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Laser Presentation Transcript

  • 1. Anesthesia in Laser Surgery
    • Presenter :Dr.Anoop kumar
    • Moderator:Dr.Anand kulkarni
  • 2. TOPICS
    • Physics of Laser
    • Clinical applications
    • Hazards associated
    • Anaesthetic management
    • Prevention of hazards
  • 3. “ Never are cooperation and communication between surgeon and anesthesiologist more important than during head and neck surgery.” Morgan, Clinical Anesthesiology
  • 4. Physics of Laser light
    • L ight A mplification by S timulated E mission of R adiation
    • 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
  • 5. Physics of Laser light. 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
  • 6. Laser system components
  • 7. Laser system component LIGHT GUIDE
  • 8.
    • Used as scalpels and electrocoagulators
    • Dermatology, thoracic surgery, ophthalmology, gynaecology, plastic surgery, ENT, urology and neurosurgery
    Clinical applications
  • 9. Laser interaction with tissue
    • Used as scalpels and electro coagulators
    • Precise microsurgery
    • Relative “dry”
    • Less damage to adjunct tissue
    • Less postoperative pain and edema
  • 10. Common used Laser lights Laser media Color Wavelength (nm) Typical application Carbon dioxide Far infrared 10,600 General, cutting Ruby Red 694 Tattoos, nevi KTP:YAG Green 532 General, pigmented lesions Argon Green 514 Vascular, pigmented lesions Xenon fluoride Ultraviolet 351 Cornea, angioplasty
  • 11.
    • Atmospheric contamination
    • Perforation of a vessels or structure
    • Embolism
    • Inappropriate energy transfer
    Laser Hazards
  • 12.
    • Plume of smoke and fine particulates (mean size 0.31um)
    • Efficiently transported and deposited in the alveoli
    • Sensitive individuals: headaches, tearing, and nausea after inhalation
    • Animal study: interstitial pneumonia, bronchiolitis, reduced mucociliary clearance, inflammation, emphysema
    Atmospheric contamination
  • 13. Atmospheric contamination contd.
    • Prevention
      • -> smoke evacuator
      • -> high-efficiency masks
  • 14.
    • Misdirected laser energy may perforate a viscus or a large blood vessel
    • Laser-induced pneumothorax
    • Perforation may occur several days later when edema and necrosis are maximal
    erforation
  • 15.
    • Venous gas embolism when laparoscopic or hysteroscopic laser surgery
    • At hysteroscopy, liquid (saline) coolant is the only safe option
    • If coolant gas must be used, CO 2 should be considered
    • -> Continuous airway CO 2 monitoring
    Venous gas embolism
  • 16.
    • Incidentally pressing the laser control trigger
    • Tissue damage outside the surgical site
    • Drape fire
    • Eye (patient or other medical staff)
    • Endotracheal tube fires
    Inappropriate energy transfer
  • 17.
    • Incidence: 0.5 – 1.5 %
    • Source:
      • direct laser illumination
      • reflected laser light
      • incandescent particles of tissue blown from the surgical site
    Endotracheal tube fires
  • 18.  
  • 19.
    • Reduce the flammability of the endotracheal tube
    • Use Venturi ventilation
    • Use intermittent apnea technique
    Approaches to reduce the incidence of airway fire
  • 20. Various endotracheal tubes for laser airway surgery Type of tube Advantages Disadvantages Polyvinyl chloride Inexpensive, nonreflective Low melting point, highly combustible Red rubber Puncture-resistant, maintains structure, nonreflective Highly combustible Silicone rubber Nonreflective Combustible, turns to toxic ash Metal Combustion-resistant, kink-resistant Thick-walled flammable cuff, transfers heat, reflects laser, cumbersome
  • 21.
    • wrapping with moistened muslin
    • coating with dental acrylic
    • wrapping with metallized foil tape
    • -> most popular approach
      • aluminium foil
      • copper foil
      • plastic tape thinly coated with metal
    Protection of the endotracheal tubes
  • 22. Cuff wrapping technique methylene blue stained saline instead of air
  • 23.
    • No cuff protection
    • Adds thickness to tube
    • Not an FDA-approved device
    • Protection varies with type of metal foil
    • Adhesive backing may ignite
    • May reflect laser onto non-targeted tissue
    • Rough edges may damage mucosal surfaces
    Disadvantages of wrapping
  • 24.
