This presentation is open for all to see and get benefitted

1. -LASER
Anesthetic Considerations
in Micro laryngeal and
Eye surgery
-Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical Care/ER

2. -CLINICAL APPLICATIONS
-Used as Scalpels and Electro coagulator in
--ENT
--Dermatology
--Thoracic surgery
--Ophthalmology
--Gynecology
--Plastics
--Urology and
--Neurosurgery

3. -MICRO LARYNGEAL and EYE SURGERY
-Laryngeal surgery aided with a microscope

4. -INDICATIONS
--Benign Growth
a-Nodules
b-Polyps
c-Cysts
b-Granulomas
--Vocal cord dysfunction and
obstructed tumor
--Recurrent respiratory
Papillomatosis and foreign
body

5. PATIENTS FOR
-MICROLARYNGEAL AND-EYE
SURGERY (MLS)
--Patients vary from young patients,
presenting with voice changes secondary
to benign vocal cord lesions
--Elderly patients, who are heavy smokers with
“Chronic obstructive pulmonary disease”
presenting with voice changes, Dysphagia
and strider caused by glottic carcinoma.

6. -PRE OPERATIVE EVALUATION
-DETAILED HISTORY AND EXAMINATION
--1-History of Hoarseness, voice change, (Low pitched,
coarse fluttering subglottic and high pitched
cracking voice, Aphonia or breathy glottic stridor
(Inspiratory or Expiratory)
--2-Dysphagia, Best breathing position, breathing
pattern during sleep gives an indication of severity
of disease
--3-Patients are likely to have CVS and respiratory
dysfunction
--4-History of previous Endoscopic procedures and
their outcome

7. -PRE OPERATIVE EVALUATION
-AIRWAY ASSESMENT
--1-Ease of ventilation,
visualization of
Laryngeal
inlet, Tracheal
intubation
--2-Direct and Indirect
Laryngoscopy
--3-Asses the severity and
size of the Lesion
--4-Chest radiography, CT,
MRI, all will give
information about
subglottic and tracheal
lesions

8. -IDENTITY
-BEFORE ANESTHESIA TO IDENTITY
-SIZE OF THE LESION
a-Indication of
potential
airflow
obstruction
b-Stridor
-MOBILITY
--Mobile lesion
cause airway
obstruction
post Induction
of Anesthesia
-LOCATION
--Supraglottic
--Sub glottic

9. -PRE OPERATIIVE
PREPARATION
--Cessation of smoking
--Continue Bronchodilators
--If with tracheostomy: steam
inhalation, nebulization
and suction

10. -PRE MEDICATION
---Routine premedication should be avoided
--Anti sialagogue e.g Glycopyrrolate
--Titrated I/V increments of Midazolam with
monitoring pe induction area

11. -MONITORING
--Routine monitoring
--ECG, HR, NIBP
--Spo2, EtCO2
--Temperature
--Additional monitoring
--Airway pressures
--Invasive monitoring

12. -ANESTHETIC TECHNIQUES
-Intubation Techniques for
Micro Laryngeal surgery
---Intermittent apnoea
--Insufflation Technique
--Spontaneous ventilation
--Jet ventilation

13. CLOSED
VENTILATION
TECHNIQUES

14. --Small – routine tracheal intubation
--Moderate and Large awake intubation
--Tracheostomy
--LA as airway obstruction may worsen
after General Anesthesia
--Limited Pre medication
--Manny factors affect on upper airway
stability and their functional
performance
like:-
a-Stridor at rest
b-Pre operative Tracheostomy
c-Pre Medication
-HOW TO SECURE AIRWAYS

15. -MICRO LARYGEAL TUBES
--Small internal and external diameter
a-46 mm ID
b-30 cm Long with
c-Standered cuff
--Low pressure high volume cuff
--Lies between Arytenoid cartilages, leaving
atleast Anterior 2/3rd of glottis
unobstructed

