The document outlines the principles and guidelines for administering anesthesia outside of the operating room, emphasizing the need for standard care, safety measures, and effective communication in various settings. It details challenges unique to remote locations such as equipment condition, environmental factors, and specific patient needs, while also reviewing sedation levels and procedural anesthesia for various medical procedures. Key guidelines include ensuring adequate monitoring, emergency preparedness, and compliance with safety standards.

1. ANESTHESIA OUTSIDE THE
OPERATING ROOM
By
Hala S. El-Ozairy,MD.
Lecturer of anesthesia and
ICU

2. Objectives
 Understanding that the standards of anesthesia care
and patient monitoring are the same regardless of
location (There are cases of minor surgery, but there
are no cases of minor anesthesia).
 Remember that the key to efficient and safe remote
anesthetic relies on open communication between
the anesthesiologist and non-operating room
personnel.
 Realize that remote locations have different safety
concerns, such as radiation and powerful magnetic
fields.

3. Remote anesthesia
 Anesthesiologists are increasingly being asked to
provide anesthetic care in locations outside of the
OR.
 These locations include: radiology suites, cardiac
labs, psychiatric units, GI lab, MRI, dental,
ophthalmic, ENT and urology clinics.
 It is the responsibility of the anesthesiologist to
ensure that the location meets the ASA guidelines
for safety.
 The anesthesia needed can range from local
anesthetics, MAC, or general anesthesia.

4. Problems related to ‘isolated’
environment
 Equipment might be old, not regularly serviced and
not in standard use as in the rest of the hospital.
 Monitoring standards may not be adequate.
 Piped medical gases may not be supplied.
 Other personnel may be unaware of the problems
facing the anesthetist.
 Space may be limited by bulky equipment making
access to the patient difficult.
 Poor environmental conditions (e.g. Lighting,
temperature).
 Recovery facilities may not be available.
 Inadequate ventilation/scavenging causing pollution.
 Problem related to transferring patients.

5. Problems related to patient
Patients who require general anesthesia are:
 Infants or uncooperative children.
 Older children or adults with psychological,
behavioral or movement disorders.
 Intubated patients such as acute trauma
victims and patients receiving intensive care.
 Interventional procedures under radio-
guidance or painful procedures like ECT,
cardioversion which require amnesia.

6. Problems related to the procedure
 MRI related problems.
 Bleeding.
 Conversion from sedation to
anesthesia.
 Contrast related problems.
 Radiation.

7. 1994 Guidelines for non-operating
room anesthetizing locations.
 Reliable oxygen source with backup.
 Suction source.
 Waste gas scavenging.
 Adequate monitoring equipment.
 Self-inflating resuscitator bag.
 Sufficient safe electrical outlets.
 Adequate light and battery-powered backup.
 Sufficient space.
 Emergency cart with defibrillator, emergency
drugs, and emergency equipment.
 Means of reliable two-way communication.
 Compliance with safety and building codes.

8. Remote monitoring
 Qualified anesthesia personnel must be
present for the entire case.
 Continuous monitoring of patient’s
oxygenation, ventilation, circulation, and
temperature:
 Oxygen concentrations of inspired gas: low
concentration alarm.
 Blood oxygenation: pulse oximetry.
 Ventilation: end-tidal carbon dioxide detection and
disconnect alarm.
 Circulation: ECG, ABP, invasive BP, and oximetry.

9. Remote facilities and equipment
 Know the physical layout of the location,
unfamiliar anesthetic equipment, and
anesthetic implications of the procedure being
performed prior to the induction of anesthesia.
 Verify the availability of assistance.
 Check piped-in gases and gas tanks.
 Check suction.
 Check power outlets (i.e. grounding and
electrical requirements).

10. Remote personnel
 Nurses and radiology techs are often less
familiar with the management of anesthesia,
therefore they are often unable to provide
skilled assistance in an emergency.

11. Remote recovery care
 Patient must be medically stable before
transport.
 Patient must be accompanied to the recovery
area.
 Provisions for O2 delivery and monitoring on
the transport cart are required.
 Appropriate recovery facilities and staff must
be provided.

