All about NORA/ ANESTHESIA OUTSIDE OPERATING ROOM

2. • Physicians are doing many things, which
were surgeons areas previously.
• E. g. Interventional
radiologists, gastroenterologists, or
interventional cardiologists
• And this means, we are getting additional..
RESPONSIBILITIES

3. Away from familiar territories…
• The indifferent reflexes shown by the non
operating room staff in emergency situation
• Insecurity due to a very realistic anticipation
of lack of equipment and staff support
• Despite these factors, we should be held
responsible if something happens…!

4. What is there in a name….?
• Nonoperating room anesthesia (NORA)
• Anesthesia at remote location
• Outpatient anesthesia
• Office-based anesthesia (OBA)

5. A very busy innings
expected….
• Number of NORA activities has increased rapidly ( CT,
MRI, neuroradiologic procedure or electroconvulsive
therapy)
• And the procedures have become more complex

6. Special problems of NORA
• Limited working place, limited access to the patient,
• Electrical interference with monitors and phones, lighting and temperature
inadequacy,
• Use outdated , old equipment
• Staff less familiar with the management of patients
• Lack of skilled personnel, drugs and supplies
• there is often no regular check up of the anaesthesia inventory
Patient desaturating..I need a mask quickly…
Sure sir…here it is…

7. Hello..hello ...
Who are you..?
• A trained anaesthesiologist should provide anaesthesia in
remote locations within the hospital.
• However non anaesthesiologists are allowed to provide
‘conscious sedation'.
• It is mandatory that all providers should be Adult Cardiac
Life Support (ACLS) certified.

8. Tour destinations!
• Radiology suites e.g. cardiac angiography, interventional
radiology, CTscan, MRI
• Endoscopy suites
• The dental clinic
• The burns unit
• Psychiatric unit for electroconvulsive therapy
• Renal unit for lithotripsy
• The gynaecology unit for in vitro fertilisation.

9. OUR AIMS
• Guard the patient's safety and welfare
• Minimise physical discomfort and pain
• Control anxiety, minimise psychological trauma
and maximize the potential for amnesia
• Control movement to allow safe completion of the
procedure
• Return the patient to a state in which safe
discharge from medical supervision is possible.

10. CHALLENGES
EQUIPMENT
.

11. Don't expect Volks Wagens! But ensure the
Ambassador is not leaking petrol !
• The design of the anaesthesia machine may not be
familiar
• do routine safety checks, such as ensuring that the
oxygen failure alarm is working
• Make sure that we can see the anaesthetic machine
during the case – e.g. radiology procedures are
invariably undertaken in darkened rooms

12. DEXMEDITOMIDINE
.
Equipment check list for anaesthesia or sedation in a remote location
away from the operating theatre
Remember the acronym S O A P M E
S (suction) – Appropriate size suction catheters & functioning suction apparatus.
O (oxygen) – Reliable oxygen sources with a functioning flow meter.
At least one spare E-type oxygen cylinder.
A (airway) – Size appropriate airway equipment:
• Face mask• Nasopharyngeal and oropharyngeal airways• Laryngoscope blades• ETT•
Stylets• Bag-valve-mask or equivalent device.
P (pharmacy) – Basic drugs needed for life support during emergency:
• Epinephrine (adrenaline)• Atropine• Glucose• Naloxone• Flumazenil
M (monitors):
• Pulse oximeter• NIBP• End-tidal CO2 (capnography)• Temperature• ECG
E (equipment):
• Defibrillator with paddles• Gas scavenging• Safe electrical outlets (earthed)• Adequate
lighting (torch with battery backup)• Means of reliable communication to main theatre site.

13. Sisterrrrrrrrrr......…. I meant
LARYNGOscope , not this…
ENDOscope…,
please get me one…..
• emergency trolley with a defibrillator should be immediately
available.
• always check O2 source, cylinder keys, illumination of
laryngoscopes,working suction, emergency and resuscitation
drugs enough number of extension lines (high pressure and low
pressure), operating table functionality soon after you enter
the room….
• back-up of at least one full E type oxygen cylinder is advisable;

14. Monitors
• Pulse Oximeter, NIBP, ECG and ETCO2 are a minimum
requirement.
• In a non-intubated patient, ETCO2 monitoring can be achieved
by taping the sampling line to the patient’s upperlip
• The expired CO2 is sensed along with the graphic display of
respiration.
• peripheral nerve stimulator

15. "Nero Fiddled While Rome
Burned." try to prevent
emergence of Neros within us
• In remote areas, where darkness and big machines
prevails, ETCO2 can be very helpful.
• If possible, mobilise end-tidal CO2 monitoring from the
operating theatres.
• Monitoring may be a particular challenge in the MRI
suite

16. DON’T DONATE THE ETT TO SURGEON…
• Certain procedures require circuits and monitors
with long extension tubings e.g. Interventional
neuroradiology….
• An AMBU should also be available to provide
positive pressure ventilation in case of oxygen
failure.