16. -MICRO LARYNGEAL TUBE

17. -ADVANTAGES
OF INTUBATION TECHNIQUE
--Routine Technique for all Anesthesiologists
--Protection of lower airway
Control of ventilation
--Control of airway
--Minimal pollution by volatile agents
--Monitor EtCO2

18. -DISADVANTAGES
OF INTUBATION TECHNIQUE
---Surgical access and visibility of lesion may be
limited
--High inflation pressure may be required
through small tube
--High resistance
--Difficulty in suctioning
--Increased chances of occlusion and kinking
--Tube related damage intubation
--Risk of LASER airway fire

19. -Blowtorch ignition of an
endotracheal tube

20. -OPEN SYSTEM
Non intubation Techniques

21. -Non intubation techniques
--1-Spontaneous ventilation technique
--2-Insufflation technique
--3-Intermittent apnoea technique
--4-Jet ventilation
--5-Supraglottic jet ventilation
--6-Transtracheal jet ventilation
--7-Subglottic jet ventilation
-OPEN SYSTEM

22. -SPONTANEOUS VENTILATION
--1-Inhalation induction with Sevoflurane or
Halothane with oxygen is done
--Laryngoscopy done and Topic LA sprayed on and
above vocal cords
--100% Percent oxygen given by Face Mask is given
(spontaneous ventilation)
--Suitable depth is attained and rigid laryngoscopy
or Bronchoscopy done

23. -SPONTANEOUS VENTILATION
ADVANTAGES
--1-Excellent Visualization of surgical field
--2-Evaluate Vocal Cord function
--3-Good for otherwise stable patients with
compromised airway
DISADVANTAGES
--1-Oxygenation / Ventilation more
difficult to asses
--2-Surgical field is not still
--3-There is Risk of Aspiration
--4-Depth of Anesthesia is not
consistent

24. -2-INSUFFLATION TECHNIQUE
-ROUTES
--1-A small catheter in the Nasopharynx, placed above
the laryngeal opening
--2-A Tracheal tube cut short and placed through the
nasopharynx emerging just beyond the soft palate.
--3-A nasopharyngeal airway is also used
--4-The side-arm or channel of a laryngoscope is used

25. -DIS ADVANTAGES
---1-No control over Ventilation
--2-Loss of protective airway reflexes
and the potential for the airway
soiling
--3-Gastric Distension
--4-Theatre Pollution
--5-Not suitable for soft floppy lesions

26. -INTERMITTENT APNOEA
TECHNIQUE
--1-Standered Anesthesia.
This is used of “Awake Laryngoscopic
Technique” to look for subglottic lesions
--2-Hyper ventilated technique with an
Anesthetic agent with Oxygen, Tracheal
tube is then removed
--3-After 2 to 3 minutes surgery is stopped
and the tracheal tube is Re inserted and
the patient is Hyperventilated

27. -INTERMITTENT APNOEA
TECHNIQUE and its
-ADVANTAGES
--1-Excellent Visibility of surgical
field
-2-Safety in the use of a LASER
DIS ADVANTAGES
--1-Surgical time limit
--2-In adequate Ventilation
--3Aspiration Risk
--4-Variable Levels of Anesthesia
--5-Potential trauma through multiple
Re intubation

28. -JET VENTILATION
--Pulsed application of Gas (Mostly Oxygen)
JET into the airway without airtight
connection of the patient to the
Ventilator
--Sanders , 1967
--16 G jet placed down the side arm of a
rigid Bronchoscope
--Modifications:-
The site at which JET emerges
a-Supra glottic
b-Sub glottic
c-Transtracheal
d-Normal, High Frequency

29. -TECHNIQUE
--1-Pre Oxygenation
--2-I/V induction and maintenance with Propofol
--3-Supplemented with opioid (Alfentanil or
Remifentanil)
--4-Confirmation of Mask ventilation, give muscle
relaxant
--5-Laryngoscopy with Topical LA administered
--6-Ventilation via Face Mask / LMA with 100%
oxygen till Primed laryngoscope is not placed
--7-Perfact alignment of JET laryngoscope and Trachea.
--8-Ventilatory Rate – 6 to 7 bpm at 30 to 50 psi(Adults)
5 to 10 psi (For infants and children) I/E ratio is 1.5
to 6 seconds
--9-Monitor chest wall motion and Spo2

