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Preoperative Evaluations

The preoperative evaluation of the patient undergoing anesthesia is both a requirement of the Centers for Medicare and Medicaid Services and important in preparing an anesthetic plan. Certain parts of the anesthesia preoperative evaluation are standard, whereas other elements are individualized depending on the patient, timing of the evaluation, type of procedure, and location. Non–operating room procedures requiring anesthesia (NORA) present a unique set of challenges…

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…

Intravenous Anesthesia and Sedation Outside the Operating Room

Acknowledgment Anil Gupta would like to thank the Department of Anaesthetics, Gisborne Hospital, Gisborne, New Zealand, for the time he was given during the nonclinical sessions, which gave him the opportunity to complete this chapter. The operating room is considered to be the most expensive part of the hospital, and therefore only procedures that require specific surgical care of the patient or dedicated anesthesia resources and…

Critical Monitoring Issues for Non–Operating Room Anesthesia

The rise in the number of nonsurgical diagnostic and therapeutic interventions is driving the surge in volume of remote anesthesia and sedation services. These procedures have simultaneously become increasingly complex as a result of technological advances and sicker patient cohorts. Complicating matters further, although these patients remain at high risk for anesthesia-related complications, they may be scheduled for such procedures precisely because they are poor surgical…

Continuous Quality Improvement for Non–Operating Room Anesthesia Locations

As described throughout this book, non–operating room anesthesia (NORA) locations present a major challenge for safe anesthesia care. A vital quality improvement and risk management system is important to prevent patient harm and improve the quality of care. This chapter will discuss continuous quality improvement (CQI), selection of quality indicators, and methods to improve quality of care, including analysis of critical incidents and sentinel events using…

The Role of the Non–Operating Room Anesthesiologist

In recent years, the number of non–operating room anesthesia (NORA) procedures has increased significantly. At our institution—Morgan Stanley Children’s Hospital of New York-Presbyterian—40% of all anesthesia procedures (∼4000/10,000 cases) were done outside of the operating room in 2011, in contrast to 20% in 2001 (∼1400/7000 cases). A similar trend is occurring nationwide. Many reasons account for this change. First, many more procedures, such as bone marrow…

Room Setup, Critical Supplies, and Medications

An increasingly large number of anesthetic cases are performed outside the traditional operating room environment. Procedures performed in areas such as the electrophysiology laboratory and interventional radiology department are becoming more complicated and often take longer. Patients are presenting with more complicated histories and comorbidities. Because of the complexity of the procedures and patients’ conditions, anesthesiologists are requested to provide services in these remote locations with…

Designing Safety and Engineering Standards for the Non–Operating Room Anesthesia Procedure Site

Acknowledgments The authors would like to thank Kurt Smith and eppstein uhen architects in Madison and Milwaukee, Wisconsin, for their generous donation of time and expertise to the composition of this chapter. Non–operating room anesthesia (NORA) services are being increasingly requested as the number of procedures and their complexity increase. These services are requested in diagnostic and interventional radiology, interventional cardiology, gastroenterology, nuclear medicine, interventional urology…

Engineering Excellence in Non–Operating Room Anesthesia Care

The past two decades have seen advances in medical technology that now allow physicians to treat a patient with noninvasive or minimally invasive procedures. Patients who would have been subjected to sternotomy, thoracotomy, major vascular surgery, or laparotomy just a few years ago may now be treated more effectively, more economically, and more comfortably by nonsurgical intervention in specialized areas outside of the operating room. These…

Anesthesia and Environmental Health

HEALTH, HEALTH CARE, AND CLIMATE CHANGE Climate change represents a defining challenge of our times, and tackling climate change could be the greatest global health opportunity of this century. Climate change poses clear environmental, technologic, and economic challenges that affect food, water, and habitation, and therefore the health of the world’s population. Table 49.1 lists health issues related to climate change. Table 49.1 Global Health Issues…