17. ETCO2 if non intubated
.

18. CHALLENGES
STAFF
.

19. Lonely walk through
dangerous paths!
• Staff  trained only in their speciality
• sole responsibility of the anaesthesiologist to check and ensure
safety
• ensure that rapid communication to colleagues in the main
theatre suite is possible.
• identify an assitant to help
• Check consent

20. Think , Plan and Communicate
• Think and plan the moment you get the call
• Anticipate problems before starting the case;
• Help from main theatre may be slow to arrive.

21. CHALLENGES
PROCEDURE
.

22. Poor illumination
• Many procedures are carried out in darkened rooms
[e.g. interventional radiology or endoscopy]
• Should be able to visualise the flow meters and to check
accurate gas flows.
• we must be vigilant to detect unexpected events such as
cessation of oxygen delivery and ETT disconnection

23. WEL[L]COME…….
We have arranged a very
nice trap , both for you and
our patient….
• Beware of the situation where the anesthesiologist is called
after the intervention has started and the patient is found to
be uncooperative.
• Without a prior plan or airway assessment the situation is
hazardous – if situation allows, it is better to abort the
procedure and come back another day when things can be
planned properly.

24. The extremes…!
• Some areas are poorly equipped to deal with any
kind of emergency
• E.g. Burn dressings, muscle biopsies etc done at
bedside

25. Positioning
• Patients undergoing ERCP, Endoscopy and CT guided biopsies
 lateral or prone position.
• ? pillows are available for safe prone positioning ? All other
routine precautions for prone position..
• Prone position becomes difficult if the patient requires routine
resuscitation – reposition the patient rapidly if this is the case.

26. Duration of the procedure
• Duration : difficult to predict
• They may finish very abruptly : Avoid long-acting
muscle relaxants and maintain close communication
with the specialist performing the procedure.

27. Post-procedure care
• Transport to a standard recovery room with the
monitors along with the anaesthesiologist
• oxygen during transport.
• Patients who require elective postoperative ventilation
must be transferred with continuous monitoring

28. Post-procedure care
• Patients undergoing aneurysm coiling may need to be
ventilated in the postoperative period.
• The availability of an ICU bed has to be confirmed prior
to the procedure.

29. SOME SPECIAL CONSIDERATIONS
• Anaphylaxis to iodinated dyes is possible. All the drugs
for Rx of anaphylaxis should be immediately available.
• Radiation exposure - anaesthesia personnel should be
aware of the radiation hazards and take precautions to
avoid radiation exposure.
• Intermittently check, whether your syringe pump is
running and adequate amount of drug is remaining, 3-
ways are turned in the proper direction, breathing
pattern is normal,

30. CHALLENGES
PATIENT
.

31. Dealing with the most
important person in any
setting...
• the reason for which they require the intervention,
• associated co-morbidities.
• Fasting status
• a quick airway assessment : unanticipated difficult
airway is very challenging in remote
• Presence of dentures

32. I won't cooperate man.......
• Children
• anxious patients
• Claustrophobic patients (especially in MRI suites)
• • Elderly or confused patients
• Patients undergoing painful procedures
• Patients requiring burns dressings.

33. ANAESTHETIC
TECHNIQUE
.

34. CHOICE OF ANAESTHESIA
• Monitoring only [do not require an anaesthesiologist]
• Sedation
• Regional anaesthesia
• Total intravenous anaesthesia
• General anaesthesia.

35. Sedation/anagesia:
easier ; but ensure frequently
that you are not in trouble!
• less invasive
• cost and time saving
• high rate of failure
• high chance of airway and respiratory depression

36. Definition of general anesthesia and levels of sedation
/analgesia [Approved by the ASA,2009]

37. MAINTAIN THE BALANCE…
• The degree of safety in conscious sedation
is much higher than deep sedation.
• The patient can easily drift from a state of
conscious sedation to deep
sedation, depending on his age, sensitivity to
drugs, health status etc.
• Titration and adjustment of the doses of the
sedative agents requires skill and experience.

38. Total intravenous anaesthesia
(TIVA)
• Drugs are used intravenously, for hypnosis and analgesia.
• Airway  chin lift/jaw thrust / an oropharyngeal airway
/ LMA may be used if the patient is deeply anaesthetised.
• oocyte retrieval, in vitro fertilisation and foetal reduction
in ultrasound rooms  usually fentanyl + propofol

39. General Anaesthesia
 E.g. Interventional Neuro radiology, MRI suite etc
 tracheal intubation / LMA
 best prevention of motion
 invasive, time and resource consuming
 atelectasis

40. …….Regional anaesthesia
• Combined spinal-epidural anaesthesia e.g. for EVAR -
Endovascular aneurysym repair.
• The conscious patient can communicate and this is a
major safety consideration.

