Energies in the operating room: understanding them better to adapt care - Actusoins nursing news

The need to dissect, cut and especially coagulate exists, whatever the type of intervention performed in the operating room.During an intervention, the surgeon will therefore use different sources of energy depending on the actions he will have to perform.

What are these different energies, how do they work and what precautions should be taken during the preoperative preparation of the patient depending on their use? Loop Electrode

Energies in the operating room: understanding them better to adapt care - Actusoins nursing news

Electricity is a form of energy produced by a flow of electrons moving inside a conductor.This movement is due to the potential difference between the two ends of this conductor and must take place in a closed circuit so that the electrons slide from atom to atom.This direct current flow results in heat production.Additionally, if resistance to this flow exists, the heat will be greater.It should be noted that electricity always seeks the path offering the least resistance, due to the concept of conductivity (Table 1a) (Table 1b).

The surgeon can modulate his actions by adjusting the voltage, frequency, and power of the current, thus varying the temperature applied to the tissues.It obtains variable effects depending on the temperature reached and the resistance of the tissues, ranging from simple hyperthermia (from 40°) to vaporization (from 300°) (Table 2).

The surgeon therefore has different tools and different types of electrical energy at his disposal to carry out his operating procedures:

“Electrosurgery consists of applying a high frequency electric current to biological tissues with the aim of obtaining a thermal effect usable for medical purposes”, according to the definition of Erbe Elektromedizin (see bibliography).

Most current electric scalpels work on the principle of transforming electricity into heat using an instrument.The patient being a conductor, he is connected to the generating device by two electrodes forming a closed circuit (generator → patient → generator).

Two modes of operation exist in high frequency surgery: monopolar or bipolar.

Monopolar energy is used as first intention regardless of the surgical procedure.The electrical path is defined by:

A generator → an active electrode positioned in the patient (instrument) → the patient's body → a return electrode (plate or neutral electrode) stuck to another location on the patient's body → return to the generator.(Diagram 1)

Current passes through the patient from the active electrode to the neutral electrode, following the path of least resistance, so any conductive instrument that may be used must be properly insulated.

The function of the return plate (neutral electrode) is to allow the current to exit the patient's body in a safe manner and return it to the generator.It is larger than the “active” electrode.It must be positioned so as to be on a large muscular area as close as possible to the operating site in order to prevent the current from passing through the patient's heart or an implanted medical device (pacemaker for example).It must not come into contact with metal or other flammable materials.

During preoperative preparation, the care and operating room teams will ensure that patients do not wear anything likely to conduct electricity in order to avoid burns.(Table 3)

One of the dangers of using monopolar scalpels is the creation of an unintentional electric arc.This is similar to the tree-like electrical discharges emanating from lightning during a storm.It can occur because the current is not concentrated in a restricted area but passes through the patient's body, particularly at high voltages.During laparoscopies, the pneumoperitoneum created is an environment favoring the propagation of current in the form of electric arcs because it is an airy, closed and humid environment.

The effect on the fabric depends on the speed and intensity of heat production.The cut or section will result from the application of a direct current, low voltage and high frequency, quickly producing strong heat.

But the longer the application time, the larger the heat zone, the greater the risk of damage to peripheral tissues.As a result, the sectioning effect is more effective on skin or muscle (tissue having an aqueous component and therefore acting as a significant conductor) than on fat (poorly conductive tissue).

Coagulation will result from a discontinuous current, of high voltage but low frequency producing lower heat.

Monopolar electrodes are reserved for coagulation of small diameter vessels because the blood absorbs heat and prevents the transmission of electrical current to the opposite wall of the vessel.As a result, the wall in contact with the electrode can dry out before the other, puncture and cause bleeding.

Bipolar energy is mainly used for the coagulation of vessels not exceeding 7 mm in diameter.

Integrating the two electrodes in the same instrument, the circuit is represented by: a generator → an active electrode positioned in the patient → the targeted tissue of the patient → a return electrode in the same instrument as the active electrode → return to the generator.(Diagram 2)

The current does not pass through the patient's body but is limited to the tissues located between the two jaws of the instrument, the use of return plate is therefore not necessary.As the heat transfer area is considerably reduced, the risk of damage to peripheral tissues is also limited.

