REVIEWARTICLE

Anesthetic Considerations for Laser Surgery

Ira J. Rampil, MS, MD
Department of Anesthesia, University of California, San Francisco, California

L aser is an acronym for Light Amplification by

Stimulated Emission of Radiation. This article
will review relevant highlights of the physics of
lasers and laser light, rationales for the variety of
lasers in clinical use, and important anesthesia-
oscillate synchronously in identical phase. In ordi-
nary light, the electromagnetic fields are phased
randomly, even at the same wavelength. Third, di-
rected beams of laser light are collimated, i.e., have
minimal dispersion. The light remains in a narrow,
related concerns during laser surgery. collimated beam, whereas ordinary light beams
spread out in all directions from a source point. These
three characteristics allow lasers to generate intense
Physics of Laser Light light beams, to send such beams efficiently and
accurately through lenses, and to deliver intense
Visual light is electromagnetic radiation, just as are energy to small target sites.
radio waves, x-rays, and yrays. These different
classes of electromagnetic radiation simply occur at
very different wavelengths. Einstein explained that Laser System Hardware
all electromagnetic radiation (e.g. , light, radio, x-ray) The essential components of a laser system include a
consisted of wavelike quanta called photons that lasing medium that holds the atoms whose electrons
Contain energy proportional to their vibrational fre- create the laser light; resonating mirrors to boost
quency, lasing efficiency; and an energy source to excite or
“pump” the lasing atoms into producing laser light
E 0) = hv, (Figure 1).The different types of lasers used in clinical
practice use a variety of lasing media and energy
where J is joules, h is Planck’s constant = 6.63 x lo-% pumps. Some lasers use a gaseous lasing media such
(J-s), and v is the frequency of the photon in cycles per
second;
as C02, argon, krypton, or helium-neon, and are
pumped by electric discharge through the gas. Gas
Propagate without diminution in vacuum at 299,800,000 lasers may produce either a continuous or intermit-
d S , tently pulsed beam output. Other lasers use solid
Have a wavelength (A) that can be calculated as rods of laser-passive material containing small quan-
2.998 x lo8 ( d s )
tities of ionic impurities, known as dopants, that are
A (m) = the actual lasing material. Dopants commonly used
v (Hz) for their laser potential include chromium (as in the
The wavelength for visible light ranges from 385 nm ruby laser), neodymium (Nd), or holmium (Ho). A
(nanometers, m) to 760 nm; shorter wavelengths synthetic gem crystal known as YAG (yttrium-
are ultraviolet, longer are infrared. aluminum-garnet) is commonly used as a passive
Laser light differs from ordinary light in three host matrix, but even glass has been used. Solid
ways. First, it is highly monochromatic. Laser light lasers are usually pumped by high-energy photons
consists of photons that have a well-defined, very from a xenon flash lamp, and therefore produce a
narrow band of wavelengths, whereas ordinary light pulsed beam. Lasers also can be made from liquid
contains a wide spectrum of wavelengths. Second, dyes and semiconductors, but these technologies
laser light is coherent. Coherence implies that the have yet to appear in a significant way in surgical
electromagneticfields of all photons in the laser beam practice. Some medically relevant lasing media and
their respective output wavelengths are listed in
Table 1.
Accepted for publication November 12, 1991.
Address correspondence to Dr. Rampil, Department of Anes- Frequency doublers convert laser light to a different
thesia, C-450 Box 0648,University of California, San Francisco, CA wavelength, enhancing therapeutic flexibility. A
94143-0648. beam of laser light passed through a crystal of potas-

81992 by the International Anesthesia Research Society

424 Anesth Analg 1992;74:42&35 0003-2999/92/$5.00
ANESTH ANALC REVIEWARTICLE RAMPIL 425
1992;74424-35 LASER SURGERY

convenient, flexible conduit for visible and near-

infrared wavelengths. Wavelengths outside this
range, such as the long infrared from a C02 laser,
require either an articulated arm containing front-
surface mirrors at each joint or newly developed
exotic materials in a fiberoptic bundle. Once the laser
beam is delivered in proximity to the surgical site, it is
either focused to the site by the lens of an operating
microscope, or the shape of the beam can be inten-
tionally altered by passing it through a contact probe
Figure 1. Generic laser hardware. A laser system consists of directly on the tissue to be lasered.
several components, irrespective of whether the laser is solid-,
liquid-, or gas-based media. The central component is the lasing An operating microscope accurately aims a laser by
media itself. This may, for example, be a solid crystal of YAG with directing a low-powered (“1 mw) visible beam,
a small concentration of neodymium, or a tube containing carbon usually from a low-powered He-Ne gas laser,
dioxide. The energy pump provides the means of obtaining a through the same optical path as the surgical laser.
population inversion (see text) of orbital electrons; it may consist of
a xenon flash lamp or an electric spark generator. A pair of axial Some surgical lasers can be focused to a spot size of
mirrors allow repeated passes of collimated photons through the 30 pm (0.030 mm), creating very high power densi-
media, allowing maximum amplification by stimulated emission. ties.
The mirror on the right is not 100%reflective, allowing the beam to
eventually escape. The optional Q-switch increases efficiency of For surgical procedures that do not require a
pulsed lasers by allowing a small delay to increase the pumping. “no-touch” technique, there are special heat-resistant
(sapphire)direct-contact probes (1)(Figure 2) that are
replaceable and can be designed for sharp cutting or
sium-titanyl-phosphate (KTP) will emerge with a diffuse coagulation as needed. These probes require
mixture of the original wavelength and a wavelength active cooling in the form of a compressed gas or
one-half of the original (double the frequency). In liquid jet, a feature that has become responsible for
medical lasers, KTP is most often used with Nd-YAG. significant recent laser-related morbidity and mortal-
Truly tunable lasers now exist, but are still relatively ity (2). The mechanism of action of the contact probe
low-powered devices. is probably a combination of thermal conversion
A light guide directs the laser beam to the surgical within the sapphire (heating the surface to >800°C) of
site as illustrated in Figure 2. Fiberoptic bundles are a most of the laser energy and transmission of perhaps
20% of the near-infrared energy to the surrounding
tissue (3).
Table 1. Laser Media Wavelengths
Laser media Color Wavelength (nm) Clinical Applications
Carbon dioxide Far infrared 10,600
Erbium-YAG Infrared 2,930 Lasers are now used as scalpels and electrocoagula-
Holmium-YAG Infrared 2,060 tors with some unique advantages. For example,
Neodymium-YAG Near infrared 1,064 lasers allow highly precise microsurgery, even in
Ruby Red 694 confined or difficult-to-reachlocations. The ability to
Krypton Red 647 focus laser beams on small target areas concentrates
Helium-neon Red 632 the intensity or power per area enormously. For
Gold (vapor) Red 632
Organic dye (liquid) Red 632
example, a 10-w beam, originally 1 cm2 in area,
Organic dye (liquid) Yellow 585 would have a power density of 10,OOO W/cm2 when
Copper (vapor) Yellow 578 focused on a target area of 0.001 an2.This power
Organic dye (liquid) Yellow 577 density delivers approximately 2500 calories per sec-
Krypton Yellow 568 ond to the target site, producing heating at a rate of
KTP-Nd-YAG Green 532 many thousand degrees per second, depending on
Krypton Green 531 the volume of energy absorption. This energy deliv-
Argon Green 515
Copper (vapor) Green 510
ery allows precise, rapid vaporization of tissue, or
Organic dye (liquid) Green 504 indeed most materials save metals and ceramics.
Argon Blue 488 Lasers do not increase the energy of a particular
Xenon fluoride Ultraviolet 351 photon, but simply can place more photons of the
Xenon chloride Ultraviolet 308 same energy at a given place and time than other
Krypton fluoride Ultraviolet 248 light sources. Laser surgery is relatively “dry,” pro-
Krypton chloride U1traviolet 222 viding near instantaneous sealing of small blood
Argon fluoride Ultraviolet 193
vessels and lymphatics, even in the presence of
426 REVIEW ARTICLE RAMPIL ANESTH ANALG
LASER SURGERY 1992;74:42&35

