Anesthesia for Procedures Outside of the Operating Room

Introduction

Nonoperating room anesthesia (NORA) and anesthesia in the nontheatre environment (ANTE), as the names suggest, provide anesthesia services at locations outside of the safe confines of the operating room. Anesthesia services are being requested at a multitude of locations as diagnostic modalities become more complex and as interventional and therapeutic modalities provide less invasive treatment options. These locations have their own unique challenges, and guidelines have been proposed by various societies, such as the American Society of Anesthesiologists. (ASA) and the Royal College of Anaesthetists (RCoA), for providing anesthesia care in nontheatre environments.

Not surprisingly, children form the largest group of patients in the NORA environment. In addition, children with suspected or diagnosed malignancy may present with associated complications of their disease (severe anemia, hyperkalemia, tumor lysis syndrome, respiratory distress, infections, pleural/pericardial effusions, etc.), which present additional challenges to anesthesia for the pediatric population. This chapter discusses the management of ANTE in children with its specific challenges and problems.

Locations Requiring NORA

The various locations external to the operating room environment that require NORA include but are not limited to:

Diagnostic and Interventional Radiology Suite: Diagnostic and interventional procedures performed in the computerized tomography (CT), digital subtraction angiography (DSA), magnetic resonance imaging (MRI), fluoroscopic, and ultrasound suites
Radiation therapy units
Endoscopy suite
Positron emission tomography (PET) suite

Other nononcologic areas may include:

Catheterization laboratory for cardiac and neurologic procedures
Dental department
Psychiatry unit for electroconvulsive therapy (ECT)
Emergency department (ED), trauma units, intensive care units (ICU)

Challenges Associated With NORA

Patient Factors

A significant proportion of children scheduled for procedures in the NORA environment may be outpatients awaiting a diagnosis and may not have been clinically stabilized or medically optimized. The functional and physiologic status of the same child may also continuously change during the course of the disease and following treatment with chemotherapy or radiotherapy. The same child may also require anesthesia at multiple times and different locations for various diagnostic and therapeutic procedures. Therefore the risk-benefit ratio of anesthesia needs to be assessed each time the child is scheduled for a procedure under anesthesia.

Children may be inadequately fasting in the absence of clear instructions or may experience dehydration and hypoglycemia from prolonged fasting. The recommendations for preoperative fasting are provided in Table 49.1 . Patients may present with an upper respiratory tract infection with a runny nose, may have mediastinal masses with dyspnea awaiting biopsy, or may be malnourished due to cancer cachexia. The child may have received chemotherapy in the past few weeks and may be neutropenic undergoing imaging to assess for response to therapy. Repeated chemotherapy in the absence of a vascular port, peripherally inserted central catheter (PICC), or a Hickman's catheter may make intravenous access increasingly difficult. Oral contrast may have been administered if the imaging involves the gastrointestinal tract, thereby increasing the risk of aspiration under anesthesia.

Table 49.1

Preoperative Fasting for Elective Procedures in Children

	Hours	Examples
Light meal and nonhuman milk	6	Formula milk, cow/buffalo milk, bread without butter, fruit juice, biscuits
Breast milk	4
Clear fluids up to 3 mL/kg	1	Water, sugar water, coconut water, clear liquids, oral rehydration solution, clear apple juice
Fatty meals require a longer time for fasting of at least 8 h due to the delayed gastric emptying of fats

Environment, Equipment, and Staffing Factors

Environmental Concerns

NORA locations are usually in remote areas of the hospital such as basements where obtaining extra help could prove difficult. Access to patients may be challenging and bulky equipment may contribute to space constraints. Children may need to be monitored and managed from a distance or remotely, thus increasing the dead space for venous access and limiting immediate access to the patient's airway ( Fig. 49.1 ). Electric connections and cables may pose a safety hazard, and the hazards of radiation exposure and ferromagnetic fields in MRI warrant particular attention.

Fig. 49.1, Radiation oncology masks for immobilization and precision delivery of radiotherapy beams making the airway less accessible.

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