It's estimated that one in four procedures involving electrosurgery results in accidental burns and that, 30 percent of the time, OR staff didn't know the injuries had occurred until much later. Laparoscopic electrosurgery in particular is even more dangerous, with three in four burn injuries going unnoticed until well after the procedure, according to the Physician Insurers Association of America.

By "well after the procedure," we're talking about 48 to 72 hours post-op, when most thermal injuries - which can result in fecal peritonitis - present. One more bit of trivia: Are you aware that, even with antibiotic therapy, about one-third of patients who develop peritonitis don't survive?

With those stats in mind, here's a six-question quiz designed to test your and your staff's knowledge on preventing electrosurgical burns. We'll warm up with some basics - terminology, how electrosurgery works - before moving into the tougher stuff, like safe practices surrounding ESU use. Good luck.

1 True or false: Cautery and electrosurgery are basically the same thing.
   A. true
   B. false

Answer: B. While both technologies can be used to coagulate blood vessels or clot blood via heat, the mechanisms by which they work are quite different. Cautery is the application of a heated instrument to tissue. Electrosurgery, on the other hand, uses voltage to pass current through tissue; when the current encounters resistance - which it will, because tissue is an impediment - heat, or wattage, is created within the tissue, causing either coagulation or cutting (at least in monopolar electrosurgery; bipolar cuts only).

2 In both monopolar and bipolar electrosurgery, through what does the current run in order to make a complete circuit?
   A. generator, handpiece, active electrode
   B. foot pedal, active electrode, patient, dispersive pad
   C. generator, active electrode, patient, return electrode
   D. generator, handpiece, return electrode

Answer: C. The complete circuit is the same in either type of electrosurgery; it's just the specific parts that are different. Put simply, monopolar uses the patient to complete the circuit, and bipolar uses tissue and impedance to complete the circuit.

In monopolar electrosurgery, the current must pass through the patient's body to a dispersive pad, which returns the current to the ground. In bipolar electrosurgery, one prong on the instrument is an active electrode, the other a dispersive electrode. Current still passes through the patient before being returned to the generator, but only through the tissue that's between the prongs. Therefore, use of a dispersive pad is not required. Bipolar is generally considered safer, because the current returns to the generator. The current is isolated, and the electrosurgery unit will shut down if the impedance level becomes too high, helping to prevent stray electrosurgical burns.

Because monopolar generators can perform two functions, surgeons prefer them. There are ways to avoid stray tissue burns using monopolar ESUs, but we'll get to that later. If your facility regularly uses both monopolar and bipolar units, some manufacturers offer ESUs that let you perform functions using either mode.

3 What percentage of monopolar laparoscopic instruments were found to have insulation flaws in a 2004 study?
   A. 5 percent
   B. 13 percent
   C. 18 percent
   D. 21 percent

Answer: C. Out of 1,438 conventional laparoscopic instruments at 33 hospitals, the study found 18 percent had insulation flaws. Of those, 58 percent had flaws in areas outside the field of view during surgical procedures and 57 percent had failures that were not visible to the naked eye.

Insulation failure is one of two phenomena that can let electrical current come in contact with non-target tissue during electrosurgery, resulting in potentially fatal burns. Manufacturers of conventional laparoscopic instruments warn that you must carefully inspect and maintain instruments to prevent laparoscopic burns, but this puts your nurses, biomedical engineers and surgeons in a tough spot.

Buying instruments with brightly colored inner layers of insulation along the electrode shaft can make it easier to spot insulation breaks. But, as we just learned, many insulation defects are so small that they're invisible to the naked eye. And the smaller the insulation defect, the more dangerous it is. Microscopic insulation defects can concentrate the current density transferred to nearby non-target tissue, increasing the chance of a severe internal burn.

You should perform electrical testing with a scanner before and after each procedure. Insulation-integrity testers don't detect non-full-thickness breaks, though, nor do they detect whether the other event that can lead to an electrosurgical burn has developed. Electrical testing can't actually prevent insulation from breaking down during surgery. Consider electrical scanning as a supplement to - not a replacement for - visual inspections.

4 Besides insulation failure, what other condition can result in an electrosurgical burn?
   A. capacitive coupling
   B. high-current densities
   C. open-circuit activation
   D. eschar development

Answer: A. Capacitive coupling occurs when a capacitor is present and two conductors are separated by an insulator. The phenomenon can occur many times during a laparoscopic procedure, because tissue, trocar and instrument (itself consisting of active electrode and primary insulation) are all conductors in close proximity. Stray current passes through intact insulation, which can result in tissue burns. Your patients are at even greater risk if you mix reusable and disposable instruments.

Electrical testing, while helpful for detecting insulation failure, can't do the same for capacitively coupled leakage current. But one technology can: At my facility, we've converted to active electrode shielding/monitoring - AEM, for short - in all 28 of our ORs. AORN recommends the technology as a way to minimize the risk of stray electrosurgical burns due to both burn-risk events.

How does it work? Under normal operating conditions, AEM technology delivers 100 percent of the power to the surgeon's intended site. Capacitively coupled energy is safely drained to the generator via a protective shield built into 5mm AEM instruments. If primary insulation fails, or the level of capacitively coupled current becomes too much, AEM technology shuts down the generator, protecting the patient from a potentially life-threatening burn, and alerts the perioperative staff.

AEM isn't foolproof when it comes to eliminating capacitive coupling and insulation failures. Pilot error, also known as direct coupling, occurs when a surgeon inadvertently places a metal instrument or the electrode tip on tissue; this can burn internal structures. However, this isn't equipment-related. Other burn causes not prevented by AEM are return electrode-related or external-cable failures.

5 Proper use of the grounding pad is key to preventing thermal injury at the site of the pad during monopolar electrosurgery. Which is not recommended for pad selection and placement?
   A. using a pad proportional to the size of the patient
   B. applying the pad to a bony area, such as the hip
   C. placing the pad on an area free of hair and scar tissue
   D. placing the pad in close proximity to the active tip

Answer: B. Place the grounding pad on a well-muscled, vascular part of the patient, such as the thigh, buttocks, abdomen or upper arm. Avoid excessive hair or use clippers to trim it. Other areas to avoid: adipose tissue, tattooed skin, metal prostheses or implants and scar tissue. Inspect and assess skin integrity both before and after placing the dispersive electrode.

Further, the pad should be compatible with the ESU and appropriately sized to the patient. With conventional return electrodes, if the sticky pad is too small, the energy density will be high and result in tissue burns. Never cut, modify or resize a pad; just use the right one. More tips:

• Make sure the pad will cover the conductive gel.
• Make sure the entire conductive surface contacts the skin.
• Replace the pad if it becomes wet.

Most dispersive electrode manufacturers recommend you orient the pad's long axis toward the operative site (double-check your product literature).

Use a return electrode contact quality monitor and a compatible ESU, which will alert you if there's no longer good contact between the dispersive electrode and the patient. AEM is compatible with most of the ESUs that have return electrode contact quality monitoring.

6 Which steps should you take to prevent electrosurgery-related fire?
   A. lubricating all hair near the surgical site with water-soluble lubricant
   B. using plastic towel clips for draping
   C. preventing build-up of eschar on the tip of the active electrode
   D. all of the above

Answer: D. The OR is already an oxygen-enriched atmosphere. The active electrode provides an ignition source and anything from patient hair or skin to surgical drapes can provide the fuel. It's the perfect recipe for a fire. Here are more fire-prevention precautions you can take:

• Set ESU voltage below 35 watts of or 45L coag.
• Moisturize all sponges that come in contact with the surgical site during ESU activation.
• Remove eschar from the tips of stainless steel electrodes using a scratch pad.
• Use an active electrode tip that's coated with polytetrafluoroethylene to prevent eschar buildup.
• Keep a basin of water/saline on the surgical field and give anesthesia a 500cc bottle of water.
• Use plastic towel clips to secure the electrode cord.
• Place the active electrode in an insulated holster when it's not in use.
• Don't use the active electrode in the presence of flammable agents, including intestinal gases.
• Use only manufacturer-approved adapters.
• Inspect the electrode and its cord for damage pre-op.

The best way to put out a fire if one does occur is using the saline. But you should also have a CO2 fire extinguisher readily available in the OR. Never use fire blankets, as they can actually spread fire.