Pediatric Anesthesia Outside the Operating Room

Anesthesia care performed outside the operating room is a growing area of pediatric anesthesia practice. The anesthesiology team expects to care for children in diverse locations, which include diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology sites, and the cardiac catheterization laboratory. To provide safe, high-quality care the anesthesiologist working in these environments must understand the unique environmental, logistical, and perioperative considerations and risks involved with each remote location. This 2-part review provides an overview of safety and system considerations in pediatric nonoperating room anesthesia before describing in more detail considerations for particular remote anesthetizing locations.

Key points

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Offsite anesthesia comprises one-third of anesthesia volume and continues to grow, requiring increasing anesthesia resources to meet this demand.
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Large registry datasets show that although radiology locations and the cardiac catheterization suite demonstrated elevated anesthesia risk, nonoperating room anesthesia risk is generally on par with that in the operating room.
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Each area where anesthesia is delivered has unique environmental and patient care challenges which must be understood and mitigated to ensure patient and staff safety.
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Standardization of patient assessment, room setup, and monitoring are recommended.
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Internal and hospital-based responses to emergencies in the outfield must be explicitly delineated. Simulation can play an important role in education around crisis response, especially in the most remote of locations.

Introduction

Anesthesia care outside the operating room, or nonoperating room anesthesia (NORA), is an expanding area of pediatric anesthesia practice. Locations include diagnostic and interventional radiology, dental clinics, gastroenterology and pulmonary suites, radiation oncology locations, and the cardiac catheterization laboratory, among others. The trend toward more outfield procedures, which is seen in both adult and pediatric anesthesia, is driven by many factors. These include evolving technology with an increasing range of treatment options, nonportable equipment such as MRI scanners, linear accelerators, and radiation sources, as well as caseload in the operating rooms, which has not decreased despite increases in NORA cases. The anesthesiologist working in these offsite locations must understand the unique environmental, logistical, and perioperative considerations to minimize risk in each remote location. With an integrative approach that focuses on these challenges, anesthesia and procedural teams can coordinate to deliver consistent, safe, high-quality care.

Demographic trends

There has been steady growth in the number of anesthesia cases outside the operating room. From 2010 to 2014, a review of the National Anesthesia Outcomes Registry (NACOR) revealed an increase from 28% to 36% of all anesthesia cases being classified as NORA. Should current trends continue, within the next decade, NORA will constitute 50% of all anesthesia encounters. ^, Although adults require anesthesia primarily for painful invasive procedures, such as cardiac catheterization and endoscopy, the largest category of cases for which children require anesthesia is diagnostic radiologic imaging, illustrating that many children cannot cooperate with procedures tolerated by awake adults. ^, There is also an increasing expectation from parents that children in the outfield receive anesthesia or sedation care for procedures that were historically done on unsedated children.

Technologic advances have allowed increasingly complex cases to be performed in a minimally invasive manner, often on patients who would be considered a higher perioperative risk for operating room procedures. This transition has increased the demand for anesthesia coverage involving cases that cannot be accommodated in the operating rooms, either due to physical limitations of equipment (ie, MRI or radiation therapy) or scheduling in operating rooms that are already fully booked. NACOR data have shown that although the number of offsite anesthetics increased, there was no decrease in the same time interval in operating room anesthetics.

Preanesthetic assessment, patient selection, and risk stratification

Regardless of the anesthetizing location, the goals of the preanesthesia evaluation remain the same: to identify the high-risk patient and evaluate the safety of a proposed anesthetic and intervention in a particular location. The anesthesiologist has a key role in determining with proceduralists and ordering physicians the risks versus indications of a particular procedure. Collaborations between anesthesiologists and radiologists to weigh the relative radiation risk of computed tomography (CT) versus the anesthesia risk of MRI, for example, describe a way forward for such conversations. ^, As the perioperative physician-expert in the perioperative surgical home, the anesthesiologist must similarly embrace this role for offsite cases to ensure patient safety. ^,

Preanesthesia evaluation for outfield and operating room procedures must be held to the same standard as the operating room. For scheduled cases, all patients receiving anesthesia regardless of anesthesia location should have standardized triage and assessment performed ideally by the same trained personnel. Emergency procedures or add-on cases occurring outside working hours, which are more common in NORA, present a significant assessment challenge. An additional obstacle is the potential lack of immediately available patient records (ie, pediatric case occurring at an adult facility with a different medical record system), which may limit timely knowledge of pertinent patient concerns. Substandard preanesthesia assessment has been implicated as contributory to poor patient outcomes in the Anesthesia Closed Claims database. Centralization of the preanesthesia evaluation as well as patient and staff scheduling has proved to be helpful at many institutions ^, ; this system allows for early anesthesiologist involvement and streamlined communication as to the need for timely preoperative testing, specialist consultation, or medical optimization in complex patients with multiple comorbidities. Several institutions have demonstrated a reduction in case delays and cancellations after adopting such a system. ^,

Monitoring and equipment

Over the past half century, safety in anesthesia has improved with the development of monitoring technology and adherence to accepted standards for appropriate monitoring and care in the operating room. The American Society of Anesthesiologists (ASA) as well as United States regulatory bodies, such as Centers for Medicare and Medicaid Services and the Joint Commission, have specified the requirements for room setup, monitoring, and staffing for anesthesia and sedation locations. ^, These standards require the continuous assessment of oxygenation, ventilation, circulation, and temperature as well as requirements for pediatric-specific airway supplies, suction, oxygen and power supply, and emergency carts. The Anesthesia Closed Claims database has shown that most of the NORA claims were paid out due to substandard care, with one-third of claims attributed to inadequate ventilation monitoring. ^,

