Room Setup, Critical Supplies, and Medications

Room Setup

NORA procedures occur in a wide array of locations ( Box 3-1 ). These sites range from a designated area in the postanesthesia care unit (PACU) where electroconvulsive therapy is performed to specially designed multiroom suites for gastrointestinal endoscopy. The equipment, supplies, and medications needed in each area will depend on the planned anesthetics and the frequency of their occurrence. The American Society of Anesthesiologists (ASA) issued a Statement on Nonoperating Room Anesthetizing Locations ( Figure 3-1 ) that provides minimal guidelines applicable to all anesthesia care in locations outside the operating room.

One challenge for anesthesia practitioners in remote locations is space. Procedural areas are often planned and built without considering that anesthesia care might be needed in that area. As a result, the anesthesia team is often given inadequate space and not always near the patient. The anesthesia team often works around C -arms in interventional radiology and an endless array of monitors and C -arms in the cardiac electrophysiology laboratory. These spaces become very crowded areas with the introduction of anesthesia equipment and monitors ( Figure 3-2 ).

Before providing anesthesia services in a NORA location, it is important to evaluate the area to ensure that the guidelines as put forth in the ASA Statement on Non–Operating Room Anesthetizing Locations are followed, along with institutional policies. If the proper equipment and systems are not in place to ensure patient safety, the area should not be used to provide anesthesia services until such changes are made.

The anesthesia department sometimes sends older equipment to the remote anesthesia areas. Remote areas are perceived as not needing the newest equipment because these areas are often not used to the same extent as rooms in the main operating room. It is an unwise practice to send older equipment to remote areas. Using older equipment in a remote area raises the possibility of unfamiliarity with the equipment and machine malfunction. If a problem arises with the equipment, the practitioner may not be able to troubleshoot the problem. Assistance may take much longer to arrive than it would in the main operating room. The ASA Committee on Equipment and Facilities published Guidelines for Determining Anesthesia Machine Obsolescence. This document has not been approved as a practice parameter or policy statement by the ASA House of Delegates, but it does provide practical advice regarding essential features needed in an anesthesia machine to provide a safe anesthetic for patients. Equipment and supplies should match as closely as possible the equipment in the main operating room. Having uniformity of equipment and supplies in all locations provides familiarity for the anesthesia providers who rotate through these areas.

Anesthesia machine check in NORA locations is just as important as in the main operating room. Anesthesia machines in remote locations may not be used every day, so it is important to do a complete machine check at the start of the day. It is important to ensure that the soda lime is fresh in an anesthesia machine that might not have been used recently. In NORA procedure areas, the anesthesia team shares the space with the procedure team. Anesthesia care may not be provided for each case in the room during the day. During nonanesthetic procedures, the procedure nurses may use monitors on the anesthesia workstation. This raises the possibility, for example, that the anesthesia machine may be moved, connections unplugged, or breathing circuits dislodged. If nonanesthesia cases were performed between anesthesia cases, the machine needs to be thoroughly checked before the next anesthesia procedure. Anesthesia machines and equipment in NORA locations need to have regular preventive maintenance, as do machines in the main operating room.

At times an anesthesia machine is transported to a location where anesthesia service is infrequently provided. In these situations, the machine needs to be checked very carefully because transportation of the machine can potentially damage the machine or loosen connections. It is essential to ensure that the anesthesia machine, monitors, and equipment are all in good working order before beginning anesthetic care.

In certain locations where sedation is the only planned action, a compact monitor with the capability of monitoring electrocardiography, blood pressure, oxygen saturation, and end-tidal carbon dioxide (ETCO ₂ ) is very useful and does not take up much space ( Figure 3-3 ). ETCO ₂ monitoring should be included in the monitoring for procedural sedation or general anesthesia in any NORA location.

In areas where anesthesia care is provided, even if sedation is the only planned action, the anesthesia provider should be able to administer general anesthesia and manage the airway. A defibrillator and emergency resuscitation cart should be immediately available to the anesthetist.

