Laser

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Laser

  1. 1. Anesthesia in Laser Surgery <ul><li>Presenter :Dr.Anoop kumar </li></ul><ul><li>Moderator:Dr.Anand kulkarni </li></ul>
  2. 2. TOPICS <ul><li>Physics of Laser </li></ul><ul><li>Clinical applications </li></ul><ul><li>Hazards associated </li></ul><ul><li>Anaesthetic management </li></ul><ul><li>Prevention of hazards </li></ul>
  3. 3. “ Never are cooperation and communication between surgeon and anesthesiologist more important than during head and neck surgery.” Morgan, Clinical Anesthesiology
  4. 4. Physics of Laser light <ul><li>L ight A mplification by S timulated E mission of R adiation </li></ul><ul><li>Electromagnetic radiation </li></ul><ul><li>Einstein: </li></ul><ul><ul><li>all electromagnetic radiation consisted of wavelike quanta called photons </li></ul></ul><ul><ul><li>-> E (J) = h v </li></ul></ul><ul><li>Wavelength for visible light ranges from 385nm to 760 nm </li></ul>
  5. 5. Physics of Laser light. contd. <ul><li>Characteristics: </li></ul><ul><ul><li>Monochromatic (one wavelength) </li></ul></ul><ul><ul><li>Coherent (oscillates in the same phase) </li></ul></ul><ul><ul><li>Collimated (exists as a narrow, parallel beam) </li></ul></ul><ul><li>Intense light beams, intense energy to small target sites </li></ul>
  6. 6. Laser system components
  7. 7. Laser system component LIGHT GUIDE
  8. 8. <ul><li>Used as scalpels and electrocoagulators </li></ul><ul><li>Dermatology, thoracic surgery, ophthalmology, gynaecology, plastic surgery, ENT, urology and neurosurgery </li></ul>Clinical applications
  9. 9. Laser interaction with tissue <ul><li>Used as scalpels and electro coagulators </li></ul><ul><li>Precise microsurgery </li></ul><ul><li>Relative “dry” </li></ul><ul><li>Less damage to adjunct tissue </li></ul><ul><li>Less postoperative pain and edema </li></ul>
  10. 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. 11. <ul><li>Atmospheric contamination </li></ul><ul><li>Perforation of a vessels or structure </li></ul><ul><li>Embolism </li></ul><ul><li>Inappropriate energy transfer </li></ul>Laser Hazards
  12. 12. <ul><li>Plume of smoke and fine particulates (mean size 0.31um) </li></ul><ul><li>Efficiently transported and deposited in the alveoli </li></ul><ul><li>Sensitive individuals: headaches, tearing, and nausea after inhalation </li></ul><ul><li>Animal study: interstitial pneumonia, bronchiolitis, reduced mucociliary clearance, inflammation, emphysema </li></ul>Atmospheric contamination
  13. 13. Atmospheric contamination contd. <ul><li>Prevention </li></ul><ul><ul><li>-> smoke evacuator </li></ul></ul><ul><ul><li>-> high-efficiency masks </li></ul></ul>
  14. 14. <ul><li>Misdirected laser energy may perforate a viscus or a large blood vessel </li></ul><ul><li>Laser-induced pneumothorax </li></ul><ul><li>Perforation may occur several days later when edema and necrosis are maximal </li></ul>erforation
  15. 15. <ul><li>Venous gas embolism when laparoscopic or hysteroscopic laser surgery </li></ul><ul><li>At hysteroscopy, liquid (saline) coolant is the only safe option </li></ul><ul><li>If coolant gas must be used, CO 2 should be considered </li></ul><ul><li>-> Continuous airway CO 2 monitoring </li></ul>Venous gas embolism
  16. 16. <ul><li>Incidentally pressing the laser control trigger </li></ul><ul><li>Tissue damage outside the surgical site </li></ul><ul><li>Drape fire </li></ul><ul><li>Eye (patient or other medical staff) </li></ul><ul><li>Endotracheal tube fires </li></ul>Inappropriate energy transfer
  17. 17. <ul><li>Incidence: 0.5 – 1.5 % </li></ul><ul><li>Source: </li></ul><ul><ul><li>direct laser illumination </li></ul></ul><ul><ul><li>reflected laser light </li></ul></ul><ul><ul><li>incandescent particles of tissue blown from the surgical site </li></ul></ul>Endotracheal tube fires
  18. 19. <ul><li>Reduce the flammability of the endotracheal tube </li></ul><ul><li>Use Venturi ventilation </li></ul><ul><li>Use intermittent apnea technique </li></ul>Approaches to reduce the incidence of airway fire
  19. 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
  20. 21. <ul><li>wrapping with moistened muslin </li></ul><ul><li>coating with dental acrylic </li></ul><ul><li>wrapping with metallized foil tape </li></ul><ul><li>-> most popular approach </li></ul><ul><ul><li>aluminium foil </li></ul></ul><ul><ul><li>copper foil </li></ul></ul><ul><ul><li>plastic tape thinly coated with metal </li></ul></ul>Protection of the endotracheal tubes
  21. 22. Cuff wrapping technique methylene blue stained saline instead of air
  22. 23. <ul><li>No cuff protection </li></ul><ul><li>Adds thickness to tube </li></ul><ul><li>Not an FDA-approved device </li></ul><ul><li>Protection varies with type of metal foil </li></ul><ul><li>Adhesive backing may ignite </li></ul><ul><li>May reflect laser onto non-targeted tissue </li></ul><ul><li>Rough edges may damage mucosal surfaces </li></ul>Disadvantages of wrapping
  23. 24. <ul><li>Oxygen and nitrous oxide are powerful oxidizers </li></ul><ul><li>Reduce FiO 2 to minimum concentration </li></ul><ul><li>Helium may benefit as a diluent gas </li></ul><ul><li>Volatile anesthetics currently used are nonflammable and nonexplosive </li></ul><ul><li>Pyrolized toxic compounds </li></ul>Effect of high oxygen and nitrous oxide gas mixture
