Electrosurgery Safety Essentials

At the heart of electrosurgery safety is a firm understanding of how the technology works and the core principles driving its use. A base knowledge of the physics behind the mechanics will lead to fewer injuries caused by electrocautery mishaps, says David Renton, MD, MPH, an associate professor of general surgery at The Ohio State University Wexner Medical Center in Columbus.

"The more you know about electrosurgery technology, the safer you are," adds Dr. Renton, "As I tell my surgical residents, 'You have to know how it all works — the settings, electricity distribution, voltage, arcing. Everything.'"

Unfortunately, there's a knowledge gap when it comes to arming new surgeons with a solid understanding of how electrosurgery works.

"In medical school, we have pharmacology courses that teach students how drugs work, their metabolism, what their mechanism is," says Thomas Robinson, MD, MS, FACS, a professor of surgery at the University of Colorado School of Medicine in Aurora, and the committee chair of the Society of American Gastrointestinal and Endoscopic Surgeons' FUSE (Fundamental Use of Surgical Energy) program. "But there's no formal education or training on electrosurgical technology and devices."

Surgeons can learn the basics from electrosurgery equipment vendors, which in certain cases is useful and adequate, but the line between education and marketing can get blurred. That's why a program like FUSE (see "Training for the Entire Team") — an educational platform geared toward providing the knowledge needed for the safe use of energy-based surgical devices in the OR, endoscopic suite or other procedure areas — is so beneficial. Dr. Robinson says FUSE's top priority is "to fill the gap in knowledge within the surgical community by informing and teaching how the technology works, so professionals fully understand the strategies they can use in the OR to safely use electrosurgery instruments."

Dr. Renton puts the program's value a bit more bluntly. "Years ago, most surgeons' understanding of electrosurgery was, 'You press this button, and this end burns things.'"

Thankfully, times have changed. So have the expectations you should have about ensuring surgeons focus on patient safety when they cut, coagulate and ablate.

Whether your surgeons rely on a program like FUSE or a trusted vendor rep, it's critical that they have a firm understanding of how electrosurgery equipment works and why it works that way. This is especially true with some technological advances in the pipeline that are slated to hit the market soon. "There are some newer generators that do multiple things at once," says Dr. Renton.

A basic, core understanding of fundamental electrosurgery principles will ensure surgeons can safely use any device, regardless of the bells and whistles that are included in the latest versions. "You have to understand the energy delivery profiles for the different electrosurgery devices," says Dr. Robinson. "Ultrasonic devices have very different complication profiles than advanced bipolar devices, even though they both basically do the same thing."

The different energy modalities of electrosurgery operate differently, and surgeons must understand those subtle differences, adds Dr. Robinson. In addition to understanding the innerworkings of the devices, surgeons should be acutely aware of the top safety risks. A study in the Journal of the American College of Surgeons (bit.ly/2Uyjgbu) looked at nearly 4,000 electrosurgical complications (injuries and deaths) that were reported to the FDA in the past 20 years and found the following incidents pose the top safety risks in the OR:

• Direct application injuries. The top complication in the study, these burn injuries occur when thehot tip of the device is placed too close to a vulnerable structure. "For example, surgeons who use the tip of an electrosurgery pencil in close proximity to the bowel can burn the edge and make a hole in it," says Dr. Robinson.

Preventing this injury often comes down to understanding the distance of the device's lateral spread of energy. Surgeons should make sure there's adequate space between the tip of the activated device and adjacent tissue, use the lowest possible effective power setting and, whenever possible, employ short activation bursts.

• Insulation defects. Another common issue with electrosurgical devices is the small amounts of current that can leak through tiny breaks and minute cracks in the instrument's shaft. Current strays from the intended energy path, causing small electrical burns to non-targeted tissue that can result in internal bleeding, lesions and infection.

"There's research that says 20% of all laparoscopic instruments have one or more defects along the shaft," says Dr. Robinson. "The rate of defects on instruments used during robotic surgery can be as high as 50%."

Preventing injuries caused by instrument defects requires having a consistent process in place to routinely examine the insulation along electrosurgical devices, says Dr. Robinson.

• OR fires. While flash fires in the surgical field may not be as common as direct application injuries, they still happen more often than they should. "As long as we still have OR fires, there's knowledge gaps to fill," says Dr. Renton.

His facility fills those gaps with fire safety education at least twice a year with a focus on understanding the fire triangle — ignition source, oxygen, fuel — is always in play whenever electrosurgery is involved. "The electrocautery serves as the heat, so the other two sides of the triangle must be mitigated as much as possible," says Dr. Renton.

Constant communication among the entire OR team about this fire risk is also a must. "Your fire prevention policies should include a strict protocol for including a fire risk announcement and discussion during the pre-op time out to alert staff to take proper precautions," says Dr. Robinson.

Knowledge is power

Whenever new or improved equipment makes its way into the OR, you have a critical responsibility to patients: Make sure everyone who uses the technology has a fundamental understanding and awareness of the safety risks inherent to the device. When surgeons and staff don't have this core understanding during electrosurgical procedures, mistakes can be disastrous.

"Complications are devasting to patients," says Dr. Robinson. "And they're avoidable if surgeons understand how the devices they're using in the operating room work. Education is prevention." OSM

"There's research that says 20% of all laparoscopic instruments have one or more defects along the shaft," says Dr. Robinson. "The rate of defects on instruments used during robotic surgery can be as high as 50%."

Preventing injuries caused by instrument defects requires having a consistent process in place to routinely examine the insulation along electrosurgical devices, says Dr. Robinson.

• OR fires. While flash fires in the surgical field may not be as common as direct application injuries, they still happen more often than they should. "As long as we still have OR fires, there's knowledge gaps to fill," says Dr. Renton.

His facility fills those gaps with fire safety education at least twice a year with a focus on understanding the fire triangle — ignition source, oxygen, fuel — is always in play whenever electrosurgery is involved. "The electrocautery serves as the heat, so the other two sides of the triangle must be mitigated as much as possible," says Dr. Renton.

Constant communication among the entire OR team about this fire risk is also a must. "Your fire prevention policies should include a strict protocol for including a fire risk announcement and discussion during the pre-op time out to alert staff to take proper precautions," says Dr. Robinson.