Resources and Tips for Safe Electrosurgery: A Conversation with Cherie Loeffler, RN


Tue Mar 29 13:00:00 CDT 2016
Cherie Loeffler, RN, CNOR
Clinical Hotline Manager, Medtronic

Electrosurgery has developed into an invaluable and reliable surgical tool. Electrosurgery units (ESU) and their accessories are becoming increasingly sophisticated, yet one of the basic tenets of electrosurgery will never change — protect the patient from harm.


“Safety is a top priority as electrosurgery continues to develop,” says Cherie Loeffler, RN, CNOR, manager of the Covidien Clinical Hotline. “Technology is constantly changing, and perioperative nurses are under a lot of pressure to keep up with these changes to ensure patient safety.”


To stay on top of the curve, perioperative nurses need to use assessment and critical thinking skills and access the right resources. You need to consider numerous factors to keep patients safe when electrosurgery is used. There are also many services available to help you and your surgical team deliver the best electrosurgical care, according to Loeffler.


Determine optimal PRE placement 


An important role of the perioperative nurse is to choose the proper patient return electrode (PRE) and place it correctly, Loeffler says. First, pick the appropriate size for the adult, pediatric, or neonatal patient.


Finding a safe site for the PRE can be challenging under certain circumstances. Ideally, the site is a well-vascularized, large, convex muscle mass near the surgical site. The PRE should not be placed so close to the surgical area that fluids or blood compromise the pad.


Placement of PREs should also be avoided in these areas:


  • Bony prominences, which can put pressure on the electrode and create current concentration
  • Scar tissue and adipose tissue, which is high in impedance and tends to resist electrosurgical current. The current may then seek an alternate pathway, which could result injury.
  • Areas with excessive hair, which can be clipped if necessary according to policy
  • Tattoos, which can have metal flecks in the ink that may get hot and could result in injury
  • Near warming devices, such as hypo/hyperthermia blankets. The warmth may dry out the conductive gel on the PRE thereby affecting its conductive properties.
  • Jewelry and body piercings, which should be kept out of the electrosurgical circuit. (SeeBody piercings and electrosurgery.)


Body piercings and electrosurgery


Trendy and unusual body piercings are becoming more common and can be a challenging safety concern during electrosurgery.  It is important to ensure the piercing is not within the electrosurgical circuit, because that can lead to a variety of risk factors such as direct coupling should the active electrode come into direct contact with the jewelry item, inadvertent contact with the deactivated electrode tip that can remain hot after activation, and heat transfer due to leakage current escaping from the active cord if in contact with the jewelry.  Other concerns are the risk of infection from microorganisms, the constricting nature of some jewelry, and the possibility of jewelry getting caught up in linens, drapes and cords.


Simple body piercings can be easily removed with the correct tools, but microdermal piercings or anchors are far more difficult. These types of piercings are similar to an old-fashioned tie tack. A small plate or anchor is implanted under the skin with a step that protrudes to the surface for securing the interchangeable jewelry.


Begin by asking patients early in the process about body piercings so they can be removed before the day of surgery, advises Cherie Loeffler, RN, CNOR, manager of the Covidien-Medtronic Clinical Hotline.


“Be aware that patients may fail to mention certain piercings,” she says. “For example, a patient may not mention a piercing in the perineal area, but it quickly becomes an issue if a vaginal procedure is planned.”


If surgery must proceed with piercings in place, it’s important to use isolated generator technology, she adds. 


Ensure good electrode contact


Another way to protect the patient is to use a return electrode monitoring (REM™) pad, or split pad. This device connects to an ESU with a contact quality monitoring (CQM) system.


“CQM technology monitors the pad-to-patient interface,” says Loeffler. “If the pad is compromised, such as peeling off due to patient diaphoresis, an alarm will sound.”  The ESU will also stop delivery of current until the problem is corrected.


