SECT2.05 - Recommended Practices for Electrosurgery - Medline

RP: ElectrosurgeryI.f.subsequently activated. 1 Appropriate matchingand use of accessories specific to theESU minimizes this risk.Health care organizations should attempt tostandardize electrosurgical equipment usedwithin the facility.Equipment standardization reduces therisk of error. 18Recommendation IIThe ESU should be used in a manner that minimizesthe potential for injuries.Electrosurgical units are high-risk equipment. 1Potential complications of electrosurgery includepatient injuries, user injuries, fires, and electromagneticinterference with other medical equipmentand internal electronic devices. 2 Electrosurgerysafety is heightened by adhering to good practices.18 Adverse events (eg, patient burns and fires)may be reduced by adhering to basic principles ofelectrosurgery safety. 15II.a.II.a.1.II.b.Instructions for ESU use, warranties, and amanual for maintenance and inspectionsshould be obtained from the manufacturerand be readily available to users. 2,19Equipment manuals assist in developingoperational, safety, and maintenance guidelines,as well as serve as a reference forappropriate use. 19Concise, clearly readable operatinginstructions specific for the deviceshould be on or attached to each ESU. 19Readily available instructions reducethe risk of operator error.The ESU should be securely mounted on atip-resistant cart or shelf and should not beused as a shelf or table.II.c. The ESU should be protected from liquids. 19Liquids entering the ESU can cause unintentionalactivation, device failure, or anelectrical hazard.II.c.1.II.c.2.Liquids should not be placed on top ofthe ESU.Foot pedal accessories should beencased in a clean, impervious coverwhen there is potential for fluid spillson the floor.II.d.II.e.II.f.II.f.1.II.f.2.II.f.3.II.f.4.Safety and warning alarms and activationindicators should be operational, audible,and visible at all times. 1,16-18,20Safety and warning alarms alert the operatorto potential electrode failure. 5 The indicatorsand alarms immediately alert the perioperativeteam when the ESU is activated. 2,18The ESU should be visually inspected andthe return electrode monitor tested accordingto manufacturer’s instructions before use. 19,20The ESU will sound an alarm and notactivate if the dispersive electrode isdisconnected. 2,20Settings should be based on the operator’spreference consistent with the intendedapplication and the manufacturer’s writteninstructions for patient size, active electrodetype, and return electrode placement.The ESU’s power output capability isdependent on multiple variables related tothe patient, generator, accessories, and theprocedure.The circulating nurse should confirmthe power settings with the operatorbefore activation of the ESU.The ESU should be operated at the lowesteffective power setting needed toachieve the desired tissue effect. 2,18,20-22The likelihood of arcing and capacitivecoupling are increased when higherthan necessary voltages are used. 22If the operator requests a continualincrease in power, personnel shouldcheck the entire ESU and accessories circuitfor adequate placement of the dispersiveelectrode and cord connections. 18,19,23Prolonged current at high power cancause patient injury. Common causesof ineffective coagulation and cuttingare high impedance at the dispersiveelectrode, poor contact between thedispersive electrode and the patient,and use of an electrolytic irrigation/distention solution. 23,24The electrode tip should be visuallyinspected before each use and replacedif damaged.A damaged active electrode tip maycause a buildup of eschar, creating100Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryII.g.II.h.II.i.increased resistance at the electrode tip.Cleaning a stainless steel tip with anabrasive pad or instrument may creategrooves where eschar can collect. 22Perioperative registered nurses should beaware of potential patient safety hazardsassociated with specific internal implantedelectronic devices (IEDs) and the appropriatepatient care interventions required toprotect the patient from injury. 25Electronic devices implanted in a patientmay be affected by other IEDs or medicalequipment with which a patient may comeinto contact in a health care facility. Thesedevices may include cardiac pacemakers,implanted cardioverter defibrillators (ICDs),neurostimulators, implantable hearingdevices, implantable infusion pumps, andosteogenic stimulators. 25After use, personnel should– turn off the ESU;– dispose of single use items;– clean all reusable parts and accessoriesaccording to the manufacturer’s directions;and– inspect accessories and parts for damage,function, and cleanliness.Following the manufacturer’s cleaningand inspection instructions promotes safeand proper functioning of the equipment.An ESU that is not working properly or isdamaged should be removed from serviceimmediately and reported to the designatedindividual responsible for equipment maintenance(eg, bioengineering servicespersonnel). 18,19,26Medical device users are required toreport serious injury and death related touse of a device to the Federal Drug Administration(FDA). 26Recommendation IIIThe electrical cords and plugs of the ESU shouldbe handled in a manner that minimizes the potentialfor damage and subsequent patient and userinjuries.Improper handling of cords and plugs may resultin breaks in the cord’s insulation, fraying, and otherelectrical hazards.III.a. The ESU’s electrical cord should be adequatein length and flexibility to reach theelectrical outlet without stress or the use ofan extension cord. 19Tension on the electrical cord increasesthe risk that it will become disconnected,frayed, or move the equipment, which mayresult in injuries to patients and personnel.III.a.1.III.a.2.III.a.3.The ESU should be placed near the sterilefield, and the cord should reach the wallor column outlet without stress on thecord and without blocking a traffic path. 19Stress on the cord may cause damageto the cord, posing an electrical hazard.The electrical cord should be free ofkinks, knots, and bends.Kinks, knots, and bends could damagethe cord or cause leakage, currentaccumulation, and overheating of thecord’s insulation.The ESU plug, not the cord, should beheld when it is removed from the outlet.Pulling on the cord may cause cordbreakage, which poses a fire hazard.III.a.4. The ESU’s cord should be kept dry. 19Fluids in or around the ESU connectionsand cord may cause an electricalhazard as a result of a short circuit.III.b. The ESU’s cord should be inspected or electricallytested for outer insulation damage. 19Cord failures can result in a fire or patientand personnel injuries.III.b.1.The ESU should be removed from use ifthere is any evidence of breaks, nicks,or cracks in the outer insulation coatingof the electrical cord. 19Recommendation IVThe active electrode should be used in a mannerthat minimizes the potential for injuries.Incomplete circuitry, unintentional activation,and incompatibility of the active electrode to theESU may result in patient and personnel injuries. 16,27IV.a. The active electrode should be visuallyinspected at the surgical field before use.Inspection should include but is not limited to2012 Perioperative Standards and Recommended Practices Equipment and Product Safety 101

