Anesthesia Outside the Operating Room

Standards and Guidelines

Anesthesia outside the OR must meet the same standards as anesthesia given in the OR. Specifically, Medicare's Conditions for Participation for hospitals are enforced by The Joint Commission (TJC) regardless of location of care. The Conditions for Participation are principles that are articulated to surveyors as instructions in the Interpretive Guidelines published in January 2011, and available at http://www.cms.gov . These guidelines describe appropriate training, credentialing, and oversight of sedation and anesthesia providers and some of the specific requirements for care documentation. The ASA has developed templates for the required policies that help institutions meet the standards of the Interpretive Guidelines. These resources can be downloaded (or links are provided) from the ASA website at http://www.asahq.org . With particular reference to NORA, there are several notable templates, as follows:

• 1.

  Preanesthesia Evaluation Policy, Form, and Note

Within 48 hours immediately before the delivery of the first dose of medication for the purpose of inducing anesthesia, a qualified practitioner must perform a preanesthesia evaluation of the patient that includes, at a minimum: (1) a review of the medical history including anesthesia, drug and allergy history, and (2) an interview if possible, given the patient's condition, and examination of the patient. In addition, the following must be reviewed and updated within 48 hours prior to anesthesia:

• • a.

    Notation of the anesthesia risk.

  • b.

    Identification of potential anesthesia problems.

  • c.

    Additional preanesthesia data or information, if applicable and as required in accordance with standard practice prior to administration of anesthesia (i.e., stress tests).

  • d.

    Development of the plan for the patient's anesthesia care, including the type of medications for induction, maintenance and postoperative care and discussion with the patient (parents) of the risks and benefits of the delivery of anesthesia.

• 2.

  Intraoperative record policy. Standard data elements and timing must be included in the intraoperative record—just as in the OR. In other words, the intraoperative electronic record should be accessible from all NORA locations within an institution.

• 3.

  Postanesthesia Evaluation Policy, Note, and Form (template). A postanesthesia note must be completed within 48 hours after surgery. The person completing the evaluation does not have to be the person who delivered the anesthetic. The elements of the postanesthesia note include assessment of the following:

  • a.

    Respiratory function

  • b.

    Cardiovascular function

  • c.

    Mental status

  • d.

    Temperature

  • e.

    Pain

  • f.

    Nausea and vomiting

  • g.

    Postoperative hydration

NORA services must be organized in such a way as to meet the Conditions for Participation (and thus TJC) standards mentioned earlier, just as they are met in the OR. Depending on how NORA is organized in a particular institution, this can be challenging. The departments that require anesthesia services must appreciate the need to meet these standards and allow for the infrastructure to meet or exceed them, particularly in preanesthesia assessment and postanesthesia follow-up requirements.

Off-Site Anesthesia: Structure

There is little literature on the organization of pediatric anesthesia services outside the OR. Based on information available from the Pediatric Sedation Research Consortium, we know some institutions organize these services through an off-site anesthesia unit that can also be used for general anesthesia or sedation cases. These units have the advantage of providing all anesthesia-related care through one location that contains the personnel and equipment required for anesthesia. Ideally, these units provide a location for preanesthesia assessment, induction, procedure location, and recovery. Children may be transported to remote locations when equipment (such as MRI scanners) cannot be brought to the sedation unit. The advantages of this organizational scheme are many. The uniform environment leads to maximum consistency in the equipment and personnel who interact with children and their families and thus adds to safety, efficiency, parent satisfaction, and effectiveness of care. Specialty teams or microsystems for provision NORA are coordinated groups of professionals who deliver a specific service that achieve the best possible outcomes by developing reliable, efficient, and responsive processes. They are able to meet the individual needs of one child, continually improving care for the next child, and create a user-friendly work environment. The NORA microsystem should be made up of pediatric anesthesiologists, nursing, technical, and administrative personnel who are familiar with the off-site service and dedicated to this care. As members gain expertise and comfort with the off-site environment, their care is consistent and reproducible, leading to less confusion with other services. Such systems of care lead to improved effectiveness (decreasing failed anesthesia and sedation cases) and improve patient, family, and staff satisfaction.

