Procedural Care of the Adult Cancer Patient Outside of the Operating Room

Introduction

The cancer patient often requires complex diagnostic, therapeutic, and palliative care procedures in nonoperating room (non-OR) sites, which has created an increasing demand for anesthesia services in remote locations outside of the traditional operating room (OR). Remote areas requiring anesthesia continues to expand, and anesthesia services are now frequently requested for endoscopy, diagnostic radiology, interventional radiology (IR), radiation oncology, nuclear medicine, as well as for procedures such as bone marrow aspiration and biopsy. Technological advancement and movement toward minimally invasive approaches have moved procedures that were once performed in the OR to non-OR locations. Historically, patients in these remote locations were given conscious sedation by a certified nurse under the supervision of the proceduralist. The relationship between anesthesia services and proceduralists can be complex and challenging, requiring that the medical specialties gain familiarity with one another. The proceduralists and personnel in remote areas must be familiar with the anesthesia practice guidelines and standards of anesthesia to promote the highest level of safety possible for the patient. The anesthesiologist must be knowledgeable of the procedure, treatment or imaging technique, potential complications, and the anesthetic needs required for a successful procedure, treatment, or scan. The increased need for anesthesia in complex diagnostic, therapeutic, and palliative procedures performed in the cancer patient has created a demand for expertise in non-OR anesthesia (NORA). This chapter discusses the principles of sedation and analgesia as well as the role and challenges of the anesthesia team while providing services in the various NORA locations such as diagnostic radiology, IR, interventional gastroenterology and endoscopy (GI), and radiation therapy (RT).

Practice Guidelines

The American Society of Anesthesiologists (ASA) has long been an advocate for patient safety. Although anesthesiologists may not be directly involved in the care of all patients receiving sedation and analgesia for a procedure outside of the OR, there is a high likelihood that they are involved in creating, revising, and organizing sedation services throughout the hospital. Some medical subspecialties, such as the American College of Radiology (ACR), have practice parameters for the safe administration and monitoring of sedation and analgesia for NORA. The key components of these guidelines and regulations are defining the continuum for sedation and anesthesia and the qualifications for those administering the sedatives and analgesia. This requirement states that qualified individuals must have competency-based education, training, and experience to evaluate patients appropriately prior to sedation; administer sedation safely; and have the ability to rescue patients from the next level of sedation. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond, therefore the practitioners administering sedation must be qualified to recover or rescue the patient from the next level of sedation. This requirement states that qualified individuals must have competency-based education, training, and experience to evaluate patients appropriately prior to sedation; administer sedation safely; and have the ability to rescue patients from the next level of sedation. Practitioners intending to induce moderate sedation must be competent to manage a compromised airway and inadequate oxygenation and ventilation. Practitioners intending to induce deep sedation are competent to rescue a patient from general anesthesia (GA), being able to manage an unstable cardiovascular system as well as a compromised airway and inadequate oxygenation and ventilation.

Screening

All patients requiring anesthesia services should be evaluated according to the ASA practice advisory for preanesthesia evaluation. Each institution or department may decide what preprocedure tests are appropriate. Specifically, guidelines for moderate and deep sedation include:

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Presedation assessment
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Appropriate patient selection
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Immediate reevaluation prior to sedation
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Post Anesthesia Care Unit (PACU) admission and discharge assessment
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Sedation plan and communication among all patient providers
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Informed consent
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ASA monitors
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Outcome collections to improve patient care

There is a wide spectrum of cancer patients who present for NORA. Some may have no other comorbidities, and some may have psychiatric or pain syndromes, rendering them unable to tolerate the required position for their diagnostic or therapeutic procedure. Some cancer patients have multiple comorbidities or may require a palliative procedure. Although the same types of patients may also come to the OR, there may be a different plan for patients who are critically ill because they may not be appropriate surgical candidates. Critically ill patients often undergo procedures that are considered minimal but urgent, such as drainage of an abscess, placement or exchange of a stent, central venous line placement, or ablation of a lesion that is not surgically treatable. Most of the procedures scheduled for NORA locations are planned and usually bloodless; however, timing is essential and may be uncertain based on patient acuity. These patients often have complex medical problems, are critically ill, and can be extremely challenging from an anesthetic and positioning standpoint.

