NON OPERATING ROOM LOCATIONS, STANDARDS

1. QUALITY & SAFETY
IMPROVEMENT EFFORTS
OUTSIDE OPERATING
ROOM.
28.10.17
Dr. PALLAVI AHLUWALIA,
PROFESSOR,
TEERTHANKER MAHAVEER
MEDICAL COLLEGE,
MORADABAD.
1

2. Common locations for Non-
Operating Room
Anaesthesia(NORA)
Radiology
 Neurointerventional
Radiology
 Vascular Radiology
 MRI/CT/ PET Scan
Endoscopy Suite
 Gastrointestinal Suite
 Bronchoscopy
Intensive Care Unit
 Tracheostomy,
Percutaneous
gastrostomy
 Intracranial catheter
placement
 Abdominal/pelvic
Invasive Cardiology
Suite
 Cardiac Catheterization
Lab
 Cardioversion
 Electrophysiology Suite
Radiation Therapy
Emergency Medicine
Suite
Psychiatry
 E C T suite
Urology - Lithotripsy
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3. Why there is concern for
safety?
Anaesthesia providers are now asked more
frequently to provide complete, integrated
anaesthetic care outside the traditional OR
setting.
The number and the complexity of such cases is
increasing over time.
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4. Problems faced by the
Anaesthesiologists
1. Lack of adequate space
2.Unfamiliar surroundings and equipments
3.Central pipeline will be missing and cylinders will
have to be used.
4.Unphysiological postures needed for some
procedures.
5.Out patients for investigations are inadequately
prepared/investigated/have associated medical
illness.
6.Adverse reactions to contrast media
7.Lack of post anaesthetic care
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5. Apsf.org
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6. 6