Figure 2. Light guides. On the left is a schematic representation of a CO, laser guide as might be found in either an operating microscope
or a hand-held wand. The guide consists of rigid hollow tubes with hinged, aligned mirrors that reflect the beam from its source through
the focusing lens. On the right of the figure is a schematic of a flexible fiberoptic guide with a sapphire contact scalpel and a coaxial cooling
system.

clotting abnormalities; however, early claims for krypton (426, 521, and 568 nm) gas lasers is transmit-
faster than normal healing and lower infection rates ted by water, but intensely absorbed by hemoglobin,
have not been validated. providing the ability to penetrate skin or ocular
structures and selectively coagulate vascular or pig-
mented regions. Although lasers that produce infra-
Laser Interaction With Tissue red or visible light have exclusively thermal effects on
Living tissue is a complex aqueous solution contain- tissue, the photons produced by ultraviolet excimer
ing a variety of molecules that absorb light. When an lasers are energetic enough to directly disrupt chem-
atom interacts with a photon whose energy does not ical bonds and cause ionization, which in turn can
exactly match a possible electron transition, its en- lead to mutation and carcinogenesis.
ergy may be translated into atomic vibrations we
recognize as heat. The degree to which a particular Risks of Laser Use
wavelength of light is absorbed and converted to heat
in the tissue of interest will determine its effect on Standards and Regulations
that tissue. Long infrared wavelengths are absorbed
with great efficiency by water, the main constituent of Because they are potentially dangerous technologic
tissue. Therefore long-wavelength laser light, like devices, the medical use of lasers is subject to both
that from CO, (operating at 10,600 nm), is completely some degree of federal regulation and to voluntary
absorbed by water in the first few layers of cells, With consensus standards to minimize possible risks. The
powerful, focused CO,beams, this leads to explosive
vaporization of the tissue surface at the target with
surprisingly little damage to underlying tissue. The
new excimer lasers produce ultraviolet light that is
even more intensely absorbed by water and other
molecules and thus has an even more superficial
effect. Near-infrared light from an Nd-YAG laser at
1064 nm is much less absorbed by water, and the
beam is transmitted and scattered through a volume
of tissue perhaps 10&1000 times the volume through
which a COz beam diffuses. Consequently, the en-
ergy of an Nd-YAG beam is more widely dissemi-
nated (Figure 3), producing less vaporization and
more thermal coagulation (i.e., a cooking effect).
Some of the effects of this beam may not be apparent
for hours or days after exposure. Red light, as from a
ruby laser (694 nm), is poorly absorbed except by cells Figure 3. Different wavelengths of laser light cause different pat-
containing dark pigment. The green and blue light terns of tissue destruction. The actual destructive effect of laser
produced by argon (488 and 514 nm, respectively) or light on tissue depends on both laser parameters and tissue factors.
ANESTH ANALG REVIEWARTICLE RAMPIL 427
1992;7442rM5 LASER SURGERY

US. Food and Drug Administration (FDA) controls

the manufacture and marketing of medical laser
equipment. There are presently no mandatory federal
regulations governing the clinical use of or safety
precautions for lasers. The current standard to which
institutions that use lasers should subscribe is the
American National Standard for the Safe Use of Lasers in
Health Care Facilities (2136.3-1988) published by the
American National Standards Institute (ANSI).
(ANSI 2136.3-1988 is available from the American
National Standards Institute, Inc., 1430 Broadway,
New York, NY 10018, or from the Laser Institute of
America, 5151 Monroe Street, 102W, Toledo, OH
43623.) This document represents a consensus of
governmental, industrial, and professional authori- Figure 4. Distribution of laser-injury type reported to the FDA
ties on the methods used to define and control the 1189490. Data from Reference 5.
risks of laser use, to define and standardize training,
and to assess and ensure safety. Several states have
adopted variations of a set of regulations suggested
by the FDA (4),and the U.S.Occupational Safety and of these particles falls within the range that is effi-
Health Administration (OSHA) is empowered to in- ciently transported and deposited in the alveoli.
tervene if the medical use of lasers threatens the Many individuals find the odor of this plume objec-
health of employees. Although patients are at most tionable, and sensitive individuals have described
risk from the surgical use of lasers, injuries to staff headaches, tearing, and nausea as a consequence of
have not been rare. The safety guidelines proposed inhalation. Deposition of laser plume particulates in
by both the ANSI and the FDA should be followed to rat lung appears capable of producing interstitial
the maximal extent possible. pneumonia, bronchiolitis, reduced mucociliary clear-
Manufacturers are presently required to report ance, inflammation, and emphysema (7,8). Laser
unusual incidents or injury as they become aware of plume also has the potential to be mutagenic (9),
them. Clinicians, however, are required to report teratogenic, or a vector for viral infection. In vitro, the
complications due to laser use only when they occur mutagenic potential of laser condensate is half that of
in the course of a premarketing testing protocol; at electrocautery (lo), and the total mutagenic potential
other times, clinical reporting is voluntary. Conse- from 1g of tissue is comparable to that from smoking
quently, the true incidence of laser injury is not three to six cigarettes. The role of the smoke plume as
known with certainty. The passage by Congress of a viral vector is controversial: viral DNA has been
the Safe Medical Devices Act of 1990 will require detected in plumes from condyloma [11,12] and skin
reporting by clinicians of all serious injuries and warts (13), but not from laryngeal papilloma (14).The
should provide more accurate data regarding the presence of HIV in laser plumes from infected tissue
prevalence of such injuries. has yet to be addressed, although HIV was not
detected in electrosurgical smoke plumes (15). Com-
petent transmission of any viral infection via smoke
Laser Hazards plume has yet to be demonstrated. Laser plume does
not appear to contain viable eukaryotic cells (i.e.,
The hazards owing to laser use can be separated into tumor cells [16,17])but may contain viable bacterial
four major categories: atmospheric contamination, spores (18,19).
perforation of a vessel or structure, embolism, and C02lasers seem to produce the most smoke owing
inappropriate energy transfer. There were 21 injuries to the vaporization of tissue; Nd-YAG contact probes,
reported to the FDA between January 1989 and June much less. The most effective means of preventing
1990, two were minor, 12 were serious, and there dissemination of the plume is with an efficient smoke
were seven mortalities (5). The distribution by type of evacuator at the surgical site (20,21). Ordinary surgi-
injury is illustrated in Figure 4. cal masks efficiently filter particles down to about
3.0 pm; therefore special high-efficiency masks (i.e.,
Atmospheric contamination. Vaporization of tissue, The Protector II, Anago, Fort Worth, Tex.) are needed
whether by electrosurgery or laser radiation, pro- to catch laser plume particulates. These high-
duces a plume of smoke and fine particulates (mean efficiency masks lose their efficiency when wet and
size 0.31 pm; range of sizes 0.1-0.8 pm [6]).The size may need to be changed periodically.
428 REVIEW ARTICLE RAMPIL ANESTH ANALG
LASER SURGERY 1992;74:42435

Perforation. Misdirected laser energy may perfo-

rate a viscus (22)or a large (uncoagulable by laser,
>5 mm) blood vessel. Laser-induced pneumothorax
after a laryngeal procedure also has been reported
(23). The depth of damage is impossible to judge
accurately when using an Nd-YAG system, and per-
foration may occur several days postoperatively
when edema and necrosis are maximal.

