Non-operating Room

Anesthesia
The Principles of Patient Assessment and
Preparation

a b,
Beverly Chang, MD , Richard D. Urman, MD, MBA *

KEYWORDS
 Non-operating room  Anesthesia  Preoperative  Evaluation  Assessment
 Procedural sedation

KEY POINTS
 Non-operating room (OR) anesthetics are becoming increasingly commonplace, which
often entails taking care of patients who are more medically challenging than patients in
the OR.
 Preoperative assessment may require a greater degree of resource coordination.
 Non-OR procedures present significantly different challenges for anesthesiologists during
preprocedure, intraprocedure, and postprocedure periods.
 There are significant ways in which anesthesiologists can add value and optimize effi-
ciency in the non-OR realm.

INTRODUCTION

Over the last decade, there has been a shift from procedures being performed strictly
in the operating room (OR) to less familiar locations within the far reaches of the hos-
pital as well as outside of the hospital setting. Especially given an increase in the aging
population with a significant disease burden, more procedures are being performed in
non-OR locations to take advantage of noninvasive techniques that potentially impart
less risk. Increasingly complex procedures are being performed in these settings in a
population that may not be amenable to traditional surgical correction. In addition, a
growing number of urgent and emergent procedures with medically unstable patients
are increasingly common occurrences in these areas.

There are no disclosures or conflicts of interest.

a
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and
Clinics, 300 Pasteur Drive H3580, Stanford, CA 94305, USA; b Department of Anesthesiology,
Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston,
MA 02115, USA
* Corresponding author.
E-mail address: [email protected]

Anesthesiology Clin 34 (2016) 223–240

http://dx.doi.org/10.1016/j.anclin.2015.10.017 anesthesiology.theclinics.com
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224 Chang & Urman

CHALLENGES OF NON-OPERATING ROOM PROCEDURES

Performing procedures outside of the OR creates a new set of challenges for anesthe-
siologists. Patients scheduled for non-OR procedures are often selected by the
severity of their disease, which prevents them from undergoing a major procedure
in the OR. These patients are sometimes more medically compromised and less opti-
mized compared with the general OR population. For some practitioners, the firmly
established familiarity with the OR and its resources is suddenly stripped away.
Many of the non-OR sites are located deep within the trenches of hospitals that often
require guides to locate for first-time visitors. Resources such as space, monitors,
anesthesia equipment, and medications may oftentimes be scarce or hidden. These
locations are often built without an anticipation for anesthesia needs and equipment,
and additional skilled personnel may be located far away. All of these difficulties create
a unique challenge that each anesthesiologist faces when delivering anesthetics in
these locations.1,2
As the interventional medical technology continues to advance, increasingly complex
procedures are being performed in all areas of non-OR specialties. In each hospital
setting, the number of non-OR cases performed is growing at a startling pace. A
medically complex patient population is often seen, and emergent procedures are
commonplace. Anesthesiologists are tasked with providing anesthetic care to patients
who are “too sick” or too frail for the OR in procedure rooms that are sometimes not staf-
fed or equipped to handle these patients. There is significant pressure to perform fast
evaluations with oftentimes only limited information, because many patients first present
on the day of the procedure or are scheduled as urgent or emergent cases. Anesthesiol-
ogists may be expected to recover patients in busy recovery suites without dedicated
extended postoperative monitoring capabilities and with staff who may not routinely
recover patients from general anesthetics. In other instances where anesthetic care by
anesthesiologists was not originally anticipated, anesthesiologists often become the first
responders to emergent situations where little to no information about the patient is avail-
able. Many patients are referred directly to the proceduralist by their regular providers,
without the benefit of a thorough preoperative evaluation until the day of the procedure;
this is also true of urgent and emergent add-on cases, where little time is available to
properly prepare the patient for anesthesia and optimize their comorbid conditions.
The reality is that many interventional procedures do not require anesthesia care,
but rather sedation by nonanesthesia providers. However, compliance with existing
standards of care for procedural sedation needs to be assured, regardless of the loca-
tion or the administering staff. Anesthesiologists will need to be the advocates for
setting standards and assuring compliance during procedures involving sedation by
nonanesthesiologists, in accordance with American Society of Anesthesiologists
(ASA) procedural sedation guidelines.3,4 There is also a growing involvement of state
and federal regulatory agencies. By monitoring outcomes and procedural events,
these agencies will continue to scrutinize non-OR areas where sedation or anesthesia
is being administered. Anesthesia and nonanesthesia physicians working in the non-
OR environment must ensure that the goals of medical optimization and regulatory
compliance that OR staff face are met in other areas. By the same token, anesthetic
care is mandated to be held to the same standard regardless of the location where
it is administered, as decreed by the Joint Commission on Accreditation of Healthcare
Organizations and the Center for Medicare and Medicaid Services.5
With the growing number of non-OR procedures, a significant number of patients
now require assessment before their procedural date. Many hospitals have a preop-
erative clinic or some kind of preoperative process in place to assess patients
 Non-operating Room Anesthesia 225