12. Procedural sedation
Procedural sedation is defined as "a
technique of administering sedatives or
dissociative agents with or without
analgesics to induce a state that allows
the patient to tolerate unpleasant
procedures while maintaining
cardiorespiratory function."

13. Levels of Procedural Sedation
 Analgesia: Decreased perception of painful Stimuli.
 Anxiolysis: Decreased anxiety.
 Sedation: Decreased awareness of environment.
 Conscious sedation: Decreased level of awareness
that allows toleration of an unpleasant procedure
while maintaining the ability to spontaneously breathe
and protect the airway.
 Deep sedation: Unconscious state during which
patients do not respond to voice or light touch;
minimal spontaneous movement; may be
accompanied by partial or complete loss of protective
reflexes.
 General anesthesia: Loss of response to painful
stimuli and loss of protective reflexes.

14. JCAHO Guidelines for sedation
 ASA class I & II.
 Responsible adult to accompany the patient.
 Responsible physician (anesthetist).
 Support personnel.
 Facilities: Immediate availability to manage emergency
situations as (apnea, vomiting, seizures, anaphylactoid
reactions and cardiac arrest).
 Back up emergency service.
 On-site equipments: monitors, emergency cart,..
 IV access.
 Health evaluation and consent.
 Proper monitoring & documentation: ECG, BP, pulse
oximetry, capnography, consciousness.

15. Medication Side Effects Route Total Dose Onset Duration
Barbiturates
Methohexital Respiratory
depression,
hypotension
IV
PR
0.75 –1 mg/kg
20 –30 mg/kg
45 sec
8 –10 min
5 –10 min
45 – 60 min
Pentobarbital Respiratory
depression,
hypotension
IV
IM
PO/PR
2.5 mg/kg
2.5 mg/kg
2– 6 mg/kg
45 sec
10 –15 min
15 – 60 min
15 min
NA
1– 4 hr
Benzodiazepines
Midazolam Respiratory
depression
IV
IM
PO
PR
Nasal
0.02– 0.1 mg/kg
0.05 – 0.15 mg/kg
0.5 – 0.75 mg/kg
0.7–1 mg/kg
0.2– 0.4 mg/kg
2–3 min
2–5 min
15 –20 min
10 –15 min
10 –15 min
30 min
30 – 40 min
45 – 60 min
45 min
45 min
Opioids
Fentanyl Respiratory
depression
IV 2 μg/kg 1–2 min 20 –30 min
Morphine Respiratory
depression,
hypotension,
nausea &
IV
IM/SQ
0.1– 0.2 mg/kg
0.1– 0.2 mg/kg
1–5 min
30 min
3 – 4 hr
4 –5 hr

16. Other sedative agents
Chloral
hydrate
Prolonged
sedation
PO/PR 50 –75 mg/kg 30 – 60 min 1–8 hr
Ketamine Post-
emergence
delirium
IV
IM
PO
PR
Nasal
0.5 –1 mg/kg
4 mg/kg
5 –10 mg/kg
5 –10 mg/kg
3 – 6 mg/kg
1 min
5 min
30 – 40 min
5 –10 min
5 –10 min
15 min
15 –30 min
2– 4 hr
15 –30 min
15 –30 min
Propofol Respiratory
depression,
hypotension
IVI
IV bolus
0.05 – 0.1 mg/kg/min
1 mg/kg
30 sec
30 sec
8 –10 min
Reversal agents
Flumazenil Withdrawal
symptoms
(agitation)
IV 0.2 mg
0.01 mg/kg
(pediatrics)
1–3 min 30 – 45 min
Naloxone Withdrawal
symptoms
(agitation)
IV/IM/SQ 0.1–2 mg 1–2 min (IV) 15 – 45 min

17. Radiology suite
 Includes: US, CT, RFA, and neuro-coiling.
 The rooms are often crowded with bulky equipment.
 Patients are often required to hold still for long
periods of time.
 Unique hazard: radiation exposure.
 Leukemia and fetal abnormalities.
 Dosimeters are required (maximum exposure 50 mSv
annually).
 Lead aprons, thyroid shields, leaded glass screens, and
video monitoring.

