Laser Safety

1. Laser Safety Adapted for use by the Ohio Region of Kaiser Permanente Nsg. Ed., 2013

2. Instructions • Review the presentation • Print Certificate of Completion from the last slide. • Sign and date the certificate and submit it to your supervisor.

3. Introduction • There are a multitude of lasers in existence designed to be used in every facet of life; product inventory, construction, military, and health care are just a few of the arenas in which lasers have application. • A laser is a device in which the atoms, molecules or ions in a crystal, a gas or a liquid dye, when stimulated by light, chemicals, gases or electrical energy, emit a narrow, very intense beam of energy (light).

4. Introduction • Light is measured in waves and the different types of lasers have specific wavelength, which also indicates their color. Wavelength is measured in nanometers. A laser is named for it’s active medium. • LaserColorWavelength • Argon Blue 488nm • Green 518nm • Nd:YAG Infrared (invisible) 1064nm • Ho: YAG Infrared (invisible) 2100nm • CO2 Infrared (invisible) 10,600nm

5. Laser Classification • The American National Standards Institute classifies lasers according to their degree of hazard: • Class I Laser:This class of laser includes the self-contained systems that do not inflict harm under normal circumstances. These lasers do not require hazard-warning labeling because the laser output is at or below the acceptable emission limits. • Class II Laser: These low-powered devices emit visible laser light (for example, the helium-neon laser). The normal aversion reflex such as blinking or turning the head provides adequate protection against this class of laser. These lasers are safe for momentary viewing, but constant, deliberate viewing without eye protection could cause degenerative eye changes, especially if an aversion reflex is absent. A sedated patient may have a compromised aversion response and should be protected against a laser port that may be emitting a helium-neon aiming beam.

6. Laser Classification • Class III Laser: This classification of lasers requires special training to operate and has the potential to cause injury if viewed directly or if specularly reflected. Some ophthalmology YAG lasers are listed as Class III lasers. • Class IV Laser: Most of the lasers used in medicine and surgery are class IV lasers (CO2, Argon, continuous wave YAG). These lasers are potentially hazardous and could cause fire, skin burns, and optical damage from either direct or scattered radiation. Specific safety measures must be employed to prevent injury from these lasers.

7. Laser Safety Like many medical devices, the laser presents hazards. The potential for eye injuries, burns, fire, toxic fumes and smoke inhalation, and electrical hazards are real. Therefore, it is important to implement safety measures that protect both patients and personnel. Laser safety measures are designed to meet regulatory standards and guidelines and to ensure the safety of both patients and health care providers participating in laser procedures. Several agencies regulate or offer guidelines on laser safety: • ANSI—The American National Standards Institute • AORN—Association of peri-operative Registered Nurses • ASLMS—American Society for Laser Medicine and Surgery • OSHA—Occupational Safety and Health Administration • CDHR—Center for Devices and Radiological Health

8. Laser Safety Laser safety involves a multitude of responsibilities which include: • Physician credentialing • Laser operator credentialing • Appointing a laser safety officer • Establishing a laser committee • Development of standards to include: • Safety • Credentialing • Scheduling • Operational procedures • Documentation • Maintenance • Staff education

9. Laser Safety • All physicians are required to be credentialed to perform laser procedures. Only healthcare personnel (laser operators and laser safety monitors) who have received the appropriate training/credentialing in accordance with Kaiser Permanente policies can operate the laser and/or monitor laser safety. • Policy: Laser Safety in the Perioperative Practice Setting • Reference: HP.AS.NI.13

10. Laser Safety Precautions Controlled access Laser warning signs must be placed at all entrances to the operating room or treatment area to prevent inadvertent access. • The laser signs should indicate “DANGER,” “LASER in use” and the type and wavelength of the laser being used. All windows must be covered with appropriate protection when using the Nd:YAG laser as the beam can be transmitted through glass.

11. Laser Safety Precautions Controlled access • Per the Ohio Policy, All personnel shall be instructed to knock before entering the laser room • Personnel may not enter without the permission of the Laser Operator. • Doors in the nominal hazard zone should remain closed when the laser is in use. • All viewing windows in the OR Room shall provide protection in accordance with the laser manufacturer’s guidelines for a specific laser during use.

12. Laser Safety Precautions • Patient Safety • Laser equipment will be checked prior to each use before the patient is brought into the operating room • The laser operator and surgeon will test the laser delivery system and safety equipment. • The laser will be in the “stand-by” mode when not in use, adjusting the power, use of instrumentation, or when the surgeon’s attention is called away from the field to prevent inadvertent firing of the laser beam. • Only the operating surgeon shall have access to the laser power pedal to prevent accidental firing of the laser by other team members. • The laser foot pedal must be situated separately from other foot pedals.

13. Laser Safety Precautions Eye protection Eye safety is of critical importance during a laser procedure. The area of possible ophthalmologic injury is dependent upon the wavelength of the laser and the tissue absorption of this energy. The CO2 laser beam can damage the cornea of the eye. The Nd:YAG and ARGON laser beam is transmitted through clear fluids or structures and can be refocused by the lens of the eye. The intensity of the beam after refocusing can permanently damage the retina. Appropriate protective eye wear must be worn by all personnel and the patient. The eye wear should be inscribed with the appropriate filtering capabilities and adequate optical density for the specific wavelength being used.

