Laser Surgery.ppt
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Transcript Laser Surgery.ppt
بسم هللا الرحمن الرحیم
Anesthesia in
Laser Surgery
“Never are cooperation and
communication between surgeon
and anesthesiologist more important
than during head and neck surgery.”
Morgan, Clinical Anesthesiology
Physics of Laser light (I)
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 (II)
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 components
Laser system components
Light guide
Clinical applications
Used as scalpels and
electrocoagulators
Dermatology, thoracic surgery,
ophthalmology, gynaecology,
plastics, ENT, urology and
neurosurgery
Laser interaction with tissue
Used as scalpels and
electrocoagulators
Precise microsurgery
Relative “dry”
Less damage to
adjunct tissue
Less postoperative
pain and edema
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
Laser Hazards
Atmospheric contamination
Perforation of a vessels or structure
Embolism
Inappropriate energy transfer
Atmospheric contamination
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
Prevention
→ smoke evacuator
→ high-efficiency masks
Perforation
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
Venous gas embolism
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, CO2 should
be considered
→ Continuous airway CO2 monitoring
Inappropriate energy transfer
Incidentally pressing the laser control
trigger
Tissue damage outside of surgical site
Drape fire
Eye (patient or other medical staff)
Endotracheal tube fires
Endotracheal tube fires
Incidence: 0.5 – 1.5 %
Source:
– direct laser illumination
– reflected laser light
– incandescent particles of tissue blown from
the surgical site
Blowtorch ignition of an endotracheal tube.
Approaches to reduce the
incidence of airway fire
Reduce the flammability of the
endotracheal tube
Use Venturi ventilation
Use intermittent apnea technique
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
Combustionresistant, kinkresistant
Thick-walled flammable
cuff, transfers heat,
reflects laser,
cumbersome
Protection
of the endotracheal tubes
wrapping with moistened muslin
coating with dental acrylic
wrapping with metallized foil tape
→ most popular approach
aluminum foil
copper foil
plastic tape thinly coated with metal
Cuff wrapping technique
methylene blue
stained saline
instead of air
Disadvantages of wrapping
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 surfacess
Effect of high oxygen and nitrous
oxide gas mixture
Oxygen and nitrous oxide are powerful
oxidizers
Reduce FiO2 to minimum concentration
Helium may benefit as a diluent gas
Volatile anesthetics currently used are
nonflammable and nonexplosive
Pyrolized toxic compounds
Metal endotracheal tubes
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
Jet ventilation
Barotrauma
Pneumothorax
Restriction to only intravenous agents
Gastric distention
Relative requirement for compliant lungs
Intermittent apnea technique
Hypoventilation
Pulmonary aspiration
Airway fires protocol (I)
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% O2, continue
anaesthesia i.v.
Direct laryngoscopy & rigid bronchoscopy for
damage and debris.
Airway fires protocol (II)
Reintubate if damage.
Blowtorch fire may need distal fibreoptic
bronchoscopy and lavage.
Severe damage may need low
tracheostomy.
Assess oropharynx and face.
CXR.
Steroids.