41. DOCUMENTATION OF
ANAESTHESIA
• A time-based anaesthesia flow sheet
• Drugs administered – time and dose
• SaO2 , Heart rate , Respiratory rate , NIBP – can omit if minimal
sedation, e.g. during MRI/CT
• Level of sedation
• Observations should be performed at 15 minute intervals for conscious
sedation, and 5 minute intervals for deep sedation and general
anaesthesia.
HAZARDOUS
IF OMITTED
FOR ANAESTHETIST

42. CHOICE OF DRUGS
• This depends on the procedure being performed, and
whether this is painful or painless.
• e.g. MRI scan compared to endoscopy compared to a
change of burns dressings.

43. DRUGS
• Midazolam: In paediatric patients, intranasal
midazolam has also been tried successfully.
• Fentanyl : 0.25-0.5mcg.kg-1 is usually sufficient.
• Propofol : A careful and slow intravenous
injection of propofol is an ideal choice.
• Ketamine
• Ketofol: provides good hemodynamic stability.
• Remifentanil : An ideal drug but not available in
India
• Prilox cream

44. DEXMEDITOMIDINE
.

45. DEXMEDITOMIDINE
.

46. DEXMEDITOMIDINE
.

47. PROPOFOL- an easy method….
 Load with 2 mg/kg over 10 minutes in a 50
mL syringe-pump
 For e.g. 10 kg child: 20mg=2mL X 6 =
12mL/hr (for first 10 mins) ; then…
 If you set the maintenance as half this dose
(i.e. 6 mL/hr)
 This will be equivalent to 100 ug/kg/min
infusion of propofol…..

48. There is substantial variability in the
response to each agent between
individuals.......
Change your tactics according to the ‘opponent’.

49. . ASA guidelines for NORA patients
.

50. Discharge criteria
• A

51. Anesthesia for MR IMAGING
• .

52. Contrast media
• Allergic reaction
• History
• Symptoms: skin reactions, airway
obstruction, angioedema, and cardiovascular
collapse.
• Treatment: corticosteroids, H1 and H2
blockers. Oxygen, epinephrine, β2-
agonists, and intubation , IV fluids
• Prevention: corticosteroids

53. Anesthesia for CT
• Less complex
• Use standard monitoring
• Less anesthetic time
• Higher levels of radiation exposure

54. Anesthesia for MRI-Physical environment
• High magnetic field
• Uncertain duration
• Need specialized compatible equipment
• Radiofrequency noise
• Metallic implants or implanted devices
• Patients with implanted pacemakers, ICDs, or
pulmonary artery catheters may not have MRI scans.

55. Special circumstances -
Magnetic resonance imaging
(MRI)
• NEVER take any ferrous metal into the MRI suite – includes
laryngoscopes, scissors and stethoscopes and mobile phones.
• In an emergency, take the patient out of the MRI room, do not
take the emergency equipment to the patient.
• can keep noise blockers in patients ears

56. Dedicating these two things to those who
sacrificed theirs’ for MRI Machines
.

57. MRI- Conduct of anaesthesia
• In the MRI centre Anaesthesia is induced outside the MRI room
and the patient is transferred to the MRI compatible machine
in the room.
• Slave monitors must always be kept outside the MRI room.
• From these monitors we can see the respiratory
tracing, ETCO2, PR, BP etc

58. Drugs for paediatric age
group for MRI
• A

59. MRI SUITE
.

60. Electroconvulsive therapy (ECT)
• Mainly to treat major depression
• Typically, ECT is performed twice weekly until there is a
lack of further improvement [6 to 12 treatments over 2 to
4 weeks]
• Physiologic effects:
> a grand mal seizure tonic phase : 10 to 15 s,
>clonic phase :30 to 50 s.

61. Electroconvulsive therapy (ECT)
• > first reaction: parasympathetic discharge lasting 10–15 s.
This can result in bradycardia, hypotension, or even
asystole
>following reaction:
hypertension,arrhythmias, tachycardia, lasts for 5-
10min↑O2 consumptionM.I.
Left ventricular systolic and diastolic function can remain
decreased up to 6 h after ECT
 ICP, intraocular and intragastric pressure increase

62. Contraindication :
• absolute contraindication: intracranial hypertension
• Relative contraindications:
Untreated intracranial mass,
aneurysm,
within 3 months of either a MI or cerebrovascular accident,
uncontrolled cardiac failure
untreated glaucoma
unstable major fracture
thrombophlebitis, pregnancy
retinal detachment,
DVT (until anticoagulated)
severe osteoporosis,
phaeochromocytoma,
Cochlear implants

63. ECT-Anesthetic goals
1. amnesia and rapid recover
2. Prevent damage
3. Control hemodynamic response.
4. Avoid interference with initiation and
duration of induced seizure.