RP: ElectrosurgeryIV.a.1.IV.b.IV.b.1.– identifying any apparent damage to thecord or hand piece (eg, impaired insulation),19 and– ensuring compatibility of the active electrode,accessories, the ESU, and theprocedure.Insulation failures allow an alternatepathway for current to leave the electrodeand may result in an electrical shock orother injury.A damaged and/or incompatible activeelectrode, accessory, or ESU should beimmediately removed from use.When not in use, the active electrode shouldbe placed in a clean, dry, non-conductivesafety holster. 2,15,22,28 A plastic or other nonconductivedevice should be used to securethe active electrode cord to the steriledrapes. 22Use of a non-conductive safety holsterprevents the active electrode from falling offthe sterile field and unintentional activation.Unintentional activation of the active electrodemay cause burns of the patient,drapes, or personnel. 2,15The protective cap of a battery-powered,hand-held cautery should be in placewhen the cautery is not in use. 29,30Application of the protective cap preventsunintended pressure on the activationbutton. 29,30IV.c. The electrode cord should be kept free ofkinks and coils during use.Kinks, knots, and bends could damagethe cord, cause current leakage or accumulation,overheat the cord’s insulation, orproduce unanticipated changes in the surgicaleffect. “Hot spots” or field intensificationare produced by coiling cables. Keepingthe cords free of kinks and coilsminimizes the risk of patient or personnelinjury from conduction of stray current andcapacitive current. 21IV.d. The active electrode should be connecteddirectly into a designated receptacle on theESU.Incompatibility of the active electrodewith the ESU may result in patient and personnelinjuries.IV.d.1.IV.e.IV.f.IV.f.1.When needed, only adaptors approvedby the manufacturers of both the ESUand the accessory should be used.Only the user of the active electrode shouldactivate the device whether it is hand orfoot controlled. 20,28Activation by the user of the active electrodeprevents unintentional discharge ofthe device to minimize potential for patientand personnel injury.Active electrode tips should be used accordingto the manufacturer’s instructions.Failure to use the active electrode as outlinedin the manufacturer’s directions foruse have resulted in patient injuries and surgicalfires. 31-34The active electrode tip• should be compatible with the ESU,• should be securely seated into thehand piece, and• should not be altered. 34A loose electrode tip may cause aspark or burn tissue that comes in contactwith the exposed, non-insulatedsection of the tip. 31,34 Bending the tip candamage the device and alter the desiredfunction. Fires and patient injuries haveresulted when insulating sheaths havebeen made from inappropriate material(eg, rubber catheters). 32,33IV.g. The active electrode tip should be cleanedaway from the incision whenever there isvisible eschar. 32Eschar buildup on the active electrode tipimpedes the desired current flow, causingthe entire unit to function less effectively andserving as a fuel source, which can lead tofires. 32 Debris on the electrode tip can teartissue, cause re-bleeding, and serve as a foreignbody when deposited in the wound. 22IV.g.1.Methods to remove debris from theactive electrode tip should include butare not limited to• a moistened sponge or instrumentwipe to clean non-stick coated electrosurgicaltips on the sterile field, 16,32 and• abrasive electrode cleaning pads toremove eschar from non-coatedelectrodes on the sterile field. 32102Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryIV.g.2.The active electrode tip should not becleaned with a scalpel blade.Cleaning with a scalpel blade putsperioperative personnel at risk for a percutaneousinjury. 35IV.h. If the active electrode becomes contaminated,it should be disconnected from theESU and removed from the sterile field.Disconnection of the contaminatedactive electrode minimizes the risk of unintentionalactivation and reduces the potentialfor patient and personnel injuries. 16IV.i.IV.j.IV.j.1.If an active monopolar electrode is beingused in a fluid-filled cavity, the fluid usedshould be an electrically inert, near isotonicsolution (eg, dextran 10, dextran 70, glycine1.5%, sorbitol, mannitol) unless the equipmentmanufacturer’s written directions foruse instruct otherwise. 2,24Using an electrolyte solution instead of anonconductive medium may render theactive electrode less effective. Electrolytesolutions conduct and disperse the electricalcurrent away from the intended site. 18,24Fire safety measures should be followedwhen electrosurgery is in use according tolocal, state, and federal regulations. 36,37Active electrodes should not be activatedin the presence of flammable agents (eg,antimicrobial skin prep or hand antisepsisagents, tinctures, de-fatting agents,collodion, petroleum-based lubricants,phenol, aerosol adhesives, uncuredmethyl methacrylate) until the agents aredry and vapors have dissipated. 2,38-42Alcohol-based prep agents remainflammable until completely dry. Vaporsoccurring during evaporation also areflammable. Trapping of solution orvapors under incise or surgical drapesincreases the risk of fire or burn injury.Alcohol-based skin prep agents are particularlyhazardous because the surroundinghair or fabric can become saturated.Pooling can occur in body foldsand crevices (eg, umbilicus, sternalnotch). Ignition of flammable substancesby active electrodes has caused fires andpatient injuries. Flammable prep agentscan be safely used by adhering to NFPAIV.j.2.IV.j.3.standards, local fire codes, and AORNrecommendations and guidance statements.Use of nonflammable prepagents will minimize this risk. 16,42-46Caution should be used during surgeryon the head and neck when using anactive electrode in the presence of combustibleanesthetic gases. 2,44,47Opened suture packets containing alcoholshould be removed from the sterilefield as soon as possible. 16Ignition of flammable substances byan active electrode has caused fires andpatient injuries. 16,43IV.k. Sponges used near the active electrode tipshould be moist to prevent unintentionalignition. 32,47,48Fires have resulted from ignition of drysponges near the incision site. 16,49,50IV.l.When battery-powered, hand-held cauteryunits are used, the batteries should beremoved before disposal of the cautery unit. 30Unintentional activation of a batterypowered,hand-held cautery unit after disposalhas caused fires. 29,30IV.m. Electrosurgery should not be used in thepresence of gastrointestinal gases.Gastrointestinal gases contain hydr ogenand methane, which are highly flammable.Fires and patient injuries haveoccurred. 16,28,40,51,52IV.n. Electrosurgery should not be used in anoxygen-enriched environment. 28,32,53-55An oxygen-enriched environment lowersthe temperature and energy at which fuelswill ignite. 28,48 Fires, including airway fires,have resulted from the active electrodesparking in the presence of concentratedoxygen. 2,16,53,54IV.n.1.IV.n.2.The lowest possible oxygen concentrationthat provides adequate patient oxygensaturation should be used. 47,48Mixing oxygen with nonflammablegases such as medical air reduces therisk of fire. 16,47Surgical drapes should be arranged tominimize the buildup of oxidizers2012 Perioperative Standards and Recommended Practices Equipment and Product Safety 103

