While the electrosurgical unit (ESU) is commonly used during surgical procedures, there are precautions that must be addressed to prevent injuries. The ECRI Institute has published two safety reports addressing patient injuries related to poor return electrode site preparation.1,2 Factors that can contribute to electrosurgical burns include poor electrode placement, inadequate site preparation, and defective return electrodes.1,2

Reduce the risk of burns

Preoperative assessment of the patient's skin is the first step in selecting the site for the ESU pad placement. Ensure that metal jewelry, including metallic body piercing jewelry, have been removed. Metal jewelry near the activation site increases the patient's risk of a burn injury.3 The ideal placement of the pad is over a well-perfused, large muscular area close to the surgical site. Avoid scar tissue, hair, and tissue over boney prominences. These areas, along with large amounts of adipose tissue, can impede the flow of the return current resulting in heating of the tissue, arcing, and subsequent burns.4

While no injuries have been reported due to tattoos or metal implants, tattoos could contain metallic dyes, and the metal in implants could superheat tissue, resulting in a burn.3 Avoid placing the ESU pad in an area where liquids could pool, preventing the pad from having adequate contact with the skin.3 Take special precautions if the patient has an implanted pacemaker or defibrillator.3

Inadequate site preparation is noted when the surgeon attempts to activate the hand piece with little or no surgical effect. Poor contact between the ESU pad and patient can result in a burn. The pad should be placed on the patient after final positioning and should be secured around all edges by running a hand over the entire pad to ensure complete contact with the patient's body. If the patient is repositioned during the procedure, the ESU pad should be reexamined.3 Also, the area under the ESU pad needs to be cleaned and hair removal may be necessary. Hair inhibits the pad-to-skin contact and can lead to heating or arcing of the tissue under the electrode resulting in a burn.2

Assessing the pad

The final step to ensure proper use of an ESU pad is to assess the pad itself.

* Is it compatible with the ESU?

* Is it the appropriate size for the patient?

* Is the conductive gel present and still moist?

* What's the expiration date?5

Recommendations for using large, reusable, capacitive-coupling return electrode systems include:

* Following manufacturer's instructions

* Using alternate measures for patients under 25 pounds

* Ensuring adequate contact is achieved

* Avoiding the use of additional linen or padding

* Preventing small metal materials, such as snaps on gowns from contacting the patient's skin.3

If there are any problems noted, a new pad should be placed on the patient before activating the ESU. OR

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