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Introduction

The Guideline for Safe Use of Energy-Generating Devices has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective September 1, 2016. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance to the perioperative team for the safe use and maintenance of energy-generating devices. The types of energy addressed in this document include electricity delivered as radio-frequency waves, ultrasound, and laser.1,2  The devices that generate the energy include electrosurgical units (ESUs), electrocauteries, ultrasonic instruments, and lasers. The energy produced is transferred to the patient by various methods, including monopolar, bipolar, advanced bipolar (eg, vessel-sealing),3  and tripolar (eg, plasma knife) devices4 ; class 3 and class 4 lasers; and ultrasound (eg, ultrasonic tissue ablation system, phacoemulsification) and argon-enhanced coagulation (AEC) modalities.

Electrosurgery, which uses high-frequency (ie, radio-frequency) electrical current, is routinely used to cut, coagulate, dissect, ablate, and shrink tissue. Ultrasonic dissectors fragment tissue by vibration. Vessel-sealing or bipolar ligating-cutting devices use a combination of pressure and heat to permanently fuse vessels and tissue.5  In the literature, the terms electrosurgery, electrocautery, and diathermy are often used interchangeably. This guideline addresses precautions to be taken during the use of each of these technologies and does not endorse any specific products. Proper care and handling of all energy-generating devices is essential to patient and personnel safety.

This document provides guidance for some elements of surgical fires and electrical safety related to energy-generating devices. For additional guidance on these two topics, the reader should refer to the AORN Guideline for a Safe Environment of Care, Part 1.6 

The following subjects are outside the scope of this guideline:

  • surgical smoke safety,

  • endoscopic distention fluid (See the AORN Guideline for Minimally Invasive Surgery),7 

  • procedure-related decisions (eg, the amount of time the tissue is exposed to the energy-generating device active electrode),

  • therapeutic diathermy,

  • use of electrical dental equipment (eg, battery-operated curing lights, ultrasonic baths, ultrasonic scalers, electric pulp testers, electric toothbrushes), and

  • selection of electrosurgical devices.

Evidence Review

A medical librarian conducted a systematic search of the databases MEDLINE®, CINAHL®, and Scopus® and the Cochrane Database of Systematic Reviews in October 2015. Results were limited to literature published in English from January 2009 through October 2015. The medical librarian also established alerts at the time of the initial search. During the development of the guideline, the lead author requested supplementary searches and additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The results of alerts were considered until February 2016.

The search terms included subject headings and keywords that address precautions and injuries related to the use of electrosurgical and laser devices. Terms for procedures included electrosurgery, ultrasonic therapy, ultrasonic surgical procedures, diathermy, argon plasma coagulation, electrocoagulation, high-intensity focused ultrasound ablation, endometrial ablation techniques, and laser therapy. Subject headings and keywords related to precautions included adverse effects, accident prevention, patient safety, equipment contamination, equipment safety, equipment failure, and risk management. Special attention was paid to terms that would retrieve literature addressing the potential causes and effects of equipment failure and injuries. Such terms included burns, fires, implantable electronic devices (eg, artificial pacemaker, implanted electrodes, electromagnetic fields), and power sources and settings (eg, electric power supplies, grounding, capacitive coupling, electric wiring). Subject headings and keywords for types of personal protective equipment and occupational hazards also were included.

Excluded were non-peer-reviewed publications, evidence from other disciplines when evidence from the perioperative setting was available, and case reports that did not provide recommendations for preventing injuries related to the use of electrosurgical devices. Editorials, news items, and other brief items were excluded. Lower-level or lower-quality evidence was excluded when higher-level or higher-quality evidence was available (Figure 1).

Figure 1.
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author and three evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference, as applicable.

The collective evidence supporting each intervention within a specific recommendation was summarized and the AORN Evidence Rating Model was used to rate the strength of the evidence. Factors considered in the review of the collective evidence were the quality of the evidence, the quantity of similar evidence on a given topic, and the consistency of evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

 

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.

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