Embolism. Venous gas embolism may occur during

laparoscopic laser surgery, but has been a particular
problem during hysteroscopic surgery with Nd-YAG
contact probes when the gas coolant for the sapphire
probe tip has accidentally inflated the uterine cavity.
This technique resulted in five widely publicized Figure 5. Surgical drape fire from an accidentally misaimed laser
cases involving four deaths in 1989 (2). The contact pulse. Reproduced with permission of Health Devices and the
probe itself is not required for injury; a fatal gas Emergency Care Research Institute, from Airway fires: reducing
the risk during laser surgery. Health Devices 1990;14:109.
embolism during uterine insertion of a sheathed
quartz fiber (with coaxial coolant gas running) pro-
duced an immediate massive embolism (24). For this Eye Protection
reason, during hysteroscopy, liquid (saline) coolant is
the only safe option. If coolant gas must be used, The ANSI standard as well as common sense dictates
using carbon dioxide will result in the least damage that eye protection be used by all operating room staff
after an embolization when compared with either and the patient during the conduct of laser surgery.
nitrogen or air. If saline is used instead of gas for Errant infrared energy from a CO, laser can quickly
cause a serious corneal injury (29), whereas argon,
uterine distention, a fluid overload similar to that (KTP)Nd-YAG, or ruby lasers are more likely to burn
seen during transurethral prostate surgery is possible the retina (30). Patients’ (nonoperated) eyes should
(25). Venous gas embolization has also been reported be taped so the lids are closed, then covered with an
during Nd-YAG resection of tumor in the trachea opaque, saline-soaked knit or metal shield (31-33).
(26,27) and during various types of laparoscopic Operating room personnel must wear safety goggles
procedures. Recently, a laser coolant malfunction or lenses that are specific for the laser wavelength in
during laparoscopic ablation of endometriosis lesions use. Safety goggles should provide wrap-around pro-
at the author’s institution resulted in complete, sub- tection from reflected light. For C 0 2 lasers, any clear
cutaneous, air emphysema from which the patient glass or plastic lenses will suffice because they are
recovered after a benign course. During laparoscopic opaque to far-infrared light. Regular eyeglasses can
surgery with CO, insufflation, mechanical hyperven- be sufficient, but contact lens are not. Other lasers
tilation should be instituted to compensate for intra- require color filters whose wavelength specificity and
abdominal C 0 2 absorption and cephalad displace- optical density are regulated. Nd-YAG lasers require
ment of the diaphragm. Continuous airway C 0 2 either special green-tinted goggles, which make as-
monitoring is highly recommended for detection of sessment of patient skin color difficult, or newly
either embolization or hypercapnia. available clear lenses (Nd:YAG Protection Glass, Sur-
gical Laser Technologies, Malvern, Pa.) with a special
Energy transfer to an inapropriate location. All avail- coating opaque to near-infrared light. Argon or kryp-
able medical laser light is transmitted transparently ton lasers require an amber-orange lens filter, and
through air and is well reflected by smooth metal KTP-Nd-YAG lasers require a red filter. As lasers
surfaces. Pressing the laser control trigger at the other than the CO, produce beams that pass through
wrong time can deliver damaging laser light across glass, all windows into the operating room should be
the wound to sites where surgical ablation was not covered during laser procedures and warning signs
desired, or across the operating room into some- should be posted as described in ANSI 2136.3.
one’s eyes. Potentially tragic scenarios include laser
ignition of surgical drapes (28) (Figure 5) and, of Endotracheal Tube Fires
special interest to anesthesiologists, accidental ir-
radiation of an endotracheal tube during airway sur- A feared complication of laser use during airway
!Fry* surgery is endotracheal tube fire. The estimated inci-
ANESTH ANALG REVIEW ARTICLE W l L 429
1992;7442435 LASER SURGERY

the incidence of airway fire: (a) reduce the flamma-

bility of the endotracheal tube; (b) use Venturi venti-
lation; or (c) use intermittent apnea. Each of these will
be discussed.

Relative flammability.Given that all common endot-

racheal tubes are potentially flammable, considerable
effort has been expended to assess the relative risks of
the various types of construction material. For many
years, reusable red rubber tubes were commonplace,
then were eventually supplanted by clear polyvinyl-
chloride (PVC) plastic tubes. Modern PVC strongly
absorbs far-infrared light and is thus very sensitive to
CO, laser energy. Polyvinylchloride tubes appear to
be much more easily ignited by CO, lasers than red
Figure 6. Blowtorch ignition of an endotracheal tube. Reproduced rubber tubes (37,43,44) and to produce more toxic
with permission of Health Devices and the Emergency Care
Research Institute, from Airway fires: reducing the risk during combustion products. In vitro, PVC is transparent,
laser surgery. Health Devices 1990;14:109. and thus immune to Nd-YAG and visible laser light;
however, a thin coating of mucous or blood in vivo
will absorb energy and restore the hazard. Two
dence of this complication during such operations is recent studies of the effects of Nd-YAG laser energy
0.5% (34)-1.5% (35). A mail survey of otolaryngolo- on common types of tubes, including those designed
gists, although not providing an incidence for fires, to be resistant to laser light, revealed that endotra-
did demonstrate that laser-induced ignition of endo- cheal tubes of all materials are in fact quite vulnerable
tracheal tube, cuff, or cottonoids was responsible for (45,46).Ossoff et al. (43) compared the extent of acute
the majority (41%) of perioperative complications, damage to the trachea from blowtorch-type ignitions
followed by postoperative laryngeal web (19%)and in dogs receiving 1% halothane and 70% nitrous
laser-relatedhnduced facial burn (11%)(36).The larg- oxide (balance oxygen) through PVC, rubber, or
est published (retrospective)series of CO, laser air- silicone endotracheal tubes. They reported easiest
way surgery documented 6 of 4416 cases (0.14%) of ignition in the case of PVC, followed by intense
airway fire (37), confirming it as the most frequent flame, widespread deposit of carbonaceous debris,
laser-related complication in this group of patients. and significant postmortem ulceration and inflamma-
Given the proximity of the endotracheal tube to tion of the trachea. Red rubber tubes were more
surgical sites around the larynx, the potential for fire resistant to ignition and produced less debris and
or other airway complications is clear. Most of these inflammation. Silicone tubes were the most resistant
fires, when appropriately handled, result in minimal to ignition but produced copious white silica ash,
or no harm to the patient (34,38,39), but catastrophic leading the authors to speculate about potential late
consequences are possible (40,41). With the energy silicosis. In a subsequent study (43, Ossoff measured
delivery rates described earlier, any hydrocarbon the time to intraluminal ignition during exposure to
material, including tissue, plastic, and rubber, can CO, laser energy to determine resistance to ignition
ignite and burn, particularly in an oxygen-enriched and reversed the ranking of silicone and red rubber,
atmosphere. Fires can result from direct laser illumi- with PVC remaining the most vulnerable. He also
nation, reflected laser light, or incandescent particles found that the addition of 2% halothane vapor re-
of tissue blown from the surgical site (42). Initially, tarded ignition. The index of flammability once igni-
most fires are located solely on the external surface of tion occurs is the minimum necessary fraction of
the endotracheal tube where they can cause local inspired oxygen (FIo,) to maintain combustion. Wolf
thermal destruction. If the fire is unrecognized and and Simpson (48) concluded that PVC is actually less
burns through to the interior of the tube, then the flammable than silicone or red rubber, having a
oxygen-enriched gas and flow owing to ventilation flammability index of 0.26 versus 0.19 or 0.18 for
will produce a blowtorch-like flame blowing heat and silicone and red rubber, respectively. When nitrous
toxic products of combustion down to the pulmonary oxide was used as the oxidant, PVC retained the
parenchyma (Figure 6). Puncturing and deflating the highest index (0.46),followed by silicone (0.41) and
tube cuff may permit oxygen-enriched gas to flood red rubber (0.37).
the operative site and increase the chance of a dev- Despite the conflicting data, many authors recom-
astating fire after a subsequent laser burst. mend the use of red rubber endotracheal tubes dur-
Three approaches have been developed to reduce ing laser surgery of the aerodigestive tract, basing
430 REVIEW ARTICLE RAMPIL ANESTH ANALG
LASER SURGERY 1992;74:42&35

