The article "Flashlamp-pumped pulsed dye laser treatment of vascular birthmarks" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Brenda S. Gregory Dawes, RN, MSN, CNOR, with consultation from Trish O'Neill, RN, MS, professional education specialist, Center for Perioperative Education.
A minimum score of 70% on the multiple-choice examination is necessary to earn one contact hour for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is July 31, 1999.
Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to
BEHAVIORAL OBJECTIVES
After reading and studying the article on flashlamp-pumped pulsed dye laser treatment of vascular birthmarks, the nurse will be able to
(1) differentiate the types of vascular malformations that can be treated with the flashlamp-pumped pulsed dye laser,
(2) identify safety precautions with use of the flashlamp-pumped pulsed dye laser, and
(3) discuss appropriate discharge teaching after treatment of hemangiomas.
The birth of a child with a vascular birthmark can be devastating for family members. Correct classification of the birthmark is essential not only for proper counselling of the family members regarding the natural history of the lesion but also for selecting appropriate therapy. The nomenclature for vascular birthmarks was quite confusing until the early 1980s, when a classification of the vascular anomalies of childhood based on biologic behavior was developed.(1) This classification is quite easy to understand, yet many physicians, including dermatologists, continue to use antiquated terms to describe vascular birthmarks. The term hemangioma frequently is used inappropriately to describe various vascular birthmarks, even when these lesions clearly are not hemangiomas.
The implications of incorrect terminology are not just semantic; the various vascular birthmarks have vast differences in morphology, natural history, potential complications, and management. If one does not understand how to classify a vascular birthmark, how can he or she counsel the parents of children with such lesions? In addition, using an inaccurate diagnostic term may have adverse consequences on medical insurance coverage for management of such vascular birthmarks--patients who have port wine stains have been labeled as having hemangiomas and have been denied coverage for laser treatment of "a lesion that will spontaneously resolve."
Vascular birthmarks are divided into two major categories: hemangiomas and vascular malformations (Table 1). Hemangiomas are vascular tumors that grow by endothelial proliferation. Their growth is characterized by two phases: the proliferative phase, which occurs during the first year of life and manifests as growth of the lesion out of proportion to the child's growth, and the involutive phase, during which the lesion gradually recedes. Vascular malformations, on the other hand, represent vascular channel abnormalities due to errors in morphogenesis. They grow in proportion to the growth of the child and persist throughout life. Vascular malformations are further subdivided depending on the vascular structure that is abnormal (Table 2). The most commonly encountered vascular malformations are the nevus flammeus neonatorum (ie, "stork bite," "angel kiss," "salmon patch"), which tends to lighten over time, and the port wine stain (PWS), which tends to darken over time.
Table 1 BIOLOGICAL CLASSIFICATION OF VASCULAR BIRTHMARKS(1)
NOTE (1) J B Mulliken, J Glowacki, "Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics," Plastic and Reconstructive Surgery 69 (March 1982) 412-422.
Table 2 TYPES OF VASCULAR MALFORMATIONS(1)
NOTE (1.) O T Tan, Management and Treatment of Benign Cutaneous Vascular Lesions (Philadelphia: Lea & Febiger, 1992) 13.
PORT WINE STAINS
Port wine stains are seen in 0.1% to 0.6% of the population and occur most commonly on the face and neck.(2) They consist of abnormally dilated capillaries, which arise secondary to decreased or absent perivascular nerve fibers. Port wine stains begin as flat, pink, red, or purple lesions that undergo gradual change over time. The blood vessels become progressively dilated, resulting in darkening of the lesion as well as thickening of the involved area. Two thirds of patients with PWS develop nodularity (ie, vascular blebs) within the PWS by the fifth decade of life. These may break down and bleed with minor trauma. Port wine stains may be associated with soft tissue thickening, especially of the eyelids and lips. They may also be associated with limb length discrepancy when located on an extremity.