    • Oxygen and nitrous oxide are powerful oxidizers
    • Reduce FiO 2 to minimum concentration
    • Helium may benefit as a diluent gas
    • Volatile anesthetics currently used are nonflammable and nonexplosive
    • Pyrolized toxic compounds
    Effect of high oxygen and nitrous oxide gas mixture
  • 25. Helium/O2 mixture(60:40)
    • Prevent ignition and fires from unwrapped PVC tubes
    • ‘ He’ has higher thermal conductivity and thermal diffusibility than N2O
    • ‘ He’ improve ventilation across an obstructive airway lesion because of its lower density, by decreasing turbulent flow
  • 26.
    • Norton. spiral wound stainless steel ETT
    • Bivona Fome-Cuff. aluminium spiral tube with a silicone polyurethane foam cuff
    • Xomed Laser-Shield. silicone elastomer tube containing metallic powder
    • Mallinckrodt Laser-Flex. airtight stainless steel spiral wound tube with two PVC cuffs
    Metal endotracheal tubes
  • 27.
    • Laser flex tracheal tube
    Flexible stainless tube Smooth surface and matte finish 2 PVC cuffs
  • 28.
    • SHERIDAN LASER TRACH TUBE
    Red rubber tube Wrapped with copper foil Over wrapped with water absorbant fabric Thick wall is a disadvantage
  • 29.                   Lasertubus                                                                                                                                                                                                                                                                                              
  • 30.   Lasertubus      
    • White rubber
    • Cuff within a cuff
    • Inner cuff with air
    • Outer cuff with water or saline
    • Recommended with argon, Nd-YAG, CO 2 laser
  • 31. LASER-TRACH® Laser Resistant Tracheal Tube For use with CO2 and KTP Lasers • Clinically proven red rubber material • Unique embossed copper foil diffuses laser energy • Atraumatic outer covering
  • 32. LASER-TRACH® contd.
    • • C-clamp, when engaged, maintains inflation of the saline filled cuff
    • • Convenient female luer lock connector secures syringe to inflation line
    • • Overall length is equivalent to standard 8.0mm tracheal tube
  • 33.
      • Barotrauma
      • Pneumothorax
      • Restriction to only intravenous agents
      • Gastric distention
      • Relative requirement for compliant lungs
    Jet ventilation
  • 34.  
  • 35.  
  • 36.  
  • 37.  
  • 38.  
  • 39. Intermittent apnea technique
      • Hypoventilation
      • Pulmonary aspiration
  • 40. Post operative considerations
    • Head up positioning
    • Humidified O2 if a venturi jet has been used
    • Complications like pneumothorax or respiratory failure may occur within first 2 hrs
    • In laryngeal oedema plan for reintubation or tracheostomy
    • In cases of airway fire plan for prolonged ventilation
  • 41. Precautions-eye protection
    • Lids of patients non operated eyes should be taped close and then covered with opaque saline soaked knit
    • Operating room personnel must wear safety goggles or lenses
  • 42.
    • Remove source of fire (the laser!).
    • Stop ventilating, disconnect circuit, extubate.
    • Extinguish fire in bucket of water (MUST have one ready!).
    • Mask ventilate with 100% O 2 , continue anaesthesia i.v.
    • Direct laryngoscopy & rigid bronchoscopy for damage and debris.
    Airway fires protocol
  • 43.
    • Reintubate if damage.
    • Blowtorch fire may need distal fibreoptic bronchoscopy and lavage.
    • Severe damage may need low tracheostomy.
    • Assess oropharynx and face.
    • CXR.
    • Steroids.
    Airway fires protocol
  • 44. SAFETY POLICY
    • Personnel qualified to use and operate lasers should be certified
    • Avoidance of potentially hazardous materials
    • Availabily of water and a means of delivery
  • 45. SAFETY POLICY contd.
    • Protection of patient eyes and neighboring tissues
    • During upper airway surgeries tracheal tube and cuff when used should be protected by appropriate means
  • 46.
    • During laser treatment of intestine, adequate suction should be used to evacuate methane
    • Wet cloth towels should be used to drape the immediate area
    • Lasers should not be used in the presence of flammable substance
    • Laser machine must be in off position when not in use
    SAFETY POLICY contd.
  • 47. SAFETY POLICY contd.
    • Instrumentation should be provided that would detract, scatter or defocus the laser beam rather than reflect it inappropriately
    • Ventilation and suction must be adequate to remove any gases, vapors, or particulate matter released during laser operations
  • 48.  
  • 49. 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
  • 50.