64. Anaesthetic technique
 No Sedative premedication
 Patients should be encouraged to empty their
bladder as incontinence is common
 Standard monitors (ECG, SPO2 , BP)
 Place rolled gauze pads

65. U R THE , NOT THE DRUG
 Objective : a rapid onset and offset of both
unconsciousness and muscle relaxation for the duration
 All currently available induction agents are suitable for
ECT , except ketamine.
 Whichever drug is used, it is preferable to utilize the
same one throughout a course of treatment to avoid
interfering with the seizure threshold (which generally
increases over a course of ECT).

66. Anaesthetic technique
• A

67. Was there 4 quite some time; now a hero!
 Preoperative α-2 agonists such as
dexmedetomidine also blunt the hyperdynamic
response as does glyceryl trinitrate, which should
be considered in patients at high risk of myocardial
ischaemia.
 Can use labetalol or esmolol when necessary.
.

68. Done it!
 Succinylcholine (0.5 mg kg−1) is most commonly
used. Larger doses up to 1.5 mg kg−1 may be
required
 Glycopyrrolate has superior anti-sialogogue
effects, no adverse central nervous system
effects, and results in less post-ECT tachycardia.
 Routine atropine premedication is not
recommended due to detrimental effects on
myocardial work and oxygen demand.
 Deleterious sympathetic effects may be controlled
with β-blockers either pre- (atenolol) or intra-
procedurally (labetalol and esmolol)

69. Anaesthetic technique
 Intubation- not routinely required, ventilation can
be gently assisted with a face mask.
 Hyperventilation lowers the seizure threshold and
can prolong seizure duration.
 a bite block protects the patient's teeth, lips, and
tongue.
 During initial treatments, the stimulus magnitude
may be titrated until an adequate seizure is
generated. In such circumstances, further boluses
of induction agent are required to maintain
anaesthesia.

70. ECT- adverse effects
• confusion, agitation, violent
behaviour, amnesia, headache, myalgia, and
nausea and vomiting.
• Emergence agitation can be the most
challenging problem to treat.
• Small doses of midazolam may be useful if
simple measures such as a secluded, calm
recovery environment do not help.
• The presence of a trained escort familiar to
the patient can be reassuring.

71. ECT- adverse effects
• arrhythmia
• myocardial infarction
• laryngospasm
• aspiration
• Transient ischaemic deficits,
• intracranial haemorrhage,
• cortical blindness
• status epilepticus; Terminate seizure with propofol or
benzodiazepines within 3 minutes
• Disorientation,
• impaired attention, and
• memory problems
What anaesthesia you ve
given? Patient is
disoriented…..

72. Anesthesia for neuroradiologic procedures
• A. Endovascular embolization
• Indication: cerebral aneurysms, arteriovenous fistulas
and malformations , vascular tumors
• Methods: femoral artery puncture, a small catheter into
the aneurysm
• Anesthetic goals :stable hemodynamics, and rapid
recovery
• Other problem: Invasive arterial blood pressure
monitoring , avoid hypertension, monitor
anticoagulation, complications include rupture of the
aneurysm

77. OTHER NEURO RADIOLOGICAL INTERVENTIONS
B. Embolization for control of epistaxis and extracranial vascular
lesions
C. Balloon occlusion test
D. Cerebral and spinal angiography
E. Vertebroplasty and kyphoplasty
F. Thrombolysis of acute stroke
G. Cerebral vasospasm

78. ESWL CONCERNS
• PAIN: stinging,sharp
• [1] @cutaneous level + visceral and [2] due to
the movement of the stone
• CLAUSTROPHOBIA
• GA usually not necessary
• Spinal / epidural
• NSAIDS, PARACETAMOL, FENTANYL, EMLA
cream for analgesia + MIDAZOLAM may suffice
• Need to mobilize the operating table
• Ensure in the operating position, you can
access for any emergency intervention

79. Upper and lower endoscopy and ERCP

80. Others interventions requiring NORA
• Anesthesia for vascular, thoracic, and
gastrointestinal/genito-urinary radiology
procedures.
• Anesthesia for cyclotron therapy and
radiation therapy/brachytherapy

82. Visit me @
.
www.thelaymedicalman.blog spot.com
FACEBOOK page “Anaesthesia Info from the
Lay Medical Man”

83. References
• Updates in Anaesthesia ,Volume 25 Number 1 June 2009, Anaesthesia Outside the Operating
Theatre Lakshmia Jayaraman*, Nitin Sethi, Jayashree Sood
• Anaesthesia for electroconvulsive therapy,Vishal Uppal, Jonathan Dourish, Alan
Macfarlane, oxfordjournals.org