When PWS are located in the periorbital area, they may be associated with vascular malformations in the choroid of the eye, putting the patient at risk for development of glaucoma. These patients need early referral to an ophthalmologist for monitoring of intraocular pressure. When PWS are located in the distribution of the first branch of the trigeminal nerve (ie, V1 distribution), there is a 5% to 8% risk of associated Sturge-Weber syndrome (characterized by ipsilateral leptomeningeal vascular malformations, which can cause seizures, contralateral hemiplegia, and motor and cognitive developmental delay), as well as risk of glaucoma.(3) Some patients with PWS, especially when they are located on the face, can suffer from low self-esteem, which can lead to other psychological disturbances.
Safe and effective treatment for PWS has been available for more than a decade.(4) Treatment with the flashlamp-pumped pulsed dye laser (FPDL) results in partial to complete clearing of PWS in 50% to 70% of cases. Contrary to prior opinion, recent literature indicates that PWS do not lighten any faster if treatment is initiated during infancy as opposed to waiting until later in childhood or adulthood.(5) Early intervention generally is recommended, however, to prevent complications of PWS (eg, soft tissue hypertrophy, vascular bleb formation, psychological problems). Most patients require four to six laser treatments, spaced approximately three months apart; some patients require more. The lateral face and neck are easier to treat than the central facial regions.(6) Port wine stains on the extremities are more difficult to treat and require more treatments for lightening to occur.(7)
THE FLASHLAMP-PUMPED PULSED DYE LASER
The FPDL operates on the theory of selective photothermolysis. When its 585 am yellow light high energy beam traverses the skin, its energy is selectively absorbed by the oxygenated red blood cells and is transferred to the blood vessel wall in the form of heat. This causes thermal damage to the vessel, resulting in intravascular coagulation. Heat is not transferred to adjacent dermal tissue because the laser energy is delivered in a pulse that lasts only 450 microseconds, which is shorter than the thermal relaxation time of the targeted tissue--the small, superficial blood vessels. This accounts for the very low risk of scarring when treating vascular lesions with the FPDL. The FPDL penetrates only 1 mm into the skin; thus, vessels deeper than 1 mm are unaffected by the laser. This represents an obstacle to complete clearing of many PWS and also explains why some PWS may recur after seemingly successful treatment.
The energy beam of the FPDL is delivered to the skin after passing through a very thin fiber optic connected to a handpiece. The handpiece contains a lens through which both a green aiming beam and the laser beam pass. The handpiece is held perpendicular to the treatment site, with its protuberant stem adjacent to the aiming beam resting directly upon the skin. The laser can be controlled either by a finger switch or a foot pedal. Pulses can be delivered either singly or by using a "cruise control," whereby the operating switch is depressed and one pulse per second is delivered until the switch is released. Pulses are overlapped slightly because the energy in each pulse is delivered in a Gaussian distribution, represented by a bell-shaped curve, in which the energy is most intense at the center of the pulse and less intense at the periphery. Inevitably, a honeycomb pattern becomes evident as the PWS fades. Subsequent treatments specifically target the relatively untreated areas.
LASER SAFETY
The following issues need to be addressed regarding safety during use of the FPDL.
Inservice education. All personnel involved with use of lasers or who work in the procedure area where lasers are used should receive inservice training regarding the potential dangers associated with lasers. Inservice programs should include, but not be limited to, the following subjects.
* Basic laser physics--This should cover definitions and explanations of laser terminology, electromagnetic energy, wavelength, stimulated emission of photons, laser systems, types of lasers, beam characteristics, and tissue responses,
* Laser energy delivery systems--This should cover the components of laser energy delivery systems, such as fiber optics, bare and sheathed fibers, handpieces, and micromanipulators. Factors affected by the quality of the delivery systems also need to be included, as does the method by which the laser energy is checked.
* Clinical applications--These vary among the different types of lasers. A given laser may be used by several different medical and surgical specialties for vastly different indications. Inservice training needs to be geared towards the specific lasers available in each institution, as well as the specific indications for laser treatment.
* Safety--This area should cover regulatory agencies, classification of lasers, preprocedure safety and equipment checks, major hazards associated with various lasers, eye protection, window coverings, warning signs and systems, electrical/ water safety, fire prevention, emergency laser shutdowns, modified instrumentation, airway management, safety with gases, smoke evacuation, and laser safety publications.
