Biomedical Engineering Reference
In-Depth Information
16
Anesthesia for cutaneous laser surgery
Mitchel P. Goldman, Sabrina G. Fabi, and Jennifer G. Wojtczak
children
Laser surgery can be uncomfortable, both for adults and for
children. Some laser treatments can be accomplished without
anesthesia, depending on the location, extent of the lesion, and
age and cooperation of the patient. Certain treatments are lim-
ited because of the pain experienced by the patient. This phe-
nomenon is particularly evident in the treatment of vascular
malformations in children, particularly port-wine stains
(PWS) and especially with large surface areas. Both children
and adults often complain of increased perception of pain
with each subsequent treatment. The reason for this increased
pain perception remains to be elucidated; however, several
potential explanations exist.
PWS have been shown to be derived from a progressive ecta-
sia of the superficial vascular plexus. One hypothesis on the eti-
ology of PWS stresses the importance of a near absence of
sympathetic innervation, which modulates blood flow, possibly
leading to defective maturation of the cutaneous sympathetic
component and forming the basis for this progressive vascular
ectasia (1,2). One would assume that as the lesion lightens (los-
ing its target vascularity), less laser energy would be absorbed,
leading to less pain. However, as previously noted, patients often
note that, as lesions lighten, successive treatments actually result
in a slight increase in their perception of pain. This increased
pain perception may occur because treating PWS reestablishes a
normal vessel growth pattern leading to normalization of vessel
innervation. Regardless of the exact reason for this phenome-
non, treating vascular malformations with minimal pain in
children is an important dilemma facing laser surgeons.
Nonetheless, the use of anesthetics in children undergoing
cutaneous laser surgery remains a controversial issue, and its
use is left to the discretion of the treating physician (3-9).
Painful laser treatments are made more tolerable by the use of
different anesthetic techniques. Anesthesia may be delivered
simply by precooling the lesion, applying a topical anesthetic
or administering intralesional/block anesthesia using 1% lido-
caine with or without epinephrine. Larger lesions in young
children may be more effectively managed with the aid of gen-
eral anesthesia or sedation. These anesthetic modalities along
with their advantages and disadvantages are detailed below.
The surgeon must balance the advantages and disadvantages
when deciding to use anesthesia. If the treating physician decides
to use anesthesia, he or she must then decide which anesthetic
modality to use. The list of criteria below will help discern phy-
sicians which anesthetic type would be most appropriate (3,8):
4. duration of procedure
5. skill and experience of anesthesiologist in different
technique options
6. availability of appropriate monitoring equipment,
medications, emergency equipment, and personnel
prevention of ignition by limiting ambient oxygen
concentration near the laser.
7. prevention of ignition by limiting ambient oxygen
concentration near the laser
The advantages of anesthesia in laser cutaneous surgery in
children include less long-term emotional trauma because fewer
details of treatments will be remembered, more treatment com-
pliance, and more thorough treatments in each session (thereby
decreasing the number of treatments required). In addition, it is
particularly crucial that children are comfortable during a laser
treatment, as erratic patient movement can result in excessive
overlapping and double pulsing of laser impacts leading to pos-
sible adverse results. Furthermore, anesthesia serves to maintain
a friendly rapport among the laser center staff, physician,
patient, and family by making the patient feel comfortable. This
is especially important in performing cosmetic procedures paid
for entirely by the patient where the treating physician would
like to see the patient in the future for additional treatments.
Nonetheless, there are several disadvantages of anesthesia
that must be considered. An exhaustive list of each complica-
tion of every anesthetic technique is beyond the scope of this
chapter. However, the most significant complications from
various anesthetic techniques include hypoxia from airway
obstruction, bronchospasm, aspiration, hypoventilation, pul-
monary edema, and laryngospasm. Allergic reactions to the
anesthetic agent may also occur, with the rare possibility of
malignant hyperthermia from inhalational anesthetic agents.
Dysphoric and dystonic reactions, including emergence delir-
ium, hallucinations, and flashbacks, may also occur with
certain anesthetic agents (e.g., ketamine hydrochloride). In
particular, with general anesthesia, children (especially those
under 2 years of age) are at greater risk for hypoxia for various
reasons. These reasons include the propensity for airway
obstruction from their relatively large tongue, a small func-
tional residual lung capacity, high oxygen consumption, pos-
sibility of undiagnosed arterial cardiac shunts, possible patency
of foramen ovale, and frequent upper respiratory tract infec-
tions, which result in prolonged hyperreactivity of airways.
hypnosis
All patients may benefit from soothing verbal and tactile rein-
forcement from both their doctors and their families. This
method uses hypnosis as an aid to improving a patient's
talkathesia
1. patient's age
2. patient's medical history
3. patient and family preference
349
 
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