General Considerations
Anesthesiologists routinely provide care to patients in locations remote from the operating room (OR) or alternate sites. In some academic practices, the proportion of “out-of-OR” (OOOR) anesthetics approaches 40%. The remote site should be interpreted as a place that is located distant from where the main operating room headquarters is located, now considered routine sites of care. Nevertheless, these remote locations present additional challenges for the anesthesia provider, since it is not uncommon that detailed protocols for provision of anesthesia care are not in place and specialized equipment is not readily available.
Intuitively, patient safety while delivering anesthesia is enhanced by the standardization and reliability built into the environment where the delivery of anesthesia is taking place. Such is true in the operating room suite, but is less so in OOOR locations. The circumstances, including unusual physical layout, energy sources, and working conditions encountered in remote sites may challenge the safety of the environment, and it potentially increases anesthetic risk to patients and to some degree, to personnel. It is the responsibility of the anesthesiologist to optimize conditions for patient safety by emphasizing teamwork and following established guidelines, when available, to minimize adverse events. Moreover, the anesthesiologist must understand the unique features of each type of remote location and how these impact the function of anesthesia equipment to effectively and safely provide anesthesia wherever it is needed. This latter concept forms the topic of this chapter.
Remote locations can be classified into four main categories, which are outlined in Table 23-1 .
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The American Society of Anesthesiologists (ASA) has published anesthesia care standards and patient monitoring requirements that must be met and uniformly maintained independent of the location where anesthesia care is provided.
To provide proper anesthetic care in remote locations, there are three major aspects that need to be taken into consideration by the anesthesiologist before administering anesthesia. This three-step approach involves evaluating the OOOR location, the procedure, and the patient.
The OOOR Location
When considering the OOOR environment, anesthesiologists must take into consideration the need for any special anesthetic and monitoring equipment, room set-up, personnel, and temperature control. They must also be aware of potential radiation hazards and dangers associated with strong magnetic fields, and they must confirm the proper functioning and location of all resuscitation equipment, including a defibrillator, a physiological monitor, suction devices, oxygen source, Ambu bag, and resuscitation drugs.
Additionally, it is important that the anesthesiologist becomes familiar with any anesthesia machines that are available in these remote locations, and make sure that the machine is working properly before initiating patient care. Sometimes the machines are older, not used often, or are serviced infrequently. However, these factors must not be allowed to affect their usability. In other words, the anesthesia machines must be maintained and serviced before being used, have standard safety features such as oxygen failure alarms and a minimum gas ratio device, and may have specific electrical requirements such as grounded power outlets. More fundamentally, the anesthesia machine, if one is provided, must meet minimum standards for usability under the rules applicable in the country where the care occurs.
The various OOOR anesthetizing locations are primarily designed with the needs of the proceduralist in mind rather then the anesthesiologist. Often there are large pieces of equipment that can be in the way of the anesthesiologist, obstructing access to the patient. Also, equipment such as piped-in gases, suction, overhead lighting, and isolated power, which are considered standard in the operating rooms, may not be available in most nonoperating anesthetizing locations. For example, as seen in Figure 23-1 , the anesthesia machine is wedged between the procedure table support and the control room window, leaving no space for the anesthesiologist. The anesthesia machine blocks visual communication between the proceduralist and the technologist in the control room. Also of note is that the piped gases are at the opposite end of the room, and that there is an unconnected air line on the anesthesia machine.
These less than ideal situations, as depicted in Figure 23-1 , are becoming increasingly unacceptable as OOOR anesthesia matures. Early involvement of anesthesiologists in the design of these facilities to account for safe and effective anesthesia care is essential, but anesthesiologists share the responsibility to assert the perogative to participate in facility design, and equipment specifications and purchasing.
When anesthesiologists contribute to the design of OOOR locations safety issues can be improved. As seen in Figure 23-2 , the design of this neurointerventional radiology suite has been improved, but a safety issue remaining is that medical equipment is plugged into a consumer grade “power strip.” Some of the positive attributes of the design of this procedure room include:
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The anesthesia machine is positioned away from the head of the bed, which eliminates competition for space around the patient’s head during the procedure.
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The procedure table rotates on its pedestal (yellow arrow), bringing the head and airway into easy reach, with the anesthesia machine in its customary location, for induction and emergence.
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The monitor data acquisition unit (lower left) is mounted on the procedure table pedestal rather than the anesthesia machine, so that the patient connection cables do not drape across a gap between the highly mobile table and a fixed anesthesia machine (the data are carried from the acquisition unit and anesthesia machine by a dedicated, fixed cable).
Anesthesia machines, monitors, and anesthesia carts for OOOR procedures are generally housed at or near the actual anesthetizing site. However, in some cases it may be necessary to use portable machines and transport them to the desired location. Not all OOOR anesthetics require an anesthesia machine, as long as the ASA standards for monitoring under anesthesia can be met. For example, infusion pumps, a physiological monitor and a transport ventilator can provide a very credible anesthetic. In either case, transporting equipment increases the possibility of malfunctions due to damage or improper setup upon arrival, increasing the need to assure that all equipment is functional before initiation of the anesthetic care.