* Policies and procedures--Each institution should develop its own set of policies and procedures that include laser policies in general, laser committees, scheduling, personnel training, safety, equipment operation and maintenance, responsibility, and resources available.
In our laser surgery center, it is mandatory that all personnel attend a laser nursing course that includes all of the above information and a hands-on practical application.
Eye protection. The major hazard for laser operators and patients is the potential for ophthalmic injury, which may occur if the laser light is absorbed by the retinal vasculature. All people (including visitors) within the procedure area must wear special eyeglasses (or goggles that can be worn over prescription eyeglasses) while the laser is in operation. At times, patients can also wear the appropriate eyeglasses or goggles; however, if the treatment site is near the periorbital area, or if the patient is unable to comply with wearing the glasses or goggles, the patient's eyes must be covered with moist eye pads and reflective foil or metal spoons. Infants and small children are usually wrapped "papoose style," and their eyes are covered with a moist blue surgical towel. During laser procedures performed with general anesthesia, the patient's eyes are lubricated, closed, and then covered with moist eye pads and reflective foil.
For treatment directly on the eyelid, lead eye shields are inserted immediately before treating that area. It is best to avoid leaving the eye shields in for more than 30 minutes because this can cause oxygen deprivation to the eyes. If the patient is under general anesthesia, it is not necessary to anesthetize the eyes before insertion of the eye shields. If the patient is awake, anesthetic eye drops are instilled into the eyes before insertion. The eyes must then be bandaged closed for one hour after the laser treatment while the ophthalmic anesthetic wears off. Failing to do so may result in corneal abrasions.
Ear protection. Pulsing the laser near the ear canal may result in absorption of the laser energy by vessels on the tympanic membrane, which can result in perforation. Moist cotton should be inserted in the ear canal before treatment of the ear.
Warning signs. Appropriate warning signs should be placed on all entrance doors to the procedure area. Appropriate protective eyewear should be placed near the door to the procedure area to provide eye protection for anyone who enters while the laser is in use. All personnel should receive inservice education about recognizing the signs on the door before being allowed to work within the procedure area.
Fire prevention. When the laser beam is misdirected or used in the presence of flammable or combustible materials, a fire can occur. The use of alcohol wipes to prep the patient's skin before treatment with the laser is discouraged because of possible flammability. Moistened towels or reflective materials (eg, dull-surfaced instruments) can be used near the laser beam path when required. The FPDL singes hair, so hair-bearing areas (eg, eyebrows, eyelid margins, near the hairline) that are being treated must be moistened; at times, the hair along the patient's hairline is shaved. For procedures performed with general anesthesia, care must be taken to avoid igniting oxygen and inhalational anesthetic agents.(8) Water is always kept on the back table in case of fire.
TREATMENT OF PORT WINE STAINS
Test patches usually are performed before the first full laser treatment when the PWS is large. Topical anesthetic cream is used to lessen the discomfort of the impact of the laser pulses, which feel like hot bacon grease splattering on the skin. Performing test patches allows the laser surgeon to choose the minimum energy that provides a good result for the first full treatment and to evaluate the potential for abnormal tissue response or scarring, which occur occasionally. It gives the patient and/or parents the opportunity to experience the laser procedure on a small scale in terms of intraoperative and postoperative discomfort as well as the heading process. Subsequent treatments are performed either with topical or local anesthesia with or without sedation or general anesthesia, which is usually reserved for infants and young children with extensive lesions.(9)
Purpura occurs at the treatment site immediately after impact of the laser beam pulse. This gradually fades during a 10- to 14-day period after treatment of the face and from two to four weeks on the trunk and extremities. Progressive lightening of the PWS is noted for approximately three months after the laser treatment, after which little further improvement is expected. Treatments are repeated at three-month intervals. As the PWS fades, the energy uptake by the remaining blood vessels decreases. This may be related in part to the depth of the remaining vessels. Consequently, the energy density of the laser is increased carefully so as to achieve maximum lightening with each treatment. Treatment of thickened areas (eg, vascular blebs) may be facilitated by compressing the site with a microscope glass slide and then pulsing the laser through it.
