Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are continuing the conversation about anesthesia patient safety and cosmetic enhancements today. Last week on the show, we discussed neurotoxins and peripheral nerve stimulator monitoring (don’t forget this is a good time to make the switch to a quantitative neuromuscular monitor if you have one available!). We also talked about eyelash extensions and oral and facial piercings. This week, we are discussing permanent jewelry and burn risk, nail polish, gel manicures, and pulse oximetry. Plus, we have some ideas for improving communication with patients about non-cosmetic enhancements.
Before we dive into the episode today, we'd like to recognize Merck, a major corporate supporter of APSF. Merck has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Merck - we wouldn't be able to do all that we do without you!"
Our featured article again today is from the February 2024 APSF Newsletter. It is “If Looks Could Kill: Anesthetic Implications of Cosmetic Enhancements” by Melissa Byrne and Danielle Saab. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.
Let’s jump right back into the article. The next cosmetic enhancement is permanent jewelry, and this is particularly concerning when electrosurgery is used which may increase the risk for burn injury. Remember, electrosurgery requires a return plate for the electrosurgical unit and this serves as the low-resistance pathway for energy to return safely to the apparatus. Okay, let’s take a quick time out and move to the other side of the drapes for a review of electrosurgery. Electrosurgery involves high frequency, alternating electric current leading to heating in tissue and ultimately cutting, tissue ablation, desiccation, or a combination. The technique requires an electrosurgical unit or generator, the active electrode, the patient, and the dispersive electrode or grounding pad. A high-frequency electrical current comes from the electrosurgical unit and travels through the active electrode with localized heating at the end for precise cutting and coagulation. The circuit for monopolar electrosurgery involves the current traveling through the active electrode to the tissues at the surgical site and then passes through the patient’s body to the grounding pad or dispersive electrode and then the energy returns to the electrosurgical unit where it started. For bipolar electrosurgery, the current travels from the generator to the active electrode which is the bipolar probe and then the current returns to through the same device. No grounding pad is needed. Did you know that electrocautery and electrosurgery are different things? We often use the terms interchangeably though. Here are the definitions:
· Electrocautery involves an electrical current to heat a metal wire that can be placed on surgical tissue for coagulation. During this process, the current does not pass through the patient’s body.
· Electrosurgery uses a high-frequency electrical current passing through the patient’s tissue to produce heat leading to cutting and coagulation.
For more information, I will include a citation in the show notes for the article, “Electrosurgical units – how they work and how to use them safely.”
Now, let’s return to the article. One of the risks with electrosurgery is if the grounding pad is not firmly adhered to the patient, becomes dislodged, or has dried electrolyte gel. When the grounding pad is not fully functional, there is a risk that patients with jewelry or piercings would be an alternative return pathway leading to a burn injury. We often ask patients to remove their jewelry prior to surgery with electrosurgery. There is likely a low risk for a burn injury, but this has not been studied extensively. The recommendation from the Association of Perioperative Registered Nurses includes the removal of metal piercing between the active electrode, the bovie tip, and the grounding pad. Jewelry removal can ensure that patients are not at risk for a burn injury. What about jewelry that cannot be removed? Has a patient with tape on their jewelry entered an operating room near you recently? There is this idea that taping jewelry can insulate the metal from coming into contact with other electroconductive material and decrease the risk for burns. Unfortunately, this is not the case. The benefit of taping appears to be helping to prevent lost jewelry.
Have you seen a patient with permanent jewelry? This is becoming more popular and involves a custom-fit solid gold or silver bracelet, anklet, or necklace adorned with natural gemstones, diamonds, or gold drops that is welded together and cannot be removed easily. Removal may be accomplished by cutting the chain at the small ring that connects the two ends of the chain. This can be re-welded later. An important consideration is that patients with permanent jewelry should be instructed to remove it as part of the preoperative instructions. If the jewelry is not removed, patients should be advised about the risks of burn injury, edema and a compressive injury, or item damage or dislodgement. Another consideration may be to use bipolar instead of monopolar electrosurgery and to take care to prevent contact between the patient and metal objects. When the patients are in the PACU, all jewelry sites should be checked for injury.
