This document discusses anesthesia considerations for LASER surgery. It begins by describing how LASERs work and their properties. It then discusses the risks of LASER use including atmospheric contamination from tissue vaporization, perforation of vessels or structures, embolism, and inappropriate energy transfer. Techniques to secure the airway are presented, including non-intubation methods like apneic oxygenation and spontaneous ventilation, as well as intubation with special LASER-resistant endotracheal tubes. The goals of anesthesia are to provide a safe environment while minimizing complications, and various techniques are described to achieve these goals.

1. Anesthesia for LASER surgery
Presenter: Dr.Ranjith Nelluri
( MD 2nd year)
Moderator: Dr.Varaprasad
(Prof&HOD)

2. LASER
• Light Amplification of the Stimulated Emission of Radiation
• Intense controlled beam of light
• Characteristics :
- Monochromatic (same wavelength )
- coherence (one phase)
- collimation ( parallel direction)

3. LASER LIGHT
1. Monochromatic
2. Consists of photons-well
defined very narrow band of
wave lenghts.
3. Coherent (electromagnetic
fields of all photons oscillate
synchronously in identical
phase).
4. Beams are collimated
(minimal dispersion-parallel).
ORDINARY LIGHT
• Polychromatic
• Wide spectrum of wave
lengths.
• Electromagnetic fields
phased randomly.
• Spread out in all directions
from a point of source.

4. HISTORY
• 1864 – Maxwell-electrical,magnetic Oscillations-
299,792,458 M/Sec
• Max Planck-photo Electric Effect-
1st Step Towards Laser Physics
1905 – Einstein –
- Theoretical Basis For Laser Action
- Electromagnetic Radiation Consists Of Photons

6. Equipment
• Laser medium:
contains the atoms whose electrons
create the laser light
• Resonating mirrors:
to boost laser efficacy
• Energy source:
to excite or pump the atoms of the laser
medium into producing laser light

7. Laser medium
• Gaseous medium:
CO2, Argon, Krypton, or Helium-Neon
• Solid medium:
- solid rods of laser passive material containing small
quantities of ionic impurities(Dopants)
- Commonly used dopants:
Chromium ( ruby laser)
neodymium (Nd), Holmium(Ho)
- Synthetic gem cystals like Yttrium-aluminium-
garnet(YAG) or glass are used

11. Advantage and clinical uses of
laser
– Scalpel and electro coagulator.
– Allow precise microsurgery.
– Relatively dry field.
– Less postoperative edema and
pain with lower infection rate.

12. BIOLOGIC EFFECTS OF LASER LIGHT
• Reflection
• Transmission
• Scatter
• Absorption

13. BIOLOGIC EFFECTS OF LASER LIGHT

14. Biological effects of laser
CRITICAL TEMP (0C) BIOLOGICAL EVENT
42 Warmed
45
Cell death, edema,
endothelial damage
60 Protein coagulation
80 Collagen denaturation
100 Tissue boils
210 Dehydrated tissue burns

15. CO2 LASER
• Wavelength 10,600 nm
• Absorbed by water
• Cells are heated to the point of vaporisation
• Penetrate only shallow depth
• Used in aesthetic facial surgery,vocal cord and
airway lesions

16. Nd-YAG LASER
• Near infrared 1064nm
• Penetrate depth of 1cm
• Absorbed by dark matter
• Produces less vaporisation and more thermal
coagulation
• Can cause delayed tissue necrosis
• Used in airway neoplasms, vascular
malformations,opthalmic surgery

17. Pulsed dye laser
• Targets RBC within blood vessels
• Minimal epidermal scarring
• Used in dermatology eg: portwine stain,
tattoo erasion

18. Laser hazards
Four major categories
• Atmospheric contamination
• Perforation of a vessel or structure
• Embolism
• Inappropriate energy transfer

20. Atmospheric contamination
(Laser Plume)
• Vaporization of tissue by laser radiation, produces a plume
of smoke and fine particulates (mean size 0.31 µm; range
0.1 to 0.8 µm) sized within the range of particles that are
efficiently transported and deposited in the alveoli
• headaches, tearing, and nausea as a consequence of
inhalation
• Deposition of laser plume can cause interstitial pneumonia,
bronchiolitis, reduced mucociliary clearance, inflammation,
and emphysema.

