LASERS
79. Lasers
What do you understand by the
term ‘laser’?
Describe the basic physics
underpinning laser technology.
What are the fundamental
components within a laser
device?
List the different types of lasers
with their clinical applications.
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Laser is an acronym for ‘light amplification by the stimulated emission of
radiation’. Lasers produce an intense beam of light that is monochromatic
(single wavelength), coherent (in phase) and collimated (parallel). Laser
technology allows high-energy intensities to be produced from relatively
low-power sources.
> The quantum theory states that electrons are confined to certain energy
states but these electrons can move between these energy states
depending on whether they absorb or emit energy.
> Einstein demonstrated that if you stimulated an atom with a photon of
energy, this stimulated atom would in turn emit a photon of equivalent
energy, which was in phase with the original stimulating photon. This
new emitted photon could now cause a further similar reaction and
as such a chain reaction and hence amplification of the system would
ensue.
> In lasers, an external source of energy (e.g. high voltage or flash of light)
is applied to a laser medium.
> This increases the energy state of the electrons within the laser medium
and moves them up from a ‘ground’ energy state to an ‘excited’ energy
state.
> When these excited electrons return to their original ground state they
emit energy in the form of light or radiation.
> This emitted energy can then stimulate further electrons within the
medium, thereby amplifying the whole process.
> The wavelength of light produced depends on the lasing medium that
is used.
> External energy source (to ‘stimulate’ the electrons)
> Laser medium (this can be a solid, liquid or a gas)
> Chamber containing the laser medium
> System of mirrors (to allow ‘amplification’ of radiation)
> A partially reflective mirror (to allow the emitted radiation to exit the
system)
> Windows at each end of the device are inclined to Brewster’s angle (this
is the angle of incidence at which light is perfectly transmitted with no
reflection, thereby ensuring that 100% of the light is transmitted through
the windows)
> Fibre-optic cable (to direct the laser beam).
> Nd-YAG (neodymium-doped-yttrium aluminium garnet) lasers
• Crystal used as a lasing medium in solid-state lasers.
• Wavelength of light produced is 1064 nm (near infrared region).
• Good tissue penetration (as it is not absorbed by water).
• Used typically for endoscopic surgery (there have been reports of
inadvertent pneumothoraces during ENT surgery due to these lasers
penetrating and affecting tissues deeper than anticipated).
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 02 PHYSICS
How are lasers classified?
What are the hazards of laser
surgery?
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> Carbon dioxide lasers
• Used as a lasing medium in gas-state lasers.
• Highest power laser currently available (also used in industry for
cutting, welding and engraving).
• Wavelength of light produced is 10.6 μm (infrared region).
• Poor tissue penetration of <200 μm (as it is absorbed by water
causing it to vaporise and destroy tissue contents).
• Used typically for superficial surgery (e.g. dermabrasion and laser
‘facelifts’).
• Unsuitable for endoscopic use.
> Argon lasers
• Used as a lasing medium in gas-state lasers.
• Wavelength of light produced is between 400 and 700 nm (blue-green
region of the visible spectrum).
• Good penetration through transparent tissues (e.g. aqueous humour,
vitreous humour and lens of the eye).
• Maximally absorbed by red-pigmented tissues (e.g. birthmarks,
haemoglobin).
• Used typically in eye surgery (e.g. retinal phototherapy) and in
dermatological procedures to cosmetically enhance pigmented
lesions.
> Dye lasers
• Organic dye used as a lasing medium in liquid-state lasers.
• Wavelength of light produced is broad and varies occurring to the dye
used.
• Used typically in ‘beauty clinics’ to even out skin tone.
> Class 1 – power does not exceed maximum permissible exposure for
the eye.
> Class 2 – power up to 1 mW and visible laser beams only. Eye protected
by blink reflex.
> Class 3a – power up to 5 mW and visible spectrum only but now laser
beam must be expanded (so that maximum irradiance does not exceed
25 W/m2); eyes protected by blink reflex.
> Class 3b – power up to 0.5 W and any wavelength; direct viewing
hazardous; dye protection essential.
> Class 4 – power > 0.5 W and any wavelength; extremely hazardous and
capable of igniting inflammable materials; eye protection essential.
Lasers are hazardous to use because they combine high-energy intensities
confined within a small spot size (i.e. very concentrated) and transmitted
in a non-divergent beam (i.e. these devices do not lose power with
increasing distance from the laser source). For comparison, when looking
directly into sunlight the eye is exposed to approximately 150 W/m2 but if
inadvertently looking into a laser beam, the eye is exposed to approximately
3 × 106 W/m2!
> Environment:
• Fire and explosions – flammable spirits, oxygen and nitrous oxide can
get collected in the drapes and these can get ignited if the laser beam
is directed to it.
> Staff:
• Eyes – if the laser beam hits the retina, a permanent blind spot can
develop, but if it hits the optic nerve permanent blindness can be
caused (CO2 lasers do not penetrate the cornea and therefore cannot
affect the retina).
• Skin – if the laser beam hits the skin, a burning sensation is felt and
this will trigger self-protecting manoeuvres.
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What precautions are taken to
minimise the hazards of laser
surgery?
What are the basic concepts
in managing an airway fire?
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LASERS
> Laser hazards affecting the anaesthetised patient:
• Eyes – as above.
• Skin – now self-protecting manoeuvres do not come to play and
therefore patients are at risk of laser burns.
• Airway fire – this is a real risk during laser surgery to the upper airway
(this is an anaesthetic emergency and therefore you must be well
versed with both the precautions needed to prevent this and the
immediate management required to deal with this).
> General:
• Designated laser protection supervisor for each theatre
• Staff all trained and educated in laser use
• Doors locked, windows closed and signs displayed to protect those
outside theatre.
> Equipment:
• Eye protection goggles (laser beam wavelength-specific) for both staff
and patient
• Surgical instruments with a black or matt finish to minimise refection
of laser beam.
> Anaesthetic considerations for upper airway laser surgery:
• Double-cuffed, laser-resistant endotracheal tube (these are often
flexible stainless steel tubes with two cuffs to ensure a tracheal seal if
the upper cuff is accidentally damaged by the laser)
• Cuffs filled with saline (air-filled cuffs may ignite if hit by the laser)
• Throat packed with wet swabs (to protect adjacent areas from
inadvertent laser burns)
• Oxygen – air mix (as nitrous oxide is more flammable)
• FiO2 < 0.25 if tolerated
> Call for help and inform your immediate theatre team.
> Surgeon to switch off laser and flood the operation site with water.
> Disconnect the anaesthetic machine.
> Remove endotracheal tube if feasible (remember that even laser-resistant
tubes can ignite).
> Ventilate the patient with a bag-valve-mask circuit (if necessary continue
anaesthesia with TIVA).
> Surgeon to inspect the airway with rigid bronchoscope.
> Refer to ITU (airway fires can cause significant lung injury and
ARDS – patient may require ventilation, dexamethasone, and humidified
oxygen).
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