Tattoos and Electrosurgery

03.02.2022 • Industry News

Michelle Lemmons, RN, BSN, PHN, CNOR, CCSVP
Clinical Educator, OR

As Operating Room nurses and surgical techs, there are many questions that come to mind when you look at this picture of this person covered in tattoos. Where would be the best location to place the dispersive electrode pad also called Patient Return Electrode (PRE) or bovie pad should this person need a surgical procedure requiring a monopolar electrosurgical device? 

While we know the basics of PRE placement: on the same side as the surgical site, as close as possible to the surgical site, on clean, dry, intact skin, we also know that it is best practice not to place the PRE over tattoos. Before we discuss where to place it and how to assess for adverse effects, let’s find out why the Association of Surgical Technologists Standards of Practice for Use of Electrosurgery states, “It is recommended that the PRE not be placed near or over a tattoo.”⁴

Up until about 20 years ago, tattoo ink was highly unregulated and unmonitored by safety organizations such as the Food and Drug Administration (FDA) and many tattoo inks contained trace amounts of heavy metals to give tattoo pigments more depth and character.⁵  While tattoo ink is still unregulated by the FDA, it does go through an approval process and monitors adverse events related to permanent and temporary tattoo ink as these are considered “cosmetics”.^1,3 The metal contained in these inks creates a risk for patient burns in electrosurgery as electrical current applied to the body through the surgical instrument can superheat the tissue and cause a burn on the skin. So how do you know if your patient’s tattoo contains metal? You don’t. It is better to be safe than sorry and relocate the PRE as you are able. 

First, consult with your team pre-procedure. Make sure each member including the surgeon and anesthesia is aware of the considerations related to tattoo placement and PRE placement. Together, discuss the procedure and ideal placement.

Second, follow the best practices for PRE placement according to the Association of Perioperative Nurses (AORN) Guidelines for Electrosurgical Safety.⁶ After the final positioning, the PRE placement should be:

• Close to the surgical site
• On clean, dry skin
• Over a large, well-perfused muscle mass
• On the same side as the surgical site
• Away from metal or monitoring leads between active and dispersive electrodes
• Away from the warming device
• In uniform contact with the patient’s skin

Finally, assess the patient’s skin before, during, and after the procedure at the site of the PRE placement. Document each consideration, intervention, and assessment and the result of the assessment according to your facility policies. Typically this is documented in the intraoperative flowsheet or in a note in a patient’s chart.

With over 145 million Americans that have tattoos and approximately 20% of those have more than one tattoo, there is a high likelihood that you will have to consider PRE placement and tattoos in your operating room. Using the tools in industry guidelines we are able to make PRE placement decisions for whether the patient has a few tattoos or a lot with confidence that we are maintaining the safety of our patients as a top priority. 
 
References:

1. https://www.fda.gov/cosmetics/cosmetics-laws-regulations/fda-authority-over-cosmetics-how-cosmetics-are-not-fda-approved-are-fda-regulated
2. https://www.fda.gov/media/93379/download
3. https://www.karger.com/Article/Fulltext/369231#:~:text=Tattoo%20inks%20have%20been%20classified,regulated%20before%20going%20to%20market.&text=As%20the%20pigments%20used%20in,%2C%20Drug%2C%20and%20Cosmetic%20Act.
4. https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard%20Electrosurgery.pdf
5. https://tattooswizard.com/blog/how-modern-ink-has-made-tattoos-safer
6. AORN Guidelines for Perioperative Practice: Electrosurgical Safety. 2022.