21. Atmospheric contamination
(Laser Plume)
• CO2 lasers seem to produce the most smoke because of vaporization
of tissue,
• Nd:YAG contact probes produce much less.
• use an efficient smoke evacuator at the surgical site.
• Ordinary surgical masks efficiently filter particles only down to 3 µm,
• and special high-efficiency masks (e.g., The Protector II; Anago, Fort
Worth, TX) are required to catch laser plume particulates.
• The high-efficiency masks are less effective when wet and may need
to be changed periodically

22. Tissue and Vessel perforation
• Misdirected laser energy may perforate a viscus or a large blood
vessel
• vessels >5 mm are not coagulable by laser
• Laser-induced pneumothorax has been reported after a laryngeal
procedure.
• With an Nd:YAG system, the depth of damage is impossible to assess
accurately or immediately,
• perforation and bleeding may not occur until edema and necrosis
have become maximal several days postoperatively.

23. Embolism
• The Nd:YAG laser system has been associated with venous
gas embolism
• The laser and its contact probe were not directly
responsible for the injury, but a liquid (saline) coolant is
• Continuous airway CO2 monitoring is highly recommended
for detection of embolization or hypercapnia

24. Energy transfer to an inappropriate location
• All available medical laser wavelengths are transmitted
transparently through air and are well reflected by smooth
metal surfaces.
• Pressing the laser control trigger at the wrong time can
deliver damaging laser light across the wound to sites at
which surgical ablation was not desired
• Can damage colleagues’ eyes, ignition of surgical drapes
and, ET tube fire during airway surgery.

25. Eye protection
• the eyes of the operating room staff and the patient be
protected during laser surgery
• Errant infrared energy from a CO2 laser can quickly cause a
serious corneal injury
• argon, KTP:Nd:YAG, or ruby lasers may burn the retina

26. Eye protection
• The lids of patients’ nonoperated eyes should be taped
closed and then covered with an opaque, saline-soaked knit
or metal shield
• Operating room personnel must wear safety goggles or
lenses specific for the specific laser wavelength in use.
• Using the wrong filter provides no protection.
• Safety goggles should provide wraparound protection
from reflected light.

29. ET tube fires
• Incidence o.5% - 1.5%
• Fires can result from direct laser illumination, reflected
laser light, or incandescent particles of tissue blown from
the surgical site
• Initially, most fires are located solely on the external
surface of the endotracheal tube, where they can cause
local thermal destruction.

30. • Blowtorch-like flame
• If a fire is unrecognized
and burns through to the
interior of the tube, the
oxygen-enriched gas
combined with the to-
and-fro gas flow owing to
ventilation
• blowing heat and toxic
products of combustion
down to the pulmonary
parenchyma

32. Airway Fire Protocol
• Remove Source
• Disconnect Circuit
• Extubate
• Mask with 100% O2
• Start TIVA
• DL/Bronch for damage
evaluation and removal
of debris
• Reintubate if significant
damage
• Fiberoptic bronchoscopy
and lavage may be
necessary for blowtorch
fire
• Severe damage may
require tracheostomy
• Assess oropharynx

33. Reduction of the flammability of ETT
A. The use of special type of laser
resistant tracheal tube.
B. Wrapped standard tubes.

34. Reduction of the flammability of ETT
A. The use of special type of laser resistant
tracheal tube;
• These tubes resist laser beams ,more bulky, stiffer
• Disadvantage:
Traumatic (mucosal abrasion)
Reflect laser beam and transfer heat
No Cuff protection
Expensive

35. Laser resistant tracheal tube
a. The Norton tube:
• Reusable
• Stainless steel
• Flexible tube
• No cuff

36. b.The Laser Flex tube (Mallinckrodt laser
tube):
• Airtight stainless steel tube
• Flexible
• Uncuffed or with two cuffs

38. Laser resistant tracheal tube
c.The Laser-Shield II (Xomed-laser shield II
tube):
• Silicone tube
• Inner aluminum wrap
• Outer Teflon coating

39. d. The Bivona Fome-Cuff laser tube:
• Designed to solve the perforated-cuff-deflation-
problem.
• It consists of an aluminum wrapped silicone
tube with unique self inflating foam sponge
filled cuff which prevent deflation after
puncture.

40. METAL TUBES
• Inflammable
• Thick wall, bulky
• Difficult to place

41. B. Wrapped standard tubes:
• Standard tracheal tubes (rubber, silicon, and
PVC).
• Wrapped with laser resistant material (except the
cuff).
• the wrapped material may be:
 Aluminum or copper foil tape with adhesive
back.
 Merocel laser guard (merocel wrap).

42. • Disadvantage of wrapping:
– No cuff protection.
– Add thickness to the tube.
– Not an FDA approved device.
– May reflect laser beam to non target tissue.
–Protection varies with the type of the metal
foil used.
–Air way obstruction.
– Rough edges may cause damage to mucosal
surface.
Wrapped standard tubes

43. Wrapped standard tubes
• Mechanism of wrapping:
– Paint the tube with medical adhesive such
as benzoin.
– Cut the end of the tape with scalpel to
approximately 60 degree.
– Start wrapping from the junction of the tube
and the proximal end of the cuff
– Wrapping in spiral with 30% to 50% overlap
layer.
– Wrapping include the inflation tube of the
cuff.

45. Wrapped standard tubes
 Protection of the cuff:
 Filling the cuff with saline colored with
methylene blue.
 Place the cuff distally in the trachea and
covered visible cuff with moistened cotton
pledgets.

46. Anesthetic Goals for Laser Airway
- Provide:
• Safe environment for patient and staff
• Quiet surgical field
• Analgesia and anesthesia
- Minimize Complications

47. Anesthetic Techniques for Laser Airway
Surgery
1) Non-intubation techniques
• Apneic Oxygenation
• Spontaneous Ventilation
• Jet Ventilation
2) Intubation Techniques

48. Apneic Oxygenation
Advantages
• Periods of apnea can
alternate with periods of
laser resection
• Excellent visibility of
surgical field
• Potential trauma to airway
is avoided
Disadvantages
• Surgical time limit
• Inadequate ventilation
• Aspiration risk

49. Spontaneous Ventilation
Advantages
• Evaluate vocal cord
function
• Excellent visualization of
surgical field
• Good for otherwise
unstable patients with
compromised airway
Disadvantages
• Oxygenation/ventilation
more difficult to assess
• Surgical field not still
• Risk of aspiration
• Depth of anesthesia not
consistent

50. Jet Ventilation
Advantages
• Decreased risk of airway fire
• Improved surgical field visibility
• Atraumatic airway manipulation
Disadvantages
• Difficult to control ventilation, likely
hypoventilation
• Oxygenation/ventilation cannot be
assessed
• Muscle relaxation required
• Increased aspiration risk
• Inability to use anesthetic gases
• Misdirection of jet may
• cause gastric distension or
• barotrauma

52. Intubation
Advantages
• Secure airway, less risk of
aspiration
• Controlled ventilation
• Administer anesthetic
gases
• Monitor O2 and EtCO2
concentrations
Disadvantages
• ETT may obstruct surgical
view
• Airway trauma
• ? Difficult Airway
• No ETT exists which
decreases risk of airway
fire to zero

53. CONCLUSION
• SPECIAL ETT
• N20,FIO2,inhalational anaesthetics support
combustion
• Special anaesthetic techniques
• Careful monitoring.
• Effective prevention,management of complications

54. SUMMARY
• Awareness of Hazards
• Availability of equipment
• Airway
• Anesthetic plan
• Arguments

56. THANK YOU