Question about jewelry and ESU

Editorial Team / Admin · Aug 20, 2006

I work in an OR where about 50% of patients have some sort of metal implant, be it a joint or hardware from an ORIF. The only surgeons who use bipolar are our neurosurgeons. I personally have never seen a burn from an ESU on any of these patients. We just make sure that the grounding pad is not overlying the implants.

ortess1971 · Aug 20, 2006

My understanding about possible ESU burns with jewelry is that they are rare, but can happen. In our OR, we have the patients sign a jewelry waiver outlining the possible dangers as well as the fact that the ring may have to be cut off if swelling occurs etc. In this waiver, it acknowledges that the patient was told of the possible problems and it absolves the OR if these problems do occur. In the nurses notes section of our paperwork, I also document any items that went to the OR with the patient(glasses, dentures), I document that these items were transported to PACU with the patient. Always, CYA!

shodobe · Aug 20, 2006

Electric current always follows the path of least resistence and jewelry always has that effect. Jewlery should always be removed unless impossible. I will not remove wedding rings usually because patients seem to still want that connection with their loved ones so I don't push it.I just inform them of the dangers. Most electrocautery is monopolar so a good grounding pad is required. Arcing isn't something you would normally see because the arc has to pass between two metal objects, so if a patient has two rings on next to each other yes it could happen. The best way to answer this is to have your rep from your cautery provider come in and give an inservice on the subject. They love this!

staceyp413 · Aug 24, 2006

All hospitals should have a policy specifically outlining this. I've never seen a burn in person (have seen pics) but I will not bring a person back who refuses to remove the jewelry.

Also, just a trick w/the rings.............slip a silk tie under the ring on the palm side of the finger. Then use the tie and wrap it around the finger and as you move the tie up to the tip of the finger the ring will follow (as you compress the skin around the finger). I've never had this trick fail. The biggest thing is to let the patient know ahead of time that it can be uncomfortable and stop if they tell you it hurts! Try it on yourself first as practice.

What's funny is that now days the jewelry most often refused for removal is the body piercings...............not rings like years prior. The body jewelry response is generally "I'm afraid they will close." I've been trying to get some "plastic," type studs to replace the metal during the surgery.

Charity, RN, APRN · Sep 2, 2006

[bANANA][/bANANA]

What's funny is that now days the jewelry most often refused for removal is the body piercings...............not rings like years prior. The body jewelry response is generally "I'm afraid they will close." I've been trying to get some "plastic," type studs to replace the metal during the surgery.

Try using an angiocath:

http://pediatrics.aappublications.org/cgi/content/full/114/3/e384

elcue · Sep 3, 2006

Shodobe said:

I will not remove wedding rings usually because patients seem to still want that connection with their loved ones so I don't push it.

I am not so much worried about burns, to be honest, as I am about edema during long procedures with lots of IV fluid intake. I have seen wedding rings become virtual tourniquets because of this.

When a patient says the ring has never been off, I respond by explaining about the possible edema and tell them it would break my heart to have to cut that ring off after so many years. I encourage the spouse to wear the ring for the patient while we are in the OR. This usually is well-received. Maintains the connection.

On a more cynical note, keep in mind also that if a patient has no jewelry with them in the OR (and you document this), then there is no chance later on that you will be in a tough situation over the claimed loss of valuables.

chiliwist · Sep 5, 2006

Look for the online education from your ESU company and take that it helped me alot. Taping jewlery will not prevent a burn it might help the ring stay on or the stone won't fall out but..... metal is metal, covered by tape or not. I have had to cut many rings off and have tried using the wrapping technique and on one patient who refused to have her ring cut off when she complained how it was uncomfortable it was , I reminded her that if she was asleep and covered by drapes no one would know that her finger was swellling and the circulation diminished until it was too late. She agreed to have it cut off and somehow got all of the other ones off too. What I have tried to do is talk with the office nurses in our small community to help ducate the patients prior. :paw:

jrbl77, RN · Sep 5, 2006

at the hospital i work at all pts going to surgery must have all jewlry removed prior to going to the or. as floor nurse we are expected to take care of this problem prior to surgery. i have had to cut rings off before and it is always as a last resort. i usually have luck witha pan of ice or cold water- seems to make the finger shrink.

stevierae · Sep 8, 2006

I've been thinking for years that this issue is really a non-issue--a sacred cow-- that should be addressed anew by an electrical engineering expert. Personally, I think we are all going on outdated information that goes back to the very early days of electrocauteries (anybody remember the giant green original Bovie machines that had reusable metal ground plates that you spread a conductive paste on--with reusable Bovie handpieces? I do!)

Nowadays, electrocautery machines are far, far more sophisticated, and the chance of the current returning anywhere BUT directly to the (properly maintained and inspected by biomedical engineering) machine itself is, in my opinion, almost nil. Most cauteries simply will shut down or alarm if there is a problem with placement of the ground pad or something else obstructing the return of the current directly to the machine itself.

Think about it this way: Think of all the metal retractors, particularly the self-retaining ones, such as Bookwalters, utilized in surgery. Do you ever see burns or any other tissue damage at the sites where the Bookwalter blades were attached to the skin? Do you ever see alternate site burns after such surgeries? Do you ever see burns or tissue damage at a site where a Deaver, Richardson or Harrington has been held in place for 30 minutes or more, while extensive cauterization has been going on? I've sure never seen a burn at a ring site.

I've never seen nor heard of one--not in over 30 years. The single ground site burn I've seen was probably 25 years ago, with an old green bovie--circulator put ground pad on after patient was already in lithotomy; under the drapes. Pad "tented" but old machine continued to operate. (I have a feeling she kept increasing the current intraoperatively without examining the ground site or wondering why the settings needed increasing in the first place.)

So why do we worry about earrings and body jewelry? I have a feeling we really do not need to do so----but I'd like to hear it from an electrical or biomedical engineer first.

Incidentally, placing tape around a ring is for security reasons--to ensure that the ring does not fall off or otherwise become misplaced while the patient is under our care. It has no effect on conductivity.

jrbl77, RN · Sep 8, 2006

i am not a surgery nurse, but i do come from the hot bed of malpractice caes. that is one of the reasons i believe that all jewelry has to be removed prior to surgery. decrease any chances of any problems ie increase chances of lawsuits.

stevierae · Sep 8, 2006

Well, as others have stated, we do so because we worry about swelling and subsequent impaired circulation. I, too, like to give the ring/rings in question to a family member to wear. Also, I don't want a ring or earrings lost on my watch, so I just tape them if they're not removed, and document it.

However, I think the potential for burns or shock secondary to wearing earrings, body piercings or wedding bands is pretty much non-existent these days, and really needs to be re-evaluated via some new studies, with input by electrical engineering experts.