Laser: Safety

Lasers are becoming increasingly common in the OR for a variety of procedures including laser lithotripsy and a variety of head and neck surgeries. When a laser is being used for a head and neck procedure, particularly in the airway, the case should be considered high risk for airway fire. This risk can be minimized by using intermittent apnea or jet ventilation techniques, using a laser-resistant endotracheal tube, limiting laser duration, avoidance of nitrous oxide, and by lowering the FiO₂ as close to room air while continuing to provide adequate tissue oxygenation. Airway Fire Protocol listed below for review.

Airway Fire Protocol

1. Stop ventilation and remove tracheal tube.

2. Turn off oxygen and disconnect circuit from machine.

3. Submerge tube in water.

4. Ventilate with face mask and reintubate.

5. Assess airway damage with bronchoscopy, serial chest x-rays, and arterial blood gases.

6. Consider bronchial lavage and steroids.

There are a variety of laser types (CO₂, neodymium yttrium aluminum garnet [ND:YAG], or potassium titanyl phosphate [KTP]) with varying focal lengths and strengths requiring specific eye protection to shield OR personnel and patients from harm. The safety of lasers depends on the wavelength of the laser as well as the application of the laser. Warning signs should be placed to alert staff to the use of intraoperative lasers. Personnel should reference the laser safety guidelines to verify they have the correct protection for the laser being used.

Common hazards of laser use include:

● Damage to eyes. Laser beams can be redirected off of reflective surfaces without decreasing their power output (e.g., argon lasers can pass through cornea and lens without causing damage, but cause damage to retina. Nd: YAG lasers injure the cornea, posterior chamber, and retina)

○ Goggles specific to the type of laser being used during the surgery should be placed on the patient as well as worn by all health care providers in room with the patient.

● Fire risk (e.g., lasers can ignite any flammable material including gowns, drapes, plastic tubing including endotracheal tubes)

○ Backstops should not be made of flammable material. Combustible materials such as alcohol should not be used with lasers.

○ During airway surgery with lasers, multiple safeguards can be taken including wrapping endotracheal tubes (ETTs) in reflective aluminum tape, use of noncombustible metal ETTs, use of methylene blue in ETT cuff, or avoidance of use of ETT at all.

● Burns: soaking materials in water may reduce incidence of patient/provider burns

● Aerolization of viral materials, such as with laser vaporization of condylomata

○ Masks should be worn by all when lasers are in use