However, the bipolar mode does not allow the sectioning of tissues or vessels (except when using bipolar scissors).

Argon is a stable inert gas, easily ionizable, and therefore a good conductor.Combined with monopolar energy, the diffusion of gas allows the transmission of electricity by electric arcs causing coagulation without direct contact with the tissues avoiding the latter sticking to the instrument and their tearing.It is used mainly for coagulation of diffuse bleeding, superficial devitalization or volume reduction by retraction, in thoracic surgery, dermatosurgery, ophthalmic surgery, etc. (Diagram 3)

Thermofusion or “advanced bipolar” combines bipolar mode and real-time analysis of the tissue concerned.This analysis consists of calculating the energy required for hemostasis of targeted tissues, providing optimization of the bipolar mode and maximum reduction of peripheral tissue damage.

The device chooses the appropriate settings for hemostasis according to the constitution of the tissues, delivers the pulsed energy and continuously monitors the resistance to contact with the return electrode.When the fusion is effective, it automatically stops delivering energy and informs the user with an audible signal.

The combination of the two mechanisms – physical force (pressure of the forceps jaws) and thermal elevation – results in denaturation of the collagen and elastin proteins in the wall.The fusion of the walls obscures the light of the vessels.This effect is stable and permanent.The clot becomes visible.The section can be done safely.

Some thermofusion forceps are equipped with integrated cold blades allowing the section to be carried out without changing instruments, an advantage compared to classic bipolar forceps.

>> READ ALSO - Hemostasis, an incredible mosaic of ordered reactions!>>

Since the creation of electrosurgery, other technologies have come to complete the range of operators in order to make their gestures more and more precise and reduce as much as possible the disadvantages linked to the use of monopolar and bipolar energies (zone of effect on peripheral tissues, risk of patient burns, etc.).Generators transforming electricity into ultrasonic vibrations (Ultracision®, Soniccision®, Sonicbeat®), those converting it into light (LASER) or more recently, those coupling ultrasound and bipolar energy (Thunderbeat®) are part of the new range of technologies available.

Sabrina JACMARD, Operating Room Nurse at the Institut Curie Subscribe for free to the Actusoins newsletter

This article appeared in issue 37 of ActuSoins Magazine (June - July - August 2020).

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• “Ultrasonic scalpels in surgery: state of play in 2015”.Boy Lauriane University Toulouse III Paul Sabatier • “Principles of electrosurgery”.Erbe • “Equipment and principles of electrosurgery”.French-speaking Virtual Medical University 2008-2009 • HAS Santé • “Basic principle of the proper use of electrocoagulation in surgery”.IBODE Corporation

Hemostasis by heat has been known since the Middle Ages.The Arabs used cauteries to stop bleeding.The technique was improved in the 16th century by Ambroise Paré who introduced the use of white-hot iron rods on wounds to cauterize them.From 1875, electrocoagulation was born.An electric current passes through fine loops of wire producing intense heat, allowing contact coagulation.

In 1890, d'Ansonval discovered that a current with an oscillation frequency greater than 100,000 hertz does not produce nerve depolarization and therefore does not cause muscle contractions or painful nerve stimulation when used.This discovery combines heat production and coagulation of targeted tissues.This technology has continued to improve since with the invention of the first high frequency generators by De Forest, Clark, Beer and Bovie (from 1908 to 1928), allowing the use of coagulation current and tissue cutting.The latest developments will allow the creation of “isolated” generators, that is to say not connected to earth, requiring the use of a plate positioned on the patient.They use domestic energy and transform it into current with a frequency between 200 kHz and 3.3 MHz in order to avoid stimulation of nerves and muscles.

Due to the various surgical needs, the usual precautions regarding preparation for surgery apply generally and systematically to all patients going to the operating room:

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Energies in the operating room: understanding them better to adapt care - Actusoins nursing news

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