The term, non–operating room anesthesia , describes a location remote from the main operating suites and closer to the patient, including areas that offer specialized procedures, like endoscopy suites, cardiac catheterization laboratories, bronchoscopy suites, and invasive radiology suites. There has been an exponential growth in such procedures and they present challenges in both organizational aspects and administration of anesthesia. This article explores the requirements for the location, preoperative evaluation and patient selection, monitoring, anesthesia technique, and postoperative management at these sites. There is a need to better define the role of the anesthesia personnel at these remote sites.
Key points
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The need for non–operating room anesthesia (NORA) increased exponentially in the past decade. This is driven by multiple factors.
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Anesthesiologists are forced to work outside their comfort zone, forcing them to think outside the box.
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Proper preprocedure evaluation and preprocedural optimization of comorbidities as appropriate are key to providing optimal care.
Introduction
The term, NORA , was coined to describe a location remote from the main operating suites and closer to the patient. The American Society of Anesthesiologists (ASA) in its newsletter in November 2013 recognized this transformation in delivery of health care that will continue to push the locus of care closer to the patient and in nontraditional settings. Unlike ambulatory procedures that might be done at designated rooms in the operating room suite, or separate designated building on or off campus, out-of–operating room procedures usually mean procedures carried out in areas that offer specialized procedures, like endoscopy suites, cardiac catheterization laboratories, invasive radiology, and so forth. As both the monitoring technology and anesthetic techniques continue to improve, the number of cases performed at remote locations continue to grow and many institutions have reported that up to 30% of anesthetics are administered to patients outside the operating room.
The need for NORA has increased exponentially in the past decade. This is driven by many factors. Most institutions have areas where the facilities are optimized to provide state-of-the-art diagnostic and therapeutic options for patients. These may involve fixed complex instruments that are impossible to move to an operating suite or might involve expensive upgrading of the operating suites to safely facilitate their use. The size or layout of these rooms may not allow for handling the extra equipment required in an already crowded operating room. In some cases, out-of–operating room procedures that are considered minimally invasive are selected as a less risky alternative to an operating room procedure. In other instances, these remote sites may be more efficient and cost saving and provide for better patient and provider satisfaction by bringing together the facility, personnel, and equipment.
The challenges anesthesiologists face are due to an unfamiliar environment and surroundings that result in confusion of the location of equipment and supplies, unavailability of some critical equipment, paucity of space, limited access to the airway due to shared airway or barriers to easy and ready access, increasing complexity of the procedures performed outside the operating room, and increasing patient acuity. Anesthesiologists are forced to work and think outside the box, develop new skill sets, and modify anesthetic techniques to provide a safe and smooth anesthetic experience.
There has been such a significant surge in these out-of–operating room procedures that the need for training graduates that addresses these complexities has been recognized by both the American Board of Anesthesiology and the major societies and is being incorporated into the training curriculum at most anesthesia residency programs. But what must be recognized is the need to provide the same levels of safety and standardization that are provided in the operating room environment that have allowed the specialty to succeed. Expansion into this realm should be driven by “what is best” for the patient and not by “what is possible.”
Introduction
The term, NORA , was coined to describe a location remote from the main operating suites and closer to the patient. The American Society of Anesthesiologists (ASA) in its newsletter in November 2013 recognized this transformation in delivery of health care that will continue to push the locus of care closer to the patient and in nontraditional settings. Unlike ambulatory procedures that might be done at designated rooms in the operating room suite, or separate designated building on or off campus, out-of–operating room procedures usually mean procedures carried out in areas that offer specialized procedures, like endoscopy suites, cardiac catheterization laboratories, invasive radiology, and so forth. As both the monitoring technology and anesthetic techniques continue to improve, the number of cases performed at remote locations continue to grow and many institutions have reported that up to 30% of anesthetics are administered to patients outside the operating room.
The need for NORA has increased exponentially in the past decade. This is driven by many factors. Most institutions have areas where the facilities are optimized to provide state-of-the-art diagnostic and therapeutic options for patients. These may involve fixed complex instruments that are impossible to move to an operating suite or might involve expensive upgrading of the operating suites to safely facilitate their use. The size or layout of these rooms may not allow for handling the extra equipment required in an already crowded operating room. In some cases, out-of–operating room procedures that are considered minimally invasive are selected as a less risky alternative to an operating room procedure. In other instances, these remote sites may be more efficient and cost saving and provide for better patient and provider satisfaction by bringing together the facility, personnel, and equipment.
The challenges anesthesiologists face are due to an unfamiliar environment and surroundings that result in confusion of the location of equipment and supplies, unavailability of some critical equipment, paucity of space, limited access to the airway due to shared airway or barriers to easy and ready access, increasing complexity of the procedures performed outside the operating room, and increasing patient acuity. Anesthesiologists are forced to work and think outside the box, develop new skill sets, and modify anesthetic techniques to provide a safe and smooth anesthetic experience.
There has been such a significant surge in these out-of–operating room procedures that the need for training graduates that addresses these complexities has been recognized by both the American Board of Anesthesiology and the major societies and is being incorporated into the training curriculum at most anesthesia residency programs. But what must be recognized is the need to provide the same levels of safety and standardization that are provided in the operating room environment that have allowed the specialty to succeed. Expansion into this realm should be driven by “what is best” for the patient and not by “what is possible.”
