ROLE OF ANASTHESIA IN LASER , CRYOSURGERY AND MRI DEVICES
DR.M.HASIF MD A.PROFESSOR MODERATOR
DR.SYAMAPRASAD.P.S P.G.SCHOLAR DEPT.OF ANAESTHEISA GOVT.MEDICAL COLLEGE KOZHIKODE.
Laser is the acronym for Light Amplification by
Stimulated Emission of Radiation. Gordon Gould It provides the ability to transfer large quantities of energy to remote locations.
SALIENT FEATURES OF LASER RAYS
LASER AND ORDINARY LIGHT Laser ray is monochromatic Laser ray is coherent in nature
It is produced as collimated beam
DESIGN OF LASER
Components of a typical laser: 1. Gain medium 2. Laser pumping energy 3. High reflector 4. Output coupler 5. Laser beam
A laser consists of a gain medium, a mechanism to supply energy to it, and something to provide optical feedback. The gain medium is a material with properties that allow it to amplify light by stimulated emission. Light of a specific wavelength that passes through the gain medium is amplified (increases in power). For the gain medium to amplify light, it needs to be supplied with energy. This process is called pumping. The energy is typically supplied as an electrical current, or as light at a different wavelength. Pump light may be provided by a flash lamp or by another laser. The most common type of laser uses feedback from an optical cavity—a pair of mirrors on either end of the gain medium. Light bounces back and forth between the mirrors, passing through the gain medium and being amplified each time. Typically one of the two mirrors, the output coupler, is partially transparent. Some of the light escapes through this mirror. Depending on the design of the cavity (whether the mirrors are flat or curved), the light coming out of the laser may spread out or form a narrow beam. This type of device is sometimes called a laser oscillator in analogy to electronic oscillators, in which an electronic amplifier receives electrical feedback that causes it to produce a signal. Most practical lasers contain additional elements that affect properties of the emitted light such as the polarization, the wavelength, and the shape of the beam.
these relatively low cost but highly coherent lasers are extremely common in optical research and educational laboratories. which produces rather incoherent UV light at 337. This emission is in the thermal infrared at 10. 488 nm and 514. The efficiency of a CO2 laser is unusually high: over 10%. however the vast majority are engineered to lase at 633 nm. The helium-neon laser (HeNe) is able to operate at a number of different wavelengths.7 nm. the most commonly used lines are 458 nm. A nitrogen transverse electrical discharge in gas at atmospheric pressure (TEA) laser is an inexpensive gas laser.1 nm. Commercial carbon dioxide (CO2) lasers can emit many hundreds of watts in a single spatial mode which can be concentrated into a tiny spot.Types of lasers
Gas lasers using many different gases have been built and used for many
purposes. Argon-ion lasers can operate at a number of lasing transitions between 351 and 528.
.5 nm. such lasers are regularly used in industry for cutting and welding. often home-built by hobbyists.6 µm. Depending on the optical design one or more of these transitions can be lasing simultaneously.
Chemical lasers are powered by a chemical reaction permitting a large amount of energy to be released quickly. have been developed and have some industrial applications. Such very high power lasers are especially of interest to the military. As examples. however continuous wave chemical lasers at very high power levels.
. fed by streams of gasses. in the Hydrogen fluoride laser (2700–2900 nm) and the Deuterium fluoride laser (3800 nm) the reaction is the combination of hydrogen or deuterium gas with combustion products of ethylene in nitrogen trifluoride.
however this appears to be a misnomer inasmuch as F2 is a stable compound. Excimer lasers typically operate at ultraviolet wavelengths with major applications including semiconductor photolithography and LASIK eye surgery. emitting at 157 nm in the vacuum ultraviolet is sometimes referred to as an excimer laser.
. Once the molecule transfers its excitation energy to a photon. These are molecules which can only exist with one atom in an excited electronic state. Commonly used excimer molecules include ArF (emission at 193 nm). KrCl (222 nm). or more precisely an exciplex in existing designs. KrF (248 nm). its atoms are no longer bound to each other and the molecule disintegrates. therefore.Excimer lasers:
Excimer lasers are a special sort of gas laser powered by an electric discharge in which the lasing medium is an excimer. and XeF (351 nm). The molecular fluorine laser. noble gasses are chemically inert and can only form compounds while in an excited state. This drastically reduces the population of the lower energy state thus greatly facilitating a population inversion. XeCl (308 nm). Excimers currently used are all noble gas compounds.