RP: Electrosurgery(eg, oxygen and nitrous oxide) underthe drapes, to allow air circulation, andto dilute the additional oxygen. 16,47,48IV.n.3. The active electrode should be used asfar from the oxygen source as possible.Personnel should be prepared to immediatelyextinguish flames should they occur. 16,47A small fire can progress to a life threateningemergency of a large fire in seconds.ESUs are a potential ignition sourceand a common cause of surgical fires andpatient injury. 28IV.o.1. Nonflammable material (eg, wet towel,sterile saline, water) should be availableon the sterile field to extinguishthe fire. 16,28Recommendation Vmonopolar electrosurgery is used, a dispersiveelectrode should be used in a manner thatminimizes the potential for injuries.Patient skin injuries at the dispersive electrode sitemost reported ESU incidents. 2 Single use dispersiveelectrode burns are decreasing withimproved technology and the use of safety features.reports of electrosurgical burns has decreased50 to 100 per month in the 1970s to one to twomonth in 2007. 2The patient’s skin condition should beassessed and documented before and afterESU use.The most frequently reported patientinjury from electrosurgery has been tissuedamage (eg, burn) at the dispersive electrodesite. 2 Preoperative and postoperativeassessments are necessary to evaluate thepatient’s skin condition for possible injuries.Return-electrode contact quality monitoringshould be furnished on general purposeelectrosurgery units. 18The technology of return-electrode contactquality monitoring inhibits the output ofthe ESU if the return electrode is not in contactwith the patient and connected to theESU. Return-electrode contact quality monitoringconfirms that there is adequate contactbetween the return electrode and thepatient. An audible alarm and visual indicatorsignals the user of a misconnection. 2,18 V.b.1.V.c. Return-electrodeshouldqualitydetectsorpluggedV.c.1.V.d. DispersivewithandpatientV.e. AusedpersivenewadheredispersivetoskinV.f. Dispersivepriateinfant,cut,electroderentsurgicalV.g. Beforepersive–Dual-foil return electrodes should beused. 18Dual-foil return electrodes are necessaryfor contact quality monitoring. 18The return electrode contact qualitymonitoring system determines differencesin impedance through patient’stissue between the two surfaces. If theimpedance is too high as a result ofpoor contact, the alarm is triggered andthe ESU stops functioning. 2continuity monitoringbe used if return-electrode contactmonitoring is not available.Return-electrode continuity monitoringbreaks in the return-electrode corda misconnection (ie, the cord is notinto the ESU). 2,19If using return-electrode continuitymonitoring, a single-foil electrodeshould be used. 2electrodes should be compatiblethe ESU.Incompatibility of the electrosurgical unitthe dispersive electrode may result ininjury.single-use dispersive electrode should beonce and discarded. If a single-use dis-electrode must be repositioned, asingle-use electrode should be used. 23,56A reused single-use electrode may notproperly to the skin. Replacing theelectrode provides an opportunityexamine the electrode and the patient’scondition.electrodes should be an appro-size for the patient (eg, neonate,pediatric, adult) and not altered (eg,folded).Using the appropriately sized dispersivereduces the concentration of cur-and minimizes the potential for electro-injuries.the application of a single-use dis-electrodethe manufacturer’s expiration date shouldbe verified and the dispersive electrodeIV.o.Whenare theThefromperV.a.V.b.104Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryV.h.V.h.1.V.h.2.V.h.3.should not be used if it is past the manufacturer’sexpiration date; 20– the package containing the dispersiveelectrode should be opened immediatelybefore use; 19 and– the integrity of the dispersive electrodeshould be checked for flaws, damage,discoloration, adhesiveness, anddryness. 18,20,23,57Expired, damaged, or dry single-use dispersiveelectrodes may fail and lead topatient injury.The conductive and adhesive surfaces of thesingle-use dispersive electrode should beplaced on clean, dry skin over a large, wellperfusedmuscle mass on the surgical sideand as close as possible to the surgical siteaccording to the manufacturer’s directionsfor use. 19,20Muscle is a better conductor of electricitythan adipose tissue. 23Single-use electrodes should not beplaced over bony prominences, scar tissue,hair, weight-bearing surfaces,potential pressure points, or areas distalto tourniquets. 5,18,19,23,58Fatty tissue, tissue over bone, scar tissue,and hair can impede electrosurgicalreturn current flow. 59 High impedanceleads to heating of the tissue, arcing tothe tissue under the dispersive electrode,and subsequent burns. Adequate tissueperfusion cannot be assured if the dispersiveelectrode is placed distal to tourniquetsor over scar tissue. 23Hair should be removed following recommendedpractices (ie, clipping) if itinterferes with single-use electrode contactwith the patient’s skin. 18,20,60Burns have resulted when electrodeshave been positioned over hairy surfaces.Hair can impede electrosurgical returncurrent flow. Hair may interfere with adequatecontact between the patient andthe dispersive electrode. 23,58,61The single-use electrode should not beplaced over an implanted metal prosthesis.The tissue over prostheses containsscar tissue, which impedes return of theelectric current. Although there hasV.h.4.V.i.V.i.1.V.i.2.V.j.been no reported injury from superheatingof the implant causing a tissue burn,this is a theoretical risk; therefore, it isprudent to avoid placing a dispersiveelectrode on the patient’s skin over thesite of a metal implant or prosthesis.Placing the single-use dispersive electrodeover a tattoo, many of which containmetallic dyes, should be avoided.Although there have been noreported electrosurgery injuries fromdispersive electrodes placed over tattoos,superheating of the tissue hasoccurred during magnetic resonanceimaging. There is a theoretical possibilityof this also happening withelectrosurgery. 62-64Following application of the single-use dispersiveelectrode, uniform contact with theskin should be verified.Injuries have been associated with inadequateadhesion of the dispersive electrode.Potential problems include tenting, gaping,and moisture, all of which interfere withadhesion to the patient’s skin. 65-67Corrective measures for poor single-usedispersive electrode contact include,but are not limited to• removing oil, lotion, moisture, orprep solution;• removing excessive hair;• changing sites; and• applying a new pad.Tape should not be used to hold the single-usedispersive electrode in place.Taping the dispersive electrode maycreate localized pressure and increasethe current concentration leading to apotential injury. 68The single-use dispersive electrode should beplaced on the patient after final positioning.Moving the patient after the applicationof the dispersive electrode may disrupt thecontact to the patient’s skin causing tenting,gapping, or moisture collection under theelectrode. Injuries have been associatedwith inadequate contact of the dispersiveelectrode. 19,65-672012 Perioperative Standards and Recommended Practices Equipment and Product Safety 105

