AORN Journal
Volume 83, Issue 3 , Pages 657-664, March 2006

Electrosurgical burns in pediatric patients undergoing liver resection with saline-enhanced radiofrequency technology

  • Janis M. Richtmyer, RN

      Affiliations

    • Janis M. Richtmyer, BSN, MS/HSA, was the interim director of perioperative services at Children's Hospital of Central California, Madera, Calif, at the time this article was written.

Article Outline

ABSTRACT 

•USE OF SALINE-ENHANCED radiofrequency (RF) technology reduces blood loss in infants undergoing liver resection. Radiofrequency systems continuously deliver much higher currents for longer periods of time than conventional coagulation instruments and thus increase the risk of complications.

•THREE INFANTS undergoing liver resection with the newer RF technology at one facility experienced electrosurgical unit (ESU) dispersive pad burns. As a result, an experiment was performed on animal subjects to determine best ESU dispersive pad placement on infants and to gather data on device impedance.

•RECOMMENDATIONS to prevent burns include central placement of the ESU dispersive pad and activating warming devices only after resection is complete. AORN J 83 (March 2006) 658–664.

 

The article “Electrosurgical burns in pediatric patients undergoing liver resection with saline-enhanced radiofrequency technology” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is March 31, 2009.

Complete the examination answer sheet and learner evaluation found on pages 667-668 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

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Behavioral Objectives 

After reading and studying the article on electrosurgical unit (ESU) burns in pediatric patients undergoing liver resection with saline-enhanced radiofrequency (RF) technology, nurses will be able to

1.discuss the benefits of saline-enhanced (RF) for infants undergoing liver resection,

2.explain the differences between saline-enhanced (RF) and conventional coagulation technologies,

3.discuss the experiment presented in this article that was used to determine best ESU dispersive pad placement for infants and gather data on device impedance, and

4.identify nursing implications that were recognized as a result of the experiment.

The possibility of a patient sustaining an electrosurgical unit (ESU) burn at the site of the return electrode (ie, dispersive pad) or an alternate site has been of concern to perioperative nurses since the technology was introduced in the late 1920s.1 With the development of newer technology and instruments designed to be used at higher currents for longer periods of time, this well-managed problem has resurfaced as a new hazard.

Some newer radiofrequency (RF) ablation procedures involve continuous delivery of high currents. Use of this nonconventional but increasingly common technology opens the door for new problems. This article addresses ESU burns in infants undergoing liver resections using saline-enhanced RF technology.

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The Pediatric Population 

In the pediatric population, preventing blood loss versus managing blood administration can make the difference in an infant's successful recovery from surgery. Current data from the Society for the Advancement of Blood Management demonstrates that administration of blood or blood products can increase operating time, recovery time, costs, and surgical complications.2, 3, 4

Using saline-enhanced RF technology has been proven to reduce blood loss in pediatric patients undergoing liver resection, which helps avoid the complications of administering blood or blood products.5, 6, 7, 8 This is especially important for infants who already are compromised by the administration of chemotherapeutic agents needed to treat some liver diseases.

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Saline-Enhanced RF Technology 

Saline-enhanced RF is one of the newer RF systems used for tissue ablation. The technology is highly effective for solid organ resections (eg, liver, lung, spleen).9 The mechanism employs normal saline as a conductive fluid and RF energy to seal tissue. This provides pretransection coagulation as opposed to coagulation during transection.

Saline-enhanced RF energy is conducted through an electrode that is continuously irrigated with saline. The saline helps conduct electrical energy to tissue and also cools the tissue so that the tissue temperature does not rise to higher than the boiling point of water (100° C [212° F]), thus preventing smoking and formation of eschar (ie, a scab of dead tissue covering a thermal burn). The electrical energy heats the tissue; boiling is seen at the surface because the tissue has become hot enough to boil some of the saline. Saline-enhanced RF technology does not heat tissue by heating saline. Conventional ESU devices have no saline cooling, and very high tissue temperatures result in burning and eschar formation. By eliminating smoke and eschar formation, visibility is greatly improved.9

During tumor resection, the saline-enhanced RF device may be used continuously for up to 30 minutes; whereas typical electrosurgery is used intermittently. Due to the higher power and lower resistance, a saline-enhanced RF-monopolar device results in a higher electrical current being generated for a longer period of time. This makes it more likely that higher skin temperatures will occur near the edges of the ESU dispersive pad.10 Return electrode monitors provide a method to monitor and prevent ESU burns caused by a decreased contact area at the dispersive pad site.11 Return electrode monitors do not prevent the burns caused by saline-enhanced RF technology because these burns are caused by higher pad temperatures rather than inadequate contact of the dispersive pad with the patient's skin.11

