Chris Bowen T? May 27 th 2011 Anesthesia Keyword Presentation

 Reported in % of laser airway cases  Believed to be grossly underreported › Risk of laser contacting ET tube 1:2  Inception › Direct illumination › Reflected › Particles  3 things every growing fire needs: › Ignition source  laser, electrocautery › Oxidant  O 2, Nitrous Oxide › Fuel  ET tubes, drapes, etc.

 Seeding  Cuff puncture releases more oxidant into field  The “blowtorch” effect  Airway trauma › Smoke and debris inhalation  Death

 D/C oxygen and extubate  Douse flames with saline  Mask ventilation › Assess feasibility of reintubation for…  Bronchoscopy to assess extent of injury › Supportive care › Consider leaving tube if not burning  Admit patient to ICU

 OR prevention › Proper eye protection › Wet towels and minimal draping › Matte/dull finished or blackened instruments › Signs posted › Extinguisher checked and in room › Laser set on pulse not continuous › Laser set on “standby” mode

 Anesthesia Preventions › Dentures and nasogastric tubes removed › Co-morbidities › Technique  Jet, apneic, spontaneous ventilation › Tube  Type  Metal vs. rubber vs. PVC  Coverings › Cuff preparation

 Tapes › 3 major types › Inexpensive  Cuff filled with saline vs. air › Mini-extinguisher effect › Methylene blue dye  Tubes › Metal  interlocking rings of stainless steel › Rubber  soft, usually without cuff › PVC  garden variety

 46% prefer laser-safe ET, 26% prefer Jet Ventilation, 16% apneic, 12% spontaneous  Sosis and Dillon  Tapes › Copper demonstrated no combustion at 60 sec. › Not FDA approved › Proper application is key  Limit flexibility  Increase diameter  Can come loose  Cuffs › Saline filled cuff perforation reduced combustion by 80% › Dye allows for quick assessment of cuff integrity › Dual cuffs made extubation problematic  Tubes › Metal is resistant not impervious  increased trauma upon insertion › PVC very resistant  Taping or covering recommended  Application must be precise › Rubber most flammable*  Blood, mucus, and tissue increased combustion rates up to 60%  The YAG laser ignited all materials within 6 sec

 Metal tubing is safe and effective › Resistant not impervious  Cuffs should be filled with saline and dye  Copper tape has superior resistance when compared to other tapes and coverings  Nothing withstands the YAG

 LMAs  Increased muscle relaxants  Are all lasers created equal?  Metallic tape vs. laser-guard coverings  F i O 2 and inhaled anesthetic levels  Tracheostomy

 Wu CC, Shen CH, Ho WM. Endotracheal tube fire induced by electrocautery during tracheostomy--a case report. Acta Anaesthesiol Sin Dec;40(4): PubMed PMID:  Mattucci KF, Militana CJ. The prevention of fire during oropharyngeal electrosurgery. Ear Nose Throat J Feb;82(2): PubMed PMID:  García-Sánchez MJ, Pérez-Rodríguez JF, Herrero-Manzano R. [Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event]. Rev Esp Anestesiol Reanim Mar;57(3): Spanish. PubMed PMID:  Awan MS, Ahmed I. Endotracheal tube fire during tracheostomy: a case report. Ear Nose Throat J Feb;81(2):90-2. Review. PubMed PMID:  Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol Dec;21(6): Review. PubMed PMID:  Roy S, Smith LP. What does it take to start an oropharyngeal fire? Oxygen requirements to start fires in the operating room. Int J Pediatr Otorhinolaryngol Feb;75(2): Epub 2010 Dec 10. PubMed PMID:  Carin A. Hagberg, MD, Benumof's Airway Management (Second Edition) Principles and practice 2007 Mosby, Inc. pg. 901, ,  John L. Atlee MD., Complications in Anesthesia 2 nd Ed Saunders. Pg. 750