The NORA location ideally should have oxygen, air, and nitrous oxide available via a central supply. It is essential to ensure an adequate supply of oxygen is available for the duration of the case. If central supply oxygen is available, a full E-type tank of oxygen should be present as a backup. If oxygen tanks are to be used for the case, it is important to ensure adequate supplies for the case are available, as well as a backup tank. The tank key must be present before beginning anesthetic care.

Central suction may not be available in NORA locations. It is important to ensure suction is available via a suction machine if central suction is not available.

The procedure tables in NORA locations often do not move into the variety of positions available with the main operating room tables. It may be advisable to induce and emerge from anesthesia on the stretcher on which the patient is brought to the procedure room. Using the stretcher will allow heads-up, Trendelenburg, and reverse Trendelenburg positioning if needed. Certain procedures, such as endoscopic retrograde cholangiopancreatography, are commonly done in the prone position. The procedure staff must keep the stretcher next to the procedure room in case the patient needs to be immediately turned to the supine position.

Monitoring standards in NORA locations should be the same as in the main operating room. Electrocardiography, pulse oximetry, blood pressure, and ETCO ₂ are minimal requirements. Gas analysis is also advised if use of volatile anesthetics is planned.

Postprocedure recovery should be the same standard as that of the main operating room. Ideally, the patient should recover in a monitored environment close to the procedural area. If this is not possible, the patient should be transported to the main PACU for recovery from anesthesia. The patient should be transported with supplemental oxygen, a transport monitor, an Ambu bag, and emergency medications in case of an emergency during transport.

Other pieces of equipment are needed in NORA locations. Many procedures done in NORA locations are done under sedation or with total intravenous anesthesia (TIVA). Using an intravenous infusion pump for medications such as propofol is very helpful in achieving an adequate level of sedation or anesthesia. A forced-air warming system is needed to ensure patients do not develop hypothermia. Certain NORA locations such as magnetic resonance imaging (MRI) and computed tomography (CT) suites are kept cool to help protect equipment, thus placing patients at risk for hypothermia. An intravenous fluid warmer is needed if there is the possibility of blood transfusion or the need for large amounts of intravenous fluids. Transducers to measure arterial blood pressure and central venous pressure should be readily available. A bispectral index monitor or other depth of anesthesia monitor is also a useful device to have available.

It is beneficial to have point-of-care laboratory testing available in NORA locations. NORA locations may be far from the operating room or main hospital laboratories; having point-of-care testing will improve efficiency. This availability will allow laboratory tests such as blood glucose, potassium level, and hematocrit to be quickly checked.

In any area where anesthesia care is to be provided, the anesthesia provider should know the location of oxygen shutoff valves and fire extinguishers. Safety and emergency evacuation procedures in NORA spaces should be reviewed with the personnel in those areas. The anesthesia provider should also ensure the presence of a defibrillator and resuscitation cart in any location where anesthesia care is to be provided.

In the main operating room, personnel are accustomed to assisting and being attentive during the movement of the patient into the room, during anesthetic induction, and during emergence from anesthesia. This is not the case in many NORA locations. Personnel in these locations are used to their routines and are unaware of the concerns of the anesthesia team. Time spent familiarizing these personnel with the issues and concerns of the anesthesia team regarding care of the patient before service is begun will be very helpful to the anesthesia team.

The anesthesia and procedural teams should collaborate to create a quiet environment during anesthetic induction and emergence. This hushed setting benefits the patient and allows the anesthesia care team to effectively communicate. The importance of safety straps on the patient needs to be stressed, especially during emergence from anesthesia. The procedural team should be instructed on the importance of being attentive and nearby during emergence from anesthesia. Spending time familiarizing the team with the anesthesia machine and airway devices such as Eschmann stylets is very helpful. If assistance is needed with bag-mask ventilation or with airway supplies, prior familiarity is much better than trying to instruct in the middle of a stressful event. Anticipation of and planning for problems that might arise in these locations is important, because help from the main operating room may take an extended time to arrive.

In many NORA locations, the setup is similar to that of the main operating room once space issues are negotiated. Setup differs significantly in two locations—radiation therapy and MRI suites.