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Technology Improvements 

In past decades, improvements in treatment and technology have increased the survival rate of infants with malignant liver tumors. Although patients with stage IV disease fare poorly, oncology patients at Children's Hospital of Central California (CHCC), Madera, Calif, who have tumors excised initially (ie, stage I and stage II) have a 90% chance of disease-free survival after four courses of adjuvant chemotherapy. Patients who have advanced disease (ie, stage III) undergo chemotherapy before surgery, resulting in a survival rate of 80%.12

SIDEBAR
Types of Coagulation Technology Currently Available

Argon beam coagulation: Incorporates an inert and noncombustible gas to create a bridge between an electrode and tissue; this noncontact coagulation is used in open surgical procedures.1

Collagen-elastin fusion vessel sealing: Employs a controlled response to determine tissue impedance while delivering the exact energy required to seal vessels and tissue bundles up to 7 mm; used in open and laparoscopic procedures.2

Electrosurgery: Uses alternating current with different electrical waveforms to vaporize (ie, cut) tissue or create a proximal thrombus (ie, coagulate); used primarily in small vessel hemostasis.3

Saline-enhanced radiofrequency (RF): Combines a conductive fluid (eg, normal saline) infused at the point of tissue contact with RF energy to seal tissue; used primarily in solid organ surgery (eg, liver, spleen, lung).4

Ultrasonic scalpel: Creates heat by using friction (ie, vibration) to cauterize 2-mm to 3-mm vessels; used in open or laparoscopic procedures.5

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References 

  1. Moffitt TP , et al.   “Mechanical properties of repaired liver using an argon beam coagulator with albumin,” . SPIE Proceedings on Lasers in Surgery . 2002;4609:178–185
  2. “The science of vessel sealing technology,” Ligasure . http://www.ligasure.com/pages/intro.htm (accessed 24 Jan 2006)
  3. “Principles of electrosurgery—Electrocautery,” Valley Lab . http://www.valleylab.com/education/poes/poes_02.html (accessed 24 Jan 2006)
  4. “Surgical specialties—Surgical oncology,” TissueLink . http://www.tissuelink.com/surg_spec/index.htm (accessed 24 Jan 2006)
  5. “Harmonic Scalpel—Technology overview,” Johnson & Johnson Gateway . http://www.jnjgateway.com/home.jhtml?loc=USENG&page=viewContent&contentId=09008b9880a2d37a&parentId=09008b9880a2d37a (accessed 24 Jan 2006)

Pediatric surgeons at CHCC have performed more than eight hepatoblastoma resections in the past three years. Four of the resections were performed with an ultrasonic scalpel in conjunction with an argon beam coagulator. The average blood loss was between 250 mL and 400 mL. All four patients required blood and blood product transfusions. The remaining four resections were performed using saline-enhanced RF energy; these four patients experienced blood loss of less than 150 mL each. Only one patient in this second group required a transfusion. Complications, although rare, have occurred in the form of ESU burns.12

Infants undergoing liver resection have undergone chemotherapy, which often compromises their immune system. These patients require special handling in the OR. Perioperative nurses are cognizant of positioning requirements, core warming needs, and ESU dispersive pad placement. In spite of receiving conscientious care, three patients experienced minor ESU burns. The burns all occurred during use of the saline-enhanced RF device. Each burn was approximately 2 cm to 2.5 cm in diameter and presented postoperatively in the form of a seconddegree burn.

The ESU dispersive pads were placed on the posterior portion of each patient's thigh. The burns presented on the adhesive portion of the pad at the corner, closest to the surgical site, not on the gel area. Two different brands of ESU generators were involved, although the ESUs are not believed to be a factor in these burns.12 The burns were identified in the OR or postanesthesia care unit by perioperative nurses who noted a small, dime-size blister. The burns were confirmed by the surgeon and reported to the risk manager and performance improvement (PI) committee.

Although the surgeons noted that the benefits of using saline-enhanced RF technology far outweighed the potential for a second-degree burn (eg, blister), patient safety initiatives dictated that a root cause analysis be performed and options be explored to prevent future problems. The hospital risk manager filed a report with the US Food and Drug Administration Medical Device Reporting Agency and the perioperative director notified the manufacturer of the saline-enhanced RF device. A manufacturer's representative responded that the manufacture wanted to identify, resolve, and prevent future problems.