scheduled for the OR, but many may not have the resources to handle this additional
influx of patients. Anesthesiologists usually play an important role in initiating and
maintaining a preoperative clinic. However, funding and staffing of such clinics may
be challenging due to concerns of where the financial backing of such clinics should
fall: should it be the hospital, anesthesiology, surgery, or procedural departments?
Non-OR consults often create a strain on anesthesia departments, as “curbside” con-
sults are generally not billable. Official anesthesia consults are billable but do not
generate substantial value while requiring a significant amount of staff time. Many
non-OR evaluations are performed on the day of the procedure, but this may be
more costly by increasing the risk of procedural cancellations or delays.6 In addition,
establishing an organized process with a buy-in from all involved specialties and hos-
pital administration establishes more efficacy, patient safety, and satisfaction for all
stakeholders involved.
A formal triage process with protocols needs to be established. The staff placed in
the preoperative assessment role, such as physicians and nurses, needs to be
educated on proper triaging and selection of patients appropriate for each procedure
and sedation.7,8 Each facility needs to develop criteria that would automatically trigger
an anesthesia consult for patients at risk of failing procedural sedation. Stringent ed-
ucation efforts are necessary to provide nonanesthesiologists with key preoperative
assessment points and proper sedative selection. An additional challenge is the ur-
gency of some procedures that oftentimes precludes a proper preoperative assess-
ment. A process needs to be in place to triage these patients and provide the
proper anesthetic and procedural care under emergent situations. Most importantly,
a process needs to be established to communicate and notify treatment teams of con-
cerning findings and comorbid conditions that may affect the procedure and anes-
thetic offered.

QUALITY ASSURANCE

Continued quality assessments of the preoperative process need to be performed to

maintain appropriate patient selection and evaluation for non-OR cases.9 The number
of anesthesia preoperative consults per day should be quantified as should the num-
ber and reason for case delays and cancellations. The number of intraprocedural con-
sultations requested and urgency of the procedure should be noted. These measures
will allow for a periodic review of institutional guidelines and processes related to the
appropriateness of each selected procedural modality and the involvement of anes-
thesia providers. A multidisciplinary committee should be formed to review each inci-
dent report related to sedation and anesthesia complications. Many of these initiatives
can be championed by anesthesiologists who are familiar with the unique challenges
of patient comorbidities and sedation techniques.

ADDING VALUE AS ANESTHESIOLOGISTS

Anesthesiologists are the natural safeguards for patients requiring any type of proce-
dural sedation. With unique training in preoperative triaging and other aspects of peri-
operative management, anesthesiologists ensure a smooth transition for both patients
and proceduralists in the perioperative process whether in or out of the OR. Studies
have demonstrated cost savings and increased efficiency when preoperative evalua-
tion and testing is performed by anesthesiologists.10,11 Hospitals place significant
effort into increasing the efficiency of the OR, setting up preoperative clinics, pain
management teams, and after-anesthesia care unit resources to maximize revenues.
These same efforts now need to be directed to the non-OR realm. Supporting a
226 Chang & Urman

preoperative assessment system reduces the costs of non-OR cancellations and de-
lays, leading to increased efficiency and an ability to perform more procedures per
day. Numerous studies have demonstrated the financial justifications of establishing
an organized preoperative assessment process.12,13 Cost reductions can be seen in
decreasing nonreimbursed preoperative laboratory and diagnostic tests as well as un-
necessary preoperative consultations by specialty clinics. Reimbursements can be
maximized by standardization and accuracy of documentation, compliance with
pay-for-performance measures, and reimbursements for preoperative assessments.
Preoperative medical management reduces potential complications, hospital costs,
and length of stay. Lastly, a smoother, safer, and more streamlined process contrib-
utes to greater patient satisfaction.6

