Anesthesia: Special Considerations in Out of the Operating Room Locations

SPECIAL CONSIDERATIONS IN OUT OF THE OPERATING ROOM LOCATIONS

Anesthesia services are requested at various loca-tions throughout the hospital facility; some of these are delineated in Table 44–15. As noted through-out, routine anesthetic standards apply wherever the patient is anesthetized. Out of the operating room patients often present with a wide range of illnesses, unlike the elective patients gen-erally found in an ambulatory setting. Furthermore,disposition postprocedure (whether discharge or admission), needs appropriate coordination by the anesthesiologist for postanesthesia care and/or safe transport from the remote unit.

Patients presenting to the gastrointestinal endoscopy suite include healthy individuals for rou-tine diagnostic screenings, as well as patients with fulminant cholangitis and sepsis or coexisting dif-ficult airways. As always, the patient’s condition, as well as the specific diagnostic/therapeutic pro-cedure, determines both the anesthetic techniques (propofol deep sedation or general anesthesia vs. general anesthesia with LMA or endotracheal tube) and the monitoring required.

General anesthesia is usually required in patients undergoing endoscopic procedures for air-way and pulmonary pathology; an added complex-ity may include the presence of a shared airway, and, in many patients, marginal pulmonary status.

Patients undergoing cardiac catheterization are routinely sedated by cardiologists without involvement of an anesthesiologist. Occasionally, a patient with significant comorbidities, (eg, morbid obesity) requires the presence of a qualified anes-thesia provider. General anesthesia is often required for placement of aortic stents, which are increasingly being performed by cardiologists in the cardiac cath-eterization laboratory. Anesthesia staff should be prepared with arterial pressure monitoring and the necessary vascular access to facilitate resuscitation, should emergent open aneurysm repair be required.

Patients requiring electrophysiology procedures for catheter-mediated arrhythmia ablation often need general anesthesia. Such patients frequently have both systolic and diastolic heart failure, leading to potential hemodynamic difficulties perioperatively. Sudden hypotension can herald the development of pericardial tamponade secondary to catheter perfo-ration of the heart. Other patients require sedation for the placement of ICDs. Once placed, the device will be tested by inducing ventricular fibrillation. During testing, deeper levels of sedation are required, as the defibrillation shock can be frightening and very uncomfortable. Likewise, anesthesia staff are called upon to provide anesthesia for cardioversion of patients in atrial fibrillation. These patients usually have associated cardiac diseases and require brief intravenous anesthetics to facilitate cardioversion. Oftentimes, a transesophageal echocardiogram must be performed prior to cardioversion to rule out clot in the left atrial appendage. In such cases, anesthesia staff may also provide sedation for this procedure. Determination as to whether a patient needs seda-tion or general anesthesia with or without intubation is dependent upon routine patient assessment.

Children and some adults (ie, those that are claustrophobic, developmentally disabled, or have conditions that prevent them to be still or to lie flat) require anesthesia or sedation for MRI and computed tomography (CT). Additionally, painful CT-guided biopsies may require anesthesia man-agement. Anesthetic technique is dependent upon patient comorbidities.

MRI creates numerous problems for anesthe-sia staff. First, all ferromagnetic materials must be excluded from the area of the magnet. Most institu-tions have policies and training protocols to prevent catastrophes (eg, oxygen tanks flying into the scan-ner). Second, all anesthetic equipment must be compatible with the magnet in use. Third, patients must be free of implants that could interact with the magnet, such as pacemakers, vascular clips, ICDs, and infusion pumps. As with all out of the operat-ing room anesthesia, the exact choice of technique is dependent upon the patient’s comorbidities. Both deep sedation and general anesthesia approaches with intubation or supraglottic airways can be used, depending on practitioner preference and patient requirements.

Patients usually require general anesthesia and tight blood pressure control to facilitate coiling and embolization of cerebral aneurysms or arteriove-nous malformations. Patients taken to the radiology suite for relief of portal hypertension via creation of a transjugular intrahepatic portosystemic shunt (TIPS) are frequently hypovolemic, despite profound ascites, and at risk of esophageal variceal bleeding and aspiration. General anesthesia with intubation is preferred for management of the TIPS procedure.

Anesthesia for electroconvulsive therapy is often provided in a separate suite in the Psychiatry Unit or a monitored area in the hospital (eg, PACU). Patient comorbidity, drug interactions with various psychotropic medications, multiple anesthetic pro-cedures, and effects of anesthetic agents on the qual-ity of electroconvulsive therapy also need to be taken into account.

Anesthesia staff are at times called to provide anesthesia in the intensive care unit (ICU) for bed-side tracheostomy or emergent chest and abdominal exploration in patients considered too critically ill to tolerate transport to the operating room. In most of these cases, the anesthesia staff generally employ ICU ventilator and monitors. Intravenous agents are typically used along with muscle relaxants. When performing anesthesia for bedside tracheostomy, it is important that the endotracheal tube not be with-drawn from the trachea until end tidal CO ₂ is mea-sured from the newly placed tracheostomy tube.

Pediatric patients deserve special mention; the (Table 44–16). Anesthesia considerations for nonoperating room anesthesia are summarized in Table 44–17.