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The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN
Transcript
Page 1: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

The Art and Science of Electrosurgery and Argon Plasma Coagulation in

Endoscopy

Rhonda Delcampo BSN RN CGRN

Electrosurgical Procedures An Art and Sciencehellip

3

My MotherhellipMy MentorhellipMy Teacher

Disclosureother pertinent facts

4

Employed full-time with ERBE-USA as a Clinical Education Manager Program has been approved as a GI-Specific contact hour program for 10 hours by the American Board for Certification of Gastroenterology Nurses (ABCGN) Separate sign-in evaluation and certificate

Objectives

1 Discuss the basics of electricity and how itrsquos adapted for use in the human body

2 Describe how Electrosurgery is used therapeutically and the variables that affect it

3 Discuss how to provide safe electrosurgical care to patients 4 Describe the basic principles and components of Argon Plasma Coagulation (APC) and how itrsquos applied safely in clinical applications

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 2: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Electrosurgical Procedures An Art and Sciencehellip

3

My MotherhellipMy MentorhellipMy Teacher

Disclosureother pertinent facts

4

Employed full-time with ERBE-USA as a Clinical Education Manager Program has been approved as a GI-Specific contact hour program for 10 hours by the American Board for Certification of Gastroenterology Nurses (ABCGN) Separate sign-in evaluation and certificate

Objectives

1 Discuss the basics of electricity and how itrsquos adapted for use in the human body

2 Describe how Electrosurgery is used therapeutically and the variables that affect it

3 Discuss how to provide safe electrosurgical care to patients 4 Describe the basic principles and components of Argon Plasma Coagulation (APC) and how itrsquos applied safely in clinical applications

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 3: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

3

My MotherhellipMy MentorhellipMy Teacher

Disclosureother pertinent facts

4

Employed full-time with ERBE-USA as a Clinical Education Manager Program has been approved as a GI-Specific contact hour program for 10 hours by the American Board for Certification of Gastroenterology Nurses (ABCGN) Separate sign-in evaluation and certificate

Objectives

1 Discuss the basics of electricity and how itrsquos adapted for use in the human body

2 Describe how Electrosurgery is used therapeutically and the variables that affect it

3 Discuss how to provide safe electrosurgical care to patients 4 Describe the basic principles and components of Argon Plasma Coagulation (APC) and how itrsquos applied safely in clinical applications

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 4: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Disclosureother pertinent facts

4

Employed full-time with ERBE-USA as a Clinical Education Manager Program has been approved as a GI-Specific contact hour program for 10 hours by the American Board for Certification of Gastroenterology Nurses (ABCGN) Separate sign-in evaluation and certificate

Objectives

1 Discuss the basics of electricity and how itrsquos adapted for use in the human body

2 Describe how Electrosurgery is used therapeutically and the variables that affect it

3 Discuss how to provide safe electrosurgical care to patients 4 Describe the basic principles and components of Argon Plasma Coagulation (APC) and how itrsquos applied safely in clinical applications

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 5: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Objectives

1 Discuss the basics of electricity and how itrsquos adapted for use in the human body

2 Describe how Electrosurgery is used therapeutically and the variables that affect it

3 Discuss how to provide safe electrosurgical care to patients 4 Describe the basic principles and components of Argon Plasma Coagulation (APC) and how itrsquos applied safely in clinical applications

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 6: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

How cauterization all started

Various tools were heated with fire -17th century

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 7: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

History - Hemostasis by cauterization

1848 Galvanocautery

Christian Heinrich Erbe

von Bruns MD

These devices were comprised of a metal wire heated by means of an electrical galvanic (direct) current - used for coagulation and separation of biological tissue and was referred to as galvanocautery

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 8: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

History of Electrosurgery

In 1978 Dr Glover published an article on the use of thermal knives in comparison to other modalities and stated ldquoThere is no group of instruments in the surgical armamentarium that is used as frequently and understood as poorly as Electrosurgery unitshelliprdquo

1923 Electrosurgical Unit (ESU) in

Europe

Christian Otto Erbe

1926 Electrosurgical Unit in the

US

William T Bovie PhD

Harvey Cushing MD

1971 ldquoplasma scalpelrdquo for

surgery

JL Glover MD

1991 APC probes for flexible

endoscopy

ERBE GmbH

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 9: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