Some laser surgeons prechill the skin with ice. This may reduce postoperative swelling and the potential for scarring. Ice is also used postoperatively. Prednisone 1mg/kg/d for three days is helpful in decreasing eyelid and lip swelling. Complications of FPDL treatment include blistering and crusting with the potential for secondary infection, scarring ([is less than] 1% incidence),(10) postinflammatory hypopigmentation or hyperpigmentation, focal dermatitis, pyogenic granuloma formation, and keloid formation.
TREATMENT OF HEMANGIOMAS
Hemangiomas are the most common benign cutaneous tumors of infancy. They are seen in 10% of infants. Some go unnoticed until one to four weeks of life. They may be single (80% of cases) or multiple. They vary in size, and the head and neck are the most common locations. Clinically, they present as either superficial lesions, deep lesions, or a combination of the two. They grow out of proportion to the growth of the child during the first year of life and then slowly involute during the next several years. The average hemangioma requires no intervention. Some require intralesional or systemic steroid therapy, particularly when a vital function is threatened by the increasing size of the tumor.
Treatment with FPDL should be considered for all early facial hemangiomas. If hemangiomas are treated when they are quite superficial during the early stage of proliferation, eradication or halt of further progression of growth may be possible.(11) This is a controversial issue, as some hemangiomas are destined to stay superficial, so early intervention may falsely give the impression of prevention of proliferation, Some authors believe that early intervention does not prevent proliferation of the deep component if it is destined to occur.(12) Our experience has been quite variable. It is clear that if treatment is delayed and proliferation does occur, the FPDL may have little to offer except for some lightening of the superficial component. The deep component of hemangiomas appears not to respond to the FPDL because of its limited depth of penetration. Treatment is repeated on a monthly basis until the proliferative element has disappeared or until it becomes clear that treatment is ineffective. Some hemangiomas require treatment with a combination of the FPDL and systemic or intralesional steroids.
Ulcerated hemangiomas may also be treated with the FPDL.(13) This modality is used when conventional treatment (eg, topical wound care and antibiotics) fails. Patients experience a marked decrease in pain of the ulceration within one day of laser treatment. Most ulcers heal after one to three treatments, spaced two weeks apart. After involution has taken place, FPDL treatment can eradicate persistent telangiectasias at the site previously occupied by the hemangioma.
NURSING CONSIDERATIONS
The continuity of nursing care is the primary consideration in our outpatient procedure area. The nurse who has responsibility for operation of the laser during the treatment must also be responsible for patient safety, education, and follow-up,
Preoperative patient care. A medical history, including allergies, current medications, and weight, is taken before the treatment begins. If general anesthesia is planned, the patient arrives in the preoperative holding area, where the anesthesia care provider and laser surgeon review the patient's medical history and obtain the consent. The laser nurse explains to the patient and/or family members how the laser works, the tissue response that will be seen, and the care that will be necessary after the treatment (Table 3), The nurse helps alleviate the patient's and family members' anxiety by answering any questions they may have and by reviewing postoperative expectations with them.
Table 3 SAMPLE CARE PLAN
Nursing diagnosis: Potential anxiety related to lack of knowledge of flashlamp-pumped pulsed dye loser (FPDL) therapy
Goals
Short-term: Laser action, expected skin response, and skin care instructions can be described.
Long-term: Anxiety will be relieved and discharge core will be followed.
Intraoperative patient care. The laser nurse is responsible for setting up the necessary equipment and supplies required for the procedure (Table 4). He or she ensures that safety standards are adhered to at all times. The patient is placed in the best position that allows accessibility to the area to be treated. Sometimes the laser surgeon uses a surgical marking pen to outline the borders of the vascular malformation.
