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Nelson 2000

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21 views2 pages

Nelson 2000

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Shuaib Ahmed
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Lasers in Surgery and Medicine 26:2–3 (2000)

Letter to the Editor


Safety of Cryogen Spray Cooling During Pulsed ine, a canister (Candela Laser Corporation, Way-
Laser Treatment of Selected Dermatoses land, MA) of HFC-134a (net weight 450 g) is usu-
ally sufficient for 40 laser procedures. Thus, for
The novel method of achieving spatially se- each patient, approximately 450 g/40 ⳱ 11.25 g
lective photocoagulation with “dynamic” also HFC-134a is released. This corresponds to 2.5 L of
known as cryogen spray cooling (CSC) is well es- HFC-134a (11.25/102 ⳱ 0.11 mol ⳱ 2.5 L at room
tablished and is being used for the laser treat- temperature), which is negligible (<70 ppm) when
ment of patients with selected dermatoses [1–6] compared with the total volume of 36,000 L air in
and in laser surgery in general [7,8]. Recently, a mid-sized room (e.g., 3 × 4 × 3 m3). In fact, air
concerns have been raised at symposia and in expired by three persons (physician, nurse, and
commercially distributed literature with respect patient; 6 L/person/min, which contains 0.36%
to possible adverse effects of using cryogens. In CO2) contains 2 L CO2 (assuming a treatment du-
this letter, we address the general issue of safety ration of 30 min), which is comparable to the
of 1,1,1,2-tetrafluoroethane (HFC-134a; C2H2F4; amount of air displaced by HFC-134a. Even in a
MW ⳱ 102 g/mol; DuPont, Wilmington, DE) as a worst-case scenario, if the canister or its valve
cooling agent for cutaneous laser surgery. were damaged and the entire content (100 L HFC-
We chose HFC-134a in our initial study of 134a) released inadvertently into a room with
CSC [1] to comply with the Montreal Protocol and standard ventilation, exposure would not even ap-
the US Food and Drug Administration (FDA) di- proach the acceptable exposure limit of 1,000
rective dealing with the replacement of chloro- ppm/12 hr for humans (Material Safety Data
fluorocarbons as commercial refrigerants, which Sheet, DuPont). From these considerations, it
deplete atmospheric ozone and contribute to glob- may be concluded that HFC-134a is a safe cooling
al heating [9]. HFC-134a is nonflammable at am- agent for cutaneous laser surgery.
bient temperature and atmospheric pressure,
FDA approved for dermatologic use, and commer- J. Stuart Nelson, MD, PhD
cially available in a medical grade formulation. Beckman Laser Institute and Medical Clinic
As far as inherent toxicology is concerned, it Departments of Surgery and Dermatology
has been abundantly proven in preclinical studies University of California, Irvine
that HFC-134a is safe at very high multiples of Irvine, California 92612
likely human exposure [10,11]. In a study of 337 Sol Kimel, PhD
asthmatic patients receiving HFC-134a propelled Department of Chemistry
albuterol from a metered dose inhaler over a Technion—Israel Institute of Technology
1-year period, only four subjects reported adverse Haifa, Israel
symptoms consisting of diarrhea or dizziness [12].
A second concern has been frostbite, which is of
minor importance for CSC because the liquid REFERENCES
cryogen is in contact with human skin for less
than 0.5 sec [1–8]. Another concern expressed is 1. Nelson JS, Milner TE, Anvari B, Tanenbaum BS, Kimel
that HFC-134a will displace air and diminish the S, Svaasand LO, Jacques SL. Dynamic epidermal cooling
oxygen content in the room where it is released during pulsed laser treatment of port-wine stain. Arch
and, ultimately, cause suffocation. This displace- Dermatol 1995;131:695–700.
ment is more serious because the density of HFC- 2. Nelson JS, Milner TE, Anvari B, Tanenbaum BS,
134a is 3.6 times higher than that of air. However, Svaasand LO, Kimel S. Dynamic epidermal cooling in
conjunction with laser-induced photothermolysis of port
in this connection, the more important consider- wine stain blood vessels. Lasers Surg Med 1996;19:224–
ation is the relative quantity of released HFC- 229.
134a versus air. At the Beckman Laser Institute 3. Waldorf HA, Alster TS, McMillan K, Kauvar ANB,
and Medical Clinic, University of California, Irv- Geronemus RG, Nelson JS. Effect of dynamic cooling on

© 2000 Wiley-Liss, Inc.


Letter to the Editor 3
585 nm pulsed dye laser treatment of port wine stain Rebeiz EE, Shapshay SM. Laser soft-palate stiffening.
birthmarks. Dermatol Surg 1997;23:657–662. Proc SPIE 1998;3245:136–144.
4. Cheng CJ, Nelson JS. Cryogen spray cooling and higher 8. Fried NM, Walsh JT. Dynamic cooling during laser skin
fluence pulsed dye laser treatment improve port wine welding. Proc SPIE 1999;3590:128–133.
stain clearance while minimizing epidermal damage. 9. Kanakidou M, Dentener RJ, Crutzen PJ. A global three-
Dermatol Surg 1999;25:767–772. dimensional study of the fate of HCFCs and HFC-134a in
5. Kelly KM, Nelson JS, Lask GP, Geronemus RG, Bern- the troposphere. J Geophys Res 1995;100:18781–18801.
stein LJ. Cryogen spray cooling in combination with non- 10. Alexander DJ. Safety of propellants. J Aerosol Med 1995;
ablative laser treatment of facial rhytides. Arch Derma- 8:S29–S34.
tol 1999;135:691–694. 11. Alexander DJ, Libretto SE. An overview of the toxicology
6. Fiskerstrand EJ, Norvang LT, Svaasand LO. Laser treat- of HFA-134a (1,1,1,2-tetrafluoroethane). Hum Exp Toxi-
ment of port-wine stains: reduced pain and shorter dura- col 1995;14:715–720.
tion of purpura by epidermal cooling. Proc SPIE 1996; 12. Ramsdell JW, Klinger NM, Ekholm BP, Colice GL. Safety
2922:20–28. of long-term treatment with HFA albuterol. Chest 1999;
7. Wang Z, McMillan K, Perrault DF, Nemati B, Carkner E, 115:945–951.

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