30. -JET VENTILATION
INSTRUMENT

31. -CONTRA INDICATIONS
FOR JET VENTILATION
--1-OBESITY:-It causes reduced chest
compliance not allowing complete
relaxation
--2-COPD
--3-Bullous emphysema
--4-Retrognethia
a-Over bite
b-Challenging oro pharyngeal alignment
--5-Glottic lesion, scarring, laryngospasm

32. -SUPRA GLOTTIC
JET VENTILATION
---Commonly used in Endoscopy procedures
--Allows a clear view for surgeon with no Risk of
LASER induced airway fires
--Problems (could be)
--Risk of Barotrauma
--Gastric distension with Entrained(entrapped) air
--Mal alignment of the rigid suspension
laryngoscope or JETTING needle
--Blood debris or fragments being blown into the
distal Trachea
--Movement of the Vocal cords
--Inability to monitor end tidal carbon di oxide

33. - SUPRA GLOTTIC
JET VENTILATION
--Allows delivery of a Jet of Gas directly
into the directly
--More efficient than supraglottic Jet
ventilation
--Results in reduced peak airway pressure
--No vocal cord motion
--good view of surgical field
--No time constraints for the surgeon
DIS ADVANTAGES
--Risk of LASER – induced airway fires is there

34. -TRNASTRACHEAL JET
VENTILATION TECHNIQUES
--Percutaneous Transtracheal catheters pass through the
“cricothyroid” membrane or trachea
--In individuals with significant airway Pathology
PROBLEMS
--Greatest risks of barotrauma of all Jet ventilation techniques
--Blockage and Kinking
--Infection
--Bleeding
--Failure to site the catheter

35. -HIGH FREQUENCY
JET VENTILATION
DETAILS
--1-Ventilatory rates :- about 100 to 150 b/minute used
--Tidal Volume >2 ml per Kg
--It allows
a-A continuous expiratory flow of air, enhancing the
removal of fragments of blood and debris from the airway
b-Reduced peak and mean airway pressures with improved
cardiovascular stability
c-Enhanced diffusion and inter-regional mixing with the lungs
resulting in more efficient ventilation
d-Particular importance in significant lung disease and obesity

36. -COMPLICATIONS
OF JET VENTILATION
INTRA OPERATIVE
--Arrythmias
--Aspiration
seeding of Polyp into trachea
--Airway sharing
POST OPERATIVE
--Laryngo-spasm
--Laryngeal edema
--Strider
--Barotrauma and Pneumothorax

37. -LASER

38. -LASER
--Light amplification by stimulated Emission of
Radiation
--CHARACTERISTICS:-
a-Monochromatic
b-Coherent collimated
--ESSENTIAL COMPONENTS
a-LASER medium- atoms whose electrons
create a laser light
b-Energy source to excite atoms
c-Resonating mirrors

39. -PROCEDURE
OF A WORKING LASER

40. -PROCEDURE
OF A WORKING LASER
--Different wavelengths of a LASER light cause different patterns of tissue destruction. The
destructive effect of laser light on tissue depends on laser parameters and tissue factors.

41. -ADVANTAGES
--1-Good homeostasis
--2-Rapid healing and minimal scarring
--3-Surgical accuracy and preservation
of normal tissue
--4-Reduced Postoperative Edema and Pain

42. -ENDOTRACHEAL TUBES
FOR LASER SURGERY
-Endotracheal tubes for LASER surgery
--1-Norton’s stainless steel spiral coil without cuff tight
--2-LASER Flex Tube:-Airtight stainless steel spiral with two
distal cuff’s
--3-Bivona Foam Cuff:-Aluminium spiral tube with outer
silicone coat and self inflating foam sponge filled cuff

