ELECTROSURGERY IN ENDOSCOPY

THE FACTS ABOUT ELECTRICTY 1. Always seeks ground 2. Always seeks the path of least resistance *Electricity always seeks the path of least resistance to ground *The path is not always straight. It can be compared to water running down a hill. The water may take multiple pathways to reach the bottom of the hill. The path may include the endoscopic team (touching patient).

THE FACTS ABOUT ELECTRICTY 54-880 MHz TV 350kHz-3MHz ESU’s 60 Hz 100 kHz 550-1550 kHz AM Radio Household *NMS still occurs in small percentage of procedure…demodulation

COMMON USES IN ENDO Polypectomy Papillotomy/Sphincterotomy (ERCP) Endoscopic Mucosal Resection (EMR) Contact Bleeding Control (Tamponade) Non-Contact Bleeding Control (APC) Ablation (APC)

COMMON USES IN ENDO monopolar electrosurgery bipolar electrosurgery

COMMON USES IN ENDO *The smaller the active electrode, the more concentrated the energy *The grounding pad is a neutral electrode dispersing the energy over a larger surface area *That is why proper grounding pad placement is so important

IMPORTANCE OF GROUNDING PERFORM LIGHT BULB DEMONSTRATION

UNDERSTANDING DISPERSIVE ELECTRODES The Dispersive Electrode Should NOT Be Placed Over: Boney prominences Scar tissue – including Tattoos Skin/Scars over an implanted metal prosthesis Hairy surfaces Lotions or oils on skin Several of the contraindications for pad placement are shown in this slide. AORN has generated Standards, Recommended Practices, and Guidelines for Electrosurgery. Those standards include these items. Most other professional bodies recognize these standards, as do courts of law, which can be very important for nurses to remember. Malpractice attorneys will likely compare any incident to these existing standards of care.

POWER VS VOLTAGE Regulation of Power Output The power output is dynamically regulated within the pre-set limits. With Power Regulation, surgical/tissue effect is consistent (independent) of: the cutting electrode the direction of the cut the tissue Several of the contraindications for pad placement are shown in this slide. AORN has generated Standards, Recommended Practices, and Guidelines for Electrosurgery. Those standards include these items. Most other professional bodies recognize these standards, as do courts of law, which can be very important for nurses to remember. Malpractice attorneys will likely compare any incident to these existing standards of care. New Generation Generators: control V (I) = doses power output= controls (predicts) tissue effect

The Importance of Bowel Preps… CLINICAL SAFETY The Importance of Bowel Preps… Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases the risk for bowel explosions. Bowel explosions can occur with ANY monopolar electrosurgery (e.g. snare, APC, hot biopsy) when combined with hydrogen and methane gases in a dirty colon. Patients should be fully prepped. Inadequate or poor Bowel Preps (any type) pose a risk of bowel explosion when combined with any electrosurgery, including APC. The risk is from trapped bowel gases (hydrogen and/or methane) in the colon, from the breakdown of non-absorbable carbohydrates by colonic bacteria. All it takes for a bowel explosion to occur is: 5% hydrogen and/or methane, a spark created by the use of electrosurgery and 5% oxygen – room air is comprised of 20% oxygen (Ladas S et. al Colonic gas explosion during therapeutic colonoscopy with electrocautery. 2007; 13(40):5295-5298). Dr. Soussan et. al. concluded that the use of enema preparation without oral prep may not be adequate when APC is used in the colon (Gastrointestinal Endoscopy. 2003;Vol 57, No 3). Non-compliant patients skipping parts of the prep or executing them poorly, are seen regularly in endoscopy units. Poor bowel preps can cause cases to be cancelled. Thankfully, bowel explosions are not extremely common, but they are a well documented risk with electrosurgery in the colon, even the sigmoid. Nurses should be informed of these risks, inform the physician of patient non-compliance on prep completion and document fecal matter observed and that the physician was informed.

