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Anesthesia in Anesthesia in Laser SurgeryLaser Surgery
Presenter :Dr.Anoop Presenter :Dr.Anoop kumarkumar
Moderator:Dr.Anand Moderator:Dr.Anand kulkarnikulkarni
TOPICSTOPICS
Physics of Laser Clinical applications Hazards associated Anaesthetic management Prevention of hazards
“Never are cooperation and communication between surgeon and anesthesiologist more important than during head and neck surgery.”
Morgan, Clinical Anesthesiology
Physics of Laser lightPhysics of Laser light
Light Amplification by Stimulated
Emission of Radiation Electromagnetic radiation Einstein:
all electromagnetic radiation consisted of wavelike quanta called photons
→E (J) = h v Wavelength for visible light ranges from
385nm to 760 nm
Physics of Laser light. Physics of Laser light. contd.contd.
Characteristics: Monochromatic (one wavelength)Coherent (oscillates in the same
phase)Collimated (exists as a narrow,
parallel beam) Intense light beams, intense energy
to small target sites
Laser system componentsLaser system components
Laser system componentLaser system componentLIGHT GUIDE
Used as scalpels and Used as scalpels and electrocoagulatorselectrocoagulators
Dermatology, thoracic Dermatology, thoracic surgery, ophthalmology, surgery, ophthalmology, gynaecology, plastic surgery, gynaecology, plastic surgery, ENT, urology and ENT, urology and neurosurgeryneurosurgery
Clinical applications
Laser interaction with tissueLaser interaction with tissue
Used as scalpels and electro coagulators
Precise microsurgery
Relative “dry”
Less damage to adjunct tissue
Less postoperative pain and edema
Common used Laser lightsCommon used Laser lights
Laser mediaLaser media ColorColor Wavelength Wavelength (nm)(nm)
Typical applicationTypical application
Carbon dioxideCarbon dioxide Far infraredFar infrared 10,60010,600 General, cuttingGeneral, cutting
RubyRuby RedRed 694694 Tattoos, neviTattoos, nevi
KTP:YAGKTP:YAG GreenGreen 532532 General, General,
pigmented lesionspigmented lesions
ArgonArgon GreenGreen 514514 Vascular, Vascular,
pigmented lesionspigmented lesions
Xenon fluorideXenon fluoride UltravioletUltraviolet 351351 Cornea, angioplastyCornea, angioplasty
Atmospheric contaminationAtmospheric contamination Perforation of a vessels or Perforation of a vessels or
structurestructure EmbolismEmbolism Inappropriate energy transferInappropriate energy transfer
Laser Hazards
Plume of smoke and fine particulates (mean Plume of smoke and fine particulates (mean size 0.31um)size 0.31um)
Efficiently transported and deposited in the Efficiently transported and deposited in the alveolialveoli
Sensitive individuals: headaches, tearing, Sensitive individuals: headaches, tearing, and nausea after inhalationand nausea after inhalation
Animal study: interstitial pneumonia, Animal study: interstitial pneumonia, bronchiolitis, reduced mucociliary clearance, bronchiolitis, reduced mucociliary clearance, inflammation, emphysemainflammation, emphysema
Atmospheric contamination
Atmospheric contamination contd.Atmospheric contamination contd.
PreventionPrevention
→ → smoke evacuatorsmoke evacuator
→ → high-efficiency maskshigh-efficiency masks
Misdirected laser energy may Misdirected laser energy may perforate a viscus or a large blood perforate a viscus or a large blood vesselvessel
Laser-induced pneumothoraxLaser-induced pneumothorax Perforation may occur several days Perforation may occur several days
later when edema and necrosis are later when edema and necrosis are maximalmaximal
erforation
Venous gas embolism when laparoscopic or Venous gas embolism when laparoscopic or hysteroscopic laser surgeryhysteroscopic laser surgery
At hysteroscopy, liquid (saline) coolant is the At hysteroscopy, liquid (saline) coolant is the only safe optiononly safe option
If coolant gas must be used, COIf coolant gas must be used, CO22 should be should be
consideredconsidered
→ → Continuous airway Continuous airway COCO22 monitoring monitoring
Venous gas embolism
Incidentally pressing the laser Incidentally pressing the laser control triggercontrol trigger
Tissue damage outside the Tissue damage outside the surgical sitesurgical site
Drape fireDrape fire Eye (patient or other medical staff)Eye (patient or other medical staff) Endotracheal tube firesEndotracheal tube fires
Inappropriate energy transfer
Incidence: 0.5 – 1.5 %Incidence: 0.5 – 1.5 % Source: Source:
– direct laser illuminationdirect laser illumination
– reflected laser lightreflected laser light
– incandescent particles of tissue incandescent particles of tissue blown from the surgical siteblown from the surgical site