Another option for NORA organization is the use of standard OR same-day unit admission services and postanesthesia care unit recovery capability while providing induction and procedural anesthesia at the site of the procedure (e.g., endoscopy suite or hematology and oncology unit). This organizational paradigm makes use of existing anesthesia ancillary services but almost always requires patient transport before and after the procedure itself.

Finally, anesthesia services outside the OR may be primarily organized at the site of procedural care (e.g., in radiology departments or gastrointestinal [GI] procedure suites). For this organizational setup, the procedure unit itself may be outfitted for admission and preanesthesia assessment and recovery of children is accomplished in a space contiguous with the procedural location. This kind of organization is most common in children's hospitals, where high volumes of procedures are performed in a given location such as the MRI scanner.

Quality Assurance of Anesthesia Services and Outcome in the Off-Site Areas

It is important to develop a strategy to track all clinically important complications associated with NORA, as we do in the OR. Each department can set its own thresholds for review; however, certain incidents require a full inquiry for example :

• ■

  Aspiration events

• ■

  Unscheduled admissions to the hospital as a direct result of the sedation (i.e., because of protracted emesis, prolonged sedation, respiratory or cardiac complication)

• ■

  Medication errors that lead to patient harm—or that could potentially lead to patient harm

• ■

  Failed procedures resulting from inadequate or problematic anesthesia or sedation

• ■

  Cardiovascular or respiratory compromise that requires assistance from an outside rescue team or leads to a “call for help”

• ■

  Cardiac arrest

• ■

  Respiratory arrest or need for airway rescue

Many institutions choose to follow outcomes such as prolonged nausea and vomiting after anesthesia or O ₂ desaturation events. Regardless of the data that the quality improvement (QI) committee chooses to review, the process should include anesthesiologists and anesthesia extenders, nurses, and other technical personnel who are routinely involved in anesthesia care and support. It is particularly important to note that in the case of off-site anesthesia, it is critical to include members of the departments (other than anesthesiology) who were involved with the case being reviewed. The timing of QI meetings depends on the number and acuity of the non-OR anesthesia cases provided at a given institution. Review committee meetings should be considered not just an opportunity to evaluate complications but also a forum for exchange of ideas, expertise, and information that can lead to improvements in the systems of patient care.

Anesthesia Versus Sedation for Non–Operating Room Procedures and Tests in Children

Anesthesiologists always have the option to deliver either deep sedation or anesthesia for procedures outside the OR. The choice of whether to deliver general anesthesia with a secured airway (tracheal tube or LMA) using potent inhalational anesthetics versus deep sedation with face mask O ₂ and propofol infusion depends on many factors, including the child's comorbid conditions, the procedure, and the experience and comfort level of the anesthesia provider. Several reviews are available on this topic. For MRI scans, propofol deep sedation has been suggested as a safe and effective option in children with airway pathologic conditions or who are premature or very young. For generally healthy children undergoing MRI scans, adverse events were reportedly less common when deep sedation/anesthesia with propofol and a natural airway were used compared with inhaled anesthesia through an LMA. The same report noted that recovery was faster after propofol (alone) compared with inhalational anesthesia. Similarly, multiple reports have recommended successful outcomes with propofol sedation and general anesthesia with tracheal intubation (GETA) techniques for endoscopies. In another study where a direct comparison was made between the techniques for GI procedures, recovery was more rapid and agitation less common after a propofol-based sedation technique rather than an inhaled anesthesia-based anesthetic technique.

No clear evidence exists that one technique is better than another for procedures since both techniques have been reported as effective and safe outside the OR. Recognizing this fact, it is appropriate to carefully evaluate the nature of the sedation/anesthesia provided in the NORA setting and consider all of the possible implications of a given technique for each patient group. For instance, how efficient and effective is the care that is provided? How well does the care provided meet the requirements of the procedure in terms of pain and movement control? How rapid is the emergence from sedation or anesthesia with a given technique? Do the short-term or long-term complications differ? Only after careful analysis can guidelines be established for the optimal technique for a given procedure.

