Anesthesia Outside of
the Operating Room
Yujuan Li
The Second Affiliated Hospital of
Sun-yet Sen University
Yujuan_04@yahoo.com.cn
Some terms
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Nonoperating room anesthesia (NORA)
Anesthesia at remote location
Outpatient anesthesia
Office-based anesthesia (OBA)
Importance
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Number of NORA activities has increased
rapidly( CT, MRI, neuroradiologic procedure
or electroconvulsive therapy)
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More Complex of the procedure, and
situation and patients
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Who does the sedation?
Mortality and Morbidity
Special problem of NORA
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Limited working place, limited access to the
patient,
Electrical interference with monitors and
phones, lighting and temperature inadequacy,
Use outdated ,old equipment
Less familiar with the management of
patients
Lack of skilled personnel, drugs and supples
ASA guidelines for NORA patients
AAP guidelines for NORA
pediatric patients
Anesthetic technique
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General anesthesia: tracheal intubation or LMA
best prevention of motion
invasive, time and resource consuming,
atelectasis
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Sedation/anagesia:
less invasive ,cost and time saving
high rate of failure, high airway and respiratory
depression
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No anesthesia
Conscious sedation versus
monitored anesthesia care
Conscious sedation : a medically controlled state of
depressed consciousness that allows protective reflexes
to be maintained and retains the patient's ability to
maintain a patent airway and to respond appropriately to
physical and verbal stimulation.
MAC: an anesthesiologist provide specific anesthesia
services to particular patients with local or no anesthesia
who undergoing a planned procedure.
Levels of sedation
Drugs for paediatric sedation
Discharge criteria
II. Contrast media
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Allergic reaction
History
Symptoms: skin reactions, airway obstruction,
angioedema, and cardiovascular collapse.
Treatment: corticosteroids, H1 and H2
blockers. Oxygen, epinephrine, β2-agonists,
and intubation , IV fluids
Prevention: corticosteroids
III. Anesthesia for CT
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Less complex
Use standard monitoring
Less anesthetic time
Higher levels of radiation exposure
IV. Anesthesia for MRI
A. Physical environment
 High magnetic field
 Need specialized compatible equipment
 Radiofrequency noise
 Metallic implants or implanted devices
Patients with implanted pacemakers, ICDs, or pulmonary artery catheters may
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not have MRI scans
B. Uncertain duration
 compatible Monitors
 anesthesia machines , ECG , pulse
oximeters , straight cables.
V. Anesthesia for
neuroradiologic procedures
A. Endovascular embolization
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Indication: cerebral aneurysms, arteriovenous fistulas
and malformations , vascular tumors
Methods: femoral artery puncture, a small catheter into
the aneurysm
Anesthetic goals :stable hemodynamics, and rapid
recovery
Other problem: Invasive arterial blood pressure
monitoring , avoid hypertension, monitor
anticoagulation, complications include rupture of the
aneurysm
B. Embolization for control of epistaxis and
extracranial vascular lesions
C. Balloon test occlusion
D. Cerebral and spinal angiography
E. Vertebroplasty and kyphoplasty
F. Thrombolysis of acute stroke
G. Cerebral vasospasm
VI. Anesthesia for vascular, thoracic, and
gastrointestinal/genito-urinary radiology
procedures.
VII. Anesthesia for cyclotron therapy and
radiation therapy
VIII. Electroconvulsive therapy (ECT)
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Objection: treat major depression, no responded to
medications, suicidal.
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Periods: 6 to 12 treatments over 2 to 4 weeks
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Physiologic effects:
a grand mal seizure tonic phase : 10 to 15 s,
clonic phase :30 to 50 s.
first reaction: bradycardia and hypotension
following reaction: hypertension , tachycardia,5-10min
ECG changes
ICP, intraocular and intragastric pressure increase
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Anesthetic goals
amnesia and rapid recover
Prevent damage
Control hemodynamic response.
Avoid interference with initiation and
duration of induced seizure.
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Contraindication :
absolute contraindication: intracranial hypertension
Relative contraindications: intracranial mass or
aneurysm , recent myocardial infarction, angina,
congestive heart failure, untreated glaucoma,
major bone fractures, thrombophlebitis, pregnancy,
and retinal detachment.
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Anesthetic management
No Sedative premedication , Anticholinergic
drugs and Ondansetron by individual.
Standard monitors (ECG, SPO2 , BP)
Induced with methohexital and
succinylcholine or Mivacurium ventilated
with 100% oxygen via mask and Ambu bag.
labetalol or esmolol when necessary
Place rolled gauze pads
Anesthetic management
5. Electroencephalogram (EEG) monitor
duration
6. Patients ventilated with O2
7. Some special attention : gastroesophageal
reflux, severe cardiac dysfunction ,
intracranial mass lesions , pregnancy
8.Terminate seizure with propofol or
enzodiazepines within 3 minutes
IX. Upper and lower
endoscopy ,ERCP and PEG