Another concern for the anesthesiologist to keep in mind is that OOOR locations are generally less secure than the operating room. Thus, anesthesia carts must easily lock and, ideally, lock automatically when the anesthesiologist is absent. One compromise solution is to use a lock that can be opened by the same proximity card technology commonly used as part of the ID badge that also opens doors. In addition to enhanced security, the OOOR anesthesia cart tends to require a wider variety of supplies than are typically stocked in the main OR carts to account for (sometimes tremendous) distance to the nearest anesthesia supply room. All these supplies must also be accounted for before initiating anesthetic care.
Procedures
Since anesthesiologists are no longer providing anesthetic care only in the operating room, the number of procedures that are carried out in alternate sites that require anesthesia or sedation are increasing exponentially. Examples of procedures most commonly performed outside of the OR include computed tomography (CT), magnetic resonance imaging (MRI), and many interventional radiology procedures, including gastrostomy tubes, nephrostomies, liver biopsies, and transjugular intrahepatic portosystemic shunts (TIPS) procedures. Other examples include interventional neuroradiology procedures, functional brain imaging radiotherapy procedures such as radiation therapy, intraoperative radiotherapy, and radiosurgery. Gastroenterology procedures that may require anesthetic care include upper gastroenterology endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), colonoscopy, and percutaneous endoscopic gastrostomy placement. In the future, weight reduction procedures involving reduction of gastric volume will be performed in the gastroenterology procedure suit. Cardiology procedures that often require anesthesia include cardiac catheterization, radiofrequency ablation of arrhythmogenic foci, cardioversion, and transesophageal echocardiography (TEE). The electroconvulsive therapy conducted in the psychiatry unit also requires anesthetic care.
The key concept, regardless of the location, is that anesthesia care and monitoring must meet the same standards as those applied in the OR. To facilitate and promote quality patient care, the American Society of Anesthesiologists publishes specific guidelines for providing anesthetic care outside of the operating room that apply to all anesthesia care and anesthesiology personnel at any location outside of the OR. These procedures are to be followed in all nonoperating room settings as long as they are applicable to the individual patient or healthcare setting.
The anesthesiologist must adapt to the challenges presented by different room settings, locations, procedures, and specialized equipment used to perform OOOR procedures. The following are but a few examples:
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When working in the MRI suite, the anesthesia staff must have specialized training to maintain proper patient safety while surrounded by a strong magnetic field.
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When iodinated contrast dye is administered to the patient, close monitoring must be maintained for any adverse reactions.
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When anesthesia is given during cardiac catheterization, special attention must be paid to the patient’s underlying cardiac morbidity.
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When patients receiving radiation therapy require general anesthetic, remote monitoring devices must be used during the procedure to protect the anesthesiologist from strong radiation.
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In the psychiatric unit, profound physiological changes may occur in patients during electroconvulsive therapy. The heart rate, respiration, blood pressure, and oxygen saturation of these patients must be carefully monitored and controlled by the anesthesiologist.
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While conducting anesthesia in the radiology suite, the anesthesiologist must have a good understanding of radiology equipment, radiation safety, and proper safety precautions.
A list of problems that can be encountered at any remote location during anesthesia, including the radiology suite, is summarized in Table 23-2 .
| Lack of continuous electrical supply |
| Lack of continuous supply of oxygen and nitrous oxide |
| Difficulty with storage of drugs and equipment |
| Difficulty in transport and supply of drugs and equipment |
| Lack of maintenance of equipment |
| Lack of skilled assistance |
To prevent injury to patients during anesthesia, The American Society of Anesthesiologists (ASA) 1994 Guidelines for Non-Operating Room Anesthetizing Locations recommends the following :
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Always have a reliable source of oxygen with a full backup E cylinder
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An adequate and reliable suction source
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A scavenging system for waste gas
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Adequate monitoring and anesthetic equipment, including a self-inflating hand resuscitator bag
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Multiple and safe electrical outlets
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Appropriate illumination with battery-powered backup (i.e., flashlight)
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Adequate space for the anesthesia personnel and equipment
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A resuscitation cart with a defibrillator and emergency drugs and equipment
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Effective telecommunication
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Compliance with safety codes of the facility
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Appropriate postanesthesia management
The Patient
There are several indications for anesthetic care at alternate sites. Patients may be too hemodynamically unstable to tolerate the procedure without homeostatic intervention from an anesthesiologist. They may have a difficult airway, unacceptably raising the risks from accidental oversedation. The patient may be unable to tolerate mild or moderate sedation, or such sedation may be inadequate for a given patient. Finally, the procedure may require prolonged, complete immobility, which can only be achieved under general anesthesia. Some of the most common patient factors for requiring deep sedation, monitored anesthesia care (MAC), or general anesthesia outside of the OR are listed in Table 23-3 . Depending on a specific situation, additional equipment such as the airway cart, defibrillating device, or a code cart may be needed.
| Pain management |
| Children, elderly, or disabled patients that will not follow instructions |
| Psychiatric disorders: anxiety and panic disorders, claustrophobia |
| Neurological disorders: movement and seizure disorders, cerebral palsy |
| Trauma: unstable cardiovascular, respiratory, or neurological status |
| Patients with significant comorbidities that require monitoring |
| Difficult airway |
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