We are educatedhellipbuthellip

50

21

10

19

None 12 to 1 Day

1+ Day

lt 1 Hour

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 10: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Chart1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
021
01
019
05
Page 11: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet1

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
21 10 19 50
Page 12: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet1

None
12 to 1 Day
1+ Day
lt 1 Hour
21
10
19
50

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 13: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet2

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 14: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet3

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 15: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Electrocautery vs Electrosurgeryhellip

350 kHz

Direct Current (Electrocautery)

Alternating Current (Electrosurgery)

Electrocautery bull Uses direct current bull Often used inaccurately to describe ldquoElectrosurgeryrdquo bull Current does not enter the patientrsquos body ndash only the heated wire tip comes in contact with tissue Electrosurgery bull Uses High-Frequency Alternating Current (AC) bull The AC Circuit must be completed includes the electrosurgical generator active electrode the patient and return electrode

hellipthere is a difference

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 16: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Using High-Frequency Alternating Current

54-880 MHz

60 Hz 100000 Hz 350000 Hz

ESUrsquos

Therapeutic Effect

550-1550 kHz

Household Neuromuscular stimulation

AM Radio

TV

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 17: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Three variables are always present during electrosurgery

Fundamental Properties of Electricity

bull Current ndash flow of electrons moving through the electrical circuit measured in amps (I) bull Voltage ndash electrical force pushing current

around the circuit through varying degrees of tissue resistance measured I volts (V)

bull Resistance (Impedance) ndash opposition to current flow - literally the tissue being treated which has varying characteristics measured in ohms (R)

The Clinical Circuit is complete when current flows from the ESU to the active electrode to the patient to the pad and back to the ESU

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 18: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Volunteers

13

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 19: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Ohmrsquos Law

Ohmrsquos Law is a set of mathematical formulas used in electronics to calculate an unknown amount of current voltage or resistance

bull Ohmrsquos Law helps to predict how ESUs will interact with tissue

bull The mathematical formula looks like this

(I) Current = (V) Voltage

(R) Resistance

or

V = I X R

German physicist - Georg Simon Ohm

1789 - 1854

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 20: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Adding Power (W) to the Equation

Power is the amount of energy produced over time and is a result of Voltage x Current

W (Power) = (V) Voltage x (I) Current

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 21: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Types of Electrosurgical Generators

bull The voltage remains constant to maintain consistent tissue effect regardless of changes in tissue resistance (muscle fatty tissue)

bull The power (watts) automatically adjusts in response to the tissue impedancecircuit variables

Constant Voltage

bull Watts (power) setting is chosen bull The Watts remain constant bull Voltage varies to maintain Watts bull All tissue is treated with same Wattage

Constant Power

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 22: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Example of CP vs CV

17

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 23: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Monopolar Circuit

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 24: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Bipolar Circuit

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 25: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Basic Principles of

bull Always seeks ground

bull Always seeks the path of least resistance

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 26: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Tissue Impedance

Tissue Impedance Varies with Water Content

Muscle Kidney Eye

Liver Oral Cavity

Gallbladder

Bowel Fat

Mesentary Brain

Scar Tissue Lung Adhesions

Least to Most Resistance

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 27: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Chart1

Muscle Kidney Eye
Liver Oral Cavity
Gallbladder
Bowel Brain Adipose
Scar Tissue Lung Adhesions
Scar Tissue Lung Adhesions
Least to Most Resistance
Bowel Fat
Mesentary Brain
Scar Tissue Lung Adhesions

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
5 10 15 20 25 30
Page 28: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet1

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
5 Muscle Kidney Eye
10 Liver Oral Cavity
15 Gallbladder
20 Bowel Brain Adipose
25 Mesentary
30 Scar Tissue Lung Adhesions
Page 29: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet2

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 30: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Sheet3

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 31: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Pad Placement

bull Well vascularized area bull Shortest circuit possible bull Optimum ndash on flank bull Alternatives ndash Thigh or Arm bull Avoid Buttock placement bull Remove pads carefully to prevent shearing of skin

GI Endoscopy Pad Placement

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 32: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Did You Knowhellip

If the hair on the hand looks like this imagine the hair at the pad placement sitehellip

bull Boney prominences bull Scar tissue ndash including Tattoos bull SkinScars over an implanted metal prosthesis bull Hairy surfaces ndash clip if necessary bull Lotions or oils on skin

The Dispersive Electrode Should NOT Be Placed Over

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 33: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