this suggestion on criteria of resistance to ignition mucosal surfaces. Perhaps the most popular ap-
and least toxic combustion products. However, at the proach to the problem has been wrapping the tube
University of California, San Francisco, one surgeon with metalized foil tape (35,44,45,47,56,59,60). Three
has performed 4000 microdirect laryngoscopies using types of tape have been used: aluminum foil with
a C 0 2 laser with two fires (0.005%), and no signifi- adhesive backing, copper foil with adhesive backing,
cant fire-related morbidity (personal communication, and a plastic tape that is thinly metalized on one side
H. H. Dedo) using foil-wrapped PVC endotracheal and has adhesive on the other. These tape products
tubes and moistened pledgets. are widely available from retail electronics, arts and
Regardless of the tube substrate material chosen, crafts, or building supply shops. A similar-appearing
there are additional safety considerations and maneu- product is the lead foil that is commonly used on
vers to consider; these are outlined below. windows for burglar alarms; this tape is toxic and
should never be used. The aluminum and copper
Effect of high oxygen or nitrous oxide gas mixture. The tapes have been assessed for their ability to protect
mixture of airway gases becomes an important issue different types of endotracheal tubes against a variety
when any type of potentially flammable endotracheal of lasers. Although taping cannot provide protection
tube is used. Combustion is more vigorous when of the inflatable cuff portion of an endotracheal tube,
excess oxidizer is present, and most clinicians recog- these metal tapes can offer a measure of protection
nize the need to reduce the FIO, below 0.40 or to the against inadvertent, unfocused C 0 2 laser hits. Metal
minimum concentration consistent with patient oxy- tape is a less certain shield against the near-infrared
genation. That nitrous oxide is also a powerful oxi- beam from a Nd-YAG laser. Sosis and Dillon (60)
dizer is less well recognized, but adding nitrous oxide found that metalized plastic tape (i.e., Radio Shack
as a diluent for oxygen is just as dangerous as having #44-1155) was actually more incendiary than an un-
a high FIO, (48). Using an aidoxygen mixture appears wrapped red rubber tube with a time to ignition
to be acceptable. Some investigators prefer helium as (50 W, beam diameter = 0.68 mm) of 6 s versus 13 s
a diluent to nitrogen because helium has a higher for the unwrapped control. The solid copper (1 mil
thermal conductivity and may delay the ignition of an Foil from Venture Tape Corp., Rockland, Mass.) or
endotracheal tube for a few seconds (47,49). The aluminum ( # a 5 or 433 from 3M Corp., Industrial
index of flammability is only reduced 1%-2% when Tape Division, St. Paul, Minn.) tapes were able to
oxygen/helium is substituted for oxygenhitrogen withstand at least 60 s of direct laser exposure with-
(50). Helium also has a lower viscosity and will allow out penetration or ignition. A recent study by Health
the use of a smaller endotracheal tube without turbu- Devices (61) also found that the metalized plastic
lence and high resistance to flow (51,52). tape, while most pliant and least likely to abrade the
The volatile anesthetics currently used in clinical larynx, provided protection only for C 0 2 lasers, not
practice are nonflammable and nonexplosive in clin- Nd-YAG or KTP-Nd-YAG lasers. The 3M aluminum
ically relevant concentrations (53,54). During an air- tape provided protection against C 0 2 and KTP-Nd-
way fire, however, they may pyrolize to potentially YAG lasers but did allow ignition of a PVC tube at the
toxic compounds (55). Thus, the ANSI 2136.3 stan- highest power setting of an Nd-YAG laser. Copper
dard recommends not using volatile anesthetics dur- tape (#1181, 3M Corp., Electrical Products Division,
ing airway laser surgery. This is an extremely con- St. Paul, Minn.) provided ignition protection from all
servative stance given the low concentration of three lasers.
anesthetic gas compared with the products of com- If a metal foil wrap is chosen to be used for laser
bustion from an endotracheal tube and the lack of surgery, its application on the endotracheal tube
evidence of toxicity owing to the pyrolytic products. requires some care. A clean tube should be wiped
In cases where Venturi ventilation is used, adminis- with alcohol to remove residue that would interfere
tration of volatile agents is not usually mechanically with adhesion, and then optionally be wiped lightly
possible. with Mastisol (Ferndale Laboratories, Ferndale,
Mich.) or tincture of benzoin. The end of the tape
Protective taping. Once the specter of endotracheal should be cut at an angle of about 60", and the cut
tube ignition was raised, extrinsic protection of the edge should be aligned with the proximal end of the
tubes was suggested (56). Patil and colleagues sug- cuff junction (Figure 7). A spiral wrap with approxi-
gested wrapping tubes with moistened muslin (57). If mately 30% overlap should continue at least to the
allowed to dry, the muslin would become flammable. exit point of the cuff pilot tube. Care needs to be
Kumar and Frost (58) suggested coating the vulnera- taken to prevent wrinkles that might abrade the
ble portion of the exterior of the tube with dental tracheal mucosa. There must be no windows of bare
acrylic. This approach, however, renders the tube tubing or areas of exposed tape adhesive (which is
rigid with a rough surface that may traumatize the quite flammable). Rewiping the wrapped tube with
ANESTH ANALG REVIEW ARTICLE RAMPlL 431
1992;74:42435 LASER SURGERY