Consider safety features


It is important to consider safety features when purchasing electrosurgery equipment, according to Loeffler. Examples include:


  • Software-based ESUs. These ESUs can be updated with the latest upgrades to provide additional features, extending the useful life of a unit.


An example is the ability to accommodate bipolar accessories used for transurethral resection of the prostate (TURP). Bipolar is considered safer than traditional monopolar resection because a PRE isn’t required and lower voltages are used.


  • Smoke evacuators, which help mitigate the hazardous byproducts of electrosurgery. It protects both patients and surgical personnel.
  • Vessel sealing technology using a hybrid bipolar output. This system is used in surgical procedures where ligation and division of vessels and lymphatics is desired. It may help reduce procedure time while significantly reducing the need for suture, staples, and clips.


Loeffler also recommends investigating all the safety advantages a technology offers. 


Consider monopolar electrosurgery. Surgeons can use this technology to improve safety when coagulation is needed to control diffuse bleeding due to multiple organ trauma, such as a lacerated liver and spleen.


“Coagulation is often associated with high voltage, but we now help the surgeon reduce high voltage use by having feedback technology based on the type of tissue,” says Loeffler.


The ESU makes adjustments several thousand times per second. When the tissue is higher in impedance, the generator delivers the higher voltage required. It reduces voltage when the surgeon is working on a section of tissue that is lower in impedance. This tissue-sensing technology allows for the use of lower power settings in all modes compared to previous technologies, according to Loeffler.


Make resources accessible


It is easy to become overwhelmed by a wealth of manuals and instructions for electrosurgery devices. Loeffler offers these tips for keeping important information assessable:

  • Store user manuals in a handy place, such as in a drawer of the ESU cart. Nurses can often find answers to common questions about settings and error codes in user manuals.
  • Keep copies of the accessory instructions for use (IFU), which contain important information, such as maximum settings or maximum peak or peak-to-peak voltages that are recommended for safe use of the accessory. This information avoids product damage.
  • Create a resource binder for single-use product instructions. Frequently, only one copy of instructions is provided for a large box of single-use electrosurgery products. When the box is opened, save the instructions and store them all in one accessible location.   
  • Compile PDFs of user manuals and instructions. This makes it easy for staff to access them on the OR computer terminal.
  • Ensure the most current manual or instruction is available.  Directly contact manufacturers for their most current IFUs or User Manuals or consider subscribing to a provider that offers accessibility to a database of such documents online.  Perioperative nurses can also contact the Covidien-Medtronic Clinical Hotline for User Manuals and instructions. (See Got questions? Help on the hotline.)

Got questions? Help on the hotline 


Help with questions related to electrosurgical safety is just a phone call away. The Covidien Medtronic Clinical Hotline team can give you the answers you need 24/7 to support the perioperative staff in protecting their patients and accessing electrosurgery safety programs through their trained sales professionals.


“We offer several services, including troubleshooting equipment and sterilization guidelines for our products,” says Cherie Loeffler, RN, CNOR, manager of the hotline. “We can also help new users with set up.”


Hotline team members answer questions about safety and offer evidence-based practice guidelines for common concerns, such as: 

  • Procedural starting settings for electrosurgery units (ESUs)
  • Using multiple generators on one patient
  • Connectivity with other equipment, such as the robot
  • Electrosurgery for patients with implanted electronic devices (IEDs).


“We use the AORN guidelines for perioperative practice and have extensive knowledge of electrosurgery products sold by Covidien, as well as its competitors,” says Loeffler. “If we don’t know the answer, we’ll find it and get back to the customer in a timely manner, usually the same day.”


Contact the Medtronic Medtronic Clinical Hotline number at 800-255-8522, option 1. or email at


Armed with good resources, Loeffler believes perioperative nurses can tackle the challenges of keeping patients safe as electrosurgery technology evolves.


“Our surgical patients can continue to rely on us to be their advocate during their time of vulnerability while in the OR,” she says.