24

Using the Dispersive Electrode Correctly

Diagonal alignment of the dispersive electrode may result in higher current densities at the corner

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 34: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

25

Using the Dispersive Electrode Correctly

The long side of the dispersive electrode must face the operating field

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 35: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

What is Current Density

bull Current Density is one of the most important elements of electrosurgery

bull Basically current density is the amount of current concentration (intensity of heat generation) at a given area

bull Thermal effect is created at the active electrode

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 36: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Current Density

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 37: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

A Small Polyp hellipor a Larger One

Which one offers more Electrical Impendence

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 38: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

hellipall shapes and sizeshellipmany variables

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 39: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Endoscopy Polypectomy Techniques

Cold Biopsy

Hot Biopsy

Cold Snare

Hot Snare

Saline Assisted Polypectomy

Piecemeal Resection

En bloc Resection

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 40: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Variables Impacting Tissue Effect

Variables Impacting

Tissue Effect

Type of Generator Constant voltage vs

constant power

Type (size) of Electrode

Waveform Cut vs Coag

Physician technique

Pad placement

Patient variables age body type

hydration tissue IEDrsquos etc

Length of activation

Anatomical location

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 41: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Electrosurgical Thermal Effects on Cells

Temperature Tissue Effect

104degF Reversible cellular trauma

120degF Irreversible cellular trauma

158degF Coagulation (Desiccation)

212degF Cutting

392degF Carbonization

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 42: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

33

Cutting bull Voltage quickly raises cell water temperature to the boiling

point bull Cell water turns to steam bull Cell explodes separating from adjoining cells bull Cleavage plane is created = clinical ldquoCUTrdquo Note For cutting to occur a minimum of 200 Vp is required to get a spark

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 43: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

ENDO CUT

bull ENDO CUT is a specialized waveform which involves a fractionated cutting mode with patented spark recognition technology characterized by alternating cutting and coagulation cycles

bull Constant VoltagePower Dosing Technology

bull Yellow Pedal

Akiho H et al Safety Advantage of Endocut Mode over Endoscopic Sphincterotomy for Choledocholelithasis World Journal Gastroenterolgy 2006122086-8

Monkemuller K et al State of the Art Clinical Gastroenterology and Hepatology 20097641-652

Frye L et al Quality of Polyps Resected by Snare Polypectomy Does the Type of Electrosurgical Current Used Matter American Journal of Gastroenterology 20061012123-27

Perini R et al Post sphincterotomy bleeding after microprocessor controlled electrosurgery Gastrointestinal Endoscopy 20056153-7

Hopper A et al Giant laterally spreading tumors of the papilla endoscopic features resection technique and outcome Gastrointest Endosc 201071967-75 Fanning S et al Giant laterally spreading tumors of the duodenum endoscopic resection outcomes limitations and caveats Gastrointest Endosc 201275805-12)

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 44: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Spark Recognition (arc regulation) technology

bull Patented algorithm capable of recognizing microelectric arc production

bull Limits the ldquospark onrdquo time to a few milliseconds depending upon the duration chosen (the higher the duration the longer the spark on up to 12 ms)

bull Rapid spark production with limited lsquoonrsquo time decreases thermal spread

ENDOCUT

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 45: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

36

Coagulation Hemostasis due to shrinking tissue

bull Waveform with spikes of high voltage followed by rest periods

bull This allows the cellular proteins to slowly denature (dehydrate)

bull Coagulation occurs

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 46: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Yellow + Blue IS NOT Green in electrosurgeryhellip

bull COAGULATION (Blue) is completely independent of CUT (Yellow)

bull BLEND-CUT or ENDO CUT is a CUT feature (Always Yellow)

bull Settings on one side do not effect the other

Like a set of rail tracks running into infinityhellip they never meet

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 47: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Argon Plasma Coagulation (APC)

38

APC is a non-contact monopolar application for hemostasis and thermal destruction

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 48: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

bull Nobel gas bull Present in air (asymp 1) bull Non-flammable bull Non-toxic bull Ionizes easily bull Heavier than air

Argon

What is Argon Plasma

bull Ionized electrically conductive gas

bull Ionization by way of high voltages

Plasma

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 49: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Argon-one of the Nobel gases

40

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 50: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

IF A QUEEN PASSES GAS IS IT CONSIDERED A NOBEL GAS

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 51: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