RP: ElectrosurgeryV.j.1.V.j.2.V.k.V.l.If any tension is applied to the dispersiveelectrode cord, the perioperativeregistered nurse should reassess theintegrity of the dispersive electrode, itscontact with the patient’s skin, and theconnection to the ESU.If the patient is repositioned, the perioperativeregistered nurse should verifythat the dispersive electrode is in fullcontact with the patient’s skin.Inadequate contact of the dispersiveelectrode may result in a burn. 65-67The single-use dispersive electrode shouldbe placed away from a warming device. 65,67The heat of a warming device may becumulative with the heating of the dispersiveelectrode and may affect how the dispersiveelectrode adheres to the skin. 65,67Dispersive electrodes should be kept dryand protected from fluids seeping or poolingunder the electrode. 23Liquids may prevent the electrode fromadequately contacting the skin. These solutionsalso can cause skin injury and burnsfrom prolonged skin exposure and concentrationof electrical current. 57V.m. Contact between the patient and metaldevices should be avoided. 69,70Metal devices (eg, OR beds, stirrups,positioning devices, safety strap buckles)could offer a potential alternate return pathfor the electrical current. 69,70V.m.1.V.m.2.Patient’s metal jewelry that is betweenthe active and dispersive electrodeshould be removed.Metallic jewelry, including body piercings,presents a potential risk of burnfrom directed current (ie, active electrodecontact); heat conducted before an electrodecools; and leakage current. Eliminatingmetal near the activation site minimizesthis risk. Jewelry that is left inplace, particularly on the hands, has thepotential to cause swelling at the site duringsurgery or recovery. 15Patient monitoring electrodes (eg, electrocardiogram,oximetry, fetal) shouldbe placed as far away from the surgicalsite as possible. 21V.m.3.V.m.4.V.n.V.n.1.V.n.2.V.o.Alternate pathway burns have beenreported at electrocardiogram (ECG)electrode sites and temperature probeentry sites with ground-referenced electrosurgeryunits. 19Needle electrodes for monitoring or nonsurgicalfunctions should be avoided. 18,21Stray current may flow through thesmall contact area of the needle electrodecausing a potential alternate pathwayand risk of patient burn. 18,21,71,72When use of needle monitoring electrodesis medically necessary, alternateelectrosurgery technologies (eg, bipolar,laser) should be considered. 18,73When multiple ESUs are used simultaneouslyduring a surgical procedure, the compatibilityof equipment and proper functioning ofcorresponding electrode monitoring systemsshould be verified with the manufacturer.Separate single-use dispersive electrodesshould be used for each ESU.The dispersive electrodes should beplaced as close as possible to theirrespective surgical sites and the single-usedispersive electrodes should not overlap.During high-current, long-activation-time,radio-frequency (RF) ablations and otherelectrosurgical procedures (eg, tumor ablation,bulk tissue resection), considerationsshould include, but not be limited to– identifying surgical procedures that requirethe use of high-current, long-activationtimeRF ablation and electrosurgicaltechniques;– taking inventory of RF generators thatrequire special or multiple dispersiveelectrodes;– following the manufacturer’s recommendationsfor use of large-size dispersive electrodesor multiple dispersive electrodes;– ensuring proper placement and full patientcontact of the dispersive electrode;– reviewing the manufacturer’s directionsfor use and requirements for accessories;– using and selecting the appropriate nonconductive,near-isotonic solution (eg,sorbitol, mannitol, dextran 10 or 70,106Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryV.o.1.V.p.V.q.V.q.1.V.q.2.V.q.3.glycine) for irrigation or distention unlesscontraindicated by manufacturer’s directions;and– using the lowest possible power settingsand minimum activation time for obtainingthe desired tissue effect. 2,24,74There is an increased risk of dispersiveelectrode site burns with high-current, longactivation-timeprocedures. 2,61,74-76When high current is not adequatelydispersed by a single dispersive electrodeand there are no specific manufacturer’sdirections, a second dispersiveelectrode with an adaptor or a returnelectrode with a larger conductive surfacemay be considered for use. 24,74A second dispersive electrode or alarger conductive surface increases theoverall dispersive pad surface area forcurrent to return to the generator. 74When removing the single-use dispersiveelectrode, the adjacent skin should be heldin place and the dispersive electrode peeledback slowly.Slowly removing the dispersive electrodewill avoid denuding the surface of the skin.Skin injuries can result when the adhesiveborder pulls on the skin during electroderemoval. 77Reusable, capacitive-coupled return electrodesystems should be used accordingto manufacturers’ written instructions forsafe operation in conjunction with a compatibleESU.Capacitive-coupling pads should be anappropriate size for the patient (ie,adult, pediatric). 78,79Skin preparation should not be performedunless otherwise recommendedby the manufacturer’s written directions. 78Adequate contact with the patient shouldbe ensured by using minimal materialsbetween the capacitive-coupled padand patient. 79 The use of thick foam, gelpads, and extra linen between thepatient and the capacitive-coupling padshould be avoided.Distance and barriers (eg, positioningdevices) between the patient andelectrode may increase the risk ofimpedance, which can result in analternate site injury when using acapacitive-coupling pad. 78V.q.4. An isolated generator should be used. 78Use of a ground-referenced orground ed generators may cause aground fault alarm.V.q.5.V.q.6.V.q.7.V.q.8.The pad should be cleaned with thehealth care facility-approved and EPAregisteredagent if contaminated withblood or body fluids in accordance withthe manufacturer’s directions. Acceptablecleaning solutions include a bleach solutiondiluted 1:10 and o-phenylphenol,o-benzyl-p-chlorophenol, or p-tertiaryamylphenol. 78The integrity of the capacitive-coupledpad and cables should be checked fortears or breaks in the surface materialbefore use, and• pad cables should be replaced ifdamaged,• surface damage may be repaired withthe manufacturer’s repair kit, and• the pad should be replaced if superficialdamage cannot be repaired.When two ESUs are used, two capacitivecoupledpads or one capacitive-coupledpad with two cords should be used.The pad should be replaced on itslabeled expiration date. 78Recommendation VIPersonnel should take additional precautionswhen using electrosurgery during minimally invasivesurgery. 18,80Minimally invasive surgery procedures usingelectrosurgery present unique patient safety risks,such as direct coupling of current, insulation failure,and capacitive coupling.VI.a. Personnel should verify that the insufflationgas is nonflammable (ie, carbon dioxide). 81Carbon dioxide is noncombustible andwill not ignite if the active electrosurgicalelectrode sparks. 81 Gases (eg, oxygen,nitrous oxide, air) are oxidizers that maysupport combustion. An oxidizer-enriched2012 Perioperative Standards and Recommended Practices Equipment and Product Safety 107