7. Morbidity & Mortality in
NORA
M&M data related to NORA infrequently studied and poorly described
Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for
procedures outside the operating room. Curr Opin Anaesthesiol 2006;19:436-
42.
 Mortality increased with NORA as opposed to
conventional operating room anesthesia
 Substandard care is more prominent in NORA, many
complications could have been prevented with better
monitoring
 NORA claims were mostly associated with monitored
anaesthesia care and with extremes of age
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8. STATEMENT ON
NONOPERATING ROOM
ANAESTHETIZING
LOCATIONS
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9. American Society of
Anaesthesiologists guidelines for
NORA locations.
 Reliable O2 source with backup
 Sufficient space for anaesthesia personnel,
equipment
 Suction apparatus, Emergency cart,
defibrillator, drugs, etc.
 Waste gas scavenging
 Reliable means for two-way communication
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10. ASA guidelines....
 Adequate monitoring equipment
 Applicable facility, safety codes met
 Safe electrical outlets
 Adequate illumination, battery backup
 Appropriate post-anaesthesia management
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11. AAP guidelines for NORA
paediatric patients
1. No administration of sedating medication without
safety net of medical supervision.
2. Careful presedation evaluation
3.Appropriate fasting for elective procedures
4.In urgent procedures balance between depth of
sedation and risk
5.A focused airway examination
6.Clear understanding of pharmacokinetic &
pharmacodynamics
7.Training skills in airway management
8.Equipment for airway management and venous
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12. How can we improve safety?
 Goal = improve the reliability of
achieving a safe NORA anesthetic
 success in NORA may be achieved by
adhering to structural and organizational
standards
 Need for evaluation & analysis of steps
required for each type of NORA
 The reliability of each step determines
whether the a particular
algorithm/protocol is reproducible
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13. Tools & Targets for Improving
Safety
 Organizational tools
 Quality improvement methods
 Protocols
 Checklists
 Communication during the procedure and during
transfer of patient care
 Continuing education
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14. Protocols & Checklists
 Haynes AB, Weiser TG, Berry WR, et al. A
surgical safety checklist to reduce
morbidity and mortality in a global
population. N Engl J Med 2009;360:491-9.
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15. Protocols & Checklists,
cont’d
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16. Specific conditions that warrant special
care for anaesthesia / sedation outside
OR
 Non-cooperate patient (e.g. intellectual
disability)
 Procedures limiting access to the airway
 Prone /Uncomfortable position
 Lengthy, complex or painful procedures
 Medical conditions predisposing patients to
reflux e.g. gastroparesis secondary to DM
 Increased intracranial pressure
 Decreased level of consciousness/depression
of protective airway reflexes
 Acute trauma & Extremes of age
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17. Red flags for sedation
 Infants <37 weeks GA
 Apnea- OSA/morbid obesity
 History of airway compromise during
sedation/GA
 Adverse reaction to sedation previously
 Potential for difficult airway
 Hypotonic/lack of head control.
 Gastroesophageal reflux
 Unstable cardiac disease-
cyanotic/hemodynamic instability.
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18. Personnel requirements for safe
sedation / anaesthesia outside
OR.
Anaesthesia staff
 Trained in the clinical assessment of patients
 Trained & experienced in airway management &
CPR
 Trained in the use of anaesthetic & resuscitation
drugs & equipment,
 must ensure that the equipment is present and
functional prior to induction
 Vigilant and Dedicated to the continuous
monitoring of the patient’s physiologic
parameters.
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19. Non-anaesthesia staff
Appropriately trained to help deal with a
cardiopulmonary emergency
Assistant for the anaesthesiologist-this
person must be familiar with anaesthetic
procedures and equipment
Assistant to help with positioning
Staff trained in
post-procedure observation
and resuscitation
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20. Standardization & Anaesthesia
Safety
Eichhorn JH, Cooper JB, Cullen DJ, et al: Standards for patient monitoring
during anesthesia at Harvard Medical School . JAMA 1986;256:1017-1020
The Harvard Anesthesia Practice Standards
written in the 1980s
 Example of the standardization of anesthesia
care has helped improve the safety .
 Identified minimum monitoring expectations (now
commonly used in every anesthetic procedure )
 Influenced widespread adoption of pulse
oximetry and capnography
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21. Quality Improvement
 Even though effective organizations take steps
to prevent adverse incidents, problematic
events still occur.
 It is vital to have a defined approach to
reacting to adverse events, including errors
and near-misses.
 Proactive vs. reactive approach
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22. NORA Safety Issues
- Location -
 Crowded rooms with limited access to
the patient
 Suboptimal light, insufficient power
supplies
 Distance from pharmacy / supply
rooms
 Availability of anesthesia staff/
help if needed
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23. Location/space requirements
for NORA (guidelines)
 Adequate size with good access to the patient
 Uncluttered floor space
 An operating table, trolley or chair which can be
tilted into Trendelenburg position
 Adequate lighting including emergency lighting
 Sufficient electrical outlets including connected
to an emergency back-up power source
 Suitable clinical area for recovery of the patient
which must include oxygen, suction,
resuscitation drugs and equipment
 Emergency back-up call system to summon
assistance from the main OR.
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24. Equipment/monitoring
requirements for NORA
 Appropriate (for deep sedation, GA and a cardio-
respiratory emergency)
 Immediately available
 Regularly serviced (service date indicated on the
equipment)
 Same standard as in the OR (minimum
SPO2,ETCO2 , NIBP, ECG and temperature)
 Alarms activated (with appropriate settings) and
sufficiently audible
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25. Monitoring req. contd....
 Airway gas with the recognized safety
devices (e.g. Indexed gas connection
system,
 reserve supply of oxygen,
 oxygen analyzer,
 oxygen supply failure alarm,
 multiple gas analyzer,
 a volatile anesthetic agent monitor,
 a breathing system disconnection alarm
 a scavenging system)
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26. Monitoring req. contd....
 Anaesthesia work cart
 stocked to OR standard (including
anaesthetic and resuscitation drugs,
 airway management equipment,
 a self-inflating hand resuscitator bag
(AMBU)
 Suction
 Defibrillator and emergency cart
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27. COMPLICATIONS ASSOCIATED
WITH SEDATION AND
ANALGESIA
 Airway
 Airway obstruction
 Aspiration
 Regurgitation
 Dental/soft tissue injury
 Respiratory
 Respiratory depression
 Hypoxemia
 Hypercarbia
 Apnea
 Cardiovascular
 Hypotension
 Cardiac arrhythmias
 Neurologic
 Deeper level of sedation
 Unresponsiveness
 Other
 Undesirable patient
movement
 Drug interactions
 Adverse reactions
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28. Goals of sedation in patients for
diagnostic & therapeutic procedures.
 Guard the patient’s safety and welfare
 Minimize physical discomfort and pain
 Control anxiety, minimize psychological
trauma,
and maximize potential for amnesia
 Control behaviour and movement to allow
safe
completion of procedure
 Return patient to a state in which safe
discharge from medical supervision is
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29. 29