The patients' cases were reviewed jointly by the perioperative medical director, director of perioperative services, and members of the PI committee. The infants who experienced burns were between the ages of nine and 11 months. Electrosurgical unit dispersive pads were all the same size and placed on the same area of the patients' thighs. The burns were identical and in exactly the same locations. Patient positioning and the use of a water-warming device were consistent. The working hypothesis was that the heat at the anterior point of the pad had reached temperatures in excess of 45° C (113° F), at which point skin burns occurred. The corner of the pad closest to the surgical site provided the pathway because electricity travels to the area of least resistance, hence a burn resulted. The hypothesis now needed to be tested.

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Animal Experiment 

To resolve concerns regarding the burns, the manufacturer of the saline-enhanced RF device invited the surgeon and interim director of perioperative services at CHCC to the laboratory at Dartmouth-Hitchcock Medical Center in Lebanon, NH, to recreate the conditions that caused the ESU dispersive burn. Piglets were chosen as the surgical subjects because piglet livers and skin are very similar to those of infants in size and texture. The engineer of the device, the surgeon, and the perioperative director conducted the experiment. National guidelines for use of laboratory animals were followed.13, 14, 15, 16 The piglets were treated ethically; care was taken to minimize their pain, provide appropriate anesthesia, and prevent anxiety with careful and gentle handling. The goals of the project were to

•determine the best pad placement, and

•gather data on device impedance (ie, resistance to the passage of electrical current through tissue) and the effect of current on very small, delicate livers.

Three piglets weighing 11,12, and 13.4 lbs were selected because they approximated the size of the patients who were burned. Liver resections similar to a right trisegmentectomy were performed on each piglet using techniques similar to those used on the infants. In all cases, tiny probes were strategically placed to measure the temperature under the adhesive portion of the pad. A saline-enhanced RF dissecting sealer was used at 70 watts. The following scenarios were created.

•Piglet 1 (Figure 1)
•The ESU dispersive pad was placed on the piglet's lower center back.

•The piglet was not placed on a water-warming pad.

•The piglet's body temperature dropped from 33.3° C to 31.7° C (92° F to 89° F) in a period of 39 minutes.

•The temperature of the probes did not exceed 35° C (96° F).


•Piglet 2 (Figure 2)
•The ESU dispersive pad was wrapped around the piglet's leg to simulate wrapping the pad around an infant's thigh.

•The piglet was not placed on a water-warming pad. The piglet's body temperature and surgery time were similar to those of piglet 1.

•The temperature of the probe in the corner of the pad closest to the surgical site registered a temperature of 45° C (113° F).


•Piglet 3 (Figure 3)
•The ESU dispersive pad was placed on the piglet's lower center back.

•The piglet was placed on a water-warming pad and bolsters were used to keep as much of the warming device against the ESU dispersive pad as possible.

•The piglet's body temperature increased from 34.4° C to 35° C (94° F to 96° F) in a similar period of time to the piglets in scenarios 1 and 2 (ie, 39 minutes).

  • View full-size image.
  • Figure 3. 

    Piglet 3—the electrosurgical unit (ESU) dispersive pad was placed on the piglet's lower center back. Bolsters were used to keep a water-warming pad against the ESU dispersive pad.


With the exception of the anterior point of the ESU dispersive pad on piglet 2, which measured temperatures high enough to cause a skin burn, all temperatures were lower than 40° C (104° F).

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Results of the Experiment 

Piglets 1 and 3 did not sustain a burn; however, piglet 2 presented with the same blister the infants had experienced. The blister was located under the anterior point of the pad where impedance had been created. Enough impedance can cause heat; enough heat can and did result in a burn.

Placing the ESU pad on the piglet's back without a water-warming pad resulted in the lowest increase in skin temperature under the edges of the pad. Placing the ESU pad around the limb resulted in a second-degree burn and a maximum skin temperature of 45° C (113° F).

When saline-enhanced RF monopolar devices are used to perform liver resections on infants, the ESU dispersive pad should be placed on the patient's lower back and not around his or her thigh. A water-warming pad may be safe to use, but forced hot air should not be used until additional testing has deemed it a safe practice. Although piglet 3 was placed on a water-warming pad at the time of resection, the recommendation for infants undergoing this procedure is not to activate any warming device until the resection portion of the procedure is completed.

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Nursing Implications 

An ESU burn occurs at temperatures greater than 45° C (113° F). Electrical current follows a pathway at the point of the pad closest to the surgical site where impedance the highest. Warming the patient and the ESU dispersive pad may increase the potential for a burn by increasing the temperature of the dispersive pad.9 Following are general considerations for solid organ resections using saline-enhanced RF technology.