When general anesthesia is used for an infant or child, the patient's parents may be allowed to be present during induction, at the discretion of the anesthesia care provider. After that, the parents are escorted to the waiting area by the laser nurse, who keeps them informed of their child's condition routinely throughout the treatment. A consideration that facilities may find helpful is to allow one parent to stay with the infant or child during the recovery process. A familiar voice or face can help calm the child during emergence from general anesthesia. If the patient or family member opts for local or topical anesthesia, the family member is given the choice of whether to stay and watch the procedure.
Postoperative care. Immediately after the treatment, the laser nurse applies a thin layer of antibiotic ointment or white petrolatum to the area that was treated. Nonadherent dressings can be applied and secured with gauze wraps or elastic bandages. The discharge instructions are reviewed (Table 5). Acetaminophen often is prescribed for postoperative analgesia (patients have described the pain after the laser procedure as being similar to that of a mild sunburn). The laser nurse places a telephone call to the patient or family members the day after the procedure. He or she answers any questions and relays any concerns to the laser surgeon.
CASE STUDY
Lydia is a two-year-old who presented at the age of three weeks for evaluation of a PWS on the right side of her face. The PWS primarily involved the distribution along the second branch of the trigeminal nerve (V2 distribution) and a small portion of her right upper eyelid (V1 distribution) and preauricular area (V3 distribution) (Figure 1). The mechanics of FPDL treatment were discussed with her parents, and the preauthorization process was initiated.
[Figure 1 ILLUSTRATION OMITTED]
Lydia was referred to a pediatric ophthalmologist to monitor for possible glaucoma of the right eye; at her initial evaluation, her right eye had a high intraocular pressure. Lydia eventually required trabeculectomy to correct the glaucoma. Given that Lydia has V1 distribution involvement of the PWS, she has a 5% to 8% risk of having Sturge-Weber syndrome; however, she has not had seizures and has developed normally.
Lydia presented to the laser surgery unit at eight months of age for placement of test patches with the FPDL. (It would have been appropriate to perform test patches months earlier; the delay was secondary to insurance issues.) After application of a topical anesthetic cream, two different energy densities were used to perform the test patches. Immediate purpura was evident at the test patch sites (Figure 2). The purpura resolved within the next two weeks, and several weeks later, significant lightening of both test sites was noted.
[Figure 2 ILLUSTRATION OMITTED]
Three and one-half months later, Lydia underwent her first full laser treatment with general anesthesia. A lead eye shield was used during treatment of the right upper eyelid. As with the test patches, the purpura from the full laser treatment resolved within two weeks, followed by significant lightening of the PWS several weeks later. Lydia underwent her second full laser treatment under general anesthesia three and one-half months later. She experienced significant lightening of all portions of her PWS after the two laser treatments (Figure 3) and had her third treatment at the age of 21.5 months. It is anticipated that she will require a few more treatments to further lighten her PWS; however, the exact number of treatments cannot be predicted.
[Figure 3 ILLUSTRATION OMITTED]
CONCLUSION
The FPDL is a safe and effective treatment modality for patients with PWS who previously had few treatment options available. The FPDL can also be useful in the treatment of certain hemangiomas. The laser nurse plays an integral role in the procedure and must be specially trained to operate the laser equipment. He or she must also devote attention to detail while the procedure is being performed. Postoperative counseling of the patient by the nurse is the key to the success of the procedure because the events that take place after the patient leaves the procedure area can have a significant impact on the outcome.
NOTES
(1.) J B Mulliken, J Glowacki, "Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics," Plastic and Reconstructive Surgery 69 (March 1982) 412-422.
(2.) J C Alper, L B Holmes, "The incidence and significance of birthmarks in a cohort of 4,641 newborns," Pediatric Dermatology 1 (July 1983) 58-68; K Osborn, R H Schosser, M A Everett, "Congenital pigmented and vascular lesions in newborn infants," Journal of the American Academy of Dermatology 16 (April 1987) 788-792.
(3.) B Tallman et at, "Location of port-wine stains and the likelihood of ophthalmic and/or central nervous system complications," Pediatrics 87 (March 1991) 323-327.