Solid state lasers
Solid-state lasers use a crystalline or glass rod
which is doped with ions that provide the required energy states. Fiber lasers: Solid-state lasers or laser amplifiers where the light is guided due to the total internal reflection in a single mode optical fiber are instead called fiber lasers. Guiding of light allows extremely long gain regions providing good cooling conditions. fibers have high surface area to volume ratio which allows efficient cooling. In addition. the fiber's waveguiding properties tend to reduce thermal distortion of the beam
PHOTONIC CRYSTAL LASERS
SEMICONDUCTOR LASERS DYE LASERS
FREE ELECTRON LASERS
BIOLASER EXOTIC LASER MEDIA
CLINICAL APPLICATION OF LASER
Corneal and retinal surgery
Dermatological uses Dental and arthroscopy
• CO2 • Nd YAG • H YAG
XF XCl KF KCl Ruby organic
Ophthalmic and ENT surgeries.
HAZARDS OF LASER
Perforation of vessel or structure Embolism Energy transfer
The lid of patient’s non operated eye should be taped and then covered with an opaque substance. 5. 4. 3. 2.Pre-cautions
1. Nd:YAG lasers requires green tinted spectacles Argon or krypton require orange lens filter KTPNd:YAG laser needs red google
. CO2 laser instead of opaque substance clear glass or plastic lens can be used.
5 percentage. Unrecognized flame can result in lung pharenchymal injury
Due to high energy delivery rate any hydrocarbon
material can ignite and burn in an oxygen enriched atmosphere.5 to 1. Fire can result form direct laser illumination or due to reflection.Endo tracheal tube fire
The most feared and dangerous complication.
Reduces FI O2 to less than 40% Nitrous oxide Use of air oxygen mixture is accepted
.Effect of respiratory gas mixture
Combustion is more vigorous and excess oxidation
.Protection of endo-tracheal tube
Usage of special tubes wrapping the tube
reducing O2 concentration.
Wrapping the tube with moistened muslin. Plastic
i. Copper foils iii. Metalized foil tape wrapping.
Three types of tapes for wrapping
Aluminum foils ii.
End of the tape should cut at angle of 60degree and
the cut end should be aligned with the proximal end of the cuff junction.Wrapping …….precautions
Clean tube should be wiped with alcohol to remove
residue and then with tincture of benzoin or mastiol.
Cover the cuff with moistened cotton.
Fill the cuff with coloured saline to signal a puncture.Protection of endo-tracheal cuff
Place the cuff as far as possible from the source of
Saline inflatable PVC.
.Metal endotracheal tube
Interlocking stainless steel tube.
These include the Laser-Shield II. the Laser-Flex Tracheal Tube. and Nd-YAG lasers. Their cuffs are filled with saline rather than air. the Bivona Fome-Cuf Laser Tube.
. tubes used in laser surgery are made of metal impregnated silicone. and the Lasertubus. the Sheridan Laser Tracheal Tube. These tubes provide variable amounts of protection against combustion with the use of CO2.TYPES OF TUBES IN LASER
Standard endo-tracheal tubes made of PVC or rubber can
ignite when exposed to lasers. There are several types of tubes manufactured for use with laser surgery. For this reason. the Norton Tube. potassium-titanyl-phosphate (KTP).
Over inflation may result in tracheal damage Recommendation: Use 30% oxygen / 70% helium.Laser-Shield II
Laser-Shield II (Medtronic) – For CO2 (10. or 30% oxygen / 70% room air
. or ANY TYPE other than CO2 or KTP.600 nm)
and KTP (532 nm) WARNING: Do not use with Nd:YAG laser or argon laser. Do not use nitrous oxide for dilution of oxygen Don not over-inflate the cuff.
Adverse effects i.
. Distal brochial seeding of papilomas obsruction to surgical
fields. Pneumo thorax iii. Intermittent high pressure oxygen supply directed at glottis through a small metal tube. Gastric distention v. Restriction of use of intravenous anesethic agents iv.Jet ventilation
Ventilation produced by a narrow high speed gas stream in a
ventury tube. Barotrauma ii.
high-frequency electromagnetic (radiofrequency) waves. Secondary dangers of these energy sources include high-level acoustic noise. systemic and localized heating. and accidental projectiles.Magnetic Resonance Imaging
magnetic resonance imaging (MRI) suite is a hazardous location because of the presence of a strong static magnetic field. the MRI environment frequently requires the anesthesiologist to assume broader responsibility for immediate patient care decisions. There may be significant challenges to anesthetic administration and monitoring capabilities due to static and dynamic magnetic fields as well as radiofrequency energy emissions. and a time-varied (pulsed) magnetic field. a conventional operating room.
