or skin disorders and ensure that the skin is fully clean and dry. Pay particular attention near the electrode return pad for monopolar electrosurgery.
Fire Safety
Electrosurgery is a leading cause of surgical fires, so fire safety measures should be followed to the letter when using an ESU. Many flammable skin prep agents used in the surgical suite can also act as fuel that an electrode can ignite, resulting in a potentially catastrophic fire or burn. These, and any other liquid present on the skin, should be allowed to completely dry before activating an electrode. Ensure the 3-minute rule is followed to allow for flammable vapors to evaporate. Other flammable materials, like suture packets containing alcohol, should be safely disposed of during the preparation of the sterile field.
Some surgeries require more fire safety protocols than others. Electrosurgery should not be used at all when operating on the GI tract due to the flammable methane gas that is present there. Also, airway surgeries are at higher risk of fire when using an electrosurgical unit, due to the often oxygen-enriched environment. To combat this, there should not be open delivery of oxygen, and instead, patients should be intubated or wear a laryngeal mask. During the use of electrosurgery, the oxygen supply should be reduced to the lowest possible level to prevent buildup of oxygen under surgical drapes.
Electrosurgical Education
The best way to prevent electrosurgical injuries and fires is a fully educated surgical team. Every member of the perioperative team should feel ownership and responsibility for ESU safety, so the CST, RN, anesthesiologist, and surgeon should all take part in buying and evaluating electrosurgical devices and accessories. This allows everyone to learn about the safety features and best practices for using the device.
Another key to electrosurgical safety is continuing education for everyone, especially CSTs. This involves taking more courses, staying up to date on recommended practices for ESU use, and training on every ESU model and accessory that is in use at the hospital. On the flip side, the entire team should be educated on what to do in the case of an ESU-related fire or injury, and how to report the incident.
Jackson Medical is dedicated to preventing surgical fires and ensuring patient safety. Whether it’s staying up to date on the latest trends in surgical fires, sharing fire safety posters, or trying out our GloShield fiber-optic light cable cover, we’re here to keep your operating room safe.