Room Setup in Magnetic Resonance Imaging

Providing anesthesia services in the MRI suite poses problems not encountered in other anesthetizing locations. If proper precautions are not taken, the MRI suite can be a hazardous environment for both the anesthesia provider and the patient. Descriptions of the science and technical aspects of MRI have been published elsewhere and are beyond the scope of this chapter. MRI has advantages in that this imaging modality does not expose the patient to ionizing radiation and thus does not have cumulative effects when serial examinations are required. The number of MRI scans done each year continues to grow, and the need for anesthesia services in the MRI suite continues to grow as well.

In 2007 the American College of Radiology published a Guidance Document for Safe MR Practices. In 2009 the ASA Task Force on Anesthetic Care for Magnetic Resonance Imaging published a practice advisory on anesthetic care for MRI. These documents provide detailed information about safe practices within the MRI environment.

The major concern in providing anesthesia care in the MRI suite is the strong magnetic field present around the scanner at all times. It takes several days to generate the magnetic field used in MRI. Therefore the magnetic field is always on, even when there is not a patient in the scanner. The magnetic field is measured in tesla units (T); 1 T equals 10,000 gauss. The earth’s magnetic field is approximately 0.5 gauss. MRI scanners used for clinical purposes are generally 1- to 3-T machines. Thus the MRI scanner generates a magnetic field thousands of times stronger than the earth’s magnetic field. Any item of equipment that contains ferromagnetic material will be attracted to the magnet. In addition to the static magnetic field that is always present, during image acquisition, radiofrequency pulses are applied. Both the static magnetic field and the intermittent radiofrequency pulses create the safety issues associated with MRI.

Four zones have been identified in the MRI environment, with increasing danger from the magnetic field with each increase in zone ( Table 3-1 ). Signs should be posted to indicate each zone in the MRI suite.

Table 3-1

Magnetic Resonance Suite Zones

Zone	Activity
Zone I	All areas freely accessible to the general public. This is the area through which personnel and patients access the MRI area.
Zone II	The area between the uncontrolled zone I and the strictly controlled zone III. This is the area where patients are greeted, histories obtained, and questions answered. Movement by non-MRI personnel and patients is under the supervision of MRI personnel.
Zone III	This is a restricted area. Movement in this area is strictly controlled by MRI personnel. Access to this area is only after screening for the presence of ferromagnetic material. Ferromagnetic objects may produce a serious hazard if brought into this area.
Zone IV	This is the MRI scanner room itself. By definition it is within zone III.

MRI, Magnetic resonance imaging.

In an area in the MRI suite known as the 5-gauss exclusion zone, ferromagnetic items become very significant risks because of abnormal operation and being drawn to the magnet. This area is generally demarcated by a red line. The distance of the 5-gauss line from the scanner bore varies depending on the strength of the MRI and the shielding of each device.

Multiple incidents have been reported of ferrous-containing objects, hospital beds, anesthesia carts, intravenous poles, oxygen tanks, and other items being drawn to the magnet ( Figures 3-4 and 3-5 ). Serious injury or death can occur in these situations. A paper clip has a terminal velocity of 40 miles per hour in a 1.5-T magnetic field. Larger objects have greater velocity and force. These items can become high-speed projectiles when they enter the magnetic field of the scanner It is imperative that all personnel, patients, and objects be screened for the presence of ferrous-containing materials before being allowed in zone III or zone IV areas.

If an employee or patient is trapped by an object drawn to the magnet, such as an anesthesia cart, the MRI has to be shut down emergently. This very expensive and potentially hazardous procedure is called a quench. The MRI scanner is super-cooled with inert gases such as liquid helium. In a quench, these gases are suddenly released to shut down the magnetic field. They usually escape by a pressure valve to the outside. If these gases do not exit outside but rather empty into the scanner room, hypoxia may occur as hundreds of thousands of liters of helium is released into the scanner room, displacing oxygen. This gas can also pressurize the room, making it impossible to open doors. The room can then become a fire hazard because flammable liquid oxygen can form as a result of the rapid drop in room temperature.

A quench is very expensive in terms of the cost of getting the scanner back on line. An emergency quench can damage the coils of the magnet as a result of the rapid change in temperature as the cryogenic material is released. The scanner has to be checked very carefully to ensure it is not damaged. Refilling the cryogen materials is also very expensive. A significant economic impact occurs from lost revenue during the time the scanner is down. An emergency quench should be initiated by MRI personnel only in life-threatening emergencies.

The MRI does not need to be quenched if a piece of equipment is attached to the magnet but no life is in jeopardy. The MRI and engineering personnel can lessen the magnetic field so that the object can be safely removed from the magnet.

The best way to avoid an emergency quench is to ensure that proper MRI procedures are followed at all times and to follow the instructions of the MRI personnel. Some institutions require personnel going into the MRI environment to complete an educational program and training before being allowed in the MRI area. It is also important to ensure that anesthesia personnel are screened for the presence of foreign bodies or implanted devices containing ferromagnetic material before being allowed to work in the MRI environment.

The American Society of Testing and Materials developed terminology regarding equipment and devices in the MRI environment. Equipment and devices are given the designations MRI safe, MRI conditional, and MRI unsafe. MRI safe equipment is identified as having no ferromagnetic parts or radiofrequency interference. MRI unsafe equipment is identified as having ferromagnetic parts or being affected by radiofrequency interference. MRI conditional equipment may be safe in certain areas of the MRI suite but cannot be identified as having no ferromagnetic parts.

Many manufacturers make MRI safe and MRI conditional anesthesia machines. It is preferable to have these machines in the MRI suite ( Figure 3-6 ). If an MRI safe or MRI conditional anesthesia machine is not available, it is important that the anesthesia machine be kept at a safe distance and that a long anesthesia circuit be used.

If an infusion pump is going to be used, it should be MRI safe or MRI conditional ( Figure 3-7 ). If it is not, it should be kept outside the scanning room and the tubing threaded through a waveguide to the patient in the scanner.

As mentioned earlier, radiofrequency pulses are emitted during MRI scanning. The radiofrequency pulses can interfere with monitors and equipment because they can heat up monitor wires and leads. The risk for patient burn exists if these leads are looped or coiled. To lessen the risk for burns, monitoring wires should be examined to ensure that insulation is intact. Leads and cables should be straight and in line with the body. Leads and cables should not be in direct contact with the skin. It is now common to have specially shielded pulse oximeters for use in MRI with wireless communication to the monitor. MRI safe electrocardiography electrodes are available. The electrocardiogram (ECG) can be transmitted via telemetry and eliminate a wire to the monitor.

In addition to the risk for patient burns related to radiofrequency pulses, risk to the hearing of patients and personnel is also an issue. The radiofrequency pulses make noise up to 90 decibels. The 3-T machines are much louder than 1.5-T machines. The patient as well as any personnel or visitors present in the scanner room should wear hearing protection provided during the procedure.

In the event of cardiac or respiratory arrest while the patient is in the scanner, basic life support measures should be started while the patient is emergently removed from the magnet room to a magnetically safe location for full resuscitation measures to take place. If resuscitation is done in the magnet room, it raises the possibility of danger from ferromagnetic objects used in the resuscitation. If the hospital resuscitation team is called to the MRI room, team members must follow MRI safety protocols. In responding to the emergency, the hospital resuscitation team may not realize the significant hazards associated with the magnetic field and thus inadvertently take a ferrous object into the magnet room, creating a serious hazard. This underscores the importance of removing the patient to a magnetically safe place for resuscitation. In addition, it is often difficult to interpret ECG data while in the magnet room, which could hamper resuscitation efforts.

In many institutions, the patient is anesthetized in an area outside the scanner room, then moved onto the MRI gantry and taken into the scanner room ( Figure 3-8 ). This process allows the anesthesia provider to use any equipment needed during the anesthetic induction. If induction is to take place in the scanner room, care must be taken to ensure that nonferrous equipment and supplies are used. It is important to ensure that the anesthesia circuit and intravenous lines are long enough to allow for movement of the MRI gantry during scanning.

Before being brought into the scanner, the patient is questioned carefully regarding the presence of any ferromagnetic devices such as pacemakers, implantable cardioverter-defibrillators, prosthetic heart valves, aneurysm clips, bullets, or shrapnel. If the patient is unable to answer, family members are questioned. Other means such as looking for scars or using plain films can be employed to determine if the patient has a device. If it cannot be determined the patient is safe to have the procedure, it should not be done.

The anesthesia provider will in most circumstances not be in the scanner room during the scan. The anesthesia provider needs to have visualization of the patient through a window and also by video cameras. The anesthesia monitors also must be visible. This can be achieved using a video camera focused on the monitors. Ideally this should be by means of a slave display at the MRI control desk.

Pregnant personnel can work throughout their pregnancies in the MRI environment. However, it is recommended that they move away from the magnet bore during actual scanning.

Cooperation and consultation between the MRI personnel and anesthesia staff are very important in the MRI environment. A good working relationship and understanding of the concerns of both the MRI personnel and the anesthesia staff will ensure a safe experience for the patient.

Critical Supplies

NORA locations need to be supplied even better than the main operating rooms. Because of the remoteness of some locations, supply support from the main operating room is often infrequent. It is important to make sure that adequate supplies are present before beginning anesthetic care. If additional supplies are needed in the middle of a procedure, it may take some time for them to arrive.

NORA locations where services are provided multiple times per week should have well-supplied anesthesia carts. These carts should remain in place. In locations where service is very infrequent, an anesthesia cart with supplies can be taken to that location on the day of a procedure. In an area where service is provided daily it is recommended to have an anesthesia supply storage area nearby, just as in the case of the main operating room. This will allow for easy stocking of anesthesia carts between cases. It is sometimes difficult to obtain space for an anesthesia supply storage area; however, the argument that efficiency will be improved and room turnaround faster will go a long way toward acquiring space. Having a dedicated anesthesia technician assist with room turnover in busy multiroom areas such as the gastrointestinal endoscopy or cardiac electrophysiology suites also improves efficiency.

The supplies needed in NORA locations are often the same as those in the main operating room, with a few exceptions. Because of the distance from the anesthesia machine to the patient in many of these locations, a longer anesthetic circuit is often needed than those used in the main operating room. Likewise, longer intravenous tubing is also necessary. A flashlight other than a laryngoscope provides illumination in darkened rooms, assisting in finding and drawing up medications and observing the patient.

A list of important phone numbers should be posted in a clearly visible place in the procedure room. This list of numbers should include the main operating room anesthesia board to request additional anesthesia assistance, the operating room pharmacy if additional medications or malignant hyperthermia supplies are needed, the number to call for anesthesia supplies, and the number to call for the difficult airway cart. Trying to remember phone numbers in the middle of an emergency is difficult. Having the team in the room make needed phone calls allows the anesthesia provider to concentrate on the emergency.

The ability to manage an airway is needed in any area where anesthesia care is provided. Sufficient airway supplies to manage an airway should be immediately available ( Box 3-2 ). It is helpful to have a video laryngoscope in NORA locations. An argument also can be made for having a difficult airway cart with a fiberoptic endoscope in NORA locations. Practical and economic concerns, however, would advocate having the cart permanently available only in busy NORA locations such as a multiroom gastrointestinal endoscopy suite. If it is necessary to call for the difficult airway cart, the personnel responsible for bringing it to the remote site need to be familiar with the remote location and the fastest route to deliver the equipment.

In circumstances in which the patient has a known difficult airway, the difficult airway cart can be called for and additional anesthesia personnel can be arranged to assist. An alternative for patients with a known difficult airway is to perform the intubation in the main operating room, where additional resources and equipment are readily available, and then transport the patient to the NORA location for the procedure. Transporting an intubated patient poses the risk for inadvertent extubation if the endotracheal tube or breathing circuit gets snagged during transport. If the patient has to be transported a considerable distance, it is recommended a transport ventilator be used rather than hand ventilating the patient with an Ambu bag. The decision to intubate a patient with a known difficult airway in the main operating room or in the NORA location should be made weighing patient and institutional factors and arriving at the best decision for the particular case.

Safety Issues in Non–Operating Room Anesthesia Locations

Safety issues for anesthesia personnel are often magnified in the NORA environment ( Box 3-3 ).