HAZARDS:-
- The use of surgical diathermy poses some danger to the patient on the one hand and the surgeon and the entire operating team on the other. It is important thatsurgeons and operating theatre staff are not only familiar with the hazards they are often exposed to daily innhandling and using diathermy appliances, but shouldnalso ensure and create a conscious effort at avertingnthese hazards. These hazards include;
a)Burn injury: The patient is at risk of sustaining three type of burn injury.
(a) Diathermy (thermoelectric) burns -this may occur in several ways; application of diathermy too close to the skin, the return of earthed current to stray 12 contact points on the operating table , inadequate application of the plate (indifferent) electrode so that 13, 14 it makes too small an area of contact, break in the cable connecting the indifferent electrode to the machine such that the current is earthed through the body; burns could occur at any of these points of14 15 contact. Most importantly, an inadvertent activation of the circuit while doing other things sothat the active electrode possibly resting near the 15,16 patient's skin could cause burns.
(b) Burns on the skin or cavities (e.g. umbilicus, vagina) may occur from the use of inflammable antiseptic , 6, 12 solutions such as alcohol especially if diathermy is used before the antiseptic dries out.
(c) Burn injury can also be sustained by the surgeon or5 any member of the operating team as a result of not17 only wrong handling of the but also from the steam and hot particulate matter generated in the 18 field of surgery. Table 1 Sources of burns injury when using diathermy
1. Diathermy burns :Application of diathermy too close to skin Return of current earth to stray contact point nadequate application of plate electrode Break in the cable connecting indifferent electrode Inadvertent activation of the active electrode
2. Inflammable antiseptic solutions (e.g. alcohol) Skin Umbilical cavity Vagina
3. From the field of surgery Steam Hot particulates
b)Explosion: This could occur commonly from two sources (though it is a remote risk now that highly flammable gases are rarely used in open circuits);
(a) During use of flammable volatile anaesthetic gases such as ether (in exceptional cases where ether is the anaesthetist's choice),and cyclopropane.
(b) In surgery involving hollow gastrointestinal viscera, if mannitol is used for bowel preparation or when there is intestinal obstruction; production of hydrogen (H ) 2 and methane from metabolism of carbohydrate in the 5, 18, 19 diet and bacterial action respectively can occur and the accumulated gases may reach sufficient explosive concentrations.
c)Channeling effect: If the organ to which diathermy is being applied has attachment or pedicle to the body narrower than the diameter of the organ concerned, then the passage of the current through a pedunculated part will concentrate its intensity so that coagulation at the narrowest point may occur ( fig; 4). The current will pass with greatest intensity where there is the highestnconcentration of electrolytic solution and this can very well be the blood vessel supplying the organ which may go into 20, 21 spasm and thrombose, resulting in ischaemia. This commonly occurs, if unipolar diathermy is used during 20, 21 procedures on organs such as penis, digits and testis. Several disasters have occurred from the use of 19-21 diathermy in circumcision.
d)Wound infection and poor wound healing: Excessive use of diathermy may lead to the formation of excessive necrotic tissue which will subsequently act as a good culture medium for the proliferation of bacteria. Also, many vessels coagulated during this procedure have been shown to cause extensive tissue ischaemia, so much so that wound healing may be delayed. This 5 may occasionally lead to wound dehiscence.
e)Secondary haemorrhage: Patients are at risk of developing secondary haemorrhage when the necrosed vessel wall sloughs off later. The bleeding may be torrential enough to threaten the patient's life, especially if moderate to large vessels are involved.
f)Perforation of hollow viscera: The use of diathermy in hollow viscera as in endoscopic surgery is expanding 3, 5, 6, 23 rapidly. Diathermy is commonly used to fulgurate intraluminal and pedunculated growths in hollow 23 viscera. During this procedure, it may be difficult to control the depth of the tissue necrosis. Hence, the risk of extensive tissue necrosis with perforation of hollow viscera may be high.
g)Electrocution: This is another common hazard that patients, surgeon and other members of the operating team are exposed to. It is usually due to faulty 5, 6, connections accompanied with electric current leak. 14, 24
Arrhythmias:.
