Anesthesia and sedation for out-of-operating-room procedures

Standards and guidelines

Hospitals that provide anesthesia services, whether in the OR or in any location within the hospital, must comply with federal requirements set forth in Medicare’s Hospital Anesthesia Services Condition of Participation 42 CFR 482.52 in order to receive Medicare/Medicaid payment ( ). The Conditions of Participation interpretive guidelines are enforced by the Joint Commission surveyors and include standards for the anesthesia organization and personnel credentialing, delivery of services, and specific requirements for care documentation ( Box 43.1 ). Off-site locations where anesthesia services are delivered must be organized to meet the Conditions for Participation standards, in addition to the institutional OR policies and standards.

Although the NORA locations, procedures, examinations, imaging, and procedural equipment can vary significantly, the provision of anesthesia services must adhere to a basic minimal standard. In 2018 the American Society of Anesthesiologists (ASA) updated previously published guidelines titled “Statement on Nonoperating Room Anesthetizing Locations” ( ). These guidelines set forth the minimal expectations for equipment and supplies needed for provision of anesthesia services in all hospital locations ( Box 43.2 ). The ASA requires the following components for anesthesia delivery outside the OR: a reliable oxygen supply, backup oxygen source (typically E-cylinder), suction apparatus, a self-inflating resuscitation bag, adequate anesthetic drugs, adequate power supplies with outlets and line isolation monitoring, adequate space and lighting, code cart, and anesthesia machines with reliable scavenging systems if inhalation agents are used. Because these off-site areas can be unfamiliar to the anesthesiologist and can be physically located in remote locations of the facility, adequate support staff must be available along with reliable means of two-way communication devices.

Structural organization

Anesthesia outside of the OR requires a medical director who can coordinate the service and ensure adherence to the guidelines and standards listed earlier. The number and types of additional personnel needed to effectively deliver off-site anesthesia depend on the volume of patients served. Some pediatric hospitals have sufficient patient volume to enable the creation of a separate unit dedicated to off-site anesthesia and sedation. These units provide the ability for preanesthesia evaluation, conduct of the procedure or imaging, and subsequent recovery in one location. Another organizational structure involves the creation of a specialty team dedicated to specific locations, such as radiology, to allow for anesthesia services to be conducted for a specific type of examination (such as magnetic resonance imaging [MRI]) or procedure (such as hematology-oncology procedures). Smaller hospitals may rely on the preexisting infrastructure of their same-day-surgery service for perianesthesia needs, including scheduling, nursing, and space. In this model, induction of anesthesia occurs in the main OR, followed by transport to the remote site for imaging/procedure, with subsequent emergence in the main OR. The variability in how an off-site anesthesia service is organized suggests that multiple models can be effective in providing appropriate and safe care.

No matter how an off-site anesthesia service is organized, it is recognized that anesthesia practitioner familiarity with the location and procedure is critical for safe patient care. Anesthesiologists who regularly rotate through these sites are familiar with the physical layout, equipment, and limitations of the locations; they are also uniquely positioned to establish a more collaborative relationship with the non-anesthesia personnel in these departments. A team-based approach may lead to improved efficiency, safety, and better testing/imaging results.

Personnel

The range of sedation and anesthesia needs in the pediatric off-site locations can be quite variable depending on the type of procedure and/or imaging in addition to patient age and complexity. Coordinating and providing care for these patients require familiarity with off-site settings and flexibility in the anesthetic approach. In pediatric hospitals, whether in the emergency department, the inpatient floors, or the radiology suites, the demand for anesthesia care far outstrips the availability of the anesthesiologist. Thus non-anesthesiologists such as pediatric emergency physicians, intensivists, hospitalists, and advanced practice pediatric nurses often provide sedation services for pediatric patients. Numerous publications, including those from the Pediatric Sedation Research Consortium (PSRC), support the use of safe sedation by non-anesthesiologists in these pediatric off-site locations ( ; ; ; ; ; ). To further promote the safe administration of sedation by non-anesthesiologists, the ASA has developed an advisory document delineating clinical privileges for non-anesthesiologists who provide deep sedation ( ). The document also includes guidance on education, training, licensure, and performance evaluation.

Other important personnel needed for providing NORA include patient schedulers and nurses. Scheduling can be a complex task depending on the variety and volume of off-site procedures and imaging offered. Many schedulers are associated with pediatric radiology departments because pediatric diagnostic radiology examinations form the largest category of off-site cases that require anesthesia or sedation ( ). Pediatric patients may need sedation or anesthesia for radiology examinations because of age, developmental level, or behavioral issues that preclude them from cooperating for the procedure. It is also common, especially with pediatric patients who have complex medical disorders, to coordinate other examinations (e.g. dental, ophthalmology), imaging studies, and phlebotomy into one anesthetic/sedation session.

Nursing needs in the off-site areas are similar to the OR environment, with added imaging or procedural considerations. The preanesthesia phone call should be undertaken by nursing staff familiar with both the anesthesia-specific concerns (nothing by mouth [NPO] instructions, illness considerations, and preanesthesia medical questionnaire) and the needs of the off-site procedure. Moreover, to provide anticipatory guidance to families and pediatric patients presenting for diagnostic radiology examinations, the nurse must be familiar with the needs of the imaging modality such as metal screening for MRIs or avoiding dextrose-containing solutions prior to positron emission tomography (PET) scans. The periprocedural nurses in the off-site location must also be knowledgeable about the procedural requirements such as witnessing informed consent, timeouts, and other circulator responsibilities. Lastly, recovery needs in the NORA location are no different from that of the OR postanesthesia care unit (PACU). Off-site nurses must have the same training and follow the same anesthesia recovery care and discharge guidelines as per hospital-specific policy for the OR.