shaft of the tube and cannot provide any protection

for the cuff.
Another commercially available, approved method
of endotracheal tube protection is to make a laser-
resistant coating an integral part of the tube. This
type of tube is available as the Xomed "Laser Shield'
tube that is fabricated from silicone with an outer
layer of finely divided aluminum powder in silicone.
The aluminized layer extends over the inflatable cuff.
The manufacturer (Xomed-Treace, Jacksonville, Fla.)
recommends this tube only be used with CO, lasers
and a beam intensity of less than 4900 W/cm2 and
specifies that the Fro, be less than 25%. This endo-
tracheal tube is more resistant to far-infrared radia-
tion than either PVC or red rubber tubes (62,63), but
the resistance is only relative and the tube will burn
vigorously once ignited in vitro (47), producing fria-
ble silica dust. There has been at least one case report
of an airway fire involving a Laser Shield tube (41).
Figure 7. Cuff wrapping technique. If a wrapped endotracheal This case involved a serious injury owing to an
tube is the chosen method for laser protection, the technique for intraluminal fire secondary to laser penetration of the
wrapping is critical in assuring both protection from ignition and cuff during a polyp excision with the power settings
from foil-induced mucosal abrasions. It is often helphl to first
sparingly paint the tube with a medical adhesive like benzoin or within specified limits but a high FIO, with balance
Mastisol. The end of the tape should be cut with a scalpel to nitrous oxide. The Laser Shield did not "pass" the
approximately 60". Begin wrapping by aligning the cut end of the Health Devices flammability test (61), igniting under
tape with the junction of the tube and the proximal end of the cuff. typical surgical conditions.
Wrap in a spiral with a 30%-50% overlap between layers. Wrap
including the inflation tube for the cuff and continue until just When using potentially flammable endotracheal
short of the pilot balloon. Take care not to wrinkle the tape at any tubes, four guidelines should be remembered:
point.
1. Minimize the FIO,
2. Use wet pledgets above the cuff after replacing the
alcohol will provide a degree of sterility before tra- pledget string with wire; remoisten pledgets fre-
cheal intubation. quently
Despite the fact that these metal foils have been 3. Use colored saline in the cuff
shown to be relatively effective in this regard, the 4. Place the cuff sufficientlydistal in the trachea to be
manufacturers have not pursued FDA review or out of direct sight of the operator.
approval as medical devices. Although it is not illegal
for a physician to create and use a custom device such Metal endotracheal tubes. In 1978, Norton and De
as a wrapped endotracheal tube, should an injury Vos (64)introduced a nonflammable endotracheal
occur, the clinician's legal position as a noncertified tube. The Norton tube is an interlocking stainless
"manufacturer" might be tenuous. Although the steel spiral coil resembling electrical cable armor. The
practice is well supported in the medical literature, tube walls are not airtight which, although allowing a
there may have been less risk of liability before the cooling gas flow to the exterior surface, may make
advent of the FDA-approved commercial products ventilation difficult in patients with relatively non-
described below. compliant lungs, particularly as this tube has no
A commercial, FDA-approved version of metallic inflatable cuff. Jet ventilation with a modified Sanders
foil wrap is the Merocel "Laser Guard" wrap (Mero- Venturi coupler has been suggested as a means to
cel Corp., Mystic, Conn.). This laser-protective wrap overcome this problem (65). Another alternative is a
has an adhesive metal foil with a synthetic sponge separate, slide-on cuff, but these are all flammable
surface. When properly placed on an endotracheal and thus may present an ignition risk. This tube was
tube and kept moist, the Merocel wrap provides available from Baxter Healthcare Corp (Niles, Ill.),
protection against COz, argon, and KTP-Nd-YAG, but its manufacture was recently discontinued.
but not YAG lasers (61). A potential disadvantage of Two other metal endotracheal tubes are commer-
this product is that the wrap adds almost 2 mm to the cially available and approved for use with specific
diameter of the endotracheal tube. Like the nonap- lasers. The "Laser Flex" tube (Mallinckrodt, St.
proved wraps, this product can only be applied to the Louis, Mo.) is an airtight stainless steel spiral with
432 REVIEW ARTICLE RAMPIL ANESTH ANALG
LASER SURGERY 1992;74:42445

two distal, PVC saline-inflatable cuffs (redundant in bined with the technique of spontaneous ventilation
case of puncture of the proximal cuff). This tube is or intermittant apnea with general anesthesia pro-
resistant to C02 and KTP laser energy, but not vided by nasal insufflation or bronchoscopic delivery
Nd-YAG (61). The Bivona "Fome-Cuf" (Bivona, of a potent inhaled anesthetic (32,55,76,77) or an
Gary, Ind.) is an aluminum spiral tube with an outer intravenous agent (78). Cohen et al. (79) and Hawk-
covering of silicone and a unique self-inflating foam- ins and Joseph (80) have advocated modest hyper-
sponge-filled cuff. The foam in the cuff prevents ventilation followed by intermittent tracheal extuba-
collapse after puncture. This feature allows continued lion by the surgeon for periods of 90-120 s during
positive pressure ventilation and segregation of air- which the laser is used. Pulse oximetry adds a mea-
way gases from the operative site, but may lead to sure of safety by confirming adequate oxygenation
injury if a puncture of the cuff or the filling tube from a denitrogenated pulmonary residual capacity
prevents deflation before removal. The Fome-Cuf is during apnea.
only approved for use with pulsed CO, lasers. The Although not specifically related to laser proce-
use of laser-resistant endotracheal tubes requires par- dures in the airway, it is prudent to be prepared to
ticular care to prevent mucosal abrasions, because recognize and treat vagal hyperactivity, which is
these tubes tend to be bulkier and more rigid than frequently seen in instrumentation of the trachea.
conventional tubes. The surgeon must also be careful
that laser energy is not reflected off smooth metal Aiwuy fire protocol. Should an airway fire or explo-
surfaces and directed at sensitive structures. Finally, sion occur, the surgeon and anesthesiologist need to
use of a metal endotracheal tube does not imply act quickly, decisively, and in a coordinated fashion.
absolute protection from ignition as 50 W of Nd-YAG This may not be easy after an explosion, as the event
beam focused to 0.68 mm ignited a Laser Flex in 6 s may be so traumatic as to temporarily incapacitate the
(45) * operating room staff. The key then, is communication
and practice (at least a mental drill of the emergency
Jet ventilation. Some authors contend that optimal procedure). Schramm and colleagues (81) have pro-
surgical conditions and patient safety can be obtained vided a useful review of the ensuing pathology and
with so-called "jet" ventilation. This technique takes suggested emergent management.
advantage of Bernouilli's Venturi principle to aug- Should a surgeon detect an endotrachea1 or other
ment the ventilation produced by a narrow stream of source of airway fire, he or she should as quickly as
high-speed gas flow. In practice, jet ventilation uses possible remove the source and simultaneously in-
an intermittent high-pressure oxygen supply, di- form the anesthesiologist, who should immediately,
rected at the glottis through a small metal tube, like a despite reflexive training to the contrary, stop venti-
ventilating bronchoscope, or even a 12-gauge blunt lation. It may be useful to temporarily disconnect the
needle (66-71). Jet ventilation with air has also been breathing circuit from the anesthesia machine. These
used via a bronchoscope when resecting distal tra- maneuvers remove the flame and the retained heat in
cheal and bronchial tumors (72-75). It has been the tube as well as stop the enriched source of
suggested that patients undergoing laser resections oxygen. The flaming material should be extinguished
of airway tumors during jet ventilation may absorb in a bucket of water that should always be available
carbon monoxide from entrained laser smoke in the during laser cases. The patient should then receive
pharynx. The carbon monoxide, in turn, would cause mask ventilation with 100% oxygen, and anesthesia
pulse oximetry to overestimate arterial oxygen satu- should be continued. A direct laryngoscopy and rigid
ration. Goldhill et al. (74) found neither a sipficant (Venturi-ventilating) bronchoscopy should be per-
increase in carboxyhemoglobin during Nd-YAG formed to survey damage and remove debris. If the
bronchoscopy nor a difference in pulse oximeter fire was an interior blowtorch type, then gentle
reading versus in vitro cooximeter measurement of bronchial lavage may be indicated, followed by fi-
arterial oxygen saturation. Although jet ventilation beroptic assessment of the more distal airways. If any
generally provides adequate ventilation without in- airway damage is seen, the patient should be reintu-
troducing flammable material or a large obstacle to bated. Fortunately, small exterior-only fires may not
the surgical field, there are several potential disad- cause appreciable damage. If the damage is severe, a
vantages including the potential for barotrauma, low tracheostomy may be indicated. The pattern of
pneumothorax, or crepitus; the restriction to only damage tends to be worst in the upper airway and
intravenous agents; gastric distention; and the rela- diminishes as one approaches and passes the carina.
tive requirement for compliant lungs. The oropharynx and face should be assessed and a
To reduce obstruction of the surgical field by chest radiograph should be obtained. Pulmonary
ventilatory instrumentation even further, several au- damage owing to heat and/or smoke inhalation may
thors have advocated its complete removal, com- necessitate prolonged intubation and mechanical
ANESTH ANALG REvlEW ARTICLE M I L 433
1992;74:42445 LASER SURGERY

