Anesthesia for Procedures Outside of the Operating Room

Introduction

Nonoperating room anesthesia (NORA) and anesthesia in the nontheatre environment (ANTE), as the names suggest, provide anesthesia services at locations outside of the safe confines of the operating room. Anesthesia services are being requested at a multitude of locations as diagnostic modalities become more complex and as interventional and therapeutic modalities provide less invasive treatment options. These locations have their own unique challenges, and guidelines have been proposed by various societies, such as the American Society of Anesthesiologists. (ASA) and the Royal College of Anaesthetists (RCoA), for providing anesthesia care in nontheatre environments.

Not surprisingly, children form the largest group of patients in the NORA environment. In addition, children with suspected or diagnosed malignancy may present with associated complications of their disease (severe anemia, hyperkalemia, tumor lysis syndrome, respiratory distress, infections, pleural/pericardial effusions, etc.), which present additional challenges to anesthesia for the pediatric population. This chapter discusses the management of ANTE in children with its specific challenges and problems.

Locations Requiring NORA

The various locations external to the operating room environment that require NORA include but are not limited to:

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Diagnostic and Interventional Radiology Suite: Diagnostic and interventional procedures performed in the computerized tomography (CT), digital subtraction angiography (DSA), magnetic resonance imaging (MRI), fluoroscopic, and ultrasound suites
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Radiation therapy units
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Endoscopy suite
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Positron emission tomography (PET) suite

Other nononcologic areas may include:

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Catheterization laboratory for cardiac and neurologic procedures
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Dental department
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Psychiatry unit for electroconvulsive therapy (ECT)
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Emergency department (ED), trauma units, intensive care units (ICU)

Challenges Associated With NORA

Patient Factors

A significant proportion of children scheduled for procedures in the NORA environment may be outpatients awaiting a diagnosis and may not have been clinically stabilized or medically optimized. The functional and physiologic status of the same child may also continuously change during the course of the disease and following treatment with chemotherapy or radiotherapy. The same child may also require anesthesia at multiple times and different locations for various diagnostic and therapeutic procedures. Therefore the risk-benefit ratio of anesthesia needs to be assessed each time the child is scheduled for a procedure under anesthesia.

Children may be inadequately fasting in the absence of clear instructions or may experience dehydration and hypoglycemia from prolonged fasting. The recommendations for preoperative fasting are provided in Table 49.1 . Patients may present with an upper respiratory tract infection with a runny nose, may have mediastinal masses with dyspnea awaiting biopsy, or may be malnourished due to cancer cachexia. The child may have received chemotherapy in the past few weeks and may be neutropenic undergoing imaging to assess for response to therapy. Repeated chemotherapy in the absence of a vascular port, peripherally inserted central catheter (PICC), or a Hickman’s catheter may make intravenous access increasingly difficult. Oral contrast may have been administered if the imaging involves the gastrointestinal tract, thereby increasing the risk of aspiration under anesthesia.

Table 49.1

Preoperative Fasting for Elective Procedures in Children

	Hours	Examples
Light meal and nonhuman milk	6	Formula milk, cow/buffalo milk, bread without butter, fruit juice, biscuits
Breast milk	4
Clear fluids up to 3 mL/kg	1	Water, sugar water, coconut water, clear liquids, oral rehydration solution, clear apple juice
Fatty meals require a longer time for fasting of at least 8 h due to the delayed gastric emptying of fats

Environment, Equipment, and Staffing Factors

Environmental Concerns

NORA locations are usually in remote areas of the hospital such as basements where obtaining extra help could prove difficult. Access to patients may be challenging and bulky equipment may contribute to space constraints. Children may need to be monitored and managed from a distance or remotely, thus increasing the dead space for venous access and limiting immediate access to the patient’s airway ( Fig. 49.1 ). Electric connections and cables may pose a safety hazard, and the hazards of radiation exposure and ferromagnetic fields in MRI warrant particular attention.

Equipment Concerns

It is essential that anesthesia and resuscitation equipment are available, checked, and well maintained. A list of equipment that may be necessary for the provision of anesthesia service within NORA locations is provided in Table 49.2 .

Table 49.2

ASA Standards for Equipment at NORA Locations

1	Oxygen source with central pipeline and backup E-cylinder
2	Working suction
3	Scavenging system if inhalational agents are used
4	Anesthesia equipment Appropriate sizes of self-inflating bags with reservoir Anesthetic drugs Operating room equivalent anesthesia machine
5	Adequate monitoring equipment as per ASA standards for basic monitoring Stethoscope, electrocardiogram, pulse oximeter, noninvasive blood pressure monitor and capnometer
6	Electrical outlets for anesthesia machine and monitors
7	Adequate illumination for patient, workstation, and monitoring equipment
8	Sufficient space to accommodate personnel and equipment
9	Defibrillator, emergency drugs, cardiopulmonary resuscitation equipment readily available
10	Adequately trained staff to assist the anesthesiologist
11	Emergency call list for facility should be available
12	Postanesthesia care monitoring with adequately trained staff including necessary equipment for transporting the patient to the intensive care unit.