14. Laser Safety Precautions Eye protection (continued) The patient’s eyes must always be protected from laser energy. If the patient is awake, appropriate goggles or glasses must be worn. Good preoperative patient education provides the patient with the rationale for eye protection during the laser procedure. The eyes of anesthetized patients must be closed, taped, and/or covered with eye pads that have been moistened with saline. Appropriate protective eye wear must be available at all entrances to the laser room. Protective eye wear must be inspected regularly by the laser safety officer. Any scratched lens surface will allow the laser beam to be transmitted and the wearer’s eyes could be harmed. ANSI standards recommend that a baseline eye exam, noting visual acuity and retinal health, be performed on those health care professionals who routinely work with lasers.

15. Laser Safety Precautions • Fire safety • Fire prevention is critical during laser surgery. A fire can be started by a reflected laser beam as easily as from a direct impact as well as from an electrical source. An inadvertent impact from a stray laser beam can ignite flammable materials. • Fire safety precautions include: • Inspection of electrical cords when setting up the laser. • A fire extinguisher should be available to control a fire within the laser system. • A container of sterile water should be immediately available to douse a small fire. • Wet towels should be used for draping near the laser target site. • Wet sponges should be used in the area of the laser application.

16. Laser Safety Precautions Fire safety (continued) • Do not prep with flammable skin preparations. • Use nonreflective instruments. • Never place hot fibers on dry surgical drapes or towels. • Use a laser-resistant endotracheal tube during oral cavity, aerodigestive tract, or laryngeal procedures. Cover the cuff area with wet cottonoids. Never use a polyvinyl chloride endotracheal tube as it will emit toxic fumes if ignited. • Good practice shows that when the laser is being used in the perianal area, a saline soaked radiopaque 4x4 should be inserted into the rectum to prevent methane gas from escaping which could be ignited by the laser beam and cause a methane gas explosion.

17. Laser Safety Precautions Fire safety (continued) • The laser should be placed in the “standby” mode when not in use. • The laser foot pedal should be used only by the operating physician. • Do not place fluids or solutions on the laser unit. • Never leave the key in the laser unit when not in use. • When applicable, according to the procedure, an additional nurse (laser operator) must be available to monitor safety practices and so that the laser can be inactivated as appropriate. • There must be open communication between the operating physician and the laser operator.

18. Laser Safety Precautions • Protecting skin and tissue • Laser burns can occur whenever a misdirected laser beam strikes non-target tissue. All non-target tissue in or near the operative site should be protected by saline or water moistened 4x4’s, laparotomy sponges or towels. Dulled, non-reflective instruments should be used to decrease the amount of reflection and scatter of the laser beam.

19. Laser Safety Precautions • Smoke evacuation • Laser plume is laser smoke which contains carbonized particles and steam. Various studies indicate the possible presence of viruses, bacteria, and cellular tissue in some laser smoke. The key to adequate smoke evacuation and elimination of inhalation hazards is to evacuate the plume as close as possible to the laser tissue impact site. • The wand should be positioned as close as possible, but no greater than two inches from the source of smoke. At 1cm from the site, plume is reduced by 98%. At 2cm from the site, plume is reduced by 50%. Always use the appropriate smoke evacuation system and follow manufacturer guidelines.

20. Laser Safety Precautions • Laser masks should always be worn during laser procedures to add further protection against unevacuated plume. Fit-tested N95 filtering face piece respirator or high filtration surgical masks must be used as secondary protection against residual plume smoke. • Used smoke evacuator filters, tubing, and wands should be considered potentially infectious waste. • When a central (wall) suction system is used to evacuate smoke, a 0.1 micron in-line filter should be used. The in-line filter should be placed between the suction connection and the suction canister.

21. Laser Safety Precautions • Protective Surfaces • Reflective surfaces will be minimized during laser surgery due to the potential for laser beam refraction off shiny surfaces, potentially causing skin or eye injury. • Anodized, dull, non-reflective, or matte-finished instruments decrease the reflectivity of laser beams. • Instruments coated (i.e., ebonized) should be inspected regularly as damage or scratches to the coating may allow the laser beam to refract, potentially causing eye or skin injury. • Refractive instruments that cannot be ebonized will be covered with saline saturated materials.

22. Documentation • A laser log will be completed for all laser procedures. • The following information will be documented on the Intraoperative Record: • Type of laser • Serial # of laser • Laser operator • Safety precautions followed • Tissue of laser application • A QRR is to be completed whenever there is any unusual event related to laser use.

23. End of Educational Learning Module on Laser Safety • You have completed the Educational Learning Module for Laser Safety. • Make sure you print and sign the last slide of this learning module, then give it • to your manager.

24. References • American National Standard for Safe Use of Laser in Health Care Facilities (ANSI Z136.3), 2005). Laser Institute of America, 2005. • American Society for Laser Medicine & Surgery, Inc., (2013), www.alms.org • Gallagher, M. & Kahn, C., (1990), 53(5); 46-53, Lasers: scalpels of light., RN. • Policy: Laser Safety in the Perioperative Practice Setting, Reference: HP.AS.NI.13

25. Certificate of Completion • By signing this document I attest to have read: • Policy: Laser Safety in the Perioperative Practice Setting • Reference: HP.AS.NI.13 • I understand the clinical practice and safety measures required for laser use in the perioperative area. • ____________________________________________________________________ • Printed Name Date • ____________________________________________________________________ • Signature Nsg. Ed., 2013