RP: Electrosurgeryenvironment may enhance ignition andcombustion. 28VI.b. Conductive trocar systems should be used. 7,8,11,82Conductive trocar cannulas provide ameans for the electrosurgical current to flowsafely between the cannula and the abdominalwall. This reduces high density current concentrationand heating of non-target tissue. 7,8,11,82VI.b.1.Hybrid trocar (ie, combination plasticand metal) systems should not beused. 8,82,83Each trocar and cannula can act asan electrical conductor inducing anelectrical current from one to the otherpotentially causing a capacitive couplinginjury.VI.c. Minimally invasive surgery electrodesshould be examined for impaired insulationbefore use. 11,83-85Insulation failure of electrodes caused bydamage during use or reprocessing providesan alternate pathway for the electrical currentto leave the active electrode. Someinsulation failures are not visible. This hasresulted in serious patient injuries. 4,7,8,11-13,85VI.c.1.VI.c.2.Methods should be used to detect insulationfailure, including but not limited to• active electrode shielding andmonitoring, 11,14• the use of active electrode indicatorshafts that have two layers of insulationof different colors, 11 and• the use of active electrode insulationintegrity testers that use high DCvoltage to detect full thickness insulationbreaks. 11Active electrode shielding continuouslymonitors the endoscopic instrumentsto minimize the risks of insulationfailure or capacitive-couplinginjuries. 4,7-9,12-14,83The inner layer of the active electrodeshaft of a different color is designed toshow through the outer black layer ifthere is an insulation break. 11Testing of the electrode before the procedureidentifies damaged electrodes thatshould be taken out of service. Testing ofthe electrode with the sterilizable probesand cables alerts the surgeon of an insulationbreak. The surgical field can beexplored and treated if necessary. 11,85The lowest power setting that achievesthe desired result should be selected. 83Lower power settings for both cut andcoagulation reduce the likelihood ofinsulation failure and capacitive-couplinginjuries. Lower power settings also minimizedamage from direct coupling whenthe active electrode is activated while inclose proximity to another metal deviceinserted into an adjacent trocar port. 7VI.d. The active electrode should not be activateduntil it is in close proximity to the tissue. 7,8Activation only when in close proximityto the tissue minimizes the risk of currentarcing and contacting unintended tissue. 7,8Activating the electrode when it is not invery close proximity to the targeted tissueincreases the risk of capacitive coupling.Capacitance is reduced during closed-circuitactivation.VI.e. Patients should be instructed to immediatelyreport any postoperative signs or symptomsof electrosurgical injury. Patient postoperativecare instructions should include symptomsto look for, including but not limited to– fever,– inability to void,– lower gastrointestinal bleeding,– abdominal pain,– abdominal distention,– nausea,– vomiting, and– diarrhea. 8,86Symptoms of a minimally invasive electrosurgicalinjury can occur days after dischargefrom the perioperative setting andmay include infection from an injured intestinaltract. Prompt reporting of electrosurgicalinjury symptoms ensures timely treatmentand minimizes adverse outcomes. 8,84Recommendation VIIBipolar active electrodes, including vessel occludingdevices, should be used in a manner that minimizesthe potential for injuries.Unlike the monopolar ESU, bipolar technologyincorporates an active electrode and a return electrode108Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: Electrosurgerymoved away from the patient’s tissue aftereach activation. 89,90There is a risk of gas emboli when theactive electrode is placed in direct contactwith tissue. If argon gas pressure exceedsvenous pressure in the circulating systemand is applied to bleeding vessels, the resultis a gas emboli in open surgical procedures.2,90,91 The flow of argon gas could enterthe open vessel and enter the heart. 2IX.e. When using the AEC unit during minimallyinvasive surgical procedures, personnelshould follow all safety measures identifiedfor AEC technology.Patient injury and death have occurred as acomplication of argon enhanced technology. 90IX.e.1.IX.e.2.IX.e.3.IX.f.IX.f.1.Endoscopic CO 2 insufflators should beequipped with audible and visual overpressurizationalarms that cannot bedeactivated. 2,90The AEC acts as a secondary sourceof pressurized argon gas that can causethe patient’s intra-abdominal pressure torise rapidly and exceed venous pressure,possibly creating argon-enrichedgas emboli formation. This has resultedin gas emboli. 90The active electrode and argon gas lineshould be purged according to the manufacturer’srecommendations. 2,90The patient’s intra-abdominal cavity shouldbe flushed with several liters of CO 2between extended activation periods. 90Flushing the intra-abdominal cavitywith several liters of CO 2 betweenextended periods of deactivationreduces the potential for argon gasemboli formation. 90Personnel using the AEC technology shouldbe knowledgeable about signs, symptoms,and treatment of venous emboli.There is a significant risk of gas embolismwhen AEC is used during laparoscopic proceduresfrom abdominal over-pressurizationand displacement of CO 2 by argon gas. 90Patient monitoring should includedevices that are considered effective forearly detection of gas emboli (eg, endtidalCO 2 ). 2,90Recommendation XPotential hazards associated with surgical smokegenerated in the practice setting should be identified,and safe practices established.Surgical smoke (ie, plume) is generated from useof heat-producing instruments such as electrosurgicaldevices. Airborne contaminants produced duringelectrosurgery have been analyzed. The electrosurgeryplume contains toxic gas and vapors (eg,benzene, hydrogen cyanide, formaldehyde); bioaerosols;dead and living cell material, includingblood fragments; and viruses. 92-94 Many additionalhazardous chemical compounds have been notedin surgical smoke. 92,95-98At some level, these contaminants have beenshown to have an unpleasant odor, cause problemswith visibility of the surgical site, cause ocular andupper respiratory tract irritation, and demonstratemutagenic and carcinogenic potential. 92,93,99 Thepossibility for bacterial and/or viral contaminationof smoke plume remains controversial, but hasbeen highlighted by different studies. 