ANESTHESIA VERSUS PROCEDURAL SEDATION

Traditionally, most non-OR procedures have been performed without the presence of
anesthesiologists but under sedation administered by nonanesthesiologists. How-
ever, as increasingly complex procedures are introduced and patients with more se-
vere comorbidities are being scheduled, anesthesiologists have an increasing
presence in non-OR procedural rooms. With the advent of new technologies, whether
a patient or a proceduralist requires an anesthesiologist is a key question to ask during
each preoperative assessment. Numerous studies have demonstrated the complica-
tions of sedation and anesthesia in the non-OR setting.1,14,15 A recent review of
approximately 63,000 non-OR cases in a tertiary care center described adverse
events associated with all types of sedation and anesthesia, advocating for a robust
quality assurance system to track and report such events.16
For example, the ASA Closed Claims analysis by Metzner and colleagues17 revealed
that the most common non-OR anesthesia (NORA) claims were related to severe res-
piratory events leading to death and permanent brain damage, which occurred twice
as frequently as in the OR. NORA was associated with a greater degree of injury
compared with OR claims, whereas patient mortality was almost double that observed
in the OR (54% in NORA vs 29% for OR claims). Respiratory depression as a result of
anesthetic overdose accounted for 30% of all monitored anesthetic care claims. In
most cases, the care was deemed to be substandard and preventable with improved
monitoring, such as adherence to basic ASA monitoring standards. Furthermore, in
15% of the cases, monitoring with a pulse oximeter was absent. Fifty-four percent
of care in NORA locations was deemed to be substandard, and injury was determined
to be preventable in up to 32% of the cases. Most of the OR claims occurred in the
gastroenterology, cardiology, or emergency departments and involved significantly
elderly and medically complex patients.17,18 A large database analysis of the National
Anesthesia Clinical Outcomes Registry of the Anesthesia Quality Institute revealed
cardiology and gastroenterology patients to be more medically complex and older
as compared with the OR population. Although overall rates of complications were still
greater in the OR, subgroup analysis revealed an increase in both major and minor
complications as well as higher mortalities among cardiology and radiology patients
in NORA locations.19 Karamnov and colleagues20 demonstrated that more than 5%
of cases associated with adverse events were related to incomplete history taking
in the preoperative process. Greater than 10% of cases were due to lack of proper
intravenous (IV) moderate sedation certification in the administrating staff. Overall
data from both closed claims and database analysis from the AQI indicate that
many NORA complications may be preventable with increased vigilance and adher-
ence to the same standards of anesthetic care that is required in the OR.
 Non-operating Room Anesthesia 227

The inclusion of an anesthesiologist is typically made by the request of the proce-

duralist. Many institutions have guidelines in place for certain comorbidities or certain
procedures that identify the need for anesthesia assistance.21 Long procedures that
have the potential for needing surgical backup and cases that may precipitate insta-
bility should at least warrant an anesthesia assessment.22 In some high-risk sedation
cases, it is important to ensure that anesthetic backup is readily available, even if there
is no continuous anesthesia presence initially required for the procedure. However,
patients should be carefully evaluated and selected to receive anesthesia consultation
in order to maximize efficiency in workflow and in use of both anesthesia and hospital
resources. If cases or consultations are not appropriately scheduled, the ability to pro-
vide anesthesiology services to out-of-OR locations may not be financially feasible.23
Ultimately, this decision for anesthesia or procedural sedation with a nonanesthesiol-
ogist needs to be made on an individual basis. Certain procedures mandate the pres-
ence of an anesthesiologist to deliver general anesthetics and paralytics. Other
procedures, such as endoscopies and colonoscopies, may commonly be performed
with nonanesthesia sedation. However, specific patient characteristics may require
the presence of anesthesia staff even in the most routine procedures. Box 1 outlines
patient-specific factors that may require an anesthesia consultation to evaluate for a
need for anesthesia services during the procedure. However, one recent report
acknowledged that even though there are numerous studies on sedation practices
in the non-OR setting, there is a dearth of high-quality studies, especially the ones
comparing patient outcomes between different types of practitioners and
specialties.24

Box 1
Patients who may require an anesthesia consult

ASA class III, IV

Anticipated difficult airway (dysmorphic facial features, oral abnormalities, neck
abnormalities, jaw abnormalities)
Severe pulmonary disease
Obstructive sleep apnea
Obesity (body mass index >35)
Coronary artery disease, prior myocardial infarction, angina, valvular disease
Congestive heart failure
Pacemaker/defibrillator
Extremes of age
Pregnancy
Substance abuse
Failed procedural sedation
Unable to assume position needed for procedure
Patients with chronic opioid use
Patients who request an anesthesiologist
Personal or family history of significant problems with anesthesia (ie, malignant hyperthermia)

