Non-operating Room Anesthesia Research Articles

Airway management in a pediatric patient with glottic web: An anesthetic challenge in non-operating room anesthesia

Airway management in a pediatric patient with glottic web: An anesthetic challenge in non-operating room anesthesia

Non-operating room anesthesia workflow (NORA) implementation to improve start times in interventional radiology

BackgroundNon-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PurposeTo investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. Materials and MethodsA retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. ResultsOne hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. ConclusionImplementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.

Nonoperating Room Anesthesia: What Is New? What Is Controversial?

Nonoperating Room Anesthesia: What Is New? What Is Controversial?

Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room?

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.

Safety of Non-Operating Room Anesthesia With Propofol Sedation in Three Pediatric Patients With Central Sleep Apnea.

Children with central sleep apnea may require sedation for procedures, including brain imaging as part of the evaluation of apnea. However, the safety of deep sedation without a protected airway is not known in this patient population. In this case series, we present 3 children with central sleep apnea who were sedated with propofol for brain imaging in a non-operating room setting. All 3 did well with no complications; those with a home oxygen requirement were on oxygen during the procedure but none experienced apnea, desaturation, or respiratory distress. While obstructive sleep apnea is a known contraindication to deep sedation with propofol, it may be safe in pediatric patients with central sleep apnea. Deep sedation may be a good option for these patients, thereby avoiding the need for general anesthesia and placement of an advanced airway.

Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation.

Beard, John MD*; Methangkool, Emily MD, MPH†; Angus, Shane CAA, MSA‡; Urman, Richard D. MD, MBA§; Cole, Daniel J. MD† Author Information

Coronary Artery Air Embolism in the Non-operating Room Anesthesia Setting: Reply.

Coronary Artery Air Embolism in the Non-operating Room Anesthesia Setting: Reply.

Coronary Artery Air Embolism in the Non-operating Room Anesthesia Setting: Comment.

Coronary Artery Air Embolism in the Non-operating Room Anesthesia Setting: Comment.

Medication error during nonoperating room anesthesia—a case report

Despite a lot has already been done in the field of safety improvement during anesthesia, medication errors still occur during everyday practice. Syringe or ampule swaps are usually the most frequent type of medication error. Recent studies prove that nearly 80% of these errors are preventable. In our case, 30 mg (3 ml) of dopamine (Dopamin Fresenius 10 mg/ml) was injected to the patient’s intravenous line instead of 3 mg (3 ml) midazolam (Midazolam Accord 1 mg/ml) during the preparation for the carotid artery stenting procedure in nonoperating room environment. The error was realized immediately after the application. Besides temporary fulminant hypertensive reaction, tachycardia, restlessness, skin rush, troponin leak, and temporary ST-segment depression, there were no permanent consequences to the patient's health. The team was able to perform the planned procedure 30 min after the event. This medication error of ampule swap, packages of which were stored in the medication cupboard one above the other, was caused by alignment of the latent vulnerable layers of the safety system (Swiss Cheese Model of System Error and Hot Cheese Model) plus the influence of the environmental factors and active failures done by the anesthesia staff. After this event, new safety measures were established by introducing color-coded ISO 26825:2020 syringe labeling, new anesthesia trolleys with color-coded medication compartments, and color-coded medication storage cupboards. Besides this safety committee was formed for the promotion of medication safety education programs.

Management of anesthetic complications outside the operating room.

Nonoperating room anesthesia (NORA) procedures have seen a significant growth over the years along with an increase in the complexity and severity of cases. Providing anesthesia care in these often-unfamiliar locations is risky, and complications are common. This review aims to report the most recent updates regarding managing anesthesia-related complications in patients undergoing procedures in non-operating room locations. Surgical innovations, advent of new technology, and the economics of a healthcare environment that strives to improve value by decreasing costs, has expanded the indications for and complexity of NORA cases. In addition, an aging population with increasing comorbidity burden, requirements for deeper levels of sedation have all increased the risk of complications in NORA environments. In such a situation, improvement in monitoring and oxygen delivery techniques, better ergonomics of NORA sites and development of multidisciplinary contingency plans are likely to improve our management of anesthesia-related complications. Delivery of anesthesia care in out-of-operating room locations is associated with significant challenges. Meticulous planning, close communication with the procedural team, establishing protocols and pathways for help, along with interdisciplinary teamwork can facilitate safe, efficient, and cost-effective procedural care in the NORA suite.

