Question regarding bovie settings and tonsillectomy.

[ChrisNZ]

Today in a case which I was running we had a 'near miss incident'.

I was working in an ENT OR for a tonsillectomy. The incident started when a more senior nurse whom was working alongside me turned up the settings on the Bovie from 8 to 30 coag (I'm not sure whether the units we use in my country differ to that of the US). Before plugging in attachments to the ESU generator I always confirm the settings with the surgeon, in this case I did so twice. As the scrub handed the diathermy over she also called the settings to the surgeon, again.

Once the unit was activated the surgeon was very upset that it was put on too high. Luckily, no harm was done to the patient. Our surgeon is also very considerate that I am new to ENT too so debriefed with the team afterwards. We wrote up the incident as a communication breakdown due to non-patient related discussions in the room.

In our debrief our surgeon told us that a coag of 30 for a tonsillectomy could cause the carotid to rupture as the electrical current found it's grounding point.

I was under the impression that in modern ESU units that the return electrodes offered the paths of least resistance due to their conductive properties. My coleagues in the OR nor I, had ever heard this before. I could only imagine it being a risk if the tissue was cut through and actually pierced, particularly seeing as we use higher settings of coag when doing adenoids.

I understand the importance of accurate communication and we have discussed as a team how this incident occurred and how we could prevent it in the future.

Could anyone give me their thoughts on this? I am curious to learn and build upon my knowledge from this experience to improve patient safety and my own practice. I am particularly curious about the risks of having too high of a power setting, particularly for ENT surgery.

[Rose_Queen, BSN, MSN, RN]

Perhaps a review with your unit educator? Your bovie settings are definitely different than the ones we use in my OR- a coag of 8 would be useless and not do much of anything. Our standard settings are 25-40 and some surgeons will go up to 75 in other specialties. There could also be a manufacturer's instruction manual that would be helpful.

[arack05]

Perhaps a review with your unit educator? Your bovie settings are definitely different than the ones we use in my OR- a coag of 8 would be useless and not do much of anything. Our standard settings are 25-40 and some surgeons will go up to 75 in other specialties. There could also be a manufacturer's instruction manual that would be helpful.

Pretty much the same here

I have never seen a surgeon use a coag of 8 on anything. And I dont imagine settings being different for locations because thats weird and wildly dangerous.

I dont do much ENT so I googled this just because it doesnt sound right

And the conclusion I came to is that either the surgeon isnt that bright (which is entirely possible)

Or the most likely scenario. Is that you werent using a bovie/esu (or werent supposed to) and instead were using (or were supposed to) be using a Coblator. Since the Coblator is frequently used in ENT, has both coag + cut, and its settings are often in the single digits.

Im willing to bet that this is almost certainly where the issues occured

[MereSanity]

I was gonna say coblator too.

[Argo]

Bovie for tonsils where I have been is usually 0 cut and 20 to 30 coag.

[fracturenurse]

OK, we always use 30 for T&A's. Most use the coblator, but I'm confused. Are the settings different for you. 8 is so low, how could this even be used in a tonsillectomy?

[MereSanity]

Coblator is usually set lower...setting at 6-9 is normal.

[fracturenurse]

I bet she is talking about the coblator and not the bovie. That makes more sense.

[kinbari08, BSN]

I agree with the those saying the coblator. The settings are always in the single digits.

One of our surgeon's uses the bovie for his T&A's. The bipolar is set at 12 and the coag at 36. Once he starts the adenoids he asks us to turn the coag down to 15.

[BCooper77]

We mostly use a Bovie and a suction Bovie. Settings are generally 25/25.

[sop832]

No matter what you say, or what format is used for timeouts and/or giving information about the case ( bovie settings, tourniquet pressure, Meds on the field, or anything either routine or out of the ordinary, ) my experience is that 97% of surgeons hear, "Whaa, Whaa, Whaa" just like Charlie Brown's teacher. Most surgeons (men and women) do not deem what nurses (men and women) say as important, even if they mouth the platitudes about being a team, blah, blah, blah. I can only count a handful of surgeons that are actually interested in what I say. Since I have a very soft voice, I have had to enlist the scrub nurses' help in not handing the knife until the surgeon acknowledges that I have been heard. Only when I think what is important has been acknowledged, is the case allowed to proceed. The ball is then in their court, and if there is a dispute over what is said, I will have made others aware. And if it comes to an incident report, believe me I will document that. Excuse my tangent, I know that wasn't your question, but this is what I find in the real world.

[sop832]

As I read over what I wrote, I don't mean to imply that you did anything wrong, you and the scrub nurse both confirmed the settings, he just wasn't listening.