100,101The National Institute of Occupational Safetyand Health (NIOSH) recommends that smokeevacuation systems be used to reduce potentialacute and chronic health risks to personnel andpatients. 92 The Occupational Safety and HealthAdministration (OSHA) has no separate standardrelated to surgical smoke. OSHA addresses suchsafety hazards in the General Duty Clause andBloodborne Pathogens Standard. 97X.a.X.a.1.X.a.2.Surgical smoke should be removed by useof a smoke evacuation system in both openand laparoscopic procedures.Potential health and liability risks may bereduced by the evacuation of smokeplume. 93When large amounts of plume are generated,an individual smoke evacuationunit with a ULPA filter should be usedto remove surgical smoke.The suction wand of the smoke evacuationsystem should be no greater thantwo inches (5.08 cm) from the source ofthe smoke generation. 92,93Close proximity of the smoke evacuationwand maximizes particulate matterand odor capture and enhances visibilityat the surgical site. 99110Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryX.a.3.X.a.4.X.a.5.X.b.Smoke evacuation units and accessoriesshould be used according to manufacturers’written instructions.Detectable odor during the use of asmoke evacuation system is a signal that• smoke is not being captured at thesite where the plume is being generated,• inefficient air movement through thesuction or smoke evacuation wand isoccurring, or• the filter has exceeded its usefulnessand should be replaced. 93When a minimal amount of plume isgenerated, a central suction system withan in-line ULPA filter may be used toevacuate the plume. 92 The in-line filtershould be placed between the suctionwall/ceiling connection and the suctioncanister. 99Central suction units are designed tocapture liquids and should not be usedwithout an in-line ULPA filter to removeairborne contaminants. 92 Low suctionrates associated with centralized suctionunits limit their efficiency in evacuatingplume, making them suitable onlyfor the evacuation of small amounts ofplume. 94When a centralized system dedicatedfor smoke evacuation is available, thesmoke evacuator lines should beflushed according to the manufacturer’sinstructions to ensure particulate matterbuildup does not occur.Plume particulate can accumulate inthe lumens of the centralized systemcausing decreased suction capabilityand potential pathogen growth.Used smoke evacuator filters, tubing, andwands should be disposed of as potentiallyinfectious waste following standard precautions.93,99Airborne contaminants produced duringelectrosurgery or laser procedures have beenanalyzed and are shown to contain gaseoustoxic compounds, bio-aerosols, and deadand living cell material. At some level, thesecontaminants have been shown to have anunpleasant odor, cause visual problems forX.c.physicians, cause ocular and upper respiratorytract irritation, and demonstrate mutagenicand carcinogenic potential. 99 The possibilityfor bacterial and/or viral contaminationof smoke plume remains controversial buthas been highlighted by different studies. 100,101Personnel should wear high-filtration surgicalmasks during procedures that generatesurgical smoke.High-filtration masks are specificallydesigned to filter particulate matter that is 0.1micron in size and larger which may protectagainst residual plume in the air that hasescaped smoke evacuation capture. 95 Thesemasks should not be viewed as absolute protectionfrom chemical or particulate contaminantsfound in surgical smoke and shouldnot be used as the first line of protectionagainst surgical smoke inhalation. 95,99Recommendation XIPersonnel should receive initial education and competencyvalidation on procedures and shouldreceive additional training when new equipment,instruments, supplies, or procedures are introduced.Initial education on the underlying principles ofelectrosurgical safety provides direction for personnelin providing a safe environment. Additional, periodiceducational programs provide reinforcement ofprinciples of electrosurgery and new information onchanges in technology, its application, compatibilityof equipment and accessories, and potential hazards.Electrosurgical equipment and accessories havebeen associated with numerous fires and patientinjuries. 2,8,19,53 The National Fire Protection Associationhas identified ESUs as high-risk equipment,warranting training and retraining of personnel. 19XI.a. Personnel working with electrosurgeryequipment should be knowledgeable aboutthe principles of electrosurgery, risks topatients and personnel, measures to minimizethese risks, and corrective actions toemploy in the event of a fire or injury. 19Electrosurgical equipment and accessorieshave been associated with numerousfires and patient injuries. 2,8XI.b. Personnel should be instructed on theproper operation, care, and handling of theESU and accessories before use. 192012 Perioperative Standards and Recommended Practices Equipment and Product Safety 111

RP: ElectrosurgeryXI.b.1.Incorrect use can result in serious injuryto patients and personnel.If multiple types of electrosurgicalequipment are used within the facility,training should be provided on all ofthe equipment. 18XI.c. Personnel should be instructed in the risksof electrosurgery during minimally invasivesurgical procedures.Direct coupling is the result of touchingthe laparoscopic active electrode to anotheranatomic structure. This can cause necrosisof underlying tissue. Insulation failure of thelaparoscopic electrode can be caused bytrauma during use or reprocessing. Currentleaves the electrode through this alternatepathway. This can cause serious patientinjury, particularly when the injury is internal.Capacitive-coupled RF currents cancause undetected burns to nearby tissue andorgans outside the endoscope’s viewingfield. Severe patient injuries have resulted. 8XI.d. Perioperative registered nurses should beknowledgeable about the types of IEDs thatmay be encountered in the practice setting,and the precautions that must be takenwhen caring for patients with these devices. 25Electronic devices implanted in a patientmay be affected by other IEDs or medicalequipment with which a patient may comeinto contact in a health care facility.XI.e. Administrative personnel should assess anddocument annual competency of personnelin the safe use of the ESU and accessories.A competency assessment provides arecord that personnel have basic understandingof electrosurgery, its risks, andappropriate corrective actions to take in theevent of a fire or injury. This knowledge isessential to minimize the risks of misuse ofthe equipment and to provide a safe environmentof care.Recommendation XIIDocumentation should be completed to enablethe identification of trends and demonstrate compliancewith regulatory and accrediting agencyrequirements.Documentation of all nursing activities performedis legally and professionally important forclear communication and collaboration betweenhealth care team members and for continuity ofpatient care.XII.a. Documentation using the PNDS shouldinclude a patient assessment, a plan of care,nursing diagnoses, identification of desiredoutcomes, interventions, and