Endotracheal tube fires
Approaches to reduce the incidence of airway fire
Reduce the flammability of the Reduce the flammability of the endotracheal tubeendotracheal tube
Use Venturi ventilationUse Venturi ventilation
Use intermittent apnea techniqueUse intermittent apnea technique
Various endotracheal tubes for laser airway surgery
Type of tubeType of tube AdvantagesAdvantages DisadvantagesDisadvantages
Polyvinyl Polyvinyl chloridechloride
Inexpensive, Inexpensive, nonreflectivenonreflective
Low melting point, Low melting point, highly combustiblehighly combustible
Red rubberRed rubber Puncture-resistant, Puncture-resistant, maintains maintains structure, structure, nonreflectivenonreflective
Highly combustibleHighly combustible
Silicone Silicone rubberrubber
NonreflectiveNonreflective Combustible, turns to Combustible, turns to toxic ashtoxic ash
MetalMetal Combustion-Combustion-resistant, kink-resistant, kink-resistantresistant
Thick-walled flammable Thick-walled flammable cuff, transfers heat, cuff, transfers heat, reflects laser, reflects laser, cumbersomecumbersome
wrapping with moistened muslinwrapping with moistened muslin
coating with dental acryliccoating with dental acrylic
wrapping with metallized foil tape wrapping with metallized foil tape
→ → most popular approachmost popular approach
aluminium foilaluminium foil
copper foilcopper foil
plastic tape thinly coated with plastic tape thinly coated with metalmetal
Protection of the endotracheal tubes
Cuff wrapping technique
methylene blue
stained saline
instead of air
No cuff protectionNo cuff protection Adds thickness to tubeAdds thickness to tube Not an FDA-approved deviceNot an FDA-approved device Protection varies with type of metal foilProtection varies with type of metal foil Adhesive backing may igniteAdhesive backing may ignite May reflect laser onto non-targeted May reflect laser onto non-targeted
tissuetissue Rough edges may damage mucosal Rough edges may damage mucosal
surfacessurfaces
Disadvantages of wrapping
Oxygen and nitrous oxide are Oxygen and nitrous oxide are powerful oxidizerspowerful oxidizers
Reduce FiOReduce FiO22 to minimum to minimum concentrationconcentration
Helium may benefit as a diluent gasHelium may benefit as a diluent gas Volatile anesthetics currently used Volatile anesthetics currently used
are nonflammable and nonexplosiveare nonflammable and nonexplosive Pyrolized toxic compoundsPyrolized toxic compounds
Effect of high oxygen and nitrous oxide gas mixture
Helium/O2 mixture(60:40)Helium/O2 mixture(60:40)
Prevent ignition and fires from unwrapped Prevent ignition and fires from unwrapped PVC tubesPVC tubes
‘‘He’ has higher thermal conductivity and He’ has higher thermal conductivity and thermal diffusibility than N2Othermal diffusibility than N2O
‘‘He’ improve ventilation across an He’ improve ventilation across an obstructive airway lesion because of its obstructive airway lesion because of its lower density, by decreasing turbulent lower density, by decreasing turbulent flowflow
Norton. spiral wound stainless steel ETTNorton. spiral wound stainless steel ETT
Bivona Fome-Cuff. aluminium spiral tube with Bivona Fome-Cuff. aluminium spiral tube with a silicone polyurethane foam cuffa silicone polyurethane foam cuff
Xomed Laser-Shield. silicone elastomer tube Xomed Laser-Shield. silicone elastomer tube
containing metallic powder containing metallic powder
Mallinckrodt Laser-Flex. airtight stainless Mallinckrodt Laser-Flex. airtight stainless
steel spiral wound tube with two PVC cuffssteel spiral wound tube with two PVC cuffs
Metal endotracheal tubes
Laser flex tracheal Laser flex tracheal tubetube
Flexible stainless tube
Smooth surface and matte finish
2 PVC cuffs
SHERIDAN LASER TRACH TUBESHERIDAN LASER TRACH TUBE
Red rubber tubeRed rubber tube
Wrapped with copper Wrapped with copper foilfoil
Over wrapped with Over wrapped with water absorbant fabricwater absorbant fabric
Thick wall is a Thick wall is a disadvantagedisadvantage
LasertubusLasertubus
LasertubusLasertubus
White rubberWhite rubber
Cuff within a cuffCuff within a cuff
Inner cuff with airInner cuff with air Outer cuff with water or salineOuter cuff with water or saline
Recommended with argon, Nd-YAG, CORecommended with argon, Nd-YAG, CO22 laserlaser
LASER-TRACH®LASER-TRACH®
Laser ResistantTracheal TubeFor use with CO2 and KTP Lasers
• Clinically proven red rubber material
• Unique embossed copper foil diffuses laser energy
• Atraumatic outer covering
LASER-TRACH® contd.LASER-TRACH® contd. • • C-clamp, when C-clamp, when