Let’s talk about another cosmetic enhancement that is very common…nail polish and gel manicures and the effects on our ability to monitor patients during anesthesia care with the pulse oximeter. We need to review the pulse oximeter first. This monitor has revolutionized safe anesthesia care. It measures functional oxygen saturation in arterial blood by determining the difference in absorbance at 660nm and 940nm wavelengths. Because of the way the pulse oximeter works, anything that increases the difference in absorbance between the two wavelengths will yield a false desaturation. Spectrophotometric evaluation of green and blue nail polish reveals increased absorbance at 660nm compared to940 nm which results in a false desaturation promoting unnecessary interventions. Gel-based manicures use polymerized acrylate monomers to decrease chipping and scratching. Orange or light-blue gel manicures produce a significant increase in the baseline pulse oximeter reading which may lead to overestimation of the actual oxygen saturation and inability to detect hypoxemia. It is important to instruct patients to remove nail polish or gel manicures prior to surgery as part of the preoperative instructions. When patients present to the operating room with nail polish in place, you may consider using a different monitoring site, such as the ear, or turning the pulse ox probe 90 degrees to avoid the painted nail bed. Check out Figure 1 in the article for a picture of this alternative placement.
We have reviewed several threats to anesthesia patient safety related to non-surgical cosmetic enhancements. Another important consideration is how to improve communication with patients during the preoperative evaluation and informed consent process. This may be a sensitive topic for patients and anesthesia professionals may not be comfortable or knowledge to facilitate the discussion. The goal is to improve communication, decrease patient and physician anxiety, and improve the accuracy and specificity of patient self-reporting. It is important that anesthesia professionals are knowledgeable about the possible implications and patient safety concerns of these cosmetic enhancements. Patients may be anxious about disclosing these procedures if the patient-physician relationship has not been well established or if family members are present. One consideration may be to include information about the potential risks associated with these cosmetic enhancements on the written informed consent or anesthesia information booklet so that patients care read and digest the material privately prior to surgery, perhaps during the preoperative evaluation and not in the preoperative holding area with time-pressured conversations, high noise levels, and minimal privacy.
When you are seeing patients just before surgery and need to gather this important information in order to keep patients safe, it may be necessary to use more direct closed-ended questions such as the following:
“Have you had any recent cosmetic procedures?”
“Do you have any nail polish, jewelry, or metal studs?”
For patients who have had recent procedures, it is important to ask follow-up questions for specific facts about neurotoxins, the location of piercings, and eyelash extensions.
Check out Table 1 in the article for a review of the different non-surgical cosmetic enhancements that we discussed on the show today including neurotoxins, eyelash extensions, oral and facial piercings, permanent jewelry, and nail polish and gel manicures. The table include a description of the procedure, the potential sources of harm, and offers options for risk mitigation. You can even print out this table and keep it in your preoperative evaluation clinic or operating room suite to make sure that all anesthesia professionals are on the same page when it comes to keeping patients with non-cosmetic enhancements safe during anesthesia care.
The authors leave us with a call to action for anesthesia professionals to be aware of and knowledgeable about the implications of non-surgical cosmetic procedures. It is vital to perform a complete and sensitive preoperative assessment, provide information about potential adverse events, and maintain vigilance during the perioperative period to keep patients safe. This is another area where anesthesia professionals can be advocates for anesthesia patient safety.
Before we wrap up for today, we are going to hear from Melissa Byrne again. I also asked her what she hopes to see going forward. Let’s take a listen now.
[Byrne] “As I reflect on this article, it is somewhat encouraging that very few case reports actually exist related to adverse patient safety events. Regrettably, I think the underreported or even unrecognized impact of non-surgical cosmetic enhancements is much more challenging to estimate.
My hope is that this article is a stepping stone to improve patient safety through several avenues. First, by identifying potential risks of the most common non-surgical cosmetic enhancements. Second, to promote meaningful conversations with patients about potential risks. And third, to highlight the importance of vigilance throughout the perioperative environment and our role as patient safety advocates.”
[Bechtel] Thank you so much to Byrne for contributing to the show today and helping to highlight these important anesthesia patient safety considerations as we work to make sure that in the operating room, looks do not kill.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
The Anesthesia Patient Safety Podcast is reaching a huge milestone. Next week, we will release our 200th episode!! Thank you for following along on this journey towards improved anesthesia patient safety. Thank you to everyone who has contributed content to the APSF Newsletter and website. We are looking forward to our next 200 episodes as we continue to bring you the latest in anesthesia patient safety. Thank you so much for listening and sharing this podcast and working hard to keep your patients safe.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
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