an evaluationof the patient’s response to the care provided.Documentation provides communicationamong all care providers involved in planningand implementing patient care.XII.b. Documentation should be recorded in amanner consistent with health care organizationpolicies and procedures and shouldinclude, but is not limited to– electrosurgical system identificationserial number; 102– range of settings used;– dispersive electrode placement;– patient’s skin condition before dispersiveelectrode placement;– patient’s skin condition after removal ofdispersive electrode; 102– adjunct electrosurgical devices used (eg,ultrasonic scalpel, bipolar forceps); and– safety holster use. 18Recommendation XIIIPolicies and procedures for electrosurgery shouldbe developed, reviewed periodically, revised as necessary,and readily available in the practice setting.Policies and procedures assist in the developmentof patient safety, quality assessment, andimprovement activities. Policies and proceduresestablish authority, responsibility, and accountabilitywithin the facility. They also serve as operationalguidelines that are used to minimize patientrisk factors, standardize practice, direct staff members,and establish guidelines for continuous performanceimprovement activities.XIII.a. The health care organization’s policies andprocedures for electrosurgery must be incompliance with the Safe Medical DevicesAct of 1990, amended in March 2000. 26XIII.a.1. When patient or personnel injuries orequipment failures occur, the ESU112Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: Electrosurgeryshould be removed from service andthe active and dispersive electrodesretained if possible. 102Retaining the ESU, the active and dispersiveelectrodes, and packaging allowsfor a complete systems check to determineelectrosurgical system integrity. 102XIII.a.2. Incidents of patient or personnel electricalinjury or equipment failureshould be reported as required by regulationto federal, state, and localauthorities and to the equipment manufacturer.102 Device identification, maintenanceand service information, aswell as adverse event informationshould be included in the report fromthe practice setting.Documentation of details of the electrosurgicalequipment and suppliesallows for retrievable information forinvestigation into an adverse event. 102XIII.b. Policies and procedures for electrosurgeryshould include, but are not limited to thefollowing:– safety features required on ESUs;– equipment maintenance programs;– required supplemental safety monitors;– equipment checks before initial use;– reporting and impounding malfunctioningequipment;– reporting of injuries;– preoperative, intraoperative, and postoperativepatient assessments;– precautions during use;– ESU sanitation; and– documentation.XIII.c. An introduction and review of policies andprocedures for electrosurgery should beincluded in orientation and ongoing educationof personnel to assist in the developmentof knowledge, skills, and attitudes thataffect surgical patient outcomes.Review of policies and procedures assistshealth care professionals in the developmentof knowledge, skills, and attitudes thataffect patient outcomes.XIII.d. A written fire prevention and managementpolicy and procedure should be developedby a multidisciplinary group that includesall categories of perioperative personnel. 18,36Fire is a risk to both patients and healthcare workers in the perioperative setting.XIII.d.1. The policy and procedure shouldde scribe processes to be implementedto safely manage different fire scenarios.Recommendation XIVA quality assurance/performance improvement processshould be in place that measures patient, process,and structural (eg, system) outcome indicators.A fundamental precept of AORN is that it is theresponsibility of professional perioperative registerednurses to ensure safe, high-quality nursingcare to patients undergoing surgical and invasiveprocedures. 103XIV.a. Structure, process, and clinical outcomesperformance measures should be identifiedthat can be used to improve patient careand that also monitor compliance withfacility policy and procedure, national standards,and regulatory requirements. 104XIV.a.1. Process indicators may include, but arenot limited to information about adversepatient outcomes and near misses associatedwith electrosurgery, which shouldbe collected, analyzed, and used forperformance improvement. 103XIV.b. Electrosurgical devices should be testedbefore initial use, inspected periodically,and receive preventive maintenance by adesignated individual responsible for equipmentmaintenance (eg, biomedical engineeringservices personnel). 19Periodic preventative maintenanceensures continued safe operation of electrosurgicaldevices. 19XIV.c. Each ESU should be assigned an identificationor serial number.This number allows designated personnelto track function problems and documentmaintenance performed on individual ESUs.XIV.d. Each health care organization should beresponsible for staying abreast of evolvingtechnology that may impact patient careand safety.Electrosurgical technology continues toevolve, changing the way in which surgicalhemostasis is achieved.2012 Perioperative Standards and Recommended Practices Equipment and Product Safety 113

RP: ElectrosurgeryGlossaryActive electrode: The electrosurgical unit (ESU)accessory that directs current flow to the surgicalsite (eg, pencils, various pencil tips).Active electrode indicator shaft: An active electrodecomposed of two layers of insulated materialof different colors. The inner layer is a bright color,the outer layer is black. When the bright coloredinner layer is evident upon visual inspection, abreak in the insulation is indicated.Active electrode insulation testing: Devicesdesigned to test the integrity of the insulation surroundingthe conductive shaft of laparoscopic electrosurgicalactive-electrode instruments. The devicesdetect full thickness breaks in the insulation layer.Active electrode monitoring: A dynamic processof searching for insulation failures and capacitivecoupling during monopolar surgery. If the monitordetects an unsafe level of stray energy, it signals thegenerator to deactivate.Alternate site injury: Patient injury caused by anelectrosurgical device that occurs away from thedispersive electrode site.Argon-enhanced coagulation: Radio frequencycoagulation from an electrosurgical generator thatis capable of delivering monopolar current througha flow of ionized argon gas.Bioengineering services personnel: Those individualsin an institution who are trained and qualified tocheck, troubleshoot, and repair medical equipment.Bipolar electrosurgery: Electrosurgery in whichcurrent flows between two tips of a bipolar forcepsthat are positioned around tissue to create a surgicaleffect. Current passes from the active electrode ofone tip of the forceps through the patient’s desiredtissue to the other dispersive electrode tip of the forceps—thuscompleting the circuit without enteringanother part of the patient’s body.Capacitance: Ability of an electrical circuit totransfer an electrical charge from one conductor toanother, even when