Practice Procedure

The provision of hospital-based, non–operating room anesthesia (NORA) has become a burgeoning part of almost every anesthesiology practice in the United States. Cost savings, facilitated scheduling (as opposed to in the main operating rooms), and increased patient satisfaction are just a few of the reasons this branch of anesthesiology is expected to continue its exponential growth in the future. Medical device technology has advanced in tandem with NORA, allowing many surgical procedures once reserved for the operating room to be performed in a less invasive manner in an alternative site (e.g., intracranial coiling and stenting has obviated the need for many craniotomies). In other procedures still performed in the operating room, anesthesia is administered at an alternative anesthetizing site before the main surgical procedure (e.g., a patient with placenta percreta may have uterine artery balloon occlusion catheters placed under anesthesia in the interventional radiology suite before a caesarean section in the operating room). However, the provision of care in alternative sites has yet to garner the same level of academic scrutiny as the mainstream anesthesia subspecialties. Initial guidelines published almost 20 years ago seem quaint considering the current diversity of alternative-site procedures requiring anesthesia and analgesia.

Similar to the pediatric anesthesiologist who scoffs at the notion that an infant is merely a scaled-down adult, those who perform NORA testify that what they do is not simply a duplication of their operating room routines. Patients who require NORA are often elderly and quite ill and may undergo procedures that are unfamiliar to the anesthesiologist. The NORA environment itself may at times appear dark, crowded, and cold. Anesthesiologists may have to rely on machines and monitors they are unaccustomed to using. Ancillary staff may be unfamiliar with the needs of the anesthesiologist, and assistance, when necessary, may not be available in a timely manner.