There are several commonly used approaches to screening patients scheduled for NORA. These include one of the following formats: an anesthetic preoperative visit prior or medical proceduralist office visit prior to the day of the procedure, telephone interview with a review of a health survey, or preprocedure screening on the morning of surgery. Each option has its own advantages and disadvantages. To satisfy the Joint Commission (TJC) requirements, the medical proceduralist will select one of these approaches. Like surgeons, some proceduralists may choose to have a clinic for consultation prior to the actual day of the procedure. The preprocedure assessment reviews medical history, medications, allergies, and fasting guidelines, and determines the need for an anesthesiologist. In the traditional OR the anesthesia care provider is always present and will select the type of anesthesia based upon the patient’s comorbidities and surgeon’s request. NORA procedures differ in that the proceduralist or oncologist must recognize the need for an anesthesia care provider and request this service. For a procedure that mandates deep sedation or a general anesthetic, the consultation is clear; however, patient factors that determine the need for an anesthesia care provider for minimal or moderate sedation are not well defined.

The ASA Task Force on Sedation and Analgesia by Nonanesthesiologists has developed guidelines to assist medical proceduralists to identify higher risk patients, such as major comorbidities, abnormal or difficult airway, and increased tolerance to pain medications that may require the presence of an anesthesia care provider. Other factors that may contribute to the need for anesthesia services are pediatric patients and patients with known or suspected difficult airways, morbid obesity, sleep apnea, prone position, claustrophobia, pain syndromes, family history of difficulty with anesthesia, or those who have had prior difficulties with nurse administered sedation. These guidelines should be transformed into an algorithm that is followed during the preprocedural assessment schedule, which can be used to determine the need for an anesthesiologist during the procedure.

Scheduling

Scheduling procedures between anesthesiology, oncologists, and proceduralists can be challenging. Most anesthesiology departments typically have clinical coordinators who are responsible for daily scheduling and staffing needs. The same is true for IR, GI, RT, and radiology, and is often referred to as the “traffic coordinator.” Anesthesiology clinical coordinators responsible for staffing and scheduling prefer a consistent day of procedures, which allows for the most efficient use of personnel. If an entire day of anesthesia services is not required, it is preferred for procedures requiring anesthesia services to be performed as “first cases.” Proceduralists typically prefer to schedule outpatient procedures prior to inpatient procedures. While the number of procedures requiring anesthesia services is increasing, there may not be a full day’s worth of procedures to require a dedicated anesthesia team. Creating a schedule requires daily communication between the “traffic” coordinator and the anesthesiology coordinator. The two service coordinators share the responsibility to keep both services on schedule. In our institution each proceduralist has a NORA suite assigned to them. The need for anesthesia personnel in a suite is determined by whether at least one of the procedures requires anesthesia services. The anesthesia team will then care for all the patients scheduled for that NORA suite. This allows for efficient use of the anesthesia staff. It also allows the medical department performing procedures to effectively staff their other suites requiring minimal or moderate sedation without anesthesia services.

Anesthesia Provider Evaluation

Although sometimes difficult to arrange, the preprocedural interview and evaluation by an anesthesiologist is beneficial. In addition to lessening anxiety about the treatment and anesthesia, the anesthesiologist will be able to identify potential medical problems, determine their etiology, and if indicated, initiate appropriate corrective measures, thereby minimizing any potential delays, cancellations as well as complications on the day of the procedure. For NORA, it is often the anesthesiologist who is most involved in the direct medical care of the patient. The anesthesiologist must ensure that the patient is appropriately screened, evaluated, and informed prior to the procedure. The anesthesiologist-patient relationship often takes on a primary care quality in NORA.

An important component of the preanesthesia evaluation is assigning ASA Physical Status to the patient ( Table 18.1 ). The anesthetic risk attributed to a procedure depends on the preoperative status of the patient. The presence of comorbidities that may influence the incidence of postoperative morbidity and mortality needs to be recognized at the preoperative visit and then clinically optimized prior to the procedure. Detailed evaluation of these major organ systems with a focus on corrective measures is combined with selected pharmacologic agents, anesthetic technique, and monitoring to provide optimal care.

Table 18.1

ASA Physical Status Classification System

ASA Physical Status Classification	Definition	Adult Examples, Including But Not Limited to:
ASA I	A normal healthy patient	Healthy, nonsmoking, no or minimal alcohol use
ASA II	A patient with mild systemic disease	Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease
ASA III	A patient with severe systemic disease	Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents
ASA IV	A patient with severe systemic disease that is a constant threat to life	Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V	A moribund patient who is not expected to survive without the operation	Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA VI	A declared brain-dead patient whose organs are being removed for donor purposes

ARD , Acute renal disease; ASA , American Society of Anesthesiologists; BMI , body mass index (kg/m ²); CAD , coronary artery disease; COPD , chronic obstructive pulmonary disease; CVA , cerebrovascular accident; DIC , disseminated intravascular coagulation; DM , diabetes mellitus; ESRD , end-stage renal disease; HTN , hypertension; MI , myocardial infarction; PCA , postconceptional age; TIA , transient ischemic attack.ASA Physical Status Classification System, 2020 is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173–4973.

