Electrosurgical Unit Safety Guidelines: Practical OR Rules

Electrosurgery hazards: what can go wrong

The main electrosurgery hazards are burns at the return electrode site, burns at unintended locations, surgical fires, interference with implanted devices, and exposure to surgical smoke. Side effects of electrosurgery are mostly the result of current finding an unplanned path or of heat building up where it should not.

Most incidents trace back to a small set of causes: a poorly applied or partly lifted return pad, damaged instrument insulation, activation outside the surgeon's view, power set higher than needed, and flammable agents in the field.

Precautions to ensure electrosurgical safety in the OR

Safe practice starts before the first incision. Inspect the generator, cables and instruments, confirm the settings with the surgeon and test the audible activation tone. Use the lowest power that achieves the desired effect, and activate only when the electrode is in view and in contact with the target tissue.

Keep the active electrode in an insulated holster when not in use, never coil cables around metal instruments, and keep the footswitch clearly assigned to one operator. Check that skin preparation solutions have dried and that drapes and gases are not trapped near the field.

• Inspect cables, handpieces and insulation for cracks before every case
• Use the lowest effective power and short activations
• Holster the active electrode between uses
• Keep alcohol-based preparations dry and avoid pooling
• Document the unit, settings and pad site in the record

Return electrode and alternate site burns

Current has to leave the patient through a pad with enough contact area. Apply the pad to clean, dry, well-perfused skin over a muscular area close to the operative site, avoiding scar tissue, bony prominences, hair and metal implants. Do not cut or fold the pad, and do not reuse single-use pads.

Modern generators monitor pad contact and will stop output if the connection is poor. For example the ARC 350 offers neutral-electrode monitoring with a baby mode, and the same function is part of the safe-use package of the BOWA range. Monitoring does not replace correct placement; see our guide to the neutral electrode and return pad and prevention of electrosurgical burns.

Fire, implanted devices and smoke

Fire needs an ignition source, fuel and an oxidiser. Electrosurgery supplies the ignition source, while alcohol preparations, drapes, gauze and oxygen-enriched air near the airway supply the rest. Agree who is responsible for the fire risk assessment, keep moist sponges near the field and communicate before activating near the airway.

For patients with pacemakers or ICDs, involve the device team before surgery and prefer bipolar energy where practical; see electrosurgery and pacemakers. Surgical smoke contains particles and chemicals, so source capture with a dedicated unit such as the BOWA SHE SHA, with a four-stage filter and ULPA-15 stage, is part of a safe theatre; more in our article on surgical smoke hazards.

Equipment, training and a pre-use checklist

Safety also depends on the equipment itself. Choose generators that comply with IEC 60601-1 and IEC 60601-2-2, with arc control, self-test and neutral-electrode monitoring, such as the BOWA ARC 400, and have them checked on a defined schedule.

Train every new team member, run a briefing at the start of the list and keep the unit's instructions for use available. Beckfinity's specialists can support user training and preventive maintenance in the UAE; contact us to discuss your theatre.