Anesthesia: Non Operating Room Anesthesia

NON OPERATING ROOM ANESTHESIA

Off-site anesthesia (nonoperating room anesthe-sia) encompasses all sedation/anesthesia provided by anesthesiology services outside of the operat-ing room environment. Over the past few decades, requests for these services in remote locations have been steadily increasing, and in many large hospitals today more anesthetics are routinely administered for procedures off-site than in the operating room suite. According to some estimates, nonoperating room anesthesia accounts for 12.4% of all anes-thetic care in the United States. As a result, some clinical facilities have determined that is it safer and more cost-effective to assign anesthesia team(s) for scheduled blocks of times to provide care for such procedures, and some institutions are constructing procedural suites where bronchoscopy, gastrointes-tinal endoscopy, cardiac, and interventional radiol-ogy procedures can be performed in a centralized area for increased safety and efficiency. It is impor-tant to remember that the same basic standards for anesthesia care need to be met, regardless of the location. Furthermore, the challenges of unfamiliar environments that are far removed from the surgical suite, including anesthesia-naïve personnel, require advance planning for the off-site anesthesiologist.

Unlike patients undergoing office-based or ambulatory surgery center procedures, out of the operating room patients are frequently among the sickest of inpatients. Anesthesia staff are often called to work in the gastrointestinal suite, cardiac cath-eterization laboratory, electrophysiology laboratory, radiology suite, radiation oncology suite, and, occa-sionally, the critical care unit. Often these locations were constructed without anticipation that anesthe-sia would be provided there. Consequently, anesthe-sia work space is routinely constrained, and access to the patient is limited. Moreover, the procedure physicians and ancillary staff in these areas often fail to understand what is required to safely deliver anesthesia (hence the frequent request to “give them a squirt” of propofol) and do not know how to assist

the anesthesia provider when difficulty arises. As noted in the ASA guidelines, the expectations for out of the operating room anesthesia are the same as in any practice location ( Table 44–8).

Basic principles for nonoperating room anes-thesia can be broadly classified into three cat-egories: patient factors, environmental issues, and procedure-related aspects. Patient factors include comorbidity, airway assessment, fasting status, and monitoring. Environmental issues include anesthe-sia equipment, emergency equipment, and magnetic and radiation hazards. Procedure-related aspects include duration, level of discomfort, patient posi-tion, and surgical support.

The ASA Closed Claims Database has dem-onstrated that claims related to out of the operat-ing room anesthesia care have a greater severity of injury than closed claims related to operating room anesthesia care. Monitored anesthesia care was the primary technique in more than half of the claims reviewed. Many of these closed claims arose from injuries related to inadequate oxygenation/ventila-tion during procedures in the gastrointestinal suite. Suggested requirements for the safe delivery of out of the operating room anesthesia are presented in Tables 44–9, 44–10, 44–11, and 44–12.

Increasingly, nonanesthesia providers in the gastrointestinal lab and the emergency department provide sedation with a variety of agents, including propofol and ketamine. In fact, some reports indi-cate that nonanesthesia providers provide admin-ister sedation and analgesia for almost 40% of the procedures performed in the United States. The ASA guidelines and the Joint Commission have described the continuum of depth of sedation, rang-ing from minimal sedation to general anesthesia (Table 44–13). Recently, the Centers for Medicare and Medicaid Services has mandated that all sedation in a hospital be under the direction of a physician— generally, the anesthesia service chief. Consequently, anesthesiologists must not only from time to time

provide anesthesia in a nonoperating room setting, but must also develop policies and quality assurance review mechanisms for nonanesthesia providers to safely provide sedation. Such policies should be focused on assuring that the “sedationist” has the necessary skills to provide for patient rescue, should mild or moderate sedation become deep sedation or general anesthesia.

Risks associated with sedation/analgesia are highlighted in Table 44–14. Sedation providers should know how to reverse benzodiazepines and opioids and provide bag/mask airway support and to be facile in the use of airway adjuvants. A mecha-nism to ensure the timely arrival of anesthesia per-sonnel capable of airway rescue must likewise be incorporated into such policies.