An increasingly large number of anesthetic cases are performed outside the traditional operating room environment. Procedures performed in areas such as the electrophysiology laboratory and interventional radiology department are becoming more complicated and often take longer. Patients are presenting with more complicated histories and comorbidities. Because of the complexity of the procedures and patients’ conditions, anesthesiologists are requested to provide services in these remote locations with increasing frequency. Non–operating room anesthesia (NORA) sites pose challenges. This chapter will address room setup, supply, and medication issues in these off-site locations. Unlike in the main operating room, each NORA site has equipment unique to that area that can pose challenges for the anesthesia care team.
Room Setup
NORA procedures occur in a wide array of locations ( Box 3-1 ). These sites range from a designated area in the postanesthesia care unit (PACU) where electroconvulsive therapy is performed to specially designed multiroom suites for gastrointestinal endoscopy. The equipment, supplies, and medications needed in each area will depend on the planned anesthetics and the frequency of their occurrence. The American Society of Anesthesiologists (ASA) issued a Statement on Nonoperating Room Anesthetizing Locations ( Figure 3-1 ) that provides minimal guidelines applicable to all anesthesia care in locations outside the operating room.
Gastrointestinal endoscopy suite
Cardiac catheterization laboratory
Cardiac electrophysiology laboratory
Pulmonary bronchoscopy laboratory
Interventional radiology department
Interventional neuroangiography department
Computed tomography suite
Magnetic resonance imaging suite
Radiation therapy suite
Electroconvulsive therapy suite
One challenge for anesthesia practitioners in remote locations is space. Procedural areas are often planned and built without considering that anesthesia care might be needed in that area. As a result, the anesthesia team is often given inadequate space and not always near the patient. The anesthesia team often works around C -arms in interventional radiology and an endless array of monitors and C -arms in the cardiac electrophysiology laboratory. These spaces become very crowded areas with the introduction of anesthesia equipment and monitors ( Figure 3-2 ).
Before providing anesthesia services in a NORA location, it is important to evaluate the area to ensure that the guidelines as put forth in the ASA Statement on Non–Operating Room Anesthetizing Locations are followed, along with institutional policies. If the proper equipment and systems are not in place to ensure patient safety, the area should not be used to provide anesthesia services until such changes are made.
The anesthesia department sometimes sends older equipment to the remote anesthesia areas. Remote areas are perceived as not needing the newest equipment because these areas are often not used to the same extent as rooms in the main operating room. It is an unwise practice to send older equipment to remote areas. Using older equipment in a remote area raises the possibility of unfamiliarity with the equipment and machine malfunction. If a problem arises with the equipment, the practitioner may not be able to troubleshoot the problem. Assistance may take much longer to arrive than it would in the main operating room. The ASA Committee on Equipment and Facilities published Guidelines for Determining Anesthesia Machine Obsolescence. This document has not been approved as a practice parameter or policy statement by the ASA House of Delegates, but it does provide practical advice regarding essential features needed in an anesthesia machine to provide a safe anesthetic for patients. Equipment and supplies should match as closely as possible the equipment in the main operating room. Having uniformity of equipment and supplies in all locations provides familiarity for the anesthesia providers who rotate through these areas.
Anesthesia machine check in NORA locations is just as important as in the main operating room. Anesthesia machines in remote locations may not be used every day, so it is important to do a complete machine check at the start of the day. It is important to ensure that the soda lime is fresh in an anesthesia machine that might not have been used recently. In NORA procedure areas, the anesthesia team shares the space with the procedure team. Anesthesia care may not be provided for each case in the room during the day. During nonanesthetic procedures, the procedure nurses may use monitors on the anesthesia workstation. This raises the possibility, for example, that the anesthesia machine may be moved, connections unplugged, or breathing circuits dislodged. If nonanesthesia cases were performed between anesthesia cases, the machine needs to be thoroughly checked before the next anesthesia procedure. Anesthesia machines and equipment in NORA locations need to have regular preventive maintenance, as do machines in the main operating room.
At times an anesthesia machine is transported to a location where anesthesia service is infrequently provided. In these situations, the machine needs to be checked very carefully because transportation of the machine can potentially damage the machine or loosen connections. It is essential to ensure that the anesthesia machine, monitors, and equipment are all in good working order before beginning anesthetic care.
In certain locations where sedation is the only planned action, a compact monitor with the capability of monitoring electrocardiography, blood pressure, oxygen saturation, and end-tidal carbon dioxide (ETCO 2 ) is very useful and does not take up much space ( Figure 3-3 ). ETCO 2 monitoring should be included in the monitoring for procedural sedation or general anesthesia in any NORA location.
In areas where anesthesia care is provided, even if sedation is the only planned action, the anesthesia provider should be able to administer general anesthesia and manage the airway. A defibrillator and emergency resuscitation cart should be immediately available to the anesthetist.
The NORA location ideally should have oxygen, air, and nitrous oxide available via a central supply. It is essential to ensure an adequate supply of oxygen is available for the duration of the case. If central supply oxygen is available, a full E-type tank of oxygen should be present as a backup. If oxygen tanks are to be used for the case, it is important to ensure adequate supplies for the case are available, as well as a backup tank. The tank key must be present before beginning anesthetic care.
Central suction may not be available in NORA locations. It is important to ensure suction is available via a suction machine if central suction is not available.
The procedure tables in NORA locations often do not move into the variety of positions available with the main operating room tables. It may be advisable to induce and emerge from anesthesia on the stretcher on which the patient is brought to the procedure room. Using the stretcher will allow heads-up, Trendelenburg, and reverse Trendelenburg positioning if needed. Certain procedures, such as endoscopic retrograde cholangiopancreatography, are commonly done in the prone position. The procedure staff must keep the stretcher next to the procedure room in case the patient needs to be immediately turned to the supine position.