Adapted from Bader AM, Pothier MM. Out-of-operating room procedures: preprocedure
assessment. Anesthesiol Clin 2009;27(1):121–6.
228 Chang & Urman

Anesthesiologists are known for their contingency planning for the worst possible
outcome or scenario and for devising ways to prevent or minimize complications.
Careful examination of each patient’s history and comorbidities during the preopera-
tive assessment can provide the means to anticipate adverse events, ideally tailored
to each patient and procedure. This type of planning is just as important in the non-OR
setting. Preoperative planning in the non-OR setting should be focused on a few
important points.23 These include the following:

1. Familiarity with the location and resources of the anesthetizing location

2. Understanding the planned procedure and the requirements to perform it, such as
type of positioning, duration, necessary level of immobility and sedation, and so forth
3. A thorough medical screening of the patient and medical optimization for all dis-
ease states
4. Determination of the need for an anesthesiologist to perform the procedure
There are several guidelines related to providing care in the non-OR locations. For
example, according to the ASA Statement of Non-operating Room Anesthetizing Lo-
cations, minimum requirements for providing care include the following25:
1. A reliable source of oxygen adequate for the length of the procedure as well as a
backup supply. A central oxygen source is preferred and a back-up source should
include at least a full E cylinder
2. A reliable suction source
3. An adequate system for scavenging waste anesthetic gases
4. A self-inflating resuscitator bag capable of administering at least 90% O2 as a
means to deliver positive pressure ventilation
5. Adequate anesthetic drugs, supplies, and equipment for the intended anesthetic
care
6. Adequate monitoring equipment that adheres to the ASA Standards for Basic
Anesthetic Monitoring, which should be applied to all cases involving general
anesthesia, regional anesthesia, and monitored anesthesia care26
a. Qualified anesthesia personnel should be present throughout to conduct any
anesthetics
b. During all anesthetics, oxygenation, ventilation, circulation, and temperature
should be continually (regularly and frequently) monitored using the following:
i. Oxygenation: oxygen analyzer, pulse oximeter
ii. Ventilation: chest excursion, breath sounds, expired carbon dioxide moni-
toring, capnography, disconnection monitors
iii. Circulation: electrocardiogram, arterial blood pressure and heart rate moni-
toring, palpation of a pulse, auscultation of heart sounds, intra-arterial pres-
sure monitoring, peripheral pulse monitoring or pulse oximetry
iv. Temperature probe
7. In any location where inhaled anesthetics are used, there should be an anesthesia
machine equivalent in function to that used in the OR and maintained to current
OR standards
8. Sufficient electrical outlets that adhere to facility standards
9. Adequate illumination of the patient and equipment
10. Sufficient space to accommodate necessary equipment and personnel to allow
fast access to the patient and equipment when needed
11. Immediate access to an emergency cart with a defibrillator, emergency drugs,
and other equipment to provide cardiopulmonary resuscitation
12. Adequate anesthesia support staff should be readily available at each location
 Non-operating Room Anesthesia 229

13. Appropriate provision of after-anesthesia management and recovery with prop-

erly trained staff and monitoring equipment

ASSESSMENT OF OUT-OF-THE-OPERATING ROOM ENVIRONMENT

Providing anesthesia in the non-OR setting requires flexibility and a thorough under-
standing of the resources that are both present and absent. Box 2 lists examples of
NORA sites. The out-of-OR environment may differ significantly from the regular
flow of the OR, and it is important for anesthesiologists to familiarize themselves
with the objectives, structure, and workflow of these locations. These spaces are often
not built with anesthesiologists in mind. The procedure room may have limited space
and a plethora of procedural equipment. Many rooms contain a procedure room with a
control room used to monitor patients when radiation-based procedures are being
administered. Other locations contain bulky MRI and computed tomographic ma-
chines that shield the patient from the anesthesiologist’s view. Fluoroscopy suites
have moveable parts that may interfere with monitoring and equipment requiring
long extensions for IVs, medication lines, O2 tubing, and breathing circuits. MRI suites
have unique requirements for nonferrous equipment, limiting what can be brought into
the procedure room. Interference with continuous monitoring from these radiology
modalities can cause additional challenges in providing care to these patients.
Equipment that is often taken for granted in the OR, such as scavenging systems,
oxygen/air delivery systems, or suction may not be readily available or located in un-
reachable areas of the room. Many anesthesiologists may have to bring portable
equipment to these locations. Each piece of equipment should be identified and
checked before use. Monitoring should also be visually accessible to the anesthesia