  24. 25. Helium/O2 mixture(60:40) <ul><li>Prevent ignition and fires from unwrapped PVC tubes </li></ul><ul><li>‘ He’ has higher thermal conductivity and thermal diffusibility than N2O </li></ul><ul><li>‘ He’ improve ventilation across an obstructive airway lesion because of its lower density, by decreasing turbulent flow </li></ul>
  25. 26. <ul><li>Norton. spiral wound stainless steel ETT </li></ul><ul><li>Bivona Fome-Cuff. aluminium spiral tube with a silicone polyurethane foam cuff </li></ul><ul><li>Xomed Laser-Shield. silicone elastomer tube containing metallic powder </li></ul><ul><li>Mallinckrodt Laser-Flex. airtight stainless steel spiral wound tube with two PVC cuffs </li></ul>Metal endotracheal tubes
  26. 27. <ul><li>Laser flex tracheal tube </li></ul>Flexible stainless tube Smooth surface and matte finish 2 PVC cuffs
  27. 28. <ul><li>SHERIDAN LASER TRACH TUBE </li></ul>Red rubber tube Wrapped with copper foil Over wrapped with water absorbant fabric Thick wall is a disadvantage
  28. 29.                   Lasertubus                                                                                                                                                                                                                                                                                              
  29. 30.   Lasertubus       <ul><li>White rubber </li></ul><ul><li>Cuff within a cuff </li></ul><ul><li>Inner cuff with air </li></ul><ul><li>Outer cuff with water or saline </li></ul><ul><li>Recommended with argon, Nd-YAG, CO 2 laser </li></ul>
  30. 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
  31. 32. LASER-TRACH® contd. <ul><li>• C-clamp, when engaged, maintains inflation of the saline filled cuff </li></ul><ul><li>• Convenient female luer lock connector secures syringe to inflation line </li></ul><ul><li>• Overall length is equivalent to standard 8.0mm tracheal tube </li></ul>
  32. 33. <ul><ul><li>Barotrauma </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><li>Restriction to only intravenous agents </li></ul></ul><ul><ul><li>Gastric distention </li></ul></ul><ul><ul><li>Relative requirement for compliant lungs </li></ul></ul>Jet ventilation
  33. 39. Intermittent apnea technique <ul><ul><li>Hypoventilation </li></ul></ul><ul><ul><li>Pulmonary aspiration </li></ul></ul>
  34. 40. Post operative considerations <ul><li>Head up positioning </li></ul><ul><li>Humidified O2 if a venturi jet has been used </li></ul><ul><li>Complications like pneumothorax or respiratory failure may occur within first 2 hrs </li></ul><ul><li>In laryngeal oedema plan for reintubation or tracheostomy </li></ul><ul><li>In cases of airway fire plan for prolonged ventilation </li></ul>
  35. 41. Precautions-eye protection <ul><li>Lids of patients non operated eyes should be taped close and then covered with opaque saline soaked knit </li></ul><ul><li>Operating room personnel must wear safety goggles or lenses </li></ul>
  36. 42. <ul><li>Remove source of fire (the laser!). </li></ul><ul><li>Stop ventilating, disconnect circuit, extubate. </li></ul><ul><li>Extinguish fire in bucket of water (MUST have one ready!). </li></ul><ul><li>Mask ventilate with 100% O 2 , continue anaesthesia i.v. </li></ul><ul><li>Direct laryngoscopy & rigid bronchoscopy for damage and debris. </li></ul>Airway fires protocol
  37. 43. <ul><li>Reintubate if damage. </li></ul><ul><li>Blowtorch fire may need distal fibreoptic bronchoscopy and lavage. </li></ul><ul><li>Severe damage may need low tracheostomy. </li></ul><ul><li>Assess oropharynx and face. </li></ul><ul><li>CXR. </li></ul><ul><li>Steroids. </li></ul>Airway fires protocol
  38. 44. SAFETY POLICY <ul><li>Personnel qualified to use and operate lasers should be certified </li></ul><ul><li>Avoidance of potentially hazardous materials </li></ul><ul><li>Availabily of water and a means of delivery </li></ul>
  39. 45. SAFETY POLICY contd. <ul><li>Protection of patient eyes and neighboring tissues </li></ul><ul><li>During upper airway surgeries tracheal tube and cuff when used should be protected by appropriate means </li></ul>
  40. 46. <ul><li>During laser treatment of intestine, adequate suction should be used to evacuate methane </li></ul><ul><li>Wet cloth towels should be used to drape the immediate area </li></ul><ul><li>Lasers should not be used in the presence of flammable substance </li></ul><ul><li>Laser machine must be in off position when not in use </li></ul>SAFETY POLICY contd.
  41. 47. SAFETY POLICY contd. <ul><li>Instrumentation should be provided that would detract, scatter or defocus the laser beam rather than reflect it inappropriately </li></ul><ul><li>Ventilation and suction must be adequate to remove any gases, vapors, or particulate matter released during laser operations </li></ul>
  42. 49. Conclusion <ul><li>Laser provide a useful tool in surgical armamentarium </li></ul><ul><li>Anaesthesiologists must prepare themselves and their patients </li></ul><ul><li>Risks of laser can be minimized by common sense and pre-considered plans </li></ul>

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