•The patient's skin should be clean and dry before dispersive pad placement.

•The ESU dispersive pad should be applied so that it is smooth and does not buckle.

•The ESU dispersive pad should be placed centrally on the patient's lower back, not on his or her thigh.

•A warming device may be placed preoperatively but should not be activated until after the organ resection portion of the procedure has been completed.

•Care should be taken to avoid pooling of fluid (eg, prep solutions, irrigation fluids).

•The ESU dispersive pad should be removed slowly and carefully, and any skin redness or breaks should be noted.

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Vigilance is Crucial 

It is imperative for perioperative nurses to recognize that ESU burns can occur in infants, even when generators equipped with return-electrode monitor systems are used.17 Vigilance is crucial during use of newer, nonconventional RF technology. Burns that occur from use of saline-enhanced RF devices are preventable if established safety procedures are followed. Facilities that use saline-enhanced RF technology should establish policies, educate staff members, and develop and employ basic competencies. All perioperative health care providers, including surgeons and anesthesia care providers, should be included in the inservice programs.

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Notes 

  1. Shuman IE . “Bipolar versus monopolar electrosurgery: Clinical applications,” . IanShuman.com http://www.ianshuman.com/pdf/biversmono1.pdf (accessed 12 Jan 2006)
  2. Vamvakas EC , Carven JH . “Allogenic blood transfusion, hospital charges, and length of hospitalization: A study of 487 consecutive patients undergoing colorectal cancer resection” . Archives of Pathology & Laboratory Medicine . February 1998;122:145–151
  3. Herbert PC , et al.   “A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care” . The New England Journal of Medicine . Feb 11, 1998;340:409–417
  4. Carson JL , et al.   “Perioperative blood transfusion and postoperative mortality” . JAMA . Jan 21, 1998;279:199–205
  5. McClurken ME , et al.   “Pre-clinical study # 204; Histological characteristics of the Tissue Link Medical's FB3.0™ floating ball coagulation on porcine liver,” TissueLink . http://www.tissuelink.com/pdf/WP204_B.pdf (accessed 11 Jan 2006)
  6. Capussott L , Polastri R . “Operative risks of major hepatic resections” . Hepatogastroenterology . January/February 1998;45:184–190
  7. Iwatsuki S , Starzl TE . “Personal experience with 411 hepatic resections” . Annals of Surgery . October 1998;208:421–434
  8. Sandblom P , Mirkovitch V , Gardiol D . “The healing of liver wounds” . Annals of Surgery . June 1976;183:679–684
  9. “Surgical specialties—Surgical oncology,” Tissue Link . http://www.tissuelink.com/surg_spec/index.htm (accessed 24 Jan 2006)
  10. M McClurken, et al., “Electrosurgical burns in pediatric patients undergoing liver resections,” presentation at the Children's Hospital of Central California Forum for Operating Room Directors, Madera, Calif, 7 Oct 2005
  11. “Patient return electrode monitoring technology,” Valleylab . http://www.valleylab.com/education/poes/poes_19.htm (accessed 12 Jan 2006)
  12. David Hodge, personal communication with the author, Fresno, Calif, 15 July 2005
  13. “Public Law 89-544 Act of August 24, 1966,” US Department of Agriculture . http://www.nal.usda.gov/awic/legislat/pl89544tm (accessed 24 Jan 2005)
  14. “Guide for the care and use of laboratory animals (1996),” Institute for Laboratory Animal Research . http://www.nap.edu/books/0309053773/html/index.html (accessed 24 Jan 2006)
  15. Public Health Service Policy on Humane Care and Use of Laboratory Animals,” National Institutes of Health . http://grants.nih.gov/grants/olaw/references/phspol.htm (accessed 24 Jan 2006)
  16. “US government principles for the utilization and care of vertebrate animals used in testing, research and training,” Office of Animal Care and Use . http://oacu.od.nih.gov/regs/USGovtPrncpl.htm (accessed 24 Jan 2006)
  17. “Principles of electrosurgery—Electrocautery,” Valley Lab . http://www.valleylab.com/education/poes/poes_02.html (accessed 24 Jan 2006)

 This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.A minimum score of 70% on the multiple-choice examination is necessary to earn 1.6 contact hours for this independent study.Purpose/Goal: To educate perioperative nurses about safe use of saline-enhanced radio-frequency technology for pediatric patients undergoing liver resection.

PII: S0001-2092(06)60193-2

doi:10.1016/S0001-2092(06)60193-2

AORN Journal
Volume 83, Issue 3 , Pages 657-664, March 2006

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