Extrapolating from the traditional and ambulatory surgery literature, geriatric and higher risk (ASA III and IV) patients may be considered acceptable candidates for NORA procedures if their systemic diseases are well controlled, and the patient’s medical condition is optimized preoperatively. ^, Often it is the presence of comorbidities that makes the risk/benefit ratio of an image-guided procedure more acceptable than traditional surgery. The anesthesiologist must have an informed discussion with the patient or the health care proxy about the increased risk of morbidity and mortality. If necessary, the anesthesiologist may collaborate with other members of the patient’s care team to determine whether any consultations or preprocedure therapies are indicated prior to the procedure to minimize the risk of anesthesia. The anesthesiologist may be asked to care for a patient whose illness is life threatening and the proceduralist’s intention may be palliative. For procedures aimed at improving the patient’s quality of life, the anesthesia care provider requires flexibility and complex case management skills. With few exceptions, the appropriateness of a case for NORA is determined by a combination of factors, including type of procedure, anesthetic technique, and risk/benefit ratio.

Non-operating Room Anesthesia

The anesthesiologist must adopt and adapt to a new mindset when providing services outside of the traditional OR. The health care providers from anesthesiology and the medical department performing the procedure are often unfamiliar with one another. The location, equipment, and room arrangement vary from the OR. In addition, the types of procedures are unfamiliar and the scheduling patterns differ. At our institution, proceduralists schedule and perform elective procedures, but they are often called upon to perform “add-on” urgent and emergent in-patient cases that may represent half of the daily schedule. These “add-on” patients often have extensive medical comorbidities resulting from recent surgery and/or end-of-life palliative care needs. The urgent or emergent need for a procedure often leaves little time for medical optimization; however, the proposed procedure may offer a cure to these acutely debilitated patients. The anesthesiologist caring for this unique patient population outside of the traditional OR must be adept at developing a safe anesthesia plan while maintaining safe clinical practice guidelines.

When anesthesiologists are not involved, the procedure suite is typically staffed with the proceduralist, a circulating registered nurse (RN), and technologists qualified to manage various equipment. Guidelines for sedation given without anesthesia services are commonly defined by specific institutional sedation policies, and the sedation process is overseen by the proceduralist performing the procedure. RNs are responsible for sedating and monitoring the patient while the technologist assists with the positioning and technical aspects to optimize the success of the procedure.

The integration of the anesthesia care team consisting of anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) or anesthesia residents alters this traditional model. The anesthesia care team training and experience is based upon the OR and surgical procedures. The NORA suite, with its equipment and diversity of procedures, is often unfamiliar ground for the anesthesia care team. The anesthesiologist is often uneasy outside of the traditional, well-equipped OR, and the presence of competent anesthesia technical support is essential in NORA locations. Anesthesia supplies, suction, oxygen supply, medications, and an anesthesia ventilator are necessary items in a NORA suite. ^, The additional anesthesia equipment and supplies potentially create space and logistical issues and concerns in the procedure suite, and communication becomes essential to a successful program. It is critical for the proceduralist to explain the procedures being performed to the anesthesia team as well as the potential complications and the depth of anesthesia required. The anesthesia team must describe the differences, indications, risks, and benefits between monitored anesthesia care (MAC) and general anesthesia (GA). The patient’s history, associated comorbidities, and required position during the procedure should also be discussed among the teams.

Adverse events are unexpected situations that occur during clinical activities and may result in temporary or permanent, physical and/or mental damage to the patient, and increased health care costs to society. In 2008 the World Health Organization (WHO) launched “Safe Surgery Saves Lives” and developed a “Surgical Safety Checklist” ( Fig. 18.1 ). NORA suites, with their varied and complex procedures, rapid patient turnovers, and patient populations with increased comorbidities would also benefit from a process that incorporates a safety checklist. Three important safety goals of TJC are improving accuracy in patient identification, improving communication between health care coworkers, and eliminating all wrong-site, wrong-patient, and wrong-procedure interventions.