This document discusses non-operating room anesthesia (NORA). It begins by defining NORA as anesthesia provided outside the operating room, such as in radiology, endoscopy suites, MRI, and dental clinics. It then outlines a three step approach to NORA involving thorough patient assessment, appropriate monitoring and anesthesia care, and post-procedure management. Several ASA guidelines for equipment and facilities in NORA locations are also reviewed. Complications associated with NORA and special considerations for procedures like X-rays, MRIs, and IV contrast administration are discussed. The document emphasizes choosing anesthesia techniques based on patient factors and needs for each specific non-operating room procedure.

1. NON OPERATING ROOM
ANAESTHESIA
Presentor: Dr Kundan Kishor Ghimire
Resident Anaesthesia and Critical Care
Moderator: Dr. Dhiraj Kesari

2. Introduction
Encompasses all sedation and anaesthesia provided
by anesthesiology services outside of the operating
room environment.
Area remote from main operating room
Radiology Department
Endoscopy suites
MRI
Dental Clinics

3. Three step approach to NORA

4. Patients
Most Patients tend to be older. (>50 yrs)
receive monitored anesthesia care (MAC) or sedation
Children commonly require sedation or anesthesia
diagnostic and therapeutic procedures.
thorough preanesthetic assessment, standard
preanesthetic care.
 sound anesthetic plan with approppriate level of
monitoring and appropriate postanesthetic care.

5. Patient factors requiring Sedation or
Anesthesia for Nonoperating Room

6. Procedures
Nature of the procedure, including patient position,
grade of painful procedure, and its duration.
Optimum anesthesia plan provides safe patient care
and facilitates the procedure.
Discussion with proceduralist for emergencies and
adverse outcomes

8. ASA guidelines for non-operating room
anesthesizing locations.
Reliable O2 source
with backup supply
Suction apparatus
Waste gas
scavenging
Self-inflating
resuscitation bag.
Adequate
monitoring
equipments
Safe electrical
outlets for
emergency power
supply
Adequate
illumination, battery
backup
Sufficient space for
anaesthesia
personnel,
equipment
Emergency cart,
defibrillator, drugs,
etc
Reliable means for
two-way
communication
Applicable facility,
safety codes met
Appropriate
postanaesthetic
management.

9. Patient Transfer
Sick, unstable patients are transferred back and forth
 between ICU, OR and NOR locations for imaging,
or diagnostic procedures.
Skilled personnel to evaluate, monitor and support he
medical condition.
Portable ventilators and adequate suppies of oxygen
Manual self inflating bag
Anesthetic and emergency drugs, equipment for intubation
intubation, portable suctions

10. Complication of NORA

11. Problems in providing NORA
Equipment might be old, not regularly serviced and not in
standard use as in the rest of the hospital
Monitoring standards may not adequate.
Piped 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
patient difficult.
Poor environment conditions( e.g. Lightening, temperature)
Recovery facilities may not be available.
Inadequate ventilation/ scavenging causing pollution.
Problems related to transferring patients.

12. Definition of general anesthesia and levels of
sedation/Analgesia

13. Environmental consideration for NORA
X ray & Fluoroscopy
C arm moves back & forth takes large space &means of
dislodging IV and ETT.
 so,
 limit the time of exposure to radiation
 increase the distance from source or radiation.
 (> or < according to inverse square of distance from
source)
 use protective shielding
 using dosimeters ( limit of 50 mSv in any year & lifetime
limit of 10 mSv multiply age in year.

14. IV CONTRAST AGENTS
Are iodinated compounds
MRI contrast are ionic & nonionic.
chelated metal containg gadolinium , iron , manganese.
Renal
CIN (contrast induced nephropathy)
increase S.Creatinine of 0.5mg/dl or 25% from
baseline within 48 hrs to 72 hrs.

15. Risk factor for CIN
 Renal disease
 Prior renal surgery
 Proteinuria
 DM
 HTN
 Gout

16. Hypersensitivity to contrast media

17. Magnetic Resonance Imaging
a noninvasive diagnostic technique that uses magnetic
properties of atomic nuclei
 to produce high-resolution, multiplanar cross-sectional
images of the body.
Strong magnetic field of 0.5-3.0 tesla.
So ferromagnetic materials should be excluded from the
area of magnet.

18. Implantable medical devices: pacemakers, vascular clips,
automatic implantable cardioverter-defribillators,
mechanical heart valves.
Radiofrequency noise: sound >85db from MRI scanners

19. Choice of anesthetic technique depends upon
 patient’s comorbidities,
duration,
 practioner preference and
 patient requirements.
Deep sedation or
 GA with intubation or supraglottic airways.
Sedation with oral route benzodiazepines or as intravenous
sedation or MAC.

20. Small infants: ” feed, wrap, and scan”
Oral chloral hydrate: 80-100mg/kg 30-60 min before
procedure.
Rectally administered barbiturates or
General anesthesia with propofol, ketamine or inhaled
anesthetics

21. Thank you