Sedation and Analgesia for the Interventional Radiologist.

The administration of sedative agents requires compliance with standards set by the American Society of Anesthesiologists (ASA), irrespective of the setting in which anesthetics are administered.[1] The interventional suite is one of many settings for nonoperating room anesthesia. By performing procedures on patients across varying levels of sedation, the interventionalist becomes part of a broader anesthesia care team tasked with minimizing anesthesia-related risk and optimizing patient outcomes. As such, the interventionalist's responsibilities extend beyond performing a technically safe and effective procedure to include the safe and effective management of sedation—and knowing when to seek assistance.

Trends in pediatric non-operating room anesthesia: Data from the National Anesthesia Clinical Outcomes Registry.

Modern pediatric anesthetic encounters occur in operating rooms and non-operating room settings. Most anesthesia providers have cared for children in radiology, endoscopy, and other interventional settings at some point in their training and career. There is an absence of published data on the frequency, timing, and demographics of these pediatric anesthesia encounters. The primary goal of our study is to present data spanning a variety of institutions and practice settings in the United States to define the percentage of non-operating room anesthetic encounters in children. We also set out to characterize the frequency of the most common procedures in the non-operating room setting within the United States. Using the National Anesthesia Clinical Outcomes Registry data from 2015-2019, we analyzed and reported data on current trends in non-operating room anesthesia including patient demographics, encounter setting, procedure type, and the time at which anesthetic encounters occurred. 2 236 788 pediatric anesthetic encounters (patient age <18 y.o.) were analyzed revealing that 22.7% of all pediatric anesthetics occur in non-operating room settings. Patients were more likely to have higher American Society of Anesthesiologists Physical Status classifications in the non-operating room anesthesia group. Gastroenterological suites are the most common setting reported for pediatric non-operating room anesthesia. Non-operating room anesthesia in the United States is a prominent segment of pediatric anesthetic practice. Pediatric patients encountered in the non-operating room setting have more comorbidities, though further studies are needed to characterize the implication of this finding.

Izazovi u proceduralnoj sedaciji i analgeziji

Introduction. There are several definitions given by various anesthesiology professional organizations that explain the term procedural sedation and analgesia (PSA). The International Committee for the Advancement of PSA has defined procedural sedation as the use of anxiolytics, sedatives, hypnotics, analgesics and/or dissociative drugs to alleviate anxiety, pain and/or movement. These agents are used to facilitate the attainment of amnesia or to reduce the consciousness and/or comfort and safety of the patient during diagnostic or therapeutic procedures. The first guidelines for sedation are based on the mandatory signing of informed consent, monitoring and measuring of vital parameters, implementing a fasting regimen before sedation, possessing the skills to establish and maintain the airway, and resuscitation measures. Since PSA is most often used outside the operating room, this type of anesthesia activity is known as NORA (Non-Operating Room Anesthesia Care). Conclusion. Preprocedural evaluation and preparation, periprocedural management, monitoring and care of postprocedural recovery from PSA is similar to those of general or regional anesthesia. In conclusion, a number of logistical and practical difficulties should be noted, such as the availability of medicines and appropriate staff training, as well as the application of global guidelines on PSA.

Coronary Artery Air Embolism in the Non-operating room Anesthesia Setting.

Coronary artery air embolism is a rare complication in the non–operating room anesthesia environment. In this setting, coronary artery air embolism is generally caused by communication between the atmosphere and the pulmonary venous system or by the creation of a bronchial-venous or alveolar-venous fistula during lung biopsy.1 Typical presentation is a result of the ensuing myocardial ischemia, and includes chest pain, arrhythmia, ST segment changes, bradycardia, hypotension, and cardiovascular collapse.2Figure 1 represents the intraprocedural computed tomography imaging of a 74-year-old woman who underwent percutaneous lung biopsy. Clearly visible is the air-fluid level in the ascending aorta, just distal to the right coronary artery ostia. Figure 2 shows air in the proximal right coronary artery. This patient’s procedural course was complicated by profound bradycardia, arrhythmia, and cardiogenic shock secondary to acute myocardial ischemia.Risk of coronary artery air embolism is underappreciated outside the cardiac operating room; thus, the anesthesiologist must maintain a high degree of suspicion and closely monitor the electrocardiogram for change. Risk factors include coughing, positive pressure ventilation, biopsy of cavitary lesions, and use of needle-within-needle biopsy systems.3 In supine patients, the right ventricle is particularly vulnerable to coronary artery air embolism secondary to the anterior takeoff of the right coronary. Treatment involves immediate Trendelenburg positioning to prevent cerebral air embolism, an inspiratory oxygen fraction of 1.0, central access, and catecholamine support of cardiac function and coronary perfusion pressure. Transcutaneous or transvenous pacing, as well as coronary angiography, aspiration, and localized vasodilator injection have also been trialed successfully in the catheterization laboratory.3 Finally, extracorporeal membrane oxygenation or cardiac bypass may be indicated if other measures fail.Support was provided solely from institutional and/or departmental sources.The authors declare no competing interests.

