How do you safely use electrocautery (electrosurgical unit) near a deep brain stimulator?

Management of Electrocautery in Patients with Deep Brain Stimulators

Turn off the deep brain stimulator before surgery, use bipolar electrocautery whenever possible, and if monopolar cautery is necessary, position the grounding pad to avoid current pathways through the DBS system while using short, intermittent bursts at minimum power settings. 1, 2, 3

Preoperative Preparation

Device Management

• Turn off the DBS device before the procedure begins to eliminate the risk of current transmission through the stimulator leads causing brain tissue heating or patient discomfort 2, 3
• Interrogate the device preoperatively to document baseline settings and ensure proper function 1
• Have the device programmer or manufacturer contact information immediately available 1
• Obtain written informed consent after discussing potential complications including device malfunction, brain tissue damage from electrode heating, and the sensation of electrical shocks 2

Equipment and Monitoring Setup

• Ensure temporary external monitoring equipment is available throughout the procedure 1
• Have cardiac monitoring in place from the time of device reprogramming until procedure completion 1
• Consider using alternative hemostasis methods such as battery-operated handheld electrocautery devices, which generate less electromagnetic interference 4

Intraoperative Electrocautery Technique

Primary Recommendation: Bipolar Electrocautery

• Strongly prefer bipolar electrocautery systems over monopolar, as they confine current flow between the two tips of the forceps and produce minimal electromagnetic interference 1, 2
• Bipolar cautery eliminates the risk of current traveling through the DBS leads to the brain 2
• Patient reports in the literature demonstrate complete absence of discomfort with bipolar cautery compared to immediate lancinating "electrical shock" sensations with monopolar devices 2

If Monopolar Cautery Must Be Used

Grounding Pad Positioning (Critical)

• Position the electrosurgical grounding plate so the current pathway does NOT pass through or near the DBS pulse generator or leads 1, 5
• For head and neck procedures, place the grounding pad on the superior posterior aspect of the shoulder contralateral to the generator position rather than the standard thigh placement 1
• The goal is to create a current path that avoids the entire DBS system 1

Power and Technique Modifications

• Use the absolute minimum power settings necessary for hemostasis 1, 5, 3
• Apply only short, intermittent, and irregular bursts rather than continuous activation 1, 5
• Maintain maximum possible distance between the cautery tip and the pulse generator or leads 1
• Avoid proximity of the cautery's electrical field to any component of the DBS system 1

Alternative Hemostasis Methods

• Consider ultrasonic (harmonic) scalpel as an alternative to traditional electrocautery, which produces no electrical current and therefore no electromagnetic interference 1, 5
• Battery-operated heat-generating handheld electrocautery devices produce minimal electromagnetic interference and have been used successfully in DBS patients 4

Postoperative Management

Immediate Device Reactivation

• Turn the DBS back on immediately after surgery completion to restore therapeutic benefit 3
• Re-interrogate the device to confirm proper function and verify settings have not changed 1
• Document any changes in device parameters 1

Monitoring for Complications

• Assess for signs of electrode heating injury, which may manifest as elevated pacing or sensing thresholds in the days following surgery 1
• Monitor for device malfunction including reprogramming, inhibition, or noise reversion mode 1
• Evaluate patient for any new neurological symptoms that could indicate brain tissue damage from electrode heating 2

Critical Pitfalls to Avoid

• Never use monopolar electrocautery with the DBS turned on, as this creates immediate risk of painful electrical sensations and potential brain tissue damage from current transmission through the leads 2
• Never position grounding pads in standard locations without considering the DBS current pathway, as this is the most common cause of electromagnetic interference complications 1
• Never use continuous or high-power cautery settings when any electrosurgical device is necessary near a DBS system 1, 5
• Never proceed without having device programming capability immediately available, as emergency reprogramming may be necessary if malfunction occurs 1

Special Considerations

Risk Stratification

• The risks are similar to those seen with cardiac rhythm management devices, including device reprogramming, inhibition, local electrode heating causing myocardial (or in this case, brain tissue) damage, and noise reversion mode 1
• Hardware complications with DBS systems occur in approximately 5% of cases at high-volume centers, though most are related to migration, fracture, or infection rather than electromagnetic interference 6

When DBS Cannot Be Turned Off

• If the patient is highly dependent on continuous DBS therapy and turning it off is not feasible, bipolar cautery becomes absolutely mandatory 2
• Optimize grounding pad positioning even more carefully 1
• Consider postponing elective procedures until device management can be optimized 1