Box 2
Non-operating room anesthetizing sites

Radiology
 Interventional
 MRI
 Computed tomography
 Ultrasound
 Radiation oncology
Gastroenterology
Cardiac interventions
 Electrophysiology
 Catheterization
 Interventional cardiology
 Transesophageal echocardiography
Lithotripsy
Electroconvulsive therapy sites
Emergency room
Intensive care units
Obstetric labor and delivery
Hospital wards
Ambulatory procedure rooms
Outpatient offices
230 Chang & Urman

team. The anesthesia provider should take note of the location of the difficult airway,
malignant hyperthermia, and Code Blue cardiopulmonary carts. A careful perusal of
each unfamiliar location should be performed before the start of the procedure. It is
important to determine where backup personnel are located and the means to reach
them. A process must be established to quickly retrieve additional medications and
equipment, if necessary. For example, having an automated medication dispensing
cabinet located inside the procedure room can facilitate quick access to the necessary
medications for the anesthesiologist and other staff. The careful planning and moni-
toring that has made anesthesiologists pioneers of patient safety in the OR should
be adhered to, just as, if not more stringently than, one does in OR-based locations.
Other considerations during procedure site reconnaissance include the
following27,28:
1. Where will the patient be induced: procedural bed, stretcher, other area?
2. Are the anesthesia equipment and O2 source close enough to the patient?
3. Is it possible to monitor the patient from a further distance when hazards such as
radiation require this?
4. Will additional portable monitors be necessary?
5. Does everyone in the procedure room know how to call a code and use the code
cart?
6. Are all personnel aware of what constitutes an anesthetic emergency?
Performing anesthetics at NORA locations requires intense communication and
teamwork. Many of the procedural staff may not be familiar with the unique require-
ments of anesthesia provision, which may impede workflow and cause unintended
harm. Team leadership should be emphasized and a collaborative environment needs
to be fostered, especially when taking care of a medically complex patient population.
These patients are often referred to interventional procedures as a last resort, when
more invasive procedures are not indicated or carry a higher risk. Therefore, both pro-
ceduralists and anesthesiologists can be faced with unexpected patient challenges
during the procedure, requiring quick responses and teamwork. Both patient and pro-
cedural concerns should be identified to the procedural team before the initiation of
the case.
Radiation safety must be a focus in the out-of-OR setting. Personnel operating in
these sites are routinely exposed to radiation doses higher than what most medical
personnel experience. The vast majority of occupational exposure is through fluoros-
copy. Long-term complications may involve thyroid disease, skin conditions,
cataracts, bone marrow suppression, and malignancy if radiosensitive cells (fast-
growing, undifferentiated cells) are not protected; this involves protecting the repro-
ductive organs, lenses of the eye, and thyroid gland. Fluoroscopy can introduce 20
times the radiation than a single exposure. Anesthesiologists who work close to the pa-
tient and the radiation beam must take care of shielding themselves. Because even
with proper leaded apparel up to 18% of all active bone marrow is still exposed to
the effects of radiation, it is important to protect as much body surface area as
possible.29 A protective panel of at least 0.25-mm lead equivalent should be positioned
between the patient and all other staff. By law, no one less than the age of 18 should be
allowed into the room during exposure. Lead aprons and thyroid shields that offer at
least 0.5 m of lead should be worn at all times and should be checked annually for dam-
age. Radiation beam attenuates are based on the inverse square law (1/d2); therefore,
placing a safe distance between the radiation beam is the safest way to decrease ra-
diation exposure.30 Radiation dosimeters should be worn outside of protective
clothing. Distance from the patient and radiation beam is the best form of protection.
 Non-operating Room Anesthesia 231

PREOPERATIVE PATIENT ASSESSMENT

The health assessment should begin with a careful history of patient’s comorbidities.
The ASA has developed a Practice Advisory for Preanesthesia Evaluation, an
evidence-based guideline that outlines all aspects of preoperative assessment and
testing.31 Each disease condition should be explored, noting severity, exacerbating
factors, and stability. Physician functional status should be assessed. Medications,
including over the counter and herbal supplements, should be reviewed. Social history
including substance, alcohol, and smoking use as well as a personal and/or family his-
tory of anesthetic complications should be noted. A targeted physical examination
should include, at the minimum, obtaining vital signs, auscultating the heart and
lung fields, abdominal examination, extremity examination, and a focused neurologic
examination. Last, a thorough airway examination with a dental assessment should be
completed, as outlined in Box 