The voltage required for ionization of gas is asymp 4000

volts

Argon gas Argon plasma with arc beam

APC is a monopolar application in which HF electrical energy is transferred to the target tissue using ionized (conductive) argon gas (plasma) without the

electrode coming in contact with the target tissue

Argon Plasma Coagulation - APC

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 52: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Argon Plasma Coagulation offers particular advantages for endoscopic applications as it can be applied en face or tangentially enabling less accessible areas to be easily treated

En face APC

Tangential APC

Argon Plasma Coagulation

Ar

Ionized Argon Gas

Ar Ar

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 53: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

APC Advantages

Argon Plasma Coagulation

bull Non-contact application

bull Smoke is reduced bull Thinner more flexible eschar

bull Widespread areas can be treated

bull Applications can be ndash

bull Axial bull Radial bull Retroflexed bull Circumferential

Non-contact No sticking to delicate tissue

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 54: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

bull Purge probe at least twice before placing in the scope channel

bull Advance the tip of the probe until the first black line is visible on the monitor at this point you can slightly pull the probe back to facilitate scope articulation depth perception and treatment as needed

bull APC probe tip must always remain in the clinicians field of vision

bull Activate only when the tissue being treated is within the field of view

bull Leave the probe stationary ndash move the SCOPE

bull Proximity to tissue 1 - 5 mm

Argon Plasma Coagulation Using APC

Probe tip

First Black Line

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 55: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Argon Plasma Coagulation Application techniques

Static

bull Probe is focused in one single area

bull Thermal penetration will increase over time

bull Carbonization and vaporization can occur with long activations in one area

bull For superficial treatment short activation times of 1-2 seconds are used

Dynamic

bull Probe is moved with paintbrush-like strokes over the target area while observing the target tissue effect

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 56: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Proper Technique

Clinical Video

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 57: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

ERBEVIOTOMMYGUNGAVEmpg

48

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 58: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Argon Plasma Coagulation

APC thermal tissue effect depends on several factors

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 59: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Duration of Activation

bull When the application time over the same area is increased the depth of the tissue being affected will increase

bull The physician should treat with an activation time to correspond with the desired thermal effect and anatomical location

Fig 12 Depth effect depending on the duration of activation with the APC modes in a bovine liver Testing was performed with an ESU (VIOreg 300 D Model)APC (APCtrade 2 Model) System along with an A-type (Straight Fire) APC probe OD 23 mm Also the application was vertical and the probe distance was 5 mm

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 60: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Power Setting or Effect Setting

In general bull Lower output settings ndash

are used for treatment of very small superficial areas or in applications with very thin-walled tissue structures

bull Higher output settings ndash

are used for treatment when devitalization is required or for the reduction of tissue

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 61: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Probe Distance

Probe distance can influence thermal tissue effect based on the mode chosen

ndash FORCED APC ndash PULSED APC

bull Effect 1 bull Effect 2

ndash PRECISE APC

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 62: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Another important factor involving thermal effect is the mode chosenhellip

FORCED

bull Constant beam

bull Areas of Application bull Rapid devitalization

of target tissue bull Hemostasis of acute

bleeding

PULSED EFFECT 1

bull Higher energy output one pulsesecond

bull Areas of Application bull ldquoStaticrdquo applications

used for more focused treatment of smaller superficial areas in need of hemostasis

PULSED EFFECT 2

bull 16 pulsessecond with a lower energy output per pulse

bull Areas of Application bull ldquoDynamicrdquo

applications used for the treatment of diffuse superficial hemostasis

PRECISE

bull Superficial coagulation effect using a low-energy output

bull Areas of Application bull Superficial hemostasis

in thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull When maintaining the probe distance from the tissue is difficult eg enteroscopic intervention due to plasma regulation

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 63: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Modes - PRECISE APC

Eickoff A et al Effectiveness and Safety of PRECISE APC for the Treatment of Bleeding Gastrointestinal Angiodysplasia - a Retrospective Evaluation Z Gastroenterol 2011 49195ndash200

reg

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 64: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Modes - PRECISE APC

Areas of Application

bull Superficial hemostasis

bull Thermosensitive areas andor within thin-walled structures

bull Devitalization and reduction of lesions or tissue remnants that are superficial in nature

bull In situations where maintaining the probe distance from the tissue is difficult eg enteroscopic intervention

Angiodysplasia

PRECISE APC Effect 5

reg

Clinical Video

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 65: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