Robust surgical scheduling for nonoperating room anesthesia (NORA) under surgical duration uncertainty

AbstractNonoperating room anesthesia (NORA) refers to the practice and administration of anesthesia or sedation outside the operating room (OR), which has been increasingly implemented in practice. The novelty of NORA is to separate the anesthesia preoperative stage from an OR for the sake of saving OR time and improving its efficiency. In this article, we study the scheduling problem for NORA considering both anesthetic rooms (ARs) and operating rooms (ORs) based on ambiguous information about surgical durations. Our goal is to devise a robust and efficient scheduling mechanism for NORA. To address this problem, we develop a two‐stage mixed‐integer Robust Optimization (RO) model that minimizes the total costs, including the sum of operating costs of opened ORs and ARs, delay cost of surgeries, and overtime cost of ORs. Decisions include the number of ARs and ORs to open, the allocation of patients to ARs and ORs, the sequence of surgeries, and the planned starting time for each surgery. Accordingly, a heuristic algorithm, so‐called column‐and‐constraint generation (C&amp;CG), is developed that renders a desirable performance. Some salient properties of the problem are also discussed. In addition, by leveraging practical data in conjunction with data reported in the extant research, the computational efficacy of the proposed algorithm is verified under various sets of parameters. Our numerical experiments reveal that (1) the implementation of NORA can reduce the OR overtime cost and the waiting time of patients; (2) our proposed Robust Optimization (RO) model possesses stronger robustness and computational efficiency than the distributionally robust model (DRO); and (3) while considering surgical duration uncertainty, the developed scheduling approach outperforms the corresponding deterministic setting in terms of decreasing the total cost and alleviating the surgery delay. Generally, the proposed approach is more adaptive to take the advantage of the surgical duration uncertainty to enhance its efficacy.

Operating room scheduling for non-operating room anesthesia with emergency uncertainty

Operating room scheduling for non-operating room anesthesia with emergency uncertainty

Frameworks for value-based care in the nonoperating room setting.

Nonoperating room anesthesia (NORA) presents a unique opportunity for the application of value-based care (VBC) principles to procedures performed in the office-based and nonoperating room inpatient settings. The purpose of this article is to review how value is defined in NORA and enabling principles by which anesthesiologists can maximize value in NORA. In order to drive value, NORA providers can target improvements in clinical outcomes where NORA lags behind operating room-based anesthesia (death, over-sedation, nerve injury), implement protocols focusing on intermediate outcomes/quality (postoperative nausea and vomiting, pain control, hypothermia, delirium), incorporate patient-reported outcomes (PROs) to assess the trajectory of a patient's perioperative care, and reduce costs (direct and indirect) through operational and supply-based efficiencies. Establishing a culture of patient and provider safety first, appropriate patient selection with targeted, perioperative optimization of comorbidities, and efficient deployment of staff, space, and resources are critical enablers for success. Value in NORA can be defined as clinical outcomes, quality, patient-reported outcomes, and efficiency divided by the direct and indirect costs for achieving those outcomes. We present a novel framework adapting current VBC practices in operating room anesthesia to the NORA environment.