Offsite environments are extremely variable and are primarily designed to accommodate a procedure or technology rather than the administration of anesthesia. In the United States, operating rooms are planned according to standards outlined by the Facility Guidelines Institute, used as a reference by various federal and state regulatory oversight agencies, but these standards may not have been followed in designing outfield locations, which have only recently begun to request pediatric anesthesia service in significant numbers. For example, a multiinstitution survey of pediatric proton therapy facilities showed that 21% did not have recovery rooms and 43% did not have gas evacuation outlets. Space and ergonomic constraints resulting from high-dose radiation, magnetic fields, bulky imaging equipment, and robotic delivery devices can interfere with access to patients and essential equipment, potentially impeding immediate patient access in emergent situations ( Fig. 1 ). In some environments, the anesthesia team must be reliant on remote patient monitoring with audiovisual equipment to assess the clinical scenario in another room, while further complicated by radiofrequency interference, noise pollution, and blind spots. All of these factors may delay early recognition and treatment of acute changes in a patient’s clinical condition. A review of the Wake Up Safe database for adverse events in radiation oncology underscores that deficiencies in monitoring with subsequent failure to respond promptly to physiologic deterioration can result in patient harm. This problem is accentuated when pediatric anesthesia services are requested at an adjoining adult-centered facility or a site completely detached from any neighboring hospital. Anesthesia events may be rare in these areas, and pediatric emergency response teams may not exist or have significantly delayed response times.

Risk of pediatric nonoperating room anesthesia

The trend in nonoperating room cases toward minimally invasive procedures may result in a decrease in procedure-related risk compared with an open surgical procedure. ^, Anesthetic risk, however, does not necessarily decrease; in some cases, this risk may be potentially greater than that of the indicated procedure, such as a patient with a compressing anterior mediastinal mass for biopsy or a child with uncompensated congenital heart disease for central venous access.

Conventional understanding has held that NORA cases involve higher risk. Contributory factors included variable locations with limited resources, unfamiliar or outdated equipment, constrained work environments, and procedural staff with minimal clinical training to assist in emergencies. The Anesthesia Closed Claims database reinforced this belief by showing that patients suffering harm during offsite procedures were more likely to be at extremes of age and have a higher ASA physical status classification than patients in the operating room and that adverse outfield events were twice as likely to result in serious injury or death. ^, Studies involving closed claim analyses, however, are limited by lack of incidence data and by the fact that minor or major adverse events that do not result in litigation are not represented.

Since 2008, the ASA Anesthesia Quality Institute’s NACOR database has allowed researchers to more completely examine incidence data for adverse anesthesia events. Data compiled from more than 3 million cases in the NACOR database confirms Closed Claims data that offsite anesthesia locations involved older patients, a higher proportion of patients who were ASA physical class III and higher, a higher rate of emergent procedures, and more anesthetics that were started after working hours. ^, Despite these potentially negative factors, NACOR data do not show that offsite anesthesia as a whole is associated with increased morbidity and mortality compared with operating-room-based anesthesia. In addition to NACOR, the Pediatric Sedation Research Consortium (PSRC) and the Wake Up Safe project, focused on pediatric anesthesia adverse events, have shown similar results. These latter sources find an increased risk in radiology and cardiac catheterization areas. ^, ^, The most recent analysis of the Closed Claims data supports the findings of these databases that cardiac catheterization and radiology suites are areas of increased risk. Further analysis of these higher-risk subgroups is certainly warranted to identify what factors or system failures are responsible so that they can be mitigated. A risk stratification for pediatric cardiac catheterization has been described, with consideration of patient and procedure factors. The anesthesia team must recognize the higher preexisting potential for risk in these patients and mitigate that risk whenever possible. Vigilant anticipation, prompt recognition, and swift management of minor adverse events before they escalate in severity is key to safe practice both in and outside the operating rooms.

Responding to emergencies

One factor that must be considered in risk mitigation is the response to inevitable emergencies. The distance from operating room support, relative frequency of after-hours NORA cases, and higher likelihood of complicated rescue in offsite locations require anesthesiologists to rely on procedural staff for immediate assistance during emergencies. The approach to critical events has 2 components: the actions and responsibilities of staff in the immediate area and the additional support from emergency response teams. Staff with training and competencies to assist in routine clinical care as well as pediatric emergencies are essential to a remote anesthesia site. However, staff in outlying areas may have little experience with anesthesia and sedation, particularly for pediatric patients, and may not know how to prioritize an anesthesiologist’s concerns in a crisis. Ongoing education and training around emergency response is critical in overcoming this gap. Nurses assisting with patient care and recovery should be Pediatric Advanced Life Support certified and technologists can have Basic Life Support certification. Cultivating an atmosphere of mutual respect is essential to the development of a highly functional team who will respond seamlessly in a crisis. Daily multidisciplinary rounds can play a valuable role, allowing information sharing and discussion of responses to anticipated complications before the start of cases. Simulation can be useful in helping staff practice the technical and communication-based skills necessary in an emergency. The improved portability of simulation mannequins allows for more practical simulation exercises in the procedure area itself ( Fig. 2 ).