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