Magnetic resonance image Imaged is produced by alternating penetration of
Ferromagentic materials must be removed.MRI DEVICES AND ANASESTIA
Patient movement will compromise the quality of
. While in scanner assess and view of patient is limited. Malfunctioning of monitor due change in magentic field. Stray radio frequency current will affect quality of image.
High-risk imaging refers to imaging in patients with
medical or health-related risks.. such as MRI-guided surgery. and procedure-related risks.
.g.ASA Definition of Anesthetic Care for MRI and High risk Imaging
This Advisory defines anesthetic care for MRI as
moderate sedation. or ventilatory and critical care support. deep sedation. monitored anesthesia care. or cardiac and airway imaging studies. radiofrequency ablation). minimally invasive procedures (e. imaging with equipment-related risks. general anesthesia.
Identify potential health hazards (e.
Promote optimal patient management and reduce adverse
patient outcomes associated with MRI. Identify potential equipment-related hazards in the MRI environment. Identify limitations of physiologic monitoring capabilities in the MRI environment.. high decibel levels) of the MRI environment.
Prevent the occurrence of MRI-associated accidents.
.g.Purposes of ASA Advisory
Promote patient and staff safety in the MRI environment.
Level III refers to facilities that are designed for
.Advisory focuses on MRI settings
Level I is excluded where no anesthetic care is
Level II refers to facilities that image patients
requiring monitoring or life support.
This region includes all areas that are freely accessible to the general public. This area is typically outside the MR environment itself and is the area through which patients. healthcare personnel. and other employees of the MR site access the MR environment.
but rather are under the supervision of MR personnel.Zone II
This area is the interface between the publicly accessible uncontrolled zone I and the strictly controlled zone III. and answers to magnetic resonance imaging screening questions are typically obtained. the patients are greeted in zone II and are not free to move throughout zone II at will. Typically. It is in zone II that patient histories.
. answers to medical insurance questions.
. with access to regions within it controlled by.Zone III
This area is the region in which free access by unscreened non-MR personnel or ferromagnetic objects or equipment can result in serious injury or death as a result of interactions between the individuals or equipment and the MR scanner’s particular environment. MR personnel. but are not limited to. These interactions include. those with the MR scanner’s static and time varying magnetic fields. and entirely under the supervision of. All access to zone III is to be strictly restricted.
by definition. Zone IV.Zone IV
This area is the MR scanner magnet room. will always be located within zone III because it is the MR magnet and its associated magnetic field. which generates the existence of zone III.
This Advisory is intended for use by anesthesiologists or other
individuals working under the supervision of an anesthesiologist. and industry representatives). technologists.
. nurses. Because the safe conduct of MRI procedures requires close collaboration and prompt coordination between anesthesiologists. and nurses.g. some responsibilities are shared among the disciplines. MRI technologists. When shared responsibilities are described in this Advisory.. or medically directed by anesthesiologists. the intent is to give the anesthesiologist a starting point for participating in the allocation and understanding of shared responsibilities. and applies to anesthetic care performed. The Advisory may also serve as a resource for other physicians and healthcare professionals (e. supervised. radiologists. biomedical engineers. hospital administrators. or to moderate sedation care supervised by other physicians. safety officers.
Deep Sedation Is Riskier Than General Anesthesia.
± Airway reflexes
Laryngospasm Uncontrolled airway Who is caring for the deeply sedated patient? Training? Credentialing?
No ASA Guidelines
.Minimal Sedation .
Moderate Sedation ASA Guidelines
Responds sluggishly and purposefully to
verbal command or tactile stimulation (stroking face. squeezing arms/thighs)
. wet cloth.
Attempts to remove painful stimulus (i.Deep Sedation .e.
Responds appropriately to repeated / painful
stimulation (Neuro exam in comatose patient pinching arms/legs.