There are differences bull Diameter bull Length bull Shape of the probersquos outlet

bull Axial direction bull Side fire bull Circumferential

Black rings bull 1cm apart (10mm)

APC Probes

1cm

Connector

Marking rings

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 66: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Applications - APC

bull Radiation Induced Proctopathy bull Watermelon Stomach (GAVE) bull Treatment of Residual Adenomatous Tissue bull Stent Shortening (eg migrated stents) bull Strictures bull Exophytic Benign or Malignant Tumors bull Oozing from Vascular Lesions (eg Angiodysplasias bull Arteriovenous Malformations (AVMs) Telangiectasias)

Gastroenterology Uses reported in Clinical Literature

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 67: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Applications

1 Adenoma of Cecum

3 Adenoma Snared (piecemeal)

2 Adenoma Injected 4 Ablation of Bed with APC

Long term clinical study results show 50 reduction in re-growth of adenomatous polyps after tissue treatment with APC

Brooker J Saunders B et al Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps A randomized trial and recommendations Gastrointestinal Endoscopy 2002 55371-375 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow Up Study Endoscopy 2003

Residual Tumor Ablation

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 68: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

References 1 ldquoThe role of endoscopy in ampullary and duodenal adenomasrdquo Gastrointestinal Endoscopy 2006 Vol 64 No 6 2 Brooker J Treatment with APC reduces recurrence after piecemeal resection of large sessile colonic polyps a randomized trial and

recommendations Gastrointestinal Endoscopy 2002 3 Buyukberber Mehmet APC in the treatment of hemorrhagic radiation proctitis Turk J Gastroenterol 2005 4 Dulai Gareth Treatment of Water Melon Stomach Current Treatment Options in Gastroenterology 2006 5 Eickhoff A et al Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction effectiveness of the new

pulsed APC versus forced APC Endoscopy 2007 39 637-642 Ferreira L et al Post-Sphincterotomy Bleeding Who What When and How American Journal of Gastroenterology 2007

6 Eickhoff A et al Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy Surg Endosc 2007

7 Fujishiro M Safety of Argon Plasma Coagulation for Hemostasis During Endoscopic Mucosal Resection Surg Laparosc Endosc Percutan Tech 2006

8 Fukami N Endoscopic treatment of large sessile and flat colorectal lesions Current Opinions in Gastroenterology 20062254-59 9 Fukatsu H et al Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation especially with regard to postoperative

anatomic factors Surg Endosc 200822717-23 10 Garcia A et al Safety and efficacy of argon plasma coagulator ablation therapy for flat colorectal adenomas Rev Esp Enferm Dig 200496315-

321 11 Herrera S et al The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in

patients admitted for GI hemorrhage Gastrointestinal Endoscopy 2008 12 Horiuchi A et al Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla Clin

Gastroenterol Hepatol 200751113-8 13 Ifadhli A et al Efficacy of argon plasma coagulation compared with topical formalin application for chronic radiation proctopathy Can J

Gastroenterol 200822129-132 14 Kitamura Tadashi Argon plasma coagulation for early gastric cancer technique and outcome Gastrointestinal Endoscopy 2006 15 Kwan V APC in the Management of Symptomatic GI Vascular Lesions American Journal of Gastroenterology 2006 16 Lecleire S et al Bleeding gastric vascular ectasia treated by argon plasma coagulation a comparison between patients with and without

cirrhosis Gastrointestinal Endoscopy 200867

Gastroenterology Uses found in Clinical Literature

Clinical Applications - APC

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 69: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

References 17 Manner H et al Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract

Digestive and Liver Disease 2006 18 Norton I et al A Randomized Trial of Endoscopic Biliary Sphincterotomy Using Pure-Cut Versus Combined Cut and Coagulation Waveforms

Clinical Gastroenterology and Hepatology 2005 31029-1033 19 Norton I et al Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury Gastrointestinal Endoscopy

2002Vol 56 No 1 20 Olmos Jorge APC for prevention of recurrent bleeding from GI angiodysplasias Gastrointestinal Endoscopy 2004 21 Ortner M et al Endoscopic Interventions for Preneoplastic and Neoplastic Lesions Mucosectomy Argon Plasma Coagulation and Photodynamic