ventilation. A brief course of high-dose steroids may Neodymium, Nd: A rare earth metal that is frequently chosen as a
lasing material within a substrate of glass or YAG.
be helpful (82,s). Output power: The rate of energy discharge, usually watts or
Lasers provide a useful new tool in the surgical jouledsecond.
armamentarium, one for which anesthesiologists Photon: A quantum of electromagnetic energy possessing both
must, with increasing frequency, prepare their pa- wavelike and particlelike properties. Photons travel at a constant
299,800,000 d s .
tients and themselves. Although some of the poten- Power density: The amount of power (energy per second) per unit
tial threats posed by lasers are unique, most are area arriving at a surface. Usually noted as wattdad.
simply extensions of the risks posed by the previous Pulsed mode: A mode of operation in which the laser delivers
discrete (usually quite brief) bursts of photons.
generation of surgical tools. As with most potentially Pump: The means of inducing an electron population inversion so
dangerous procedures, the risks of laser use can be that stimulated emission might occur.
minimized by common sense and preconsidered con- Resonutor: The combination of lasing material and mirrors neces-
sary to support laser activity.
tingency plans. Spontaneous emission: The emission of a photon when an excited
~_______
orbital electron decays back to its baseline energy.
Stimulated absorption: The process by which an orbital electron
~~ ~

I gratefully acknowledge the comments provided by Lawrence Litt, captures the energy of an colliding photon and is boosted to a
P ~ D ,MD, and Herbert H.Dedo, m, and the editorial assistance of higher energy orbital pattern.
Winifred von Ehrenburg. Stimulated emission: An electron in a high-energy orbital will, if
struck by an appropriate photon, emit a second photon of equal
wavelength, phase, and direction to the original, colliding pho-
ton.
Glossary Tumble laser: A laser that can be adjusted to provide a selected
output wavelength from a range of possibilities.
Ablation: Removal of tissue by vaporization. Ultraviolet: Electromagnetic radiation having wavelengths shorter
Absorption: The transformation, by interaction with matter, of than visible light, in the range between 0.01 and 0.38 m.
radiant energy to a different form of energy. YAG: A synthetic crystalline matrix composed of yttrium, alumi-
Active medium: A material that lases with the proper exatation. num, and garnet with a chemical formula of Y & , 0 , 2 .
Aiming beam: A very low-powered laser beam that is collimated Wavelength:The distance from peak to peak of a photon wave. The
with the high-powered, often-invisible therapeutic beam to usual units for light waves are nanometers (nm) or micrometers
illuminate the target site. (tun).
Angstrom (A): lo-'" meter.
Anode: The positive terminal in a gas discharge laser.
Attenuation: The reduction in beam energy by absorption or scat- References
tering as it passes through matter.
Brmster windm: Transparent windows at the ends of a gas laser 1. Daikuzono N, Joffe SN. Artificial sapphire probe for contact
discharge tube set at an angle to the optical axis of the tube photocoagulation and tissue vaporization with the Nd:YAG
(Brewster's angle) so as to provide maximum light transmission. laser. Med Instrum 1985;19173-8.
Coherent light: Light in which the photons all have the same 2. Baggish MS, Daniell JF. Catastrophic injury secondary to the
wavelength and maintain a constant in-phase relationship with use of coaxial gas-moled fibers and artifiaal sapphire tips for
each other. intrauterine surgery: a report of five cases. Lasers Surg Med
Collimution: The property of a light beam that describes the degree 1!%39;9581-4.
to which the constituent photons move in a single direction. 3. Shirk GJ. Use of the NdYAG laser with sapphire scalpels. In:
Highly collimated beams do not spread in diameter as they move McLaughlin DS, ed. Lasers in gynecology. Philadelphia: Lip-
away from the source. pincott, 1991:28%307.
CW: Continuous wave mode, a mode of operation in which the 4. Suggested state regulations for control of radiation. Volume 2:
laser discharge is continuous. Lasers. Rockville, Md.:Government Printing Office, 1983:
Difimtion: The modulation in intensity and apparent bending DHHS(FDA)W220.
exhibited by photons as they pass an opaque body. 5. Special report: laser safety. Laser Nursing 1990;43-12.
Dopant: A chemical added to a crystal matrix to serve as an active 6. Nezhat C, Winer WK,Nezhat F, Nezhat C, Forrest D, Reeves
lasing constituent. WG. Smoke from laser surgery: is there a health hazard?
Energy density: The amount of energy per unit area arriving at a Lasers Surg Med 1987;7376-82.
surface. Usually noted in jouledad. 7. Baggish MS, Elbakry M. The effects of laser smoke on the lungs
Excimer: Exciter dimer, a type of laser based on the transition states of rats. Am J Obstet Gynecol 1987;156:1260-5.
of a diatomic molecule (e.g., ArF, KrF, or XeCl). These lasers 8. Freitag L, Chapman G, SielczakM, Ahmed A, Russin D. Laser
produce very energetic photons. smoke effect on the bronchial system. Lasers Surg Med 1987;
Extinction length: The thickness of a specified media that absorbs 72834.
98% of the incident beam intensity, measured in m-'. 9. Kokosa J, Eugene J. Chemical composition of laser-tissue
Infrared: Electromagnetic radiation with a wavelength in the band interaction smoke plume. J Laser Appl 1989;2:5%3.
0.7 w-1.0 mm, i.e., longer wavelengths than visible light, but 10. Tomita Y, Mihashi S, Nagata K, et al. Mutageniaty of smoke
shorter than microwave/radio. condensates induced by C0,-laser and electrocauterization.
Interference: The phenomena of photons of like wavelength but Mutat Res 1981;89145+9.
different phase combining constructively and destructively to 11. Ferenwy A, Bergeron C, Richart RM. Human papillomavirus
modulate the resulting intensity. DNA in COz laser-generated plume of smoke and its conse-
lode: A unit of energy, 1 joule = 1 watt-second. quences to the surgeon. Obstet Gynecol 1990;75114-6.
Micrometer, Micron, p n : meter. 12. Ferenwy A, Bergeron C, Richart RM. Carbon dioxide laser
Mode: A description of the intensity cross-section of a laser beam. energy disperses human papillomavirus deoxyribonucleicadd
Monochromutic: Light of a single wavelength or color. onto treatment fields. Am J Obstet Gyneco11990;163:1271-4.
Nanometer: meter. 13. Sawchuk WS, Weber PJ, Lowy DR, Dzubow LM. Infectious
434 REVIEW ARTICLE RAh4PIL ANESTH ANALG
LASER SURGERY 1992;7442435

papillomavirus in the vapor of warts treated with carbon 39. Meyers A. Complications of C 0 2 laser surgery of the larynx.
dioxide laser or electrocoagulation: detection and protection. Ann Otol 1981;90:1324.
J Am Acad Dermatol 1989;21:41-9. 40. Cozine K, Rosenbaum LM, Askanazi J, Rosenbaum SH. Laser-
14. Abramson AL, DiLorenzo TP, Steinberg BM. Is papillomavirus induced endotracheal tube fire. Anesthesiology 1981;55:583-5.
detectable in the plume of laser-treated laryngeal papilloma? 41. Sosis MB. Airway fire during C 0 2 laser surgery using a Xomed
Arch Otolaryngol Head Neck Surg 1990;116:604-7. laser endotracheal tube. Anesthesiology 1990;72747-9.
15. Johnson GK, Robinson WS. Human immunodeficiency virus-1 42. Hirschman CA, Smith J. Indirect ignition of the endotracheal
(HIV-1) in the vapors of surgical power instruments. J Med tube during carbon dioxide laser surgery. Arch Otolaryngol
Virol 1991;33:4750. Head Neck Surg 1980;106:639-41.
16. Voorhies RM, Lavyne MH, Strait TA, Shapiro WR.Does the 43. Ossoff RH, Duncavage JA, Eisenman TS,Karlan MS. Compar-
CO, laser spread viable brain-tumor cells outside the surgical ison of tracheal damage from laser-ignited endotracheal tube
field? J Neurosurg 1984;60:81%20. fires. Ann Otol Rhino1 Laryngol 1983;92333-6.
17. Oosterhuis JW. Tumor surgery with the C 0 2 laser. Studies 44. Patel KF, Hicks JN. Prevention of fire hazards associated with
with the cloudman S91 mouse melanoma. Groningen, Neth- the use of carbon dioxide lasers. Anesth Analg 1981;60:885-8.
erlands: Veenstra-Visser, 1977. 45. Sosis MB. What is the safest endotracheal tube for Nd-YAG
18. Walker NP, Matthews J, Newsom SW. Possible hazards from laser surgery?-A comparative study. Anesth Analg 1989;69:
irradiation with the carbon dioxide laser. Lasers Surg Med 8024.
1986;6&M. 46. Geffin 8, Shapshay SM, Bellack GS, Hobin K, Stezer SE.
19. Byrne PO, Sisson PR, Oliver PD, Ingham HR. Carbon dioxide Flammability of endotracheal tubes during Nd-YAG laser
laser irradiation of bacterial targets in vitro. J Hosp Infect application in the airway. Anesthesiology 1986;65:5115.
1987;9:265-73. 47. Ossoff RH. Laser safety in otolaryngology-head and neck
20. Smith JP, Moss C, Bryant C, Fleeger AK. Evaluation of a smoke surgery: anesthetic and educational considerations for laryn-
evacuator used for laser surgery. Lasers Surg Med 1989;9:276- geal surgery. Laryngoscope 1989;991-26.
81. 48. Wolf GL, Simpson JI. Flammability of endotracheal tubes in
21. Smith JP, Topmiller JL, Shulman S. Factors affecting emission oxygen and nitrous oxide enriched atmosphere. Anesthesiol-
collection by surgical smoke evacuators. Lasers Surg Med ogy 1987;67236-9.
1990;1022433. 49. Pashayan AG, Gravenstein JS. Helium retards endotracheal
22. Faintuch JS. Endoscopic laser therapy in colorectal carcinoma. tube fires from carbon dioxide lasers. Anesthesiology 1985;62:
Hematol Oncol Clin North Am 1989;3:15570. 274-7.
23. Ganfield RA, Chapin JW. Pneumothorax with upper airway 50. Simpson JI, Schiff GA, Wolf GL. The effect of helium on
laser surgery. Anesthesiology 1982;56:398-9. endotracheal tube flammability. Anesthesiology 1990;73:538-
24. Challener RC, Kaufman B. Fatal venous air embolism follow- 40.
ing sequential unsheathed (bare) and sheathed quartz fiber 51. Lu T, Ohmura A, Wong KC, Hodges MR. Helium-oxygen
Nd-YAG laser endometrial ablation. Anesthesiology 1990;73: treatment of upper airway obstruction. Anesthesiology 1976;
54~1. 45678-80.
25. Jamieson WM, Chamberlain JA. Patient response to endome- 52. Pashayan AG, Gravenstein JS, Cassisi NJ, McLaughlin G. The
trial ablation with the Nd:YAG laser. Lasers Surg Med 1989;7
374. helium protocol for laryngotracheal operations with COzlaser:
26. Peachey T, Eason J, Moxham J, Jarvis D, Driver M. Systemic air a retrospective review of 523 cases. Anesthesiology 1988;68:
embolism during laser bronchoscopy. Anaesthesia 1988;43: 8014.
872-5. 53. Brown TA, Moms G. The ignition risk with mixtures of oxygen
27. Ross DJ, Mohsenifar Z, Potkin RT, Roston WL, Shapiro SM, and nitrous oxide with halothane. Br J Anaesth 1966;38:164-8.
Alexander JM. Pathogenesis of cerebral air embolism during 54. Leonard PF. The lower limits of flammability of halothane,
neodymium-YAG laser photoresection. Chest 1988;9466&2. enflurane and isoflurane. Anesth Analg 1975;54323&40.
28. Bauman N. Laser drape fires: how much of a risk? Laser Med 55. Hunton J, Oswal VH. Anaesthetic management for carbon
Surg News Adv 1989;7:25. dioxide laser surgery in tracheobronchial lesions. Anaesthesia
29. Liebowitz HM, Peacock GR. Corneal injury produced by 1987;42:12225.
carbon dioxide laser radiation. Arch Ophthalmol 1980;52: 56. Snow JC, Kripke BJ, Strong MS, Jako GJ, Meyer MR, Vaughan
993-7. CW. Anesthesia for carbon dioxide microsurgery on the larynx
30. Wolbarski M, Fligster KE, Hayes JR. Retina: pathology of and trachea. Anesth Analg 1974;53:507-12.
neodymium and ruby laser bums. Science 1965;150:1453-4. 57. Patil V, Stehling LC, Zauder HL. A modified endotracheal tube
31. Gary BD, Bivens HE. Anesthetic technique for safe laser use for laser microsurgery (letter). Anesthesiology 1979;51:571.
in surgery. Semin Surg Oncol1990;6:1844. 58. Kumar A, Frost E. Prevention of fire hazard during laser
32. Keon TP. Anesthetic considerations for laser surgery. Int microsurgery (letter). Anesthesiology 1981;54:350.
Anesthesiol Clin 1988;26:503. 59. Sosis MB. Evaluation of five metallic tapes for protection of
33. Spiess BD, Ivankovich AD. Anesthetic management of laser endotracheal tubes during COz laser surgery. Anesth Analg
airway surgery. Semin Surg Oncol 1990;6189-93. 1989;68:392-3.
34.Snow JC, Norton ML, Salvja TS, Estanislao AF. Fire hazard 60. Sosis M, Dillon F. What is the safest foil tape for endotracheal
during COz laser microsurgery on the larynx and trachea. tube protection during Nd-YAG laser surgery? A comparative
Anesth Analg 1976;55:146-7. study. Anesthesiology 1990;7255M.
35. Hermens JM, Bennett MJ, Hirsdunan CA. Anesthesia for laser 61. Laser-resistant endotracheal tubes and wraps. Health Devices
surgery. Anesth Analg 1983;62:21&29. 1990;19:11239.
36. Fried MP. A survey of the complications of laser laryngoscopy. 62. Fontenot R Jr, Bailey BJ, Stiemberg CM, Jenicek ]A. Endotra-
Arch Otolaxyngol1984;110314. cheal tube safety during laser surgery. Laryngoscope 1987;97
37. Healy GB, Strong MS, Shapshay S, Vaughan C, Jako G. 919-21.
Complications of C 0 2 laser surgery of the aerodigestive tract: 63. Hayes DM, Gaba DM, Goode RL. Incendiary characteristics of
experience of 4416 cases. Otolaryngol Head Neck Surg 19M; a new laser-resistant endotracheal tube. Otolaryngol Head
92:lM. Neck Surg 1986;95:374.
38. Burgess GE 111, LE Juene FE Jr. Endotracheal tube ignition 64. Norton ML, De Vos P. New endotracheal tube for laser surgery
during laser surgery of the larynx. Arch Otolaryngol1979;105: of the larynx. Ann Otol Laryngol 1978;87554-7.
561-2. 65. W o o P, Strong MS. Venturi ventilation through the metal
ANESTH ANALG REVIEWARTICLE RAMPIL 435
1992;74:42&35 LASER SURGERY