. Cherry angiomas can be treated with one 10second freeze-thaw cycle with a 1-mm margin. iv. Vascular malformations of blue rubber bleb nevus syndrome have been treated with a single 10second freeze
i. Capillary hemangioma can be treated with two 30second freeze-thaw cycles with a 1-mm margin.CRYOTHERAPY
AIDS-related Kaposi sarcoma can be treated by performing two 30-second freeze-thaw cycles with 3-mm margins every 4 weeks. iii.
i. iv. Skin tags can be treated with one 10-second freezethaw cycle. Seborrheic keratosis can be treated with one 10second freeze-thaw cycle. For milia.
Cysts and tumors
One 10-second freeze-thaw cycle with a 1-mm margin can be used to treat acne cysts. a short freeze-thaw cycle of 5-10 seconds is usually adequate iii. ii.
CRYO. or simply dabbed on with a cotton or foam swab.METHODS
A common method of freezing lesions is using liquid
nitrogen as the cooling solution. doctors use carbon dioxide "snow" formed into a cylinder or mixed with acetone to form a slush that is applied directly to the treated tissue. Carbon dioxide Less frequently.
. circulated through a tube called a cryoprobe. The super-cooled liquid may be sprayed on the diseased tissue.
The mixture is stored in an aerosol spray type container at room temperature and drops to −41 °C (−42 °F) when dispensed. The mixture is often dispensed into a straw with a cotton-tipped swab. Scholl's Freeze Away.METHODS
Argon Recent advances in technology have allowed for the use
of argon gas to drive ice formation using a principle known as the Joule-Thomson effect.CRYO.
. and minimizing complications using ultra-thin 17 gauge cryonee Dimethyl ether – propane: A mixture of dimethyl ether and propane is used in some preparations such as Dr. This gives physicians excellent control of the ice.
permanent. Acute complications include headache. keloids. (2) delayed. hyperpigmentation. Delayed complications include hemorrhage. atrophy. and excessive granulation tissue formation. and ectropion formation. Prolonged-temporary complications include milia. and change in sensation. and blister formation. scarring.
. hypopigmentation. (3) prolonged-temporary. pain. Permanent complications include alopecia. infection.COMPLICATIONS
ice massage. The pain-
relieving benefits of snow and ice were first written about by the Greek physician Hippocrates thousands of years ago. and whirlpools. you are treating your pain with a modern (although basic) version of cryotherapy.CRYO AND PAIN
Cryotherapy literally means cold therapy. coolant sprays. When used to treat injuries at home. Cryotherapy can be applied in various ways.
. cryotherapy refers to cold therapy with ice or gel packs that are usually kept in the freezer until needed. time-tested remedies for managing pain and swelling. These remain one of the simplest. When you press a bag of frozen peas on a swollen ankle or knee. including icepacks.
compression.E. Pain and swelling after a hip or knee replacement. Cryotherapy is the "I" component of R. It increases pain tolerance. ice.C. It reduces the nerve activity. and elevation).I. (rest.
. To treat pain or swelling under a cast or a splint. Cryotherapy for pain relief may be used for: Runner's knee . particularly ones caused by sports. Arthritis pain Controlling heat exhaustion until help arrives. a treatment recommended for the home care of many injuries. Lower back pain Studies have shown the benefits of applying ice: It lowers your skin temperature.
Nerve ablation by cryo therapy interprets the axonal
conduction and help to reduce the pain for a long duration.
the time the cells remain frozen and the subsequent rate of heating during thawing. Important factors which influence the procedure are the rate of temperature reduction after the initiation of freezing.Cryosurgical ablation or cryotherapy is a minimally invasive procedure that uses very precise freezing and thawing technology to destroy prostate cancer cells. when Egyptians applied cold water to relieve pain. especially during the past decade with the introduction of accurate imaging using ultrasound. Today.
.C. The damage caused by freezing cells is scientifically evident at molecular. cellular and whole tissue levels. controllable freezing using Argon gas and reduced complications using ultra-thin cryoablation needles (size of the biopsy needle). The concept of cryotherapy was used as far back as 2500 B. modern cryotherapy has experienced great advances.
Contraindications can be divided into 2 groups:
relative contraindications and absolute contraindications.cryoglobulinemia. Relative contraindications include cold intolerance. and Raynaud disease.
. history of pyoderma gangrenosum. Absolute contraindications include the use of cryotherapy near the eye margins.
which may leads to reduce and difficult outcome from general anesthesia.
HYPOTHERMIA is the main complication of