Therapy Digestive Diseases 200220 167-172 22 Perini Rafael Post-sphincterotomy bleeding after microprocessor-controlled electrosurgery Gastrointestinal Endoscopy 2005 23 Regula J Argon Plasma Coagulation after Piecemeal Polypectomy of Sessile Colorectal Adenomas Long-Term Follow-Up Study Endoscopy 2003 24 Repici A Endoscopic polypectomy techniques complications and follow-up Tech Coloproctol 2004 8 S283-S290 25 Rerknimitr R Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator Cardio Vascular and Interventional Radiology 2006 26 Ross A Flat and Depressed Neoplasms of the Colon in the Western World American Journal of Gastroenterology 2006 27 Schubert D Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with

diathermy Surg Endosc 2003171579-1582 28 Soctikno R et al Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults JAMA 2008

Vol 299 No 9 29 Vargo John Clinical Applications of APC Gastrointestinal Endoscopy 2004 30 Zlatanic J et al Large sessile colonic adenomas use of argon plasma coagulator to supplement piecemeal snare polypectomy Gastrointestinal

Endoscopy 1999 Vol 49 No 6

Clinical Applications - APC Gastroenterology Uses found in Clinical Literature

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 70: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Applications Pulmonary Uses reported in Clinical Literature

bull Granulation Tissue bull BleedingHemoptysis bull Exophytic Tumors bull Stent Over-growthIn-growth

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 71: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Applications - APC

Pulmonary Uses found in Clinical Literature References

1 Bergler Wolfgang Treatment of recurrent respiratory papillomatosis with argon Plasma coagulation Journal of Laryngology and Otology 1997

2 Bolligner CT et al Therapeutic bronchoscopy with immediate effect laser electrocautery argon plasma coagulation and stents European Respirartory Journal 2006 271258-1271

3 Capaccio P et al Flexible Argon Coagulation Treatment of Obstructive Tracheal Metastatic Melanoma American Journal of Otolarynogology 2002 Vol 23 No 4

4 Crosta C et al Endoscopic argon plasma for palliative treatment of malignant airway obstructions early results in 47 cases Lung Cancer 2001 33 75-80

5 Lee P et al Advances in Bronchoscopy-Therapeutic Bronchoscopy JAPI 2004 Vol 52 6 Morice Roldofo Endobronchial Argon Plasma Coagulation for Treatment of Hemoptysis and Neoplastic Airway

Obstruction Chest 2001 7 Orino K et al Bronchoscopic Treatment with Argon Plasma Coagulation for Recurrent Typical Carcinoids Report of a

Case Anticancer Research 2004 244073-4078 8 Sheski F Endobronchial Electrosurgery Seminars in Respiratory and Critical Care Medicine 2004 Vol 25 No 4 9 Sohrab S Management of Central Airway Obstruction Clinical Lung Cancer 2007 10 Sutedja G Endobronchial Electrocautery and Argon Plasma Coagulation Prog Respir 2000 Vol 30 11 Tremblay A Endobronchial electrocautery and Argon Plasma Coagulation A Practical Approach Can Respir 2004

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 72: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

63

Clinical Safety Considerationshellip

hellipletrsquos discuss further

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 73: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Safety

bull Use the lowest possible output settings as well as the shortest activation times

bull Confirm gas flow (with APC use) and settings prior to activation

bull Continuously monitor for signs of over-distention

bull Brief and repeated aspirations should be routinely performed throughout the procedure

Important Considerations for Endoscopy

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 74: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

APC is a non-contact modality

If an lsquoAxialrsquo Probe probe is too close to the tissue an undesirable thermal effect or

submucosal emphysema may occur

Clinical Safety

Important Considerations for Endoscopy

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 75: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Avoid APC activation in close proximity of metal objects

bull The APC probe should not be activated if the tip is in close proximity to metal objects

bull Unintended thermal injury of the surrounding tissue may occur

bull Metal objects may receive unintentional damage

bull Exceptions - ldquotrimmingrdquo of migrated metal stents

Clinical Safety

Important Considerations for Endoscopy

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 76: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

bull Incomplete Preps or enema-only preps for Flexible Sigmoidoscopy increases

the risk for bowel explosions bull Bowel explosions can occur with ANY

monopolar electrosurgery (eg snare APC hot biopsy) when combined with hydrogen and methane gases in a dirty colon

bull Patients should be fully prepped

The Importance of Bowel Prepshellip

Clinical Safety

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 77: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Quiz Whorsquos has the most gas Hint Not the female

68

122408-073116

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 78: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Safety - Oxygen Management

