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Georgiadis PL, Tsai MH, Routman JS. Patient selection for nonoperating room anesthesia. Curr Opin Anaesthesiol 2024; 37:406-412. [PMID: 38841978 DOI: 10.1097/aco.0000000000001382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Given the rapid growth of nonoperating room anesthesia (NORA) in recent years, it is essential to review its unique challenges as well as strategies for patient selection and care optimization. RECENT FINDINGS Recent investigations have uncovered an increasing prevalence of older and higher ASA physical status patients in NORA settings. Although closed claim data regarding patient injury demonstrate a lower proportion of NORA cases resulting in a claim than traditional operating room cases, NORA cases have an increased risk of claim for death. Challenges within NORA include site-specific differences, limitations in ergonomic design, and increased stress among anesthesia providers. Several authors have thus proposed strategies focusing on standardizing processes, site-specific protocols, and ergonomic improvements to mitigate risks. SUMMARY Considering the unique challenges of NORA settings, meticulous patient selection, risk stratification, and preoperative optimization are crucial. Embracing data-driven strategies and leveraging technological innovations (such as artificial intelligence) is imperative to refine quality control methods in targeted areas. Collaborative efforts led by anesthesia providers will ensure personalized, well tolerated, and improved patient outcomes across all phases of NORA care.
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Affiliation(s)
- Paige L Georgiadis
- Department of Anesthesiology, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Mitchell H Tsai
- Department of Anesthesiology and Perioperative Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Anesthesiology, University of Colorado, Anschutz School of Medicine, Aurora, Colorado
- Departments of Anesthesiology, Orthopaedics and Rehabilitation, and Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Justin S Routman
- Department of Anesthesiology and Perioperative Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Beard J, Methangkool E, Angus S, Urman RD, Cole DJ. Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation. Anesth Analg 2023; 137:e8-e11. [PMID: 37224074 DOI: 10.1213/ane.0000000000006539] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- John Beard
- From the Department of Medical Affairs, GE HealthCare, Patient Care Solutions, Chicago, Illinois
| | - Emily Methangkool
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine; University of California, Los Angeles, California
| | - Shane Angus
- Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University School of Medicine, Washington, DC
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, Columbus, Ohio
| | - Daniel J Cole
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine; University of California, Los Angeles, California
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Bazerbachi F, White RM, Forbes N, Goudra B, Abu Dayyeh BK, Chandrasekhara V, Sweitzer B. Endo-anesthesia: a primer. Gastroenterol Rep (Oxf) 2022; 10:goac069. [PMID: 36381224 PMCID: PMC9664071 DOI: 10.1093/gastro/goac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.
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Affiliation(s)
- Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital, St Cloud, MN, USA
| | - Rodger M White
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Basavana Goudra
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - BobbieJean Sweitzer
- Systems Director, University of Virginia, Preoperative Medicine, InovaHealth, Falls Church, VA, USA
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Urdaneta F, Wardhan R, Wells G, White JD. Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting. Curr Opin Anaesthesiol 2022; 35:493-501. [PMID: 35787534 DOI: 10.1097/aco.0000000000001158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting. RECENT FINDINGS NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19. SUMMARY The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.
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Affiliation(s)
- Felipe Urdaneta
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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Prielipp RC, Amateau SK. Evolving Standards for Anesthesia During Advanced GI Endoscopic Procedures. Anesth Analg 2022; 134:1189-1191. [PMID: 35595692 DOI: 10.1213/ane.0000000000005874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Stuart K Amateau
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, Minnesota
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Herman AD, Jaruzel CB, Lawton S, Tobin CD, Reves JG, Catchpole KR, Alfred MC. Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review. Br J Anaesth 2021; 127:729-744. [PMID: 34452733 DOI: 10.1016/j.bja.2021.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.
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Affiliation(s)
- Abigail D Herman
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Candace B Jaruzel
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Sam Lawton
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Catherine D Tobin
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Joseph G Reves
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth R Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Myrtede C Alfred
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Routman J, Boggs SD. Patient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology. Curr Opin Anaesthesiol 2021; 34:430-436. [PMID: 34010175 DOI: 10.1097/aco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring. RECENT FINDINGS There have been improvements in the required monitors that are used for intraoperative patient care. Some of these changes have been with new technologies and others have occurred with software refinements. In addition, specialized monitoring devises have also been introduced into NORA locations (depth of hypnosis, respiratory monitoring, point-of care ultrasound). These additions to the monitoring tools available to the anesthesiologist working in the NORA-environment push the boundaries of procedures which may be accomplished in this setting. SUMMARY NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.
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Affiliation(s)
- Justin Routman
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Alabama, USA
| | - Steven Dale Boggs
- Department of Anesthesiology, College of Medicine, The University of Tennessee Health Science Center, Tennessee, USA
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