Monitoring standards in NORA locations should be the same as in the main operating room. Electrocardiography, pulse oximetry, blood pressure, and ETCO 2 are minimal requirements. Gas analysis is also advised if use of volatile anesthetics is planned.
Postprocedure recovery should be the same standard as that of the main operating room. Ideally, the patient should recover in a monitored environment close to the procedural area. If this is not possible, the patient should be transported to the main PACU for recovery from anesthesia. The patient should be transported with supplemental oxygen, a transport monitor, an Ambu bag, and emergency medications in case of an emergency during transport.
Other pieces of equipment are needed in NORA locations. Many procedures done in NORA locations are done under sedation or with total intravenous anesthesia (TIVA). Using an intravenous infusion pump for medications such as propofol is very helpful in achieving an adequate level of sedation or anesthesia. A forced-air warming system is needed to ensure patients do not develop hypothermia. Certain NORA locations such as magnetic resonance imaging (MRI) and computed tomography (CT) suites are kept cool to help protect equipment, thus placing patients at risk for hypothermia. An intravenous fluid warmer is needed if there is the possibility of blood transfusion or the need for large amounts of intravenous fluids. Transducers to measure arterial blood pressure and central venous pressure should be readily available. A bispectral index monitor or other depth of anesthesia monitor is also a useful device to have available.
It is beneficial to have point-of-care laboratory testing available in NORA locations. NORA locations may be far from the operating room or main hospital laboratories; having point-of-care testing will improve efficiency. This availability will allow laboratory tests such as blood glucose, potassium level, and hematocrit to be quickly checked.
In any area where anesthesia care is to be provided, the anesthesia provider should know the location of oxygen shutoff valves and fire extinguishers. Safety and emergency evacuation procedures in NORA spaces should be reviewed with the personnel in those areas. The anesthesia provider should also ensure the presence of a defibrillator and resuscitation cart in any location where anesthesia care is to be provided.
In the main operating room, personnel are accustomed to assisting and being attentive during the movement of the patient into the room, during anesthetic induction, and during emergence from anesthesia. This is not the case in many NORA locations. Personnel in these locations are used to their routines and are unaware of the concerns of the anesthesia team. Time spent familiarizing these personnel with the issues and concerns of the anesthesia team regarding care of the patient before service is begun will be very helpful to the anesthesia team.
The anesthesia and procedural teams should collaborate to create a quiet environment during anesthetic induction and emergence. This hushed setting benefits the patient and allows the anesthesia care team to effectively communicate. The importance of safety straps on the patient needs to be stressed, especially during emergence from anesthesia. The procedural team should be instructed on the importance of being attentive and nearby during emergence from anesthesia. Spending time familiarizing the team with the anesthesia machine and airway devices such as Eschmann stylets is very helpful. If assistance is needed with bag-mask ventilation or with airway supplies, prior familiarity is much better than trying to instruct in the middle of a stressful event. Anticipation of and planning for problems that might arise in these locations is important, because help from the main operating room may take an extended time to arrive.
In many NORA locations, the setup is similar to that of the main operating room once space issues are negotiated. Setup differs significantly in two locations—radiation therapy and MRI suites.
Room Setup in Radiation Therapy
Providing anesthesia care for patients undergoing radiation therapy poses challenges for the anesthesia provider. Radiation therapy can consist of traditional external beam radiation therapy or can be delivered in a targeted fashion via a Gamma Knife or CyberKnife. The CyberKnife delivers gamma-ray beams via a robot arm that moves around the patient and delivers radiation from different directions. In this situation, the anesthesia provider must make sure all hoses and tubing, the anesthesia machine, and the cart are away from the area traveled by the robot arm. Because of the high levels of scatter radiation during radiation therapy treatment, the anesthesia provider cannot remain in the room during treatment. The anesthesia monitors and patient must be viewed via video surveillance. It takes 20 to 30 seconds to stop treatment and open the heavy lead door if immediate access to the patient is required.
Room Setup in Magnetic Resonance Imaging
Providing anesthesia services in the MRI suite poses problems not encountered in other anesthetizing locations. If proper precautions are not taken, the MRI suite can be a hazardous environment for both the anesthesia provider and the patient. Descriptions of the science and technical aspects of MRI have been published elsewhere and are beyond the scope of this chapter. MRI has advantages in that this imaging modality does not expose the patient to ionizing radiation and thus does not have cumulative effects when serial examinations are required. The number of MRI scans done each year continues to grow, and the need for anesthesia services in the MRI suite continues to grow as well.
In 2007 the American College of Radiology published a Guidance Document for Safe MR Practices. In 2009 the ASA Task Force on Anesthetic Care for Magnetic Resonance Imaging published a practice advisory on anesthetic care for MRI. These documents provide detailed information about safe practices within the MRI environment.
The major concern in providing anesthesia care in the MRI suite is the strong magnetic field present around the scanner at all times. It takes several days to generate the magnetic field used in MRI. Therefore the magnetic field is always on, even when there is not a patient in the scanner. The magnetic field is measured in tesla units (T); 1 T equals 10,000 gauss. The earth’s magnetic field is approximately 0.5 gauss. MRI scanners used for clinical purposes are generally 1- to 3-T machines. Thus the MRI scanner generates a magnetic field thousands of times stronger than the earth’s magnetic field. Any item of equipment that contains ferromagnetic material will be attracted to the magnet. In addition to the static magnetic field that is always present, during image acquisition, radiofrequency pulses are applied. Both the static magnetic field and the intermittent radiofrequency pulses create the safety issues associated with MRI.
Four zones have been identified in the MRI environment, with increasing danger from the magnetic field with each increase in zone ( Table 3-1 ). Signs should be posted to indicate each zone in the MRI suite.
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