Combustion requires a heat source fuel and oxygen all components of the fire triangle

bull Conscious Sedation Patient Supplemental nasal cannula O2 at 3 LM or LOWER Mask delivery is considered high risk

bull Intubated Vent Patient FiO2 Concentration should be reduced to 40 or less

bull Activation Activate APC during the patientrsquos exhalation phase or during apnea

Maintain oxygen concentration at safe levels

Preventative Measures to Avoid Combustion

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 79: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Patient Return Electrode Monitoring

bull Introduced in the 1980rsquos

ndash Return Electrode Monitoring (REM)

ndash Aspen Return Monitoring (ARM)

bull Introduced in the early 1990rsquos

ndash Neutral Electrode Safety System (NESSY)

bull Introduced in 2012

ndash Neonatal Monitoring

According to AORN guidelines return-electrode contact quality monitoring (RECQM) should be furnished on general purpose electrosurgical units

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 80: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Dispersive Electrodes

bull According to AORN

bull Dispersive electrode site burns are the most reported electrosurgical injury

bull With improved technology and the use of safety features pad-site burns have decreased from 50 to 100 in the late 1970rsquos to one to two per month in 2007

bull Return electrode quality monitoring must be furnished

bull Dual pads should be used

2013 Perioperative Standards and Recommended Practices AORN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 81: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Dispersive Electrodes

bull MONO Foil or Single pad ndash Performs only completion of the

electrical circuit ndash The current density of the pad

edges is not measured ndash The correct orientation of the

pad is not measured

Mono Pads bypass the pad safety system of generatorshellip

bull DUAL Foil or Split Pad ndash Completes the electrical circuit ndash Disperses the current density ndash Engages the safety system of the

unit to monitor for high current density (and correct orientation with NESSY )

Always recommended

reg

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 82: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Dispersive Electrode Reminders

bull Open the pad only when ready to use

bull Pads cannot be repositioned always replace the pad bull Remove pad SLOWLY to prevent skin shearing bull Always check the pad placement before activation of the ESU

bull Do not ldquotestrdquo instruments on the pad eg snares hot forceps

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 83: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Safety

Navel and genital jewelry can be in the circuit increasing risk of burns

bull ESU Manufacturers and Clinical Guidelines recommend removal of ALL pierced and non-pierced jewelry due to the risk of burn if within the electrical circuit bull Removal helps to

minus Avoid Burns minus Avoid accidental injury minus Lower staff liability

Jewelry Removal

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 84: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Challenge

76

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 85: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Clinical Safety ndash Additional Challenges

Body modifications require special attention for maintenance of the patients skin integrityhellip

Sub-dermal implants Trans-dermal and micro-dermal implants ndash

thin metal posts protruding through skin

Additional risks are posed due to - Patient positioning - Patient transfers - Electrosurgery use and pad placement

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 86: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Implanted Electronic Devices Implanted Electronic Devices (IEDs) are battery operated devices placed within a patientrsquos body to treat a physiological defect or to replace a sensory function bull Cardiac

ndash Pacemakers ndash Internal Cardiac Defibrillators (ICDs) ndash Ventricular Assistive Devices (VADs)

bull Neurostimulators ndash Deep brain stimulators ndash Spinal cord stimulators ndash Vagal nerve stimulators ndash Programmable ventricular shunts

bull Implantable Hearing Devices Cochlear Implants Auditory Brainstem Implant (ABI) Bone-conduction stimulators

bull Implanted Infusion Pumps bull Osteogenic (Bone-growth) Stimulators bull Gastric Electronic Pumps

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 87: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Safety Considerations ndash IEDrsquos Pre-planning is crucialhellip bull Pre-procedure knowledge of IED patients allows time

for adequate planning bull Determine the type and location of the device bull Contact the implanting physician to determine -

bull Last device evaluation bull Any specific pre-oppost-op orders for the device

bull Consider having a policy in place specific to IED patients

bull Utilize anesthesia and manufacturer device-specific guidelines as warranted to assist with establishing facility protocols and guidelines for care of IED patients

bull Contact appropriate device representatives and arrange presence during procedures based on protocols

bull Notify the physician anesthesia and other team members in advance of an IED patient

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 88: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Implanted Electronic Devices

ldquoAORN Guidance Statement Care of the Perioperative Patient With an Implanted Electronic Devicerdquo

