This ppt is on NORA in space

1. NORA IN
SPACE
MODERATED BY: DR. DAWOOD FAIZ SIR
PRESENTED BY: DR. VIDUSHI

2. • In anesthesia, NORA stands for Non-Operating Room Anesthesia —
situations where anesthesia is delivered outside of the operating
theatre (like in radiology, cath labs, GI suites, ECT, etc.).
• If we extend that concept to space medicine, it refers to providing
anesthesia outside the usual hospital setting, in the extreme
environment of spacecraft, lunar, or Martian habitats.

4. HERE’S HOW NORA IN SPACE WOULD
BE UNDERSTOOD:
CHALLENGES:
• Environment: Microgravity alters drug distribution, ventilation,
airway management, and positioning.
• Resources: No full operating room; limited drugs, monitoring,
airway tools.
•Team: Non-anesthesiologist crew may need to provide anesthesia.
•Emergency evacuation: Not possible — care must be definitive on
site.

5. Airway & Breathing Issues
•Mask ventilation is harder in microgravity (no head tilt leverage,
floating fluids).
•Intubation: Risk of floating secretions, limited space, reduced
suction efficiency.
•Supraglottic devices (like LMA) may be preferred.
•Ventilation: Mechanical ventilators designed for Earth may not
work well without gravity.

6. Pharmacology in Space
•Altered pharmacokinetics.
•Fluid redistribution affects volume of distribution.
•Hepatic/renal metabolism may change.
•Nitrous oxide not suitable (expands closed gas spaces, storage difficulty).
•IV agents (propofol, ketamine) preferred for simplicity.
•Regional anesthesia (spinal/nerve blocks) may reduce systemic drug
risks.

7. Monitoring Limitations
•Space environment may only allow portable, minimal monitoring
(ECG, SpO₂, EtCO₂ if available).
•Power supply, compactness, and robustness are critical.

8. Practical Scenarios in Space
•Orthopedic emergencies (fractures, dislocations).
•Appendicitis or acute abdomen.
•Dental surgery.
•Radiation therapy or imaging-guided procedures in orbital/planetary
hospitals.

9. Approaches
•Sedation/analgesia with ketamine, fentanyl, midazolam.
•Regional anesthesia (brachial plexus, spinal, epidural) to avoid
airway/ventilation issues.
•Simulation training for astronauts to provide anesthesia without an
anesthesiologist present.

10. HEMODYNAMIC CHANGES IN SPACE
Cardiovascular changes:
• Increase in LV end diastolic volume
• Paradoxical reduction in CVP due to microgravity
• Reduced LV mass due to cardiac atrophy /injury
• Central redistribution of blood
• Diuresis with plasma volume depletion (≥20%)

11. • Autonomic dysfunction:
• * Especially on return to earth
• * Occurs due to:
• Cardiovascular deconditioning
• Reduced intravascular volume
• Increased NO expression
• Downregulation of a-adrenergic receptors
• Ventricular atrophy
• Changes in arterial stiffness

12. • Gravitational forces
• Increase in gravitational forces during launch asspace craft
accelerates to orbital speed
• Absence of gravitational stress (microgravity)during the period in
space
• Neuromuscular changes:
• Skeletal muscle atrophy even after short missions

13. TECHNICAL CHALLENGES
• Airway:
Difficult intubation due to facial edema
Both intubator and patient to be secured Space Motion Sickness
Intubator to stabilize head of patient by holding it between knees
Use smaller size ETT if vocal cord edema is present
LMA, intubating LMA, cuffed oropharyngeal airway used
alternatively

14. • Fluid Therapy
• Hypovolemia may not be adequately treatable due toreduced
quantities of supplies
• Air fluid interface in IV fluids generate bubbles as fluid and gases
do not separate on basis of differing densities due to lack of
gravity.
• Air bubbles do not rise up but remain mixed in solution
• IV bag to be degassed before flight/ removed by in-line as IV fluid
bags contain fluids akin to foam

15. • Neuromuscular Blockade
• Succinylcholine to be avoided as it may cause cardiovascular
collapse
• Disuse and skeletal muscle atrophy due to immobilization causes
proliferation of extra-junctional receptors causing hyperstimulation
and cardiac arrest on SCH use
• Resistance to NDMR may occur.

16. • Vaporizers
• Devices which depend on gravity induced separa-tion of fluids and
gases malfunction
• This is because vaporizers require gravity to confine liquids to
bottom of reservoir

17. Closed Environment
• Safe use of anesthetic gases difficult in space craft
• Drugs used in flight should not be capable of reaching crew
through the closed cabinet atmosphere
• Dumping of exhaust O, into cabin atmosphere avoided to prevent
fire hazard
• Minimum flow system for xenon may be useful

19. ALTERED PHARMACOKINETICS &
PHARMACODYNAMICS
• Reduced plasma volume (from fluid shift & diuresis): increases drug
concentration for water-soluble drugs (e.g., propofol, ketamine).
• Reduced muscle mass and body weight : alters drug distribution
(especially lipophilic drugs like fentanyl).
• Changes in hepatic and renal blood flow can alter drug
metabolism and clearance (e.g., longer half-life of certain agents).
• Overall: Expect greater sensitivity to standard drug doses; dosing
may need to be lower and titrated cautiously.

20. NEUROVESTIBULAR CHANGES
• Space motion sickness and vestibular dysfunction may increase
post-anaesthesia nausea or interact with sedatives.
• CNS responses (e.g., cerebral blood flow, intracranial pressure)
are altered in space : may affect how anaesthetics work on the brain.

21. CARDIOVASCULAR CHANGES
• Hypovolemia, lower systemic vascular resistance, and cardiac
deconditioning increase risk for hypotension during induction.
• Blunted baroreceptor responses make astronauts less tolerant
to drops in blood pressure.
• Anaesthetic drugs that normally lower BP (e.g., propofol,
volatile agents) could cause dangerous hypotension in microgravity.