engaged, maintains engaged, maintains inflation of the saline inflation of the saline filled cufffilled cuff
• • Convenient female luer Convenient female luer lock connector secures lock connector secures syringe to inflation linesyringe to inflation line
• • Overall length is Overall length is equivalent to standard equivalent to standard 8.0mm tracheal tube8.0mm tracheal tube
BarotraumaBarotrauma PneumothoraxPneumothorax Restriction to only intravenous agentsRestriction to only intravenous agents Gastric distentionGastric distention Relative requirement for compliant Relative requirement for compliant
lungslungs
Jet ventilation
Intermittent apnea techniqueIntermittent apnea technique
HypoventilationHypoventilation
Pulmonary aspirationPulmonary aspiration
Post operative considerationsPost operative considerations
Head up positioningHead up positioning Humidified O2 if a venturi jet has been usedHumidified O2 if a venturi jet has been used Complications like pneumothorax or Complications like pneumothorax or
respiratory failure may occur within first 2 hrsrespiratory failure may occur within first 2 hrs In laryngeal oedema plan for reintubation or In laryngeal oedema plan for reintubation or
tracheostomytracheostomy In cases of airway fire plan for prolonged In cases of airway fire plan for prolonged
ventilation ventilation
Precautions-eye protectionPrecautions-eye protection
Lids of patients non operated eyes Lids of patients non operated eyes should be taped close and then should be taped close and then covered with opaque saline soaked covered with opaque saline soaked knitknit
Operating room personnel must wear Operating room personnel must wear safety goggles or lenses safety goggles or lenses
Remove source of fire (the laser!). Remove source of fire (the laser!). Stop ventilating, disconnect circuit, extubate. Stop ventilating, disconnect circuit, extubate. Extinguish fire in bucket of water (MUST Extinguish fire in bucket of water (MUST
have one ready!). have one ready!). Mask ventilate with 100% OMask ventilate with 100% O22, continue , continue
anaesthesia i.v. anaesthesia i.v. Direct laryngoscopy & rigid bronchoscopy for Direct laryngoscopy & rigid bronchoscopy for
damage and debris. damage and debris.
Airway fires protocol
Reintubate if damage. Reintubate if damage. Blowtorch fire may need distal Blowtorch fire may need distal
fibreoptic bronchoscopy and lavage. fibreoptic bronchoscopy and lavage. Severe damage may need low Severe damage may need low
tracheostomy. tracheostomy. Assess oropharynx and face. Assess oropharynx and face. CXR. CXR. Steroids. Steroids.
Airway fires protocol
SAFETY POLICYSAFETY POLICY
Personnel qualified to use and Personnel qualified to use and operate lasers should be operate lasers should be certifiedcertified
Avoidance of potentially Avoidance of potentially
hazardous materialshazardous materials
Availabily of water and a Availabily of water and a means of delivery means of delivery
SAFETY POLICY contd.SAFETY POLICY contd.
Protection of patient eyes and Protection of patient eyes and neighboring tissuesneighboring tissues
During upper airway surgeries During upper airway surgeries tracheal tube and cuff when tracheal tube and cuff when used should be protected by used should be protected by appropriate means appropriate means
During laser treatment of intestine, During laser treatment of intestine, adequate suction should be used to adequate suction should be used to evacuate methaneevacuate methane
Wet cloth towels should be used to Wet cloth towels should be used to drape the immediate areadrape the immediate area
Lasers should not be used in the Lasers should not be used in the presence of flammable substancepresence of flammable substance
Laser machine must be in off position Laser machine must be in off position when not in usewhen not in use
SAFETY POLICY contd.
SAFETY POLICY contd.SAFETY POLICY contd.
Instrumentation should be provided Instrumentation should be provided that would detract, scatter or that would detract, scatter or defocus the laser beam rather than defocus the laser beam rather than reflect it inappropriatelyreflect it inappropriately
Ventilation and suction must be Ventilation and suction must be adequate to remove any gases, adequate to remove any gases, vapors, or particulate matter vapors, or particulate matter released during laser operationsreleased during laser operations
Conclusion
Laser provide a useful tool in surgical armamentarium
Anaesthesiologists must prepare themselves and their patients
Risks of laser can be minimized by common sense and pre-considered plans
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