AORN offers guidelines for Implanted Electronic Devices

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 89: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

bull Use Bipolar when possible

bull Keep 15 cm between the active electrode and any EKG electrode

bull Have resuscitation equipment at the ready ndash DOCUMENT

bull Have the device clinical support line available

bull Contact the IED manufacturer for specific deactivation recommendations

Electrosurgical Safety for Patients with IEDrsquos

Safety Considerations ndash IEDrsquos

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 90: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Safety Considerations ndash IEDrsquos

If the physician must use Monopolar current bull Apply the dispersive electrode close to the

operative site but as far away from the IED as possible (eg for patients with pacemakersICDrsquos place on the opposite lower extremity to draw current away from the device)

bull Use the lowest settings possible

bull Use the shortest possible activations

bull If the ICD is deactivated re-establish integrity of the device post-procedure

Electrosurgical Safety for Patients with IEDrsquos

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 91: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Summary

bull The ldquoartrdquo of therapeutically utilizing high-frequency (HF) electricityelectrosurgery within the hollow lumen of the GI tract requires a fundamental working knowledge of the scientific principles involved in order to optimize clinical outcomes while minimizing risks

bull It is important for the clinician to understand the basic principles and properties of electrosurgery and APC and how itrsquos adapted for clinical use

bull In addition staying well-informed on the current standards and recommended practices for clinical safety eg SGNA and AORN enhances our ability to make critical decisions and to promote optimal patient outcomes

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 92: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

84

Gratitude to my family

122408=073116

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85
Page 93: Electrosurgery and Argon Plasma Coagulation - SCSGNA · PDF fileThe Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN, RN, CGRN

Copyright copy 2016 Erbe USA Inc

Erbe USA Inc 2225 Northwest Pkwy Marietta GA 30067 Tel 800778ERBE wwwerbe-usacom

  • The Art and Science of Electrosurgery and Argon Plasma Coagulation in Endoscopy Rhonda Delcampo BSN RN CGRN
  • Electrosurgical Procedures An Art and Sciencehellip
  • My MotherhellipMy MentorhellipMy Teacher
  • Disclosureother pertinent facts
  • Objectives
  • How cauterization all started
  • Slide Number 7
  • Slide Number 8
  • We are educatedhellipbuthellip
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Volunteers
  • Slide Number 14
  • Adding Power (W) to the Equation
  • Types of Electrosurgical Generators
  • Example of CP vs CV
  • Monopolar Circuit
  • Bipolar Circuit
  • Slide Number 20
  • Tissue Impedance
  • Slide Number 22
  • Did You Knowhellip
  • Slide Number 24
  • Slide Number 25
  • What is Current Density
  • Slide Number 27
  • Slide Number 28
  • hellipall shapes and sizeshellipmany variables
  • Slide Number 30
  • Variables Impacting Tissue Effect
  • Slide Number 32
  • Slide Number 33
  • ENDO CUT
  • ENDOCUT
  • Slide Number 36
  • Yellow + Blue IS NOT Green in electrosurgeryhellip
  • Argon Plasma Coagulation (APC)
  • Slide Number 39
  • Argon-one of the Nobel gases
  • Slide Number 41
  • Slide Number 42
  • Slide Number 43
  • Slide Number 44
  • Slide Number 45
  • Argon Plasma Coagulation
  • Proper Technique
  • ERBEVIOTOMMYGUNGAVEmpg
  • Slide Number 49
  • Slide Number 50
  • Slide Number 51
  • Slide Number 52
  • Another important factor involving thermal effect is the mode chosenhellip
  • Slide Number 54
  • Slide Number 55
  • APC Probes
  • Slide Number 57
  • Clinical Applications
  • Slide Number 59
  • Slide Number 60
  • Slide Number 61
  • Clinical Applications - APC
  • Slide Number 63
  • Clinical Safety
  • Clinical Safety
  • Slide Number 66
  • Slide Number 67
  • Quiz Whorsquos has the most gas Hint Not the female
  • Slide Number 69
  • Slide Number 70
  • Patient Return Electrode Monitoring
  • Slide Number 72
  • Dispersive Electrodes
  • Slide Number 74
  • Slide Number 75
  • Challenge
  • Clinical Safety ndash Additional Challenges
  • Slide Number 78
  • Safety Considerations ndash IEDrsquos
  • Slide Number 80
  • Slide Number 81
  • Safety Considerations ndash IEDrsquos
  • Slide Number 83
  • Gratitude to my family
  • Slide Number 85

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