Continuum of sedation and anesthesia

Child life experts are a valuable resource to decrease the sedation and anesthesia needs for many procedures and imaging modalities. Child life provides distraction techniques and other coping strategies that are age and developmentally suitable. Music and light devices may be employed for distraction in younger children, whereas older children may benefit from electronic tablets or portable movie players ( Fig. 43.1 ). Child life services may be comprehensive, ranging from preparation of a challenging patient prior to entry into the hospital to helping manage their care in recovery. They can assist with placement of peripheral intravenous (IV) lines or may assist in the entire examination or procedure, obviating the need for medication.

Medication-based approaches can range from providing anxiolysis to general anesthesia. It is important to understand the continuum of sedation and what defines the different depths of sedation and general anesthesia. The ASA has produced guidelines that define the levels of drug-induced sedation ( ; Table 43.1 ). Anxiolysis is described as a state where physical coordination and cognition may be impaired but patients respond to verbal commands. Airway reflexes, ventilatory, and cardiovascular function are unaffected with minimal sedation/anxiolysis. Moderate sedation is a drug-induced depression of consciousness where patients will respond purposefully to verbal commands and airway, ventilation, and cardiovascular function are not affected. Deep sedation involves a more pronounced depression of consciousness where patients are not easily aroused but will respond purposefully to repeated or painful stimulation. Ventilatory function may be impaired with deep sedation. General anesthesia is a drug-induced state where patients are not arousable even with painful stimulation.

Procedural sedation is a common approach for accomplishing pediatric NORA examinations and procedures. Practice guidelines for providing moderate sedation were published in 2018 by a task force of the ASA and other relevant stakeholders ( ). These guidelines specifically address moderate sedation, but the recommendations can be applied to all sedation and anesthesia services because they focus on patient evaluation and preparation, personnel availability, and monitoring. The evaluation and preparation of patients include a thorough review of the patient’s medical and anesthesia history to reduce any sedation- or anesthesia-related adverse outcomes. Patient preparation should be completed well enough in advance should there be a need to consult other medical specialties. The guidelines also specifically address the need to designate an individual other than the practitioner performing the procedure to monitor the patient. Ideally this person should possess the knowledge and skills to recognize and treat airway complications. The monitoring recommendations include continuous assessment of ventilatory function with pulse oximetry and capnography. In addition, supplemental oxygen is recommended unless it is contraindicated for the patient or procedure. Similar sedation and anesthesia guidelines that encompass patient preparation, monitoring, and periprocedural care have been published by .

Postanesthesia and sedation recovery

The recovery of patients after administration of sedative anesthetics and analgesic medications must follow the same guidelines and principles as those in the main OR recovery area. Without the continued stimulation of the patient from the procedure or examination, resedation may occur, with possible respiratory and hemodynamic compromise. For this reason, patients require continued observation and monitoring at regular intervals (every 15 minutes) until discharge. The recovery facility must have equipment available for suction, the ability to deliver oxygen, and positive pressure ventilation (bag-valve mask) for all ages and sizes of patients treated. Discharge criteria should reflect the same procedures and policies as the main OR PACU. Additional considerations for patient discharge must consider the procedure and examination that were completed, such as the need to remain supine for a period after catheter access in the groin. These recovery needs must be coordinated with the extramural department and proceduralist.

Anesthesia complications outside of the operating room

Monitored anesthesia care (MAC) is common in the adult NORA setting ( ); however, in children, moderate-to-deep sedation and general anesthesia are usually necessary. Sedation and anesthesia outside of the OR can be safe, and serious injury from sedation in children is rare ( ). In a study of 30,000 sedations from the PSRC Database, Cravero and others identified few serious outcomes (no death, one cardiac arrest), and less serious events such as oxygen desaturation, vomiting, excessive secretions, and unexpected apnea occurred with frequencies of 157, 47, 42, and 24 per 10,000 sedations, respectively. Propofol is commonly used for moderate-to-deep sedation outside of the OR. A specific investigation into over 49,000 pediatric sedations with propofol using the PSRC Database again revealed few serious adverse events. These included four instances of aspiration, two arrests, and no deaths ( ). The most common adverse events reported were airway related, with 1 in 400 procedures associated with laryngospasm, stridor, wheezing, or apnea. They also found that 1 in 65 sedations with propofol required airway and/or ventilation interventions such as chin-lift, oral airway insertion, or bag-mask ventilation. These data demonstrated that propofol, and other sedation medications, can be safely administered by well-trained non-anesthesia providers.

Radiology

Pediatric radiologic imaging uses various modalities. Each modality has unique considerations and safety risks for patients and caregivers. X-rays are used in radiography, fluoroscopy, computed tomography (CT), and angiography. Gamma rays are predominantly used in nuclear medicine. Ultrasound and MRI do not use ionizing radiation. Ultrasonography uses inaudible sound waves, and MR images are created using a strong magnetic field and radiofrequency pulses.