When delivering general anesthesia to children outside the OR, the risk benefit of instrumenting the airway must be carefully evaluated. The LMA has been found to be useful in the MRI or computed tomography (CT) setting because it can be used with spontaneous ventilation, enables the anesthesiologist to monitor etco ₂ continuously, and provides a clear airway for a child who may otherwise have an airway obstruction or who is in a position where the airway is not readily accessible. With the LMA in place, the child can be maintained with a relatively small inspired concentration of anesthesia, allowed to breathe spontaneously, and then rapidly awakened at the conclusion of the scan. After the LMA is placed, anesthesia can be provided with either a continuous infusion of propofol or with a low-dose inhalation agent (e.g., sevoflurane 1.5% in 50% N ₂ O/O ₂ ). In some circumstances, the LMA may provide a suitable airway in children with bronchopulmonary dysplasia, cystic fibrosis, severe asthma, or active respiratory issues. In children with upper respiratory tract infections, the incidence of mild bronchospasm, laryngospasm, breath-holding, and O ₂ desaturation (<90%) in those whose airway was managed with an LMA was reduced compared with those whose airway was managed with a tracheal tube. Similarly, the use of LMAs in former preterm infants with bronchopulmonary dysplasia resulted in less coughing and wheezing and greater hemodynamic stability than in those managed with tracheal tubes. In children who underwent a vitrectomy for retinopathy of prematurity, the time to discharge after an LMA was less than that after a tracheal tube. LMAs provide more hemodynamic stability during their removal than during tracheal extubation and may offer a specific advantage in some children.

In healthy children, deep sedation is appropriate (e.g., for an MRI scan); it usually includes a propofol infusion, an optimally positioned upper airway (with a roll under the cervical spine and the neck extended), and noninvasive monitoring (nasal capnometry supplemented with oximetry, an ECG, and noninvasive blood pressure monitoring). The majority of children do not require an airway during deep sedation for medical tests. However, in some (e.g., those with excess secretions or obstructive sleep apnea), the following algorithm of airway intervention may be followed to relieve the obstruction: (1) reposition the head and shoulders, (2) insert an oral or nasal airway, (3) if partial obstruction persists, place an LMA, and (4) if the LMA fails to provide adequate gas exchange and oxygenation, place a tracheal tube.

Logistics of Managing Acute Emergencies and Cardiopulmonary Arrest Outside the Operating Room

Although the actual management of a cardiopulmonary arrest should not vary between the OR setting and the non-OR setting, the logistics of performing a resuscitation may be challenged by unanticipated factors, such as personnel who may not be familiar with code situations, an environment that makes performing a resuscitation difficult, or equipment that may be unsafe if used in the particular location (e.g., the MRI environment). It is important that all personnel in the off-site location be familiar with the location and operation of the code cart. The anesthesia cart and the code cart in the off-site location should be stocked in the same precise configuration as all others throughout the hospital and ORs. Standardizing the code carts throughout the hospital ensures that all ancillary personnel can be helpful in locating critical items. If the code cart is kept locked, the key or access code must be readily accessible and in a location that is known to all essential personnel. A hard board on which chest compressions may be performed should be readily available. Each off-site location should have an identified and rehearsed routine for announcing a code situation and summoning aid. Responders to a code must be assured of access to the location to which they are called; in the current age of card-key access, this should be simple but needs to be established in advance of need. The use of patient simulation can be very helpful in testing the team response to critical events. Simulators can be used in place in off-site locations to replicate critical events and evaluate the ability of the care team and backup systems to resuscitate a patient. This methodology has documented significant variation in the ability of rescuers to resuscitate children from sedation or anesthesia critical events in locations outside the OR.