43. -ENDOTRACHEAL TUBES
FOR LASER SURGERY

44. -LASER HAZARDS
--1-Atmospheric contamination
--2-Perforation of a vessels or structure
--3-Airway fire
--4-Venous air Embolism
--5-Inappropriate energy transfer

45. -LASER HAZARDS
ATMOSPHERIC CONTAMINATION
--Plume of smoke and fine particles
(mean size 0.31 micro meter
--Efficiently transported and deposited
in the alveoli
--Sensitive individuals:-
a-Headaches
b-Tearing and
c-Nausea after inhalation
--Animal study:-
a-Interstitial Pneumonia
b-Bronchiolitis
c-Reduced muco-ciliary clearance
b-Inflammation
d-Emphysema
PREVENTION
--Smoke evacuator
--To wear High Efficiency Masks

46. -LASER HAZARDS
PERFORATION
--1-Misdirected LASER energy may perforate
a viscous or a large Blood vessel
--2-LASER induced pneumothorax
--3-Perforation may occur several days later
when edema and necrosis are maximal
VENOUS AIR EMBOLISM
--1-Associated with Nd-YAG LASER system
--2-Coolant gas
--3-Precaution- use liquid coolant

47. -LASER HAZARDS
-INAPPROPRIATE ENERGY TRANSFER
--1-Incidentally pressing the LASER control
trigger
--2-Tissue damage outside of surgical site
a-Drape fire
b-Eye(patient or other medical staff)
c-Endotracheal tube-damage, fire

48. -SAFETY
CONSIDERATIONS
--OT warning signs for LASER use
--Restrict entry into OT
--Wear protective glasses
--Avoid flammable materials
a-Drapes
b-Plastic tubes
--Patient’s eyes – taped closed and
cover with wet pads
--Wet towels to drape
--Competent personnel for equipment
use
--Avoid misdirection of beam

49. -SAFETY
CONSIDERATIONS
--1-Avoid ETT in short procedures (use venturi)
--Ready bucket of clean water for dipping the tube
--Smoke evacuators at surgical site
--Reduce the flammability of the endotracheal tube
--Use venturi ventilation / intermittent apnea technique
--Reduction of available oxygen content to minimum
required for reasonable arterial saturation

50. -PROTECTION OF
Endotracheal Tube
-Wrapping with moistened Muslin
---Wrapping metabolized foil
tape most popular approach
--Aluminium foil
--Copper foil
--Plastic Tape thinly Coated with
metal

51. -TECHNIQUE OF
WRAPPING
--Distal end of tape cut at 60 degrees angle
--Start at proximal end of cuff junction
--Overlap – 30% and no PVC exposed.
--Cuff filled with methylene blue

52. --1-No cuff protection
--2-Adds thickness to tube
--3-Not an FDA –approved device
--4-Protection varies with type of metal
foil
--5-Adhesive backing may ignite
--6-May reflect laser onto non-targeted
tissue
--7-Rough edges may damage mucosal
surfaces
-DISADVANTAGES
OF WRAPPING

53. -FIRE TRIANGLE
--Only if three components of the
fire triangle are present
--To Minimize these risks:-
a-Use lowest FiO2 to maintain
SpO2
B-Air should be preferred to
N2O
c-Potential fuel source:-
-Laser resistant
-Laser tubes
-FIRE TRIANGLE

54. -EXTRACT/ELIMINATE/EXTINGUISH
---Put out fire – flood field with saline
--Remove energy source – stop LASER
--Remove oxidant source disconnect circuit
stop ventilation and gas
--Remove fuel source (Blow torch effect)
--Extubate and remove burning fragments

55. -EVALUATE
---Review airway – ensure no burning
fragments
--Oxygenate – 100% Oxygen by Bag and Mask
--Review damage – Flexible or rigid
bronchoscopy
--Establish airway – Re-intubate, Laryngeal
Mask airway or Jet ventilation
--No airway damage – may proceed with
surgery
--Severe airway damage – tracheostomy or
oral intubation, ICU admission and
controlled ventilation