KEY POINTS

1. All electrical equipment used in the operating room should be grounded (such equipment also contains ungrounded circuits). If the power cord for a piece of equipment has a plug with only two prongs (i.e., no grounding prong to go in the third hole in the outlet), the equipment should not be in the operating room.
2. Patient should not be directly connected to the operating room's electrical ground.
3. When electrosurgery is in use, a grounding pad should be used that connects the patient to the ground connection provided on the electrosurgery machine. The grounding pad should be well gelled and placed in contact with the patient across a large area. The grounding pad should be inspected during long cases and gelled again or replaced if necessary. The electrosurgical ground pad should be placed as near to the operative site as reasonably possible and as far as possible from pacemaker wires and ECG wires.
4. The anesthesiologist should beware if increasing current levels are required for electrosurgery, taking that as a cue to check for faulty connection of the electrosurgical grounding pad. In the case of very wet patients, with or without increasing current levels for electrical surgery, the physician should beware of errant current paths that include the grounding pad and other electrical contacts (e.g., ECG electrodes). An example was saline in a very wet abdominal case that extended beyond the operative site, under the drapes, and connected the grounding pad and some ECG electrodes.
5. If the LIM alarms after someone activates equipment, the anesthesiologist should immediately unplug the piece of equipment that caused the LIM to sound. This piece of equipment has allowed the secondary side of the main isolation transformer to be coupled to the ground. It is also possible that so many items were plugged in simultaneously that their combined capacitance coupled the secondary side to the ground. The anesthesiologist can try various combinations of unplugging one piece of equipment and plugging in another. However, if she or he finds that one piece of equipment causes the LIM to alarm under several combinations, that piece of equipment should be removed from the operating room and examined for an unwanted connection to the ground contact.
6. If possible, a bipolar unit electrocautery unit should be used if the patient has an implanted cardiac pacemaker. A preoperative consultation with a cardiologist having pacemaker expertise should be obtained, and documentation should be provided regarding the type of pacemaker, the appropriate magnets or equipment that should be available in the operating room for immediate use, and the plan of action for different scenarios of pacemaker dysfunction. A plan for pharmacologic treatment of complete heart block should be in place, particularly for pacemaker-dependent patients.
7. All electrical equipment should be tested periodically by experienced personnel; this usually is a clinical bioengineering group associated with the operating rooms. Anesthesiologists should verify that equipment has been maintained properly, that standards of performance have been met, and that the entire electrical environment also meets NFPA standards.^{[21] [51] [52] [53] [54] [55] [56]}
8. When using a pulse oximeter to monitor the oxygen saturation of patients in an MRI magnet, the connection between the oximeter console and the patient must occur through a long fiberoptic cable having no wires or conducting segments.
9. If the cause of an electrical burn or incident is uncertain, the relevant equipment or areas should be secured until experienced biomedical personnel participate in a thorough investigation that may include simulation of patient conditions.^[14]