18. Radiology suite, contd.
 Iodinated contrast media.
 Older ionized contrast media were hyperosmolar
and toxic.
 Newer non-ionized contrast media have lower
osmolality and improved side-effects.
 Predisposing factors to adverse reactions from
contrast media include a history of:
bronchospasm, allergy, cardiac disease,
hypovolemia, hematologic disease, renal
dysfunction, extremes of age, anxiety, and
medications (beta-blockers, aspirin, and NSAIDs).

19. Radiology suite, contd.
 Reactions to iodinated contrast media.
 Mild: nausea, perception of warmth, headache,
itchy rash, and mild urticaria.
 Severe: vomiting, rigors, feeling faint, chest pain,
severe urticaria, bronchospasm, dyspnea,
arrythmias, and renal failure.
 Life-threatening: glottic edema/bronchospasm,
pulmonary edema, arrythmias, cardiac arrest, and
seizures/unconsciousness.
 Treatment: O2, bronchodilators, epinephrine,
corticosteroids, and antihistamines.

20. CT
 Two-dimensional, cross-sectional image.
 Each cross-section requires a few seconds of
radiation exposure.
 Pt immobility is required.
 It is often noisy, warm, and claustrophobic.
 CT can be used for diagnostic and therapeutic
purposes.
 Number one problem: inaccessibility to the
patient.

21. Anesthesia for CT
 Anesthetist can remain in the room wearing X-
ray protection or view the patient and monitors
from the control room.
 The CT scanner does not interfere with
monitoring equipment.
 The scans are short and can be interrupted.
 The patient couch moves during examination.
 Temporarily interruption of ventilation to
improve image quality – immediately re-
ventilate.
 Patient positioning.

22. Radiology RFA
 Often done in CT but occasionally MRI.
 Kidney, lung, and liver.
 Currently requesting general anesthesia
with ETT secondary to prone positioning
and the need to lay still for extended
periods of time.
 It is our job to check pressure points and
padding. Radiology techs are not trained
to be concerned.

23. Interventional Radiology
 Embolization of cerebral and dural AVM’s,
coiling of cerebral aneurysms, angioplasty of
sclerotic lesions, and thrombolysis of acute
thromboembolic stroke.
 These procedures often require deliberate
hypotension and deliberate hypocapnia.
 Radiologist may request rapid transition
between deep sedation and an awake
responsive state.

24. Cerebral Coiling
 The anesthetist should prepare:
 Arterial line set up.
 Fluid warmer.
 Infusion pump.
 Medications: NTG, nipride, esmolol, labetalol, heparin,
and protamine.
 ACT machine.
 Radiologist may request anything from deep IV sedation to
GA with ETT.
 Always have 2 large-gauge IV’s in place. One for drug
infusion and one for rapid fluid administration.
 Stay in constant communication with OR in case of an
emergency.
 Pt often transported to the ICU post-op.

25. Remote Cardiac Lab
 Elective cardioversion:
 Cart with emergency drugs.
 Induction drug (Etomidate).
 Standard monitoring.
 Preoxygenate.
 Give small incremental doses of etomidate until the
eyelash reflex is abolished.
 Remove the mask immediately before the shock and
confirm no one is touching the pt.
 Ventilate with 100% O2 post-shock until consciousness is
regained.
 Consider RSI with ETT if high risk for aspiration.

26. Remote Cardiac Lab contd.
 Cardiac RFA
IV sedation to GA with ETT depending
on the pt’s co-morbidities.
Possible need for an arterial line setup.
Propofol is oftenly used.
Midazolam and fentanyl are used to
titrate in during the more painful parts of
the procedure (esp. the ablation).