Preventing patient positioning injuries in the nonoperating room setting

Postprocedural positioning injuries are an under-appreciated source of morbidity for patients. These injuries may not present until days after anesthesia and may be missed for multiple reasons including the distracting injury of the procedural site, illness of the patient, lack of follow-up, and insufficient awareness of this type of injury. Risks for these adverse events are exacerbated in the nonoperating room anesthesia (NORA) population for several reasons. These patients tend to be older and sicker than patients presenting to the operating room, increasing the risk of an injury. Proceduralists and anesthesia providers are usually consultants, not the primary care team, so may have limited patient follow-up. This review will discuss the risk factors for position-related injuries and how to prevent them with proper positioning and padding. The mainstay of preventing periprocedural positioning injuries is careful positioning of the patient and proper padding of pressure points. This may be particularly challenging because of physical constraints and positioning requirements for NORA procedures, as well as preference for radiolucent positioning materials. Recent studies have shown the potential benefit of monitoring somatosensory evoked potentials (SSEP) in high-risk patients. Careful consideration of patient positioning and thorough understanding of peripheral nerve and pressure injuries is essential for anesthesia providers to avoid positioning injuries during NORA procedures. http://links.lww.com/COAN/A87.

Editorial introduction.

Current Opinion in Anesthesiology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of anesthesiology is divided into 16 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Vesna Jevtovic-TodorovicVesna Jevtovic-TodorovicVesna Todorovic is the inaugural CU Medicine Endowed Chair and Chair of the Department of Anesthesiology at the University of Colorado School of Medicine, USA. Dr Todorovic received her graduate education at the University of Belgrade, Serbia (MD) and the University of Illinois, Chicago (PhD), USA and completed residency training in anesthesia at the Washington University School of Medicine in St. Louis, USA. She earned an MBA from the University of Virginia, Charlottesville, Virginia, USA and received the Harold Carron Professor of Anesthesiology Endowment from the University of Virginia Health System during her time on the faculty there. Dr Todorovic is a practicing anesthesiologist and has been working simultaneously as a clinician scientist for over 25 years. Dr Todorovic has developed three major lines of research: anesthetics as neurotoxins, the management of chronic pain and the mechanisms of anesthesia-induced developmental neurodegeneration. Dr Todorovic's research is federally funded and has resulted in over 140 peer-reviewed publications and 11 patents. She has received numerous grants from organizations such as the National Institute of Health, March of Dimes, the American Heart Association and the American Diabetes Association. Dr Todorovic served as the Chair of the National Institute of Health's Surgery, Anesthesiology and Trauma study section. She also serves on the Editorial Board for the Journal of Neurosurgical Anesthesiology and the Associate Editorial Board for British Journal of Anaesthesia. In addition, she serves as an Associate Editor for Anesthesiology. Dr Todorovic was a member of the Board of Directors for the International Society for Anaesthetic Pharmacology from 2007 and served as the Chairman in 2015. In her role as a PI, Dr Todorovic has mentored and trained over 60 graduate students, medical students and post-docs. As Chair of the Department of Anesthesiology, her focus extends to the mentorship and growth of junior faculty, expanding clinical programs, increasing collaboration with the School of Medicine and surrounding community. Richard D. UrmanRichard D. UrmanRichard D. Urman, MD, MBA, FASA is a staff anesthesiologist at the Brigham and Women's Hospital Department of Anesthesiology, Perioperative and Pain medicine in Boston, Massachusetts, USA and Associate Professor of Anesthesia at Harvard Medical School, USA, where he also received his MD and MBA degrees. He serves as Associate Chair for Dana-Farber Cancer Institute, Boston, Massachusetts, USA, and as a Medical Director for Procedural Sedation Services at the Brigham and Women's Hospital. In addition, he is the founding co-Director of the Center for Perioperative Research and the Director of the Perioperative Medicine Fellowship. He has edited a dozen textbooks, including the one on non-operating room anesthesia (NORA) entitled Anesthesia Outside the Operating Room (Cambridge Press, 2018) and has published papers on NORA safety, efficiency and outcomes. He is currently funded by the NIH, NSF, AHRQ and the industry. His research interests include pharmacology, acute pain management, patient safety and efficiency in the perioperative and periprocedural setting. He also serves as the scientific reviewer for the Department of Defense and sits on the FDA Analgesics panel. He is on the editorial boards of the Journal of Clinical Anesthesia and Anesthesia & Analgesia. Dr Urman is active in the Society for Ambulatory Anesthesia, where he serves as Assistant Treasurer and member of the executive committee. He is also Treasurer of the Society for Perioperative Assessment and Quality Improvement (SPAQI) and Treasurer of the Association of Anesthesia Clinical Directors (AACD).

Editorial: Improving quality and safety in nonoperating room anesthesia locations.

Editorial: Improving quality and safety in nonoperating room anesthesia locations.