Sleep Medicine and Anesthesia

INTRODUCTION Human interest in sleep is as old as humanity itself, but the specialty of sleep medicine is less than 50 years old. The characterization of sleep into periods based on electroencephalography (EEG) and the presence or absence of rapid eye movements (REMs) did not occur until the 1950s. Early developments in the field included the original description of sleep apnea and the development of all-night…

Palliative Care

INTRODUCTION Patients with serious illnesses often have an intense burden of symptoms that are poorly treated, such as pain, dyspnea, anxiety, and depression. These patients also have frequent but often unsatisfying interactions with the health care team, often as a result of poor communication. Palliative care is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening…

Quality and Patient Safety in Anesthesia Care

INTRODUCTION Clinical anesthesia practice is often considered a model for quality and safety in medicine. In 1999 the Institute of Medicine report, “To Err Is Human” specifically identified anesthesia as “an area in which very impressive improvements in safety have been made.” Such attention to a specialty comprising approximately 5% of U.S. physicians highlights the many contributions to perioperative quality and safety generated by the specialty…

Cardiopulmonary Resuscitation

INTRODUCTION Cardiopulmonary resuscitation (CPR) was initially defined over 50 years ago as the administration of mouth-to-mouth ventilation and closed chest cardiac compressions in a pulseless patient. Since that time, significant advances in CPR and cardiovascular life support have been made. Today, the early descriptions of CPR are termed basic life support (BLS), whereas adult advanced cardiovascular life support (ACLS) and pediatric advanced cardiovascular life support (PALS)…

Chronic Pain Management

INTRODUCTION Expertise in pain management is a core element of anesthetic care, and from this expertise there has emerged a distinct distinct medical specialty: pain medicine. Regardless of chronicity, the practice of this medical specialty is inherently multifaceted and multidisciplinary. There are multiple certification pathways for pain medicine. The American Board of Medical Specialties (ABMS) recognizes pain medicine as a distinct medical specialty. The American Board…

Anesthesia for Trauma

INTRODUCTION Background Injury is the leading cause of fatality worldwide, causing more than 5 million deaths—9% of the world's deaths—each year. According to the Centers for Disease Control and Prevention (CDC), trauma accounted for nearly 230,000 U.S. deaths in 2018, costing over $400 billion in health care and lost productivity. Trauma is the most frequent cause of fatality in those aged 1 to 44 years, accounting…

Perioperative Medicine

INTRODUCTION The practice of anesthesiology historically focused on the care of an individual patient undergoing surgery. The specialty has an impressive track record for improving quality and safety in patient care (also see Chapter 46 ). Although anesthesia practice continues to evolve, patients undergoing major surgery still experience adverse outcomes related to their physiologic reserve and the metabolic and inflammatory response to the surgical intervention. The…

Critical Care Medicine

ICU DEFINITIONS, INTERPROFESSIONAL CARE, AND PHYSICIAN STAFFING Intensive care units (ICUs), as defined by The Joint Commission, are geographically separated nursing care areas that provide intensive observation, diagnosis, and therapeutic procedures for patients who are critically ill. Though the first modern ICU was started in 1953 to provide mechanical ventilation to patients with polio, they have since evolved to allow for monitoring and support of critically…

Perioperative Pain Management

Postoperative pain is a complex physiologic reaction to tissue injury. For many patients, the primary concern about surgery is how much pain they will experience after the procedure. Similarly, postoperative pain management is an integral part of anesthesia care. Postoperative pain is directly related to patient satisfaction, which has evolved into an important measure for high-quality health care. Postoperative pain produces acute adverse physiologic effects with…

Postanesthesia Recovery

The postanesthesia care unit (PACU) is managed by anesthesiologists, who provide general medical supervision and coordination of patient care. Historically, PACUs did not become a standard part of hospital design until the late 1940s, after an influential study of mortality within 24 hours of anesthesia induction noted a significant number of deaths resulting from inadequate nursing care and respiratory obstruction in the immediate postoperative period. In…