Mod9: Otolaryngologic Surgery - Laser surgery - Tonsillectomy & Adenoidectomy - UPPP Flashcards
Otolaryngologic Surgery - Laser Surgery
LASER
stands for:
Light
Amplification by
Simulated
Emission of
Radiation
Otolaryngologic Surgery - Laser Surgery
LASER
Characteristics:
Monochromatic
One wave length
Coherent
Oscillates in same phase
Collimated
Narrow, parallel beam
Otolaryngologic Surgery - Laser Surgery
Use of LASER in surgery
Provides:
Surgical precision
Minimal bleeding/edema
Preservation surrounding tissue
Otolaryngologic Surgery - Laser Surgery
Lasers most commonly used
CO2 lasers
ND: YAG & KPT lasers
Otolaryngologic Surgery - Laser Surgery
CO2 lasers
characteristics:
Produces a beam with a long wavelength of 10,600-nm
Absorption by H20 increased decreasing tissue penetration
More superficial/localized (High Heat)
May produce Cornea damage, not retinal
(b/c the beam is not as strong as the YAG lasers)
Otolaryngologic Surgery - Laser Surgery
ND: YAG & KPT lasers
characteristics:
Produces a shorter wavelength of 1064-1320-nm,
Nearly 10 x the ability to penetrate tissue
Deeper tissue penetration (retinal damage)
Exert more precautions and use specialized eye protection with these lasers!!!
Otolaryngologic Surgery - Laser Surgery
Major Hazards
to take into consideration:
Toxic fumes (laser plume) from tissue vaporization
Eye injury
Airway fire!!!
Otolaryngologic Surgery - Laser Surgery - Major Hazards
Toxic fumes (laser plume) from tissue vaporization
be careful if the pt has:
HPV
HIV
Ensure adequate evacuation
Wear protective masks
Otolaryngologic Surgery - Laser Surgery - Major Hazards
Eye injury
Precautions:
Protective goggles for both patient and OR personnel
(Protect pt’s eyes with goggles even if they are taped!!!)
CO2: <u>clear</u> glasses
Nd-YAg: <strong><em>green</em></strong> tint glasses
KTP-dYAG: <strong>red/amber/orange</strong>
Wet soaked gauze to eyes in anesthetized patient
(because of the potential for fire)
Avoid Lacri-Lube ointment (flammable)
Otolaryngologic Surgery - Laser Surgery - Major Hazards
Airway fire!!!
considerations and precautions:
Greatest fear
Prevention best plan!
Consider alternatives to tracheal intubation
(Intermittent apnea or jet ventilation)
ETT resistant to laser ignition
No cuffed ET or currently available ETT is completely laser proof!!!
Otolaryngologic Surgery - Laser Surgery - Preventing <strong>Airway fire</strong>
ETT resistant to laser ignition
How to use it?
Wrap PVC with metallic tape
No cuff protection
Not an FDA approved device
Adhesive may ignite
Reflective/damage non targeted tissue
Specialized laser tube
Stainless steel reflects laser beam
Defocuses beam, decrease tissue damage
Double cuffed
Otolaryngologic Surgery - Laser Surgery
Airway fire!!!
Precautions to take:
Deliver lowest possible FiO2
(<30% any time fire is possible)
Avoid N20
Replace with helium/air (Heliox)
Fill cuff with saline dyed methylene blue
saline will help Dissipate heat/ID cuff rupture
Limit laser intensity and duration
Combustibility depends on fraction of FiO2 and laser energy
Keep FiO2 below 30% limit laser exposure
N20 can fuel a fire although not flammable
Helix rationale:
Nonflammable
Posses a lower density than nitrogen and oxygen (main constituents of air)
Improving flow dynamics
Laminar flow is described by a lower calculated Reynold’s number
Reynolds number = vpd/n
v: linear velocity of fluid
p: density of fluid
d: diameter of tube
n: viscosity
The lower the Reynold’s number the greater degree of laminar flow (decreased resistance to flow) Reynolds > 2000 = predominantly turbulent flow
Reynolds < 2000 = reflects predominantly laminar flow
allows use of lower oxygen levels during laser thus lowering the risk of combustion
Otolaryngologic Surgery - Laser Surgery
Airway-fire protocol
What do you do in case of fire?
1) . Stop ventilation & Turn off O2 & disconnect anesthesia circuit from ETT
2) . Remove ETT and flood surgical field if flame persists
3) . Extinguish fire by placing removed ETT in H20
4) . Ventilate with 100% O2 by face mask
5). Reintubate with regular ETT
6) . Assess airway damage with bronchoscopy and flush with saline to remove debris & dissipate heat
7) . Obtain CXR
8) . Consider bronchial lavage and steroids
Great board exam technique to put in correct order.
The first action in an airway fire is to stop ventilation and remove the endotracheal tube, followed immediately by turning off/ disconnecting the oxygen. The sequence of subsequent actions varies (different references give slightly different orders) but includes: mask ventilation and reintubation; diagnose the injury, treat by bronchoscopy and laryngoscopy; administer short-term steroids; monitor the patient for at least 24 hours; and, administer antibiotics and provide ventilatory support as necessary.
[Longnecker, Tinker, and Morgan, PPA, 2nd ed., 1998, p1793; Morgan, et al., Clin. A nesthesiol., 3rd ed., 2002, p774; Miller, Anesthesia, 5th ed., 2000, p2 1871-0
Otolaryngologic Surgery
Tonsillectomy & Adenoidectomy
Preoperative considerations
Increased risk for airway complications
Chronic airway obstruction
(OSA - CO2 retention - Cor Pulmonale)
Increased risk for bacterial endocarditis
Postpone if acute infection present/clotting dysfunction (recent ASA ingestion)
Premedicate with antisialagogue
Procedures often performed separately or together
Adenoidectomy is less painful than Tonsillectomy**
Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy
Intraoperative considerations
Inhalation induction with pediatrics
No muscle relaxants until ability to ventilate is established
Reinforced or oral RAE tube
Reinforced tube Decreases kinking with self-retaining mouth gag
Throat pack placed
Decrease amount blood in stomach
Document placement and removal
Fairly painful (Tonsil> adenoidectomy)
Consider local anesthesia at surgical site
Decadron (↓ inflammation)