endotracheal tube: a nodammable system. Ann Otol Rhinol Tubeless anaesthesia for microlaryngeal surgery. Anaesth
Laryngol1983;92:405-7. Intensive Care 1990;16497-503.
66. Anand VK, Herbert J, Robbett WF, Zelman WH. Safe anesthe- 79. Cohen SR, Herbert WI,Thompson JW.Anesthesia manage-
sia for endoscopic laryngeal laser surgery. Lasers Surg Med ment of microlaryngeal laser surgery in children: apneic tech-
1987;7275-7. nique anesthesia. Laryngoscope 1988;98:347-8.
67. Herbert JT,Berlin I, Eberle R. Jet ventilation via a copper tube 80. Hawkins DB, Joseph MM.Avoiding a wrapped endotracheal
for C02 laser surgery at the oropharynx. Laryngoscope 1985; tube in laser laryngeal surgery: experiences with apneic anes-
95:1276-7. thesia and metal Laser Flex endotracheal tubes. Laryngoscope
68. Borland LM, Reilly JS. Jet ventilation for laser laryngeal sur- 1990;100.12$3-7.
gery in children. Modification of the Saunders jet ventilation 81. s c h r a m m VL Jr, Mattox DW, Stool SE. Acute management of
technique. Int J Ped Otorhinolaryngol 1987;146571. laser-ignited intratracheal explosion. Laryngoscope 1981;91:
69. Crockett DM, McCabe BF, Shive CJ.Complications of laser 1417-26.
surgery for recurrent respiratory papillomatosis. Ann Otol 82. Dressler DP, Skornik WA, Kupersmith S. Corticosteroid treat-
Rhinol Laryngol1987;96639-44. ment of experimental smoke inhalation. Ann Surg 1976;183:
70. Gussack GS, Evans RF, Tacchi EJ. Intravenous anesthesia and 4642.
jet ventilation for laser microlaryngeal surgery. Ann Otol 83. Demling RH.Smoke inhalation injury. Postgrad Med 1987;82:
Rhinol Laryngol1987;%.2%33. 63-8.
71. Paes ML.General anaesthesia for carbon dioxide laser surgery
within the airway. A review. Br J Anaesth 1987;59:1610-20.
72. Blomquist S,Algotsson L, Karlsson SE. Anaesthesia for resec-
tion of tumours in the trachea and central bronchi using the
Suggested Further Readings in Lasers
Nd-YAGlaser technique. Acta Anaesthesiol S a n d 1990;34: and Physics
506-10.
73. George PJ, Garrett CP, Nixon C, Hetzel MR, Nanson EM, 1. Wilson J, Hawkes JFB. Lasers: prinaples and applications. New
Millard FJ.Laser treatment for tracheobronchialtumours:local York Prentice Hall, 1987. A detailed but rendable review of the
or general anaesthesia? Thorax 1987;42:65660. atomic physics and optics of lasers.
74. Goldhill DR, Hill A], Whitbum RH, Fen& RO, George PJ, 2. Apfelberg DB. Evaluation and installation of surgical laser
Keeling P. Carboxyhaemoglobin concentrations, pulse oxime- systems. New York Springer-Verlag, 1987. Contains nice sections
try and arterial blood-gas tensions during jet ventilation for a the organizational and safety aspects of lasers in medical practice, as
Nd-YAG laser bronchoscopy. Br J Anaesth 1990;65:749-53. w l l as brief revieus of laser use in several surgical subspecialties.
75. Jackson KA, Morland MH.Anaesthesia for resection of lesions 3. Einstein A. Zur quantum theorie der strahlung. (On quantum
of the trachea and main bronchi using the neodymium yttrium theory of radiation) Physikalische Zeitsduift 1917;18:121-8.
aluminium garnet (Nd-YAG) laser. A report of 75 treatments in Translated in: Barnes ES, ed. Laser theory. New York: IEEE
52 patients. Anaesth Intensive Care 1990;18:69-75. Press, 1972. Einstein’s original description of the quantum nature of
76. Talmage EA.Safe combined general and topical anesthesia for light in whidr he predicts the possibility of laser action.
laryngoscopy and bronchoscopy. South Med J 1973;66:4559. 4. Schawlow AL, Townes CH. Infrared and optical masers. Phys
77. Johans TG, Reichert TJ. An insufflation device for anesthesia Res 1958;112194&1949. The original theoretical description of prac-
during subglottic carbon dioxide laser microsurgery in chil- tical lasers which earned a Nobel prize.
dren. Anesth Analg 1984;63:368-70. 5. Maiman TH.Stimulated optical radiation in ruby. Nature 1960;
78. Aun CS, Houghton IT, So HY, Van Hasselt CA, Oh TE. 1874934. The first description of a working laser.