separated by an insulator.Capacitive coupling: Transfer of electrical currentfrom the active electrode through intact insulationto adjacent conductive items (eg, tissue, trocars).Capacitively coupled return electrode: A large,nonadhesive return electrode placed close to andforming a capacitor with the patient, returningelectrical current from the patient back to the electrosurgicalunit (ESU).Current: A movement of electrons analogous tothe flow of a stream of water.Direct coupling: The contact of an energizedactive electrode tip with another metal instrumentor object within the surgical field.Dispersive electrode: The accessory that directselectrical current flow from the patient back to theelectrosurgical generator—often called the patientplate, return electrode, inactive electrode, orgrounding pad.Dual foil electrode: A dispersive return electrodethat has two foil conductive surfaces on a single nonconductiveadhesive pad. The two foil surfaces areconnected independently through the same returnelectrode cord to the ESU. The dual foil designallows the return electrode quality monitor to detectimpedance differences between the conductive surfaces.If a difference is detected between the two foilsurfaces, the ESU will alarm and shut down. Dualfoil electrodes are a necessary component of returnelectrode quality monitoring.Electrosurgery: The cutting and coagulation ofbody tissue with a high-frequency (ie, radio frequency)current.Electrosurgical accessories: The active electrodewith tip(s), dispersive electrode, adapters, and connectorsto attach these devices to the electrosurgerygenerator.Electrosurgical unit: The generator that producesa high-frequency current waveform that is deliveredto tissues, the foot switch with cord (if applicable),the electrical plug, cord, and connections.Endoscopic minimally invasive: Surgical techniquesthat use endoscopic approaches rather thandissection.Eschar: Charred tissue residue.Generator: The machine that produces radio frequencywaves (eg, ESU, power unit).Ground-referenced electrosurgical unit: A systemin which electrical current is sent to the patientand follows the path of least resistance back to theground. This technology, which no longer is manufactured,produces high-frequency, high-voltagecurrent and sometimes is referred to as a “sparkgap” unit.Insulator: A material that does not conductelectricity.Insulation failure: Damage to the insulation ofthe active electrode that provides an alternate pathwayfor the current to leave that electrode as itcompletes the circuit to the dispersive electrode.Isolated electrosurgical unit: A system in whichelectrical current is sent to the patient and selectivelyreturns and is grounded through the generator.114Equipment and Product Safety2012 Perioperative Standards and Recommended Practices

RP: ElectrosurgeryMonopolar electrosurgery: Electrosurgery inwhich only the active electrode is in the surgicalwound, and the electrical current is directed throughthe patient’s body, received by the dispersive pad,and transferred back to the generator, completing themonopolar circuit.Oxygen-enriched environment: Atmospherecontaining more than 21% oxygen, frequentlyoccurring in the oropharynx, trachea, lower respiratorytract, and near the head and neck duringadministration of oxygen to the patient.Return electrode continuity monitor: A safetyfeature of a single foil dispersive electrode thatdetects an unconnected dispersive electrode or abreak in the return electrode cord.Return-electrode contact quality monitoring: Adynamic monitoring circuit measuring impedanceof the dispersive return electrode. If the dispersiveelectrode becomes compromised, the circuit inhibitsthe ESU’s output.Ultra low particulate air (ULPA): Theoretically, aULPA filter can remove from the air 99.9999% ofbacteria, dust, pollen, mold, and particles with asize of 120 nanometers or larger.Ultrasonic scalpel: A cutting/coagulation devicethat converts electrical energy into mechanicalenergy, providing a rapid ultrasonic motion.Vessel sealing device: Bipolar technology thatfuses collagen and elastin in the vessel walls andpermanently obliterates the lumen of the vessel.References1. Association for the Advancement of MedicalInstrumentation. ANSI/AAMI HF18:2001. ElectrosurgicalDevices. Arlington, VA: Association for the Advancementof Medical Instrumentation; 2001.2. ECRI. Electrosurgery. Healthcare Risk Control RiskAnalysis. 2007;4(Surgery and Anesthesia 16).3. Electrosurgical units. Health Devices. 1998;27(3):93-111.4. Odell RC. 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RP: Electrosurgery32. Ignition of debris on active electrosurgical electrodes.Health Devices. 1998;27(9-10):367-370.33. Center for Devices and Radiological Health.Manufacturer and User Facility Device Experience(MAUDE) Database Adverse Event Report 393590.Reported May 7, 2002. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=393590. Accessed November 4, 2009.34. ECRI Institute. Hazard report. Improperly seatedelectrosurgical active electrodes can burn patients. HealthDevices. 2007;36(10):337-339.35. AORN guidance statement: sharps injury preventionin the perioperative setting. In: Perioperative Standardsand Recommended Practices. Denver, CO: AORN, Inc;2009:275-280.36. Recommended practices for a safe environment ofcare. In: Perioperative Standards and RecommendedPractices. Denver, CO: AORN, Inc; 2009:415-437.37. AORN guidance statement: fire prevention in theoperating room. In: Perioperative Standards and RecommendedPractices. 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RP: Electrosurgery101. Hallmo P, Naess O. Laryngeal papillomatosiswith human papillomavirus DNA contracted by a lasersurgeon. Eur Arch Otorhinolaryngol. 1991;248(7):425-427.102. ECRI Institute. Investigating device-related skin“burns”. Operating Room Risk Management. 2(3):1-10.103. Quality and performance improvement standardsfor perioperative nursing. In: Perioperative Standardsand Recommended Practices. Denver, CO: AORN, Inc;2009:65-74.104. Improving organization performance. In: ComprehensiveAccreditation Manual for Hospitals: TheOfficial Handbook. Oakbrook Terrace, IL: Joint Commissionon Accreditation of Healthcare Organizations;2007:PI-8–PI-9.AcknowledgementsLead AuthorMary Ogg, RN, MSN, CNORPerioperative Nursing SpecialistAORN Center for Nursing PracticeDenver, ColoradoContributing AuthorCecil A. King, MS, RN, CNORPerioperative Clinical EducatorCape Cod HospitalHyannis, MassachusettsPublication HistoryOriginally published March 1985, AORN Journal.Revised April 1991; revised July 1993.Revised November 1997; published January1998, AORN Journal. Reformatted July 2000.Revised November 2003; published February2004, AORN Journal.Revised November 2004; published in Standards,Recommended Practices, and Guidelines, 2005 edition.Reprinted March 2005, AORN Journal.Revised July 2009 for online publication in PerioperativeStandards and Recommended Practices.Minor editing revisions made in November2009 for publication in Perioperative Standardsand Recommended Practices, 2010 edition.118Equipment and Product Safety2012 Perioperative Standards and Recommended Practices