30. Concerns in Radiology Suite
 Radiology hazard.
(Principle of ALARA-As Low As Reasonably
Achievable),Lead aprons/thyroid
shields/leaded eyeglasses.
 Intravenous contrast agents
• Hypersensitivity reactions
• Contrast induced Nephropathy-Rise in S.Cr.
By 0.5mg/dl with in 24 hrs, with peak at 5
days.
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31. Computed Tomography
CONCERNS
 Possibility of full stomach- oral contrast
 Airway management- head not accessible.
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32. 32

33. Problems of MRI
 Ferro magnetic materials within 30 G contour- X
 Implanted biological devices- cardiac
pacemaker, vascular clips, mechanical heart
valves, automatic implantable cardioverter-
defibrillator, cochlear implants –
Contraindicated.
 Ear protection-noise exceeds permissible limits.
 Heat generation in wires-electromagnetic
induction.
 Malfunction of electric equipment-magnetic
fields.
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34. Contd....
 NIBP –connections of cuffs and hoses=plastic
 Capnography-long sampling lines=delay upto
20 sec.
 Temperature monitoring=probes with
radiofrequency filters.
 MRI safe infusion pumps=TIVA.
 IF NOT AVAILABLE-
Standard machine +long breathing
circuit=secured to wall outside 5G contour.
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35. Precautions :GA for MRI
 ET, LMA, connections- no ferromagnetic
material.
 Laryngoscope-plastic, lithium batteries&
aluminium spacers.
 ECG/Pulse Ox. Wires –straight/no loops/should
not touch patient at more than one location.
 MRI Compatible Pulse Ox.- use fiber-optic
signal.
 ECG-Artifacts minimized by high impedence,
braided, short leads.
 MRI safe electrodes are available. To be placed
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36. Interventional Neuro-radiological
procedures
Considerations-
 Radiation exposure
 Contrast reactions
 Difficult access to patient airway
 Need for IBP monitoring/EEG/Brain stem
evoked potentials.
INHALATIONAL ANAESTHETICS avoided
for their confounding effects on EEG
&evoked potentials.
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37. Interventional
gastroenterology
Endoscopy-opioid/BDZ sedation+ LA spray
Colonoscopy concerns-
 Preparatory bowel regimen induced
hemodynamic instability.
 Uncompensated anemia-severe GI bleeding.
ERCP- prone
 Concerns: limited airway access, avoidance
of drugs affecting tone of
sphincter of oddi.
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38. IVF-Oocyte retrieval
 OPTIONS-Concious sedation,
paracervical block, electroacupuncture,
GA, RA.
 SPINAL adv. Over GA- Excellent
anaesthesia with min. I.V. Medication.
 Consider-short anaesthetic exposure with
min. penetration to follicular fluid.
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39. ECT
INITIAL-parasympathetic followed by sympathetic
response.
BP- cuff inflated before MR to monitor seizure.
Bite block to prevent injuries.
Concerns-
 avoid sedative premedicants,
 use glycopyrrolate to prevent bradycardia&
secretions,
 interaction of anaesthetic agent with
antidepressants,
 need to obtund hemodynamic response to ECT.
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40. TAKE HOME MESSAGE
 Follow minimum guidelines ASA
 Knowledge about procedure, Its requirements
& complications
 Have close communication with proceduralist.
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41. THANK YOU.41

42. drpallaviahluwalia@yahoo.com
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