Avoid activation in close proximity of metal objects CLINICAL SAFETY Important Considerations for Endoscopy Avoid activation in close proximity of metal objects The active probe should not be activated if the tip is close to or touching metal objects Unintended thermal injury of the surrounding tissue may occur Metal objects may receive unintentional damage. Exceptions - “trimming” of migrated metal stents. Do not activate an APC probe if the probe tip is in close proximity to metal, e.g., metal clips, metal stents, etc., unless the metal is the intended object, such as “trimming” of metal stents. The electric arcs could flash over to the metal object, creating an unintended coagulation of the surrounding tissue. As metal is a good conductor of electrical current, metal objects may be damaged or the tissue in contact with the metal object may be unintentionally burned. Using PRECISE APC may exaggerate this issue, due to its ability to offer plasma regulation. Hence, choose another mode.

CLINICAL SAFETY Alternate Site Burns Electricity Always Seeks Ground…. Observe skin touching conductive objects - IV poles, metal bed rail parts Watch for fingers, toes, ankles, and elbows touching metal Check for arms over bedrails and hands grasping handrails Separate all wires, including heart monitor wires from active cords and dispersive electrode cords Modern ESUs mostly are isolated units that keep current flowing within a contained circuit, but electricity still adheres to the two principles; it seeks ground and follows the path of least resistance. Circuit failures can still happen, and as the patient advocate during a procedure, safety is a top priority. Remember to document your safety measures. Isolation of body parts from metal goes unmonitored more often than we realize. Skin touching metal is an opportunity for current to stray from the circuit and burn patients.

Minimal Coag i.e Soft Coag THERAPEUTIC WAVERFORMS IN GI Endo Cut™ (ERBE only) YELLOW pedal - NO TAPPING Mode Setting Hemostasis Output Effect Intensity of Coag Effect 1 Cut only Effect 2 Minimal Coag i.e Soft Coag Effect 3 Moderate Coag Effect 4 Marked Coag

THERAPEUTIC WAVERFORMS IN GI Endocut I & Q ENDOCUT is a proprietary cutting output that can be very effectively used in polypectomy and papillotomy. ENDOCUT measures resistance variables 1000 times per second via feedback between target tissue electrode and return electrode (grounding pad). Variables would include amount of wire in contact with tissue (i.e., amount of tissue being resected every millisecond), tissue resistance (i.e, fibrous versus vascular), pressure exerted on snare, etc. ENDOCUT Effect – Level of hemostasis for bleed control. ENDOCUT Cut Duration – the length of the cutting phase. The higher the value, the longer the cutting phase lasts. ENDOCUT Cut Interval – the cut & coag cycle. The lower the number, the faster the cut. Longer cut intervals results in slower, more controlled cuts Once set, the Cut Duration and Cut Interval may not always be displayed on the screen. Cut Duration Cut Interval Cut Effect

ARGON PLASMA COAGULATION (APC) APC is a non-contact monopolar application for hemostasis and thermal destruction

ARGON PLASMA COAGULATION (APC)

ARGON PLASMA COAGULATION (APC) Argon Plasma Coagulation occurs when there is transfer of energy from the APC probe using ionized argon gas (argon plasma) in combination with HF electrical energy for treating tissue. Activation of the footswitch causes an electrical current and inert argon gas to flow through the probe. When the electrical current meets the argon gas at the end of the probe, the gas is ionized to form a plasma, thereby resulting in non-contact superficial desiccation and thermal coagulation.

ARGON PLASMA COAGULATION (APC) One of the major advantages of APC is that it is non-contact, so there is no sticking to tissue, causing re-bleeds. APC is applied in a controlled, gradual manner, resulting in even, uniform hemostasis and coagulation. The coverage area is also broader. Tissue damage is low compared to laser coagulation and standard electrocoagulation. Depth of coagulation is limited to approximately 3mm, depending on mode, length of activation, technique, power setting and probe distance. Surgical smoke is reduced, improving visibility and eliminating odors. Current seeks areas of better conductivity (axial, radial, retroflexed, circumferential). The possibility for shorter procedure times, as hemostasis is immediate, allows for efficient coagulation of large surface bleeding and minimization of blood loss. Thinner eschar potentially reduces the risk of re-bleeding.

ERBE Electrosurgery & Interventional Endoscopy THANK YOU!