(4.) O T Tan, K Sherwood, B A Gilchrest, "Treatment of children with port-wine stains using the flashImp-pulsed tunable dye laser," The New England Journal of Medicine 320 (Feb 16, 1989) 416-421; J S Nelson, J Applebaum, "Clinical management of port-wine stains in infants and young children using the flashlamp-pulsed dye laser," Clinical Pediatrics 29 (September 1990) 503-509; B A Reyes, R Geronemus, "Treatment of port-wine stains during childhood with the flashlamp-pumped pulsed dye laser," Journal of the American Academy of Dermatology 23 (December 1990) 1142-1148.
(5.) S S Orten et at, "Port-wine stains: an assessment of 5 years of treatment," Archives of Otolaryngology-Head and Neck Surgery 122 (November 1996) 1174-1179.
(6.) L Renfro, R G Geronemus, "Anatomical differences of port-wine stains in response to treatment with the pulsed dye laser," Archives of Dermatology 129 (February 1993) 182-198.
(7.) S W Lanigan, "Port wine stains on the lower limb: response to pulsed dye laser therapy," Clinical and Experimental Dermatology 21 (March 1996) 88-92.
(8.) S Fretzin, W H Beeson, C W Hanke, "Ignition potential of the 585-nm pulsed-dye laser: Review of the literature and safety recommendations," Dermatologic Surgery 22 (August 1996) 699-702.
(9.) Anonymous, "Anesthesia and/or sedation for pulsed dye laser therapy," Pediatric Dermatology 9 (June 1992) 132-153; J M Grevelink et at, "Pulsed laser treatment in children and the use of anesthesia," Journal of the American Academy of Dermatology 37 (July 1997) 75-81.
(10.) V J Levine, R G Geronemus, "Adverse effects associated with the 577- and 585-nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: A study of 500 patients," Journal of the American Academy of Dermatology 32 (April 1995) 613-617.
(11.) R Ashinoff, R G Geronemus, "Capillary hemangiomas mid treatment with the flash lamp-pumped pulsed dye laser," Art hives (if Dermatology 127 (February 1991) 202-205; J M Garden, A D Bakus, A S Puller, "Treatment of cutaneous hemangiomas by the flashlamp-pumped pulsed dye laser: Prospective analysis," The Journal of Pediatrics 120 (April 1992) 555-560; M Winter et al, "Laser photocoagulation of superficial proliferating hemangiomas," The Journal of Dermatologic Surgery and Ontology 20 (January 1994) 43-46; H Maier, R Neumann, "Treatment of strawberry marks with flashlamp-pumped pulsed dye laser in infancy," The Lancet 347 (Jan 13, 1996) 131-132; R J Barlow, N P Walker, A C Markey, "Treatment of proliferative haemangiomas with the 585 nm pulsed dye laser," British Journal of Dermatology 134 (April 1996) 700704.
(12.) R Ashinoff, R G Geronemus, "Failure of the flashlamp-pumped pulsed dye ]met to prevent progression to deep hemangioma," Pediatric Dermatology 10 (March 1993) 77-80; J H Scheepers, A A Quaba, "Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience," Plastic and Reconstructive Surgery 95 February 1995) 305-312.
(13.) J G Morelli, O T Tan, W L Weston, "Treatment of ulcerated hemangiomas with the pulsed tunable dye laser," American Journal of Diseases of Children 145 (September 1991) 1062-1064; J G Morelli et at, "Treatment of ulcerated hemangiomas in infancy," Archives of Pediatric sand Adolescent Medicine 148 (October 1994) 1104-1105.
Sheryll L. Vanderhooft, MD is assistant professor, Department of Dermatology, and adjunct assistant professor, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City.
William W. Doidge, RN, BSN, is a staff nurse and lithotripsy coordinator, laser surgery unit, University of Utah Health Sciences Center, Salt Lake City.
Taunt Maughan, RN, BSN, is clinical care coordinator, laser surgery unit, University of Utah Health Sciences Center Salt Lake City.
COPYRIGHT 1998 Association of Operating Room Nurses, Inc.
COPYRIGHT 2001 Gale Group
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