Staffing Concerns

It is essential for anesthesia staff to familiarize themselves with a particular NORA environment and its associated challenges before delivery of care. The remoteness of these locations makes calling for help in emergencies difficult. Identifying a fellow practitioner who could be called upon for emergencies could prove beneficial.

Procedural Factors

The anesthesiologist should be familiar with the nature of the procedure to be performed. The approach, position, and need for special equipment for the procedure should be discussed before the child is anesthetized. Adequate analgesia for the procedure, estimated duration, blood loss, blood product availability, and anticipated problems and complications should be discussed prior to beginning the procedure. Pediatric patients in these locations often require deep sedation or general anesthesia. ^,

Who Should be Administering Sedation and Anesthesia?

The Roles, Responsibilities, and Training Requirements for Anesthesiologists and Assistants

Societies, such as the ASA, offer clear guidelines on the roles, responsibilities, and minimum training requirements for professionals administering sedation and anesthesia. ^, Recommendations have also been proposed for pediatric procedural sedation outside the operating room. The roles, responsibilities, and skill requirements for providing sedation and anesthesia outside the operating room are described in Table 49.3 . Similarly, the RCoA provides guidelines defining the roles and training requirements for administering sedation and/or anesthesia.

Table 49.3

Staffing Requirements and Specific Additional Skills Requirement for Providing Sedation and Anesthesia to Children Outside the Operating Room ^,

Personnel	Skills and Training Required
Anesthesiologist Should be a licensed and board-certified physician	Preanesthesia assessment of children
	Pediatric airway management
	Use of equipment and medications
	Cardiopulmonary resuscitation
	Dedicated towards continuous monitoring and patient care
Nonanesthesia staff assisting anesthesiologist	Familiar with procedure and equipment
	Positioning for patients under anesthesia
	Basic life support
	Postprocedure monitoring
Sedation performed by nonanesthesiologist	Ability to assess the depth of sedation
	Pediatric advanced life support: techniques needed to open the airway and provide bag mask ventilation
	Should comply with hospital sedation policy
	Should be responsible for continuous monitoring and patient care during sedation with no other responsibilities

Patient Evaluation, Preparation, and Preprocedure Checklist

The ASA has recommended a checklist for the equipment necessary for providing sedation or anesthesia services within NORA locations (see Table 49.2 ). The mnemonic called SOAPME (Suction, Oxygen, Airway equipment, Pharmacy, Monitors, and Equipment) is useful in the anesthesia setup of NORA locations.

A detailed medical history of the patient with an emphasis on the presenting symptoms and past medical history should be elicited. The last dose of chemotherapy, radiotherapy, or surgery should be documented. The anesthesiologist should be aware of the various implications of chemotherapeutic drugs on various body organ systems. A detailed physical examination, including an airway exam, should be performed. The fasting status, WHO surgical safety checklist, and parental consent or child’s assent should also be confirmed. For a complete evaluation of the pediatric patient for NORA, see Table 49.4 . A frequent challenge is the management of the child presenting with a runny nose.

Table 49.4

Preoperative Evaluation of a Pediatric Patient for NORA

Demographics: age, sex, and weight of the child.
Current illness presenting complaints.
History of URTI/mediastinal mass with dyspnea at rest or in supine position. Functional status of the child with daily medications.
Past history
Birth and immunization history
Any comorbidities with hospital admissions
Allergies
Previous procedure and anesthetic history
The last dose of chemotherapy and radiotherapy; implications on various body organ systems
Personal and family history
Nature of procedure to be performed with position, risks and bleeding
Assessing the need for blood and blood products
Assessing the need for postprocedure hospital or ICU admission
Fasting status to be confirmed
Examination
General examination with ease of securing IV access
Airway examination
Systemic examination
Investigation review
Consent for the procedure from parent and child explaining the risks
WHO surgical safety checklist with site and side of procedure
Correct size of equipment and medication doses checklist with anesthetic plan

URTI , upper respiratory tract infection; WHO ; World Health Organization.

Infants and preschool children may have 6–8 episodes of an upper respiratory tract infection (URI) in any given year. Typically, the airway remains hyperactive for 3–6 weeks after an URI, increasing the risk of laryngospasm and other respiratory complications. In the event of a suspected malignancy, diagnostic procedures or treatment may not always be delayed for possible medical optimization. This, in and of itself, presents a significant challenge to anesthesiologists, especially at NORA locations. An approach towards a child with an upper respiratory tract infection for a procedure under anesthesia is described in Figure 49.2 .