27. Remote Cardiac Lab contd.
 Pacemaker/ ICD placement:
 We are often called just for the ICD check, in which
case proceed like an elective cardioversion.
 If the pt. is very sick, they may require GA. Therefore,
proceed like RFA.
 These pt’s will often need an arterial line for BP monitoring.
 These ICD checks are not without risk. Check pulses
and watch the ECG, pulse oximetry and arterial wave-
forms closely. People have been known to code and
require CPR.

28. GI Lab
 Endoscopy, Colonoscopy and ERCP.
 Pt’s are often uncooperative or very sick.
 Current rooms in the GI lab are very small.

29. Anesthesia for GI Procedures
 Pre anesthetic assessment: Age, cooperative,
anxiety, allergies, fluid status, electrolytes, cardiac
history, GERD.
 Type of anesthesia:
 Moderate sedation- midazolam and Fentanyl.
 Deep sedation- Addition of propofol.
 Some cases may require general anesthesia.
 Anesthetic considerations:
 Strong vagal nerve stimulation as result of stimulation
to colon.
 Most patients tolerate these procedures well.

30. ECT
 Major depression.
 Mania.
 Certain forms of
schizophrenia.
 Parkinson’s
syndrome.
 Pheochromocytoma.
 Increased ICP.
 Recent CVA.
 Cardiovascular
conduction defects.
 High risk pregnancy.
 Aortic and cerebral
aneurysms.
Indications Contraindications

31. Physiologic effects of ECT
 Electrical stimulus: brief period of muscular
contraction followed by the tonic and then clonic
phases of the seizures.
 Cardiovascular effects of ECT: immediate
parasympathetic response followed within
seconds by a sympathetic response.
 The muscular activity of the seizure and the
increased sympathetic activity causes a rise in
myocardial oxygen consumption, increases
CMRO2, cerebral blood flow, intracranial, intra-
ocular intra-gastric pressure briefly.

32. Anesthesia for ECT
 General anesthesia is used to provide a
brief period of amnesia and modify the
motor effects of the seizure to protect the
patient.
 Don’t forget the suction and the Bite block.

33. ECT contd.
 Pre-op: These pt’s have often had this procedure multiple times,
therefore you can use old records as templates.
 Place IV and give glyco (0.2 mg IV). Give caffeine if the
psychiatrist requests.
 Treats the bradycardia/ asystole from the initial parasympathetic
discharge from the seizure activity.
 Hyperventilate the pt. with 100% O2.
 Thiopentone and suxamethonium are commonly used.
 Place the bite block.
 Goal is a seizure 30-60 seconds long.
 Ventilate until spontaneous respirations return.
 The parasympathetic discharge is often followed by a
sympathetic discharge associated with HTN and tachycardia.
This is treated with esmolol.

34. Dental Procedures
 Pediatric Dentistry: fillings, crowns, pulpotomies,
tooth extractions and space maintainers.
 Oral and Maxillofacial Surgery: extractions of
impacted teeth, insertion of dental implants,
treatment of infections of the head and neck and
facial cosmetics.
 Peridontics: surgery of teeth, gingiva, connective
tissue, periodontal ligament and alveolar bone.
 Anesthesia : general anesthesia, minimal
sedation, moderate sedation with local anesthetic
for particular areas of surgery.

35. Ophthalmology
 Cataract extraction is the most common
procedure done for the elderly.
 Strabismus operations are the most common
pediatric procedures.
 Requirements for anesthesia:
 Unmoving globe.
 Minimal bleeding.
 Smooth emergence.
 Usually done under MAC.

36. Urologic Procedures
 ESWL: sound waves are focused on kidney and ureteral
stones. The stone located by flouroscopy.
 Cystoscopy/ ureteroscopy: are performed to diagnosis
and treat lesions of the lower (urethra, prostate, bladder)
and upper (ureter, kidney) urinary tracts.
 Type of Anesthesia
 Depending on the pt and procedure anesthesia can
range from topical lubrication ,MAC, or regional.
 If regional is used T-6 level of blockade is required for
upper tract instrumentation and T-10 for lower-tract
surgery.

37. Thank you