Selection of location
Most of the interventional procedures in the gastrointestinal (GI) suite done before this millennium did not need much anesthesia support; hence, the configuration of the rooms was not designed with the anesthesia provider in mind. In 2009, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage eliminated the distinction between a sterile operating room and a nonsterile procedure room. In 2013, the ASA published the standards, guidelines, and policies that should be adhered to in all nonoperating room settings except where they are not applicable to an individual patient or care setting. The goal of these guidelines is to advance NORA to the same level of safety and standardization that is mandated in the operating room environment ( Boxes 1 and 2 , Fig. 1 ).
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Need to observe all applicable building and safety codes and facility standards, where they exist
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Sufficient space to accommodate necessary equipment and personnel and to allow expeditious access to the patient, anesthesia machine (when present) and monitoring equipment
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Sufficient electrical outlets to satisfy anesthesia machine and monitoring equipment requirements, including clearly labeled outlets connected to an emergency power supply
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Isolated electric power or electric circuits with ground fault circuit interrupters in any wet location
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Adequate illumination of the patient, anesthesia machine (when present), and monitoring equipment; battery-powered illumination for backup
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Reliable oxygen source with the piped gases, when available, meeting the applicable codes with a backup supply
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Reliable and adequate source of suction
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An anesthesia machine equivalent in function to that used in operating rooms and maintained to current operating room standards
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Reliable and adequate scavenging of waste anesthetic gases, if applicable
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A self-inflating hand resuscitator
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An adequate supply of anesthesia drugs and equipment for the intended anesthesia care
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Monitoring that adheres to the Standards for Basic Anesthesia Monitoring . This includes a pulse oximetry with audible pulse tone and low-threshold alarm, continuous ECG monitoring, automated blood pressure monitoring every 5 minutes or more frequently as indicated, and temperature in cases expected to be associated with significant changes in body temperature. With the use of propofol to provide deep sedation, with or without instrumentation of the airway, the ASA guidelines now recommend the use of end-tidal CO 2 monitoring with an audible alarm for patients undergoing both moderate and deep sedation.
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An emergency cart with a defibrillator, emergency drugs, and other equipment adequate to provide cardiopulmonary resuscitation
Anesthesia outside the operating room is away from the usual operating room environment and, therefore, requires careful monitoring to avoid adverse events. The ASA addressed this issue in their Statement on Nonoperating Room Anesthetizing Locations and Standards for Basic Anesthesia Monitoring The important guidelines include the following.
Selection of the anesthetic technique
It is important to recognize that the level of sedation or anesthesia during a procedure is often variable. Some routine diagnostic endoscopic procedures can be performed with minimal or no sedation, but procedures that are more complex are better tolerated when deeper levels of sedation are used. Procedures that are painful or require an absolutely still patient also necessitate a deeper plane of sedation or general anesthesia (GA) with or without instrumentation of the airway.
Nonanesthesiologists sometimes fail to realize that sedation is a continuum and can range from minimal sedation through conscious sedation, deep sedation, and GA. There is a progressive depression of central nervous system (CNS) with progressive decrease in the levels of consciousness and responsiveness to painful stimuli, loss of protective reflexes, and ultimately depression of the cardiovascular and respiratory system ( Table 1 ). There is considerable overlap between the medications used for anxiolysis, conscious and deep sedation, and GA. With adequate doses, a deeper plane of anesthesia may be entered than intended, even when using a medication not designed for deeper planes. In addition, combination of an anxiolytic/sedative and an opioid may produce significant respiratory depression. It is important that when nonanesthesiologists are involved in providing sedation that they should be adequately trained to recognize and rescue patients when they enter a deeper plane of anesthesia than intended.
| Response | Airway | Cardiovascular System | Neuromuscular Function | |
|---|---|---|---|---|
| Minimal sedation | Normally to verbal commands | Normal | Normal | Normal |
| Conscious sedation | Purposefully to verbal commands, alone or by light tactile stimulation | Normal | Normal | Normal |
| Deep sedation | Cannot be easily aroused but responds purposefully after repeated or painful stimulation | May be difficult to maintain | Usually not affected | Normal |
| GA | Does not respond to painful stimuli | Will need assistance to maintain airway | May be impaired | Depressed |
Medications commonly used for anxiolysis/conscious sedation
In most institutions in the United States, conscious sedation for endoscopic procedures usually involves the intravenous (IV) bolus administration of a benzodiazepine and a narcotic.
Benzodiazepines
Benzodiazepines stimulate the γ-aminobutyric acid (GABA) receptors ( Table 2 ), which results in an increased inhibitory effect of GABA on neuronal excitability. Benzodiazepines produce sedation, anxiolysis, anterograde amnesia, muscle relaxation, and anticonvulsant activity through their effect on the CNS. The commonly used benzodiazepines are midazolam, diazepam, lorazepam, oxazepam, clonazepam, flurazepam, temazepam, triazolam and quazepam, differing in speed of onset and duration of action. They have a ceiling effect that limits CNS depression, but when they are combined with other anesthetic agents, they can lead to profound respiratory depression.
| Agent | Route of Administration | Onset of Action | Half-Life | Metabolism |
|---|---|---|---|---|
| Oral/IV/IM/transnasal | IV—30–60 s IM—15 min Oral—15 min | 1–4 h | Liver Metabolites are active but are rapidly cleared. |
| Diazepam | Oral/IV/IM/rectal | IV—5 min IM—20–30 min PO—30–60 min | 21–37 h | Liver Metabolites are active but slowly cleared. |
| Lorazepam | Oral/IV/IM | IV—5 min IM—20–30 min PO—30–60 min | 10–20 h | Liver Metabolites are inactive. |
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