PREVENTION AND CONTROLOF HAZARDS
- Surgical diathermy machine should be properly 5, 6, 15 connected with the indifferent electrode properly placed and adequate contact ensured particularly if unipolar diathermy is intended to be used. Its function should be tested before application during 5, 6
operation.
- The surgeon should be the only person to activate and control the diathermy and the active electrode often 3, 5, 6, 15 placed in a quiver when not in use.
- Surgical diathermy should never be used until “prep” solution has had time to evaporate and any pool such as in the umbilicus or in the vagina must be thoroughly 5, 6 mopped up .
- Flammable gases should not be used in patients where diathermy is intended to be used and the old habit of consulting the anaesthetist before switching the 5, 6 diathermy machine should not be discarded. Hazards of Surgical Diathermy, Makama J. G. Ameh E. A.
Nigerian Journal of Medicine, Vol. 16, No. 4, October- December 2007299
- Infusion of carbon dioxide through a scope during gastrointestinal endoscopy has been shown to discourage combustion. Avoidance of mannitol and oral antibiotics during bowel preparation if diathermy is intended to be used for the patient should be borne in mind.
- Use of diathermy should be avoided in operations that will involve the body appendages/end organs and if it must be used the adequate and proper contact with the rest of the body during surgery will go a long way to prevent 5, 20, 21 channeling effect.
- Large vessels should be ligated and patients with cardiac pace makers should be seen and reviewed by the 5, 6 cardiologists. Also, use of unipolar diathermy should be avoided in these patients as much as possible.
a)Theatre scavenging system: Operating room scavenging system if properly designed is meant to filter 8 and evacuate aerosol and air contaminants and introduce fresh air in a gentle laminar flow pattern. Where this is not very effective, air contaminants and other aerosols would abound in the theatre and thereforeincrease the risk of inhaling them.
b)Use of face mask: The protection obtained by wearing of facial masks only concerns large particles. The American conference of government hygienists, international standard organization, the comite Euro peer de ormalization, have defined respirable aerosol as containing particles of 4.5um or smaller. Hence, airborne particles may not be effectively filtered by facial mask.
c)Use of suction device: Simply holding a suction device 8 close to the diathermy probe, have been shown to reduce significantly the amount of smoke that the patient, the urgeon and the operating team are exposed to. However, this is not a satisfactory long term solution as it
requires an experienced assistant so that the surgeons' view is not impeded.
d)Government policy: The need to enforce government policy where they exist and to enact laws where they don't exist, on the control of airborne contaminants especially during surgical procedures can not be over emphasized. Issues like this have been addressed in many countries. For instance, in 1994 the Australian standard addressing the issue of airborne contaminant in workplace was published (and updated 1998) outlining the need to confine and contain contaminants generated by diathermy during surgical procedures. In UK, the updated control of substances hazardous to 7, health (COSHH) regulation came into force in November 2002. All these and many other recommended efforts should be directed towards the controlled removal of surgical plume
e)Use of diathermy plume extraction system: The use of diathermy plume extraction system like the lina grey TM TM shark , EMT Health care and clearflow have resulted in significant reduction of smoke reaching the surgeon's 8 TM mask. Clearflow particularly have been noted to clear
more than 99.9% particles down to 0.02um thus ensuring that hazardous products are not carried into the environment . It is easy to set up, simple to operate and the pencil thickness was the same as that of a standard instrument making it comfortable in the hands. Clearing the plume improves vision in the operative field and noticeable reduction in the characteristic diathermysmell.
CONCLUSION
Potential risk to the patient, surgeon and the operating team of continuous exposure to electrocautery 5,8 appliances have been documented. It should be emphasized that estimated level of exposure of the patient, surgeon and the operating team in the course of the surgical procedure have not been determined. Optimizing health and safety in work place should be an 3, 5, 6 ongoing goal in most institutions. Nevertheless, in view of the importance and the wide spread use of electrocautery, further studies would appear to be necessary to determine the extent of exposure of all operating room personnel and if necessary, to develop and enhance methods to reduce risk to health.