Anesthesia Considerations for Out of Operating Room (OOR) Locations

Andrew J. Pittaway

Karen J. Souter

▪ INTRODUCTION

An “out of operating room” (OOR) location is an area located at some variable distance from a hospital’s operating rooms (ORs). In the last two decades, there has been considerable expansion in the services provided at OOR locations and consequentially the need for general anesthesia (GA) and sedation in these areas is growing exponentially. There are a number of synonyms for the term OOR including “anesthesia at alternate sites,” “non-operating room anesthesia,” and “remote location anesthesia.” In this chapter, we will use the terms OOR and “out of operating room anesthesia” (OORA). An OOR location may be a site within a large hospital that is separated from the general OR suite but is within the same hospital. This could include a cardiac catheterization laboratory (CCL), a radiology suite, or a gastrointestinal (GI) endoscopy suite. Alternatively, the OOR location may be a site that is completely separate from a main hospital with no OR facilities, such as a dental clinic or a radiation therapy unit. Office-based anesthesia also falls within this category, but it will not be discussed in this chapter. The most significant concern for the anesthesiologist related to OORA is providing patient care in a location where he or she does not routinely work. OOR areas are often unfamiliar to the anesthesiologist. The anesthesiologist may work in OOR locations infrequently. The personnel are not the ones the anesthesiologist works with on a regular basis, and they may not be as acquainted with anesthesia care as OR personnel. The equipment, including the anesthesia machine, cart, and available drugs, are often different or in different locations than those in the OR. This unfamiliar environment requires extra vigilance to provide safe care. It is in the OOR arena that the skill and expertise of a trained anesthesia technician is perhaps most valued and the partnership between an anesthesiologist and technician is most important.

▪ GENERAL PRINCIPLES

The scope of cases performed in the OOR arena covers a wide range of procedures performed on an increasingly diverse group of patients. There are a wide variety of techniques, equipment, and approaches to be considered, and it is easy for the anesthesia team to become distracted. A simple three-step approach is suggested to help you remain focused and to avoid omitting any important aspects of the patient’s care (Table 48.1). When providing anesthesia services in an OOR location, always consider each of the following very carefully:

The environment
The patient
The procedure

▪ THE ENVIRONMENT

Considerations related to the environment of the OOR location include the following:

Diagnostic and imaging equipment
Provision of standard anesthetic equipment
Availability of appropriate anesthesia monitors including invasive monitors
Constraints related to diagnostic and therapeutic imaging techniques
Unfamiliarity of OOR technical staff with anesthesia requirements
Environmental hazards posed to anesthesia staff, especially ionizing radiation

TABLE 48.1 A THREE-STEP APPROACH TO ANESTHESIA IN OUT OF OPERATING ROOM LOCATIONS

ENVIRONMENT		PROCEDURE	PATIENT
Anesthetic machine and monitors		Diagnostic or therapeutic	Ability to tolerate sedation
	• Availability	duration	vs. general anesthesia
	• Maintenance	Level of discomfort/pain	ASA grade
	• Familiarity	Position of patient	Comorbidity(ies)
Resuscitation equipment		Special requirements	Airway assessment
	• Ambu bag	(e.g., functional monitoring)	IV access
	• Suction	Potential complications	Allergies—IV contrast
	• Code cart + Defibrillator	Surgical support	Monitoring requirements—simple
OOR personnel			vs. advanced
	• Familiarity with anesthesia		Pediatric considerations
	• Training in emergencies		Postanesthesia care
Technical equipment hazards
	• Radiation safety
	• Magnetic resonance concerns (magnetic field noise)
	• Temperature control
	• Allergic reactions
Postanesthesia care
Transport to and from OOR
ASA, American Society of Anesthesiologists; IV, intravenous; OOR, out of operating room.

Diagnostic Imaging Equipment

OOR locations generally contain large heavy, immobile equipment used for procedures such as fluoroscopy, magnetic resonance scanning, and computed tomography (CT). Fluoroscopy is widely used in many OOR locations, including interventional radiology, cardiac catheterization, and in the gastroenterology suite. Fluoroscopy is a technique used to obtain real-time moving images of the internal structures of a patient by using a fluoroscope. The patient is positioned between the x-ray source and the fluorescent screen and by coupling the fluoroscope to an x-ray image intensifier and video camera the images can be recorded and played on a monitor. Large C-shaped mobile fluoroscopy devices (C-arms) are used to provide images in multiple dimensions; these are moved back and forth around the patient and take up large amounts of space. Advances in technology have resulted in increasingly complex imaging techniques for both diagnostic and therapeutic purposes.

Anesthetic Equipment

The American Society of Anesthesiologists (ASA) Standards and Practice Parameters Committee issued guidelines for standards to be followed for all non-OR procedures involving anesthesiology personnel. These are outlined in Table 48.2. The Joint Commission requires that patients undergoing anesthesia or sedation receive the same care in OOR sites as they would in the OR. The anesthesia equipment and monitors in the remote location should be of the same standard as in the main OR. This creates a dilemma because OOR sites may only require anesthesia services intermittently. The anesthesia equipment, drugs, and monitors may be left in the OOR site for use when needed or all this equipment may be brought in each time an anesthetic is required. In areas where anesthesia is required on a fairly regular basis (at least 3-4 times a week) equipping and maintaining the OOR site with basic anesthesia equipment that can be quickly supplemented for a case is a reasonable model. However, problems may occur with this setup. Anesthesia equipment left in the OOR site may be damaged as a result of nonanesthesia personnel moving it, tampering with it, and/or borrowing pieces and not replacing them. Anesthesia machines and other anesthesia-related equipment need regular maintenance and can easily be overlooked if they are kept in
an area not routinely serviced by anesthesiology technicians. Hospitals may be reluctant to finance state-of the-art anesthesia equipment for a site where it is used infrequently and often the older machines are “retired” to the OOR site. This can create problems, as anesthesia personnel may not be familiar with anesthesia machine and monitors if they are different than the ones routinely used in the OR. Additionally drugs left in a remote site may go out of date if not used regularly.

TABLE 48.2 ASA GUIDELINES FOR MINIMAL STANDARDS OF CARE FOR ANESTHESIOLOGY PERSONNEL PROVIDING CARE IN NON-OPERATING ROOM LOCATIONS

STANDARD/REQUIREMENT		COMMENTS
1.	Oxygen—A reliable source of oxygen adequate for the length of the procedure	Piped oxygen is strongly encouraged. Prior to the anesthetic, the capacities, limitations, and accessibility of the oxygen supply must be considered. Backup oxygen—at least a full E cylinder is essential.
2.	Suction—A reliable and adequate source of suction	Suction standards should meet OR requirements.
3.	Scavenging—Where inhalation anesthetic agents are used, an adequate and reliable system for scavenging waste gases is required.	Extra lengths of tubing may be required to reach the patient.
4.	Resuscitation Equipment—A self-inflating hand resuscitator bag capable of administering at least 90% oxygen as a means to deliver positive pressure ventilation; an emergency cart with defibrillator, emergency drugs, and equipment to provide CPR must be immediately available.	MH cart and difficult airway carts should also be available.
5.	Anesthetic Drugs and Supplies	A supply of all the standard anesthetic drugs as well as emergency rescue drugs. Ideally, a cart similar to those used in the OR.
6.	Anesthetic Equipment	A functional anesthesia machine, ideally similar to those used in the OR.
7.	Monitoring Equipment	Adequate monitoring equipment to meet the ASA standards for basic monitoring. Invasive monitoring equipment may also be required.
8.	Electrical Outlets—The location must have sufficient electrical outlets to satisfy anesthesia machine and monitoring equipment requirements.	Clearly labeled outlets connected to an emergency power supply must also be available. In a “wet location,” isolated electrical power or electrical circuits with ground fault interrupters should be provided.
9.	Illumination—Adequate illumination of the patient, the anesthesia machine, and monitors is required.	Backup illumination must be available.
10.	Space—Sufficient space must be available to accommodate the equipment and personnel and allow expeditious access to the patient, anesthesia machine, and monitors
11.	Trained Anesthesia Support Staff—Adequately trained support staff and a reliable means of two-way communication.
12.	Building And Safety Codes—These must always be observed.
13.	Postanesthesia Management—Appropriate care for patients recovering from anesthesia must be provided together with trained recovery staff and facilities for safe transport of patients to the postanesthesia care unit.
CPR, cardiopulmonary resuscitation; MH, malignant hyperthermia; OR, operating room.

The alternative solution is to bring all the anesthesia equipment, drugs, and monitors into the OOR each time an anesthetic is required. A number of small portable anesthesia machines are available for this purpose; this is a more practical approach if anesthesia is performed infrequently. This setup does require extra preparation time; it is easy to forget essential equipment requiring anesthesia staff to make multiple trips back to the central anesthesia supply room. The development of a standard anesthesia cart containing all the necessary equipment that is restocked after every case and the use of checklists for all the drugs and equipment to bring each time an OOR anesthetic is required are essential. Checklists and preprepared carts will help the anesthesia technician prepare for an OOR anesthetic quickly and efficiently. It is also important for the anesthesiologist and technician to communicate ahead of time to make sure extra equipment such as special monitors or advanced airway devices are readily available if the case requires them. The provision of anesthesia in the magnetic resonance imaging (MRI) suite is a special situation. The presence of a strong magnetic field prohibits the use of any equipment containing ferrous metal. Specially developed anesthesia machines, monitors, and ancillary equipment are available for use in the MRI scanner.

Constraints Related to Imaging Techniques

In a regular OR the anesthesia station is usually well laid out with plenty of space so the anesthesia team has easy access to the patient and monitors. This may not be the case in an OOR site. Frequently, the anesthesia team, equipment, and monitors are crammed in around the bulky radiology equipment, and this may limit the anesthesiologist’s access to the patient, especially in an emergency (Fig. 48.1). The imaging techniques often require the patient to be moved in and out of the imaging device or to have the fluoroscopic imaging equipment move around the patient’s body. This is particularly true in neuroradiological procedures and in CT and MRI. It is extremely important to make sure the anesthesia circuitry, intravenous (IV) lines, urinary catheters, and monitoring cables are all of sufficient length to accommodate the patient moving back and forth on the imaging table. If breathing circuit and IV line lengths are not checked prior to starting the procedure, they are at risk of being dislodged with potentially disastrous results. Other challenges related to space and layout of the OOR site include the need for the anesthesiology team to be shielded from radiation. Transparent leadlined screens are positioned to protect the anesthesia team, but these may limit access to the patient.

▪ FIGURE 48.1 OOR location with radiology equipment and a limited anesthesia workspace.

Out of Operating Room Staff

In the OR, the nursing and technical staff are all very familiar with the role of the anesthesia team and are available to help in any anesthetic emergency. In the remote OOR sites, technical and nursing staffs have different skill sets and may not be so familiar with the conduct of anesthesia or how to help in an emergency. It is vital that the anesthesiologist has experienced anesthesia technical support immediately available to help and provide the correct equipment rapidly
in case of emergencies. One area where both the anesthesiology technician and the anesthesiologist can bring additional value to the OOR sites is to lead team communication and efforts to train OOR staff in emergency protocols. The whole team needs to know where the code cart with defibrillator and resuscitation drugs is located; these items need to be checked daily. All the staff working in OOR areas should be able to provide support and help manage emergencies such as cardiac arrest, airway emergency, and anaphylaxis. The management of anaphylaxis is particularly important, as patients may be allergic to the IV contrast media used in a number of radiological procedures. Although OOR personnel’s lack of familiarity with anesthesia emergencies can be a serious problem, they may also not be familiar with procedures that are routine in the OR. For example, patient positioning and padding are closely monitored in the OR, whereas OOR personnel may not be familiar with proper positioning and padding techniques for the lateral or prone position.

Environmental Hazards

Anesthesiology personnel are at risk from exposure to radiation every time they provide patient care in an OOR location that uses fluoroscopy or CT scanners. It is vitally important that all personnel are informed about the risks of radiation and the procedure to avoid exposure. The two most effective methods anesthesiology personnel can use to prevent occupational exposure to radiation are to (1) ensure they wear high-quality protective garments and (2) monitor their cumulative exposure using dosimetry badges. The risks of exposure to radiation are well known. Radiation directly damages cells in a dose-dependent manner, resulting in cell death. In addition, radiation causes defects in cellular DNA resulting in gene mutations, which can lead to the development of cancer, infertility, and in pregnant women, to fetal abnormalities. Recently, the eye has been recognized as being particularly vulnerable to radiation. Lens opacities and cataract formation are a significant risk for radiologists and other personnel working in radiology suites. Occupational exposure to radiation is carefully controlled and regulated by the National Council on Radiation Protection (NCRP). Personal dosimeters are small badges containing x-ray film; they are used to measure the radiation dose received. It is recommended that at least two dosimeters be worn, one under the lead apron and one at the collar above the lead apron. This allows an estimate of the amount of radiation delivered to unshielded areas as well as the integrity of protective lead aprons. It is important for the anesthesia team to be aware of, and to participate in, dosimetry monitoring if they routinely work in the radiology suite. The greatest source of radiation exposure for the anesthesiology team is scatter from the patient rather than being in the direct line of the x-ray beam. Controlling the dose delivered to the patient helps to reduce exposure for the staff, and protective shielding provides further protection. There are three types of shielding: