a. The most common injury when using radiofrequency devices is a direct heat or direct application injury, says Dr. Robinson. These injuries occur when the surgeon holds the tip of the activated, hot instrument too close to vital tissue, which is then unintentionally burned. "While it seems like this is an obvious issue, and one that should be easy to prevent, 30% of all surgical energy-based device complications reported to the FDA occur via this injury pattern," says Dr. Robinson. "But because it's not as headline-grabbing as surgical fires or capacitive coupling burns, it doesn't get as much attention." To help prevent this complication, remind surgeons and staff that they must remain vigilant to ensure the electrosurgical device's tip does not get too close to vulnerable tissue.

False. All electrosurgical devices have roughly the same level of risk and are safe to use if you follow the manufacturer's instructions for use and follow proper precautions, says Byron L. Burlingame, MS, RN, BSN, CNOR, a senior perioperative practice specialist with the Association of periOperative Registered Nurses (AORN). There are a few exceptions, though. "Alternative technologies should be used instead of monopolar electrosurgery if there is a high risk of fire or if there is an implanted medical device within the pathway between the active and dispersive electrodes," says Mr. Burlingame. To improve your staff and surgeons' safety with all electrosurgical devices, keep the following tips from Mr. Burlingame in mind: Always use the lowest possible power setting, follow the devices manufacturer's instructions for use at all times, do not bend or manipulate the active electrode tip and remember that only the operator of the device should use the foot pedal.

False. Trick question. Monopolar technologies require the use of a dispersive electrode, often referred to as a grounding pad, says Dr. Robinson. When using monopolar devices, an active electrode — typically the tip of the Bovie pencil or other device — is used to apply the electrosurgical energy to the targeted tissue. The electrical current then passes through the patient to a return pad, and then back to the electrosurgery generator to complete the circuit. However, with bipolar instruments, the surgeon will use a set of forceps to hold the tissue, says Dr. Robinson. The electrical current passes from one side of the forceps, through the tissue and to the other side, and then returns back to the generator. Because the current is restricted to the tissue between the forceps, you won't need a dispersive electrode.

False. As more and more surgeons start picking up ultrasonic energy devices like the harmonic scalpel and the cordless, ultrasonic dissection devices, it's crucial to understand their most common injury risks, says Dr. Robinson. Even after you cut off energy to the device, it can still harm patients or staff because the heat retained in the tip of the instrument can inadvertently burn tissue. According to Dr. Robinson, that's because vibrations created by the ultrasonic energy can cause the tip of the instrument to heat up dramatically — in some cases to more than 300 ?C. The tip holds this residual heat, which poses a risk to any tissue it may touch on both the patient and the OR team using the device. "If the surgeon releases the trigger that activates the ultrasonic device and then accidentally brushes the tip of the instrument against the bowel, you can still burn the tissue," says Dr. Robinson.

c. Though surgical fires are rare, they are one of the most preventable adverse events, says Mr. Burlingame. Surgical fires can occur whenever the elements of the fire triangle are present. Are your surgeons and OR staff aware of the fire triangle? Refresh their memory: The fire triangle is when there's an ignition source (heat), a fuel source and an oxidizer (oxygen) present. The ignition source is often a spark caused by an electrosurgical device, says Dr. Robinson, while the fuel source can be anything from drapes to skin preps to the patient's own tissue. To prevent a fire, "you need to avoid, at minimum, 1 of the 3 parts of the fire triangle," says Dr. Robinson. That means performing a fire risk assessment before procedures when electrosurgery is being used, preventing alcohol-based (flammable) antiseptics from pooling around the patient and using draping techniques that avoid accumulation of oxygen in the surgical field.

FIRE TRIANGLE Stop oxygen flow or decrease it to the lowest possible percentage before activating the energy-generating device if the surgery is occurring in the vicinity of the head, face or neck.

a. Though oxygen is always present in the OR's air, an abundance of it increases the risk of a surgical fire. When giving a patient supplemental oxygen, especially with a nasal cannula or other open oxygen source, stop the flow of oxygen or decrease it to the lowest possible percentage before activating the energy-generating device, especially if the surgery is occurring in the vicinity of the head, face or neck, says Mr. Burlingame. Also keep moist sponges near the surgical site and make sure you have a solution ready on the back table to extinguish a surgical fire if one does occur.

d. The OR team faces all of these risks when electrosurgery is in use. To decrease clutter on the OR floor, keep the energy-generating device as close to the surgical field as possible and bunch cords on the floor together to decrease the trip hazard, says Mr. Burlingame. You can also cover cords to prevent tripping. To reduce surgical smoke, convince your surgeons to use evacuators. The latest models are quieter and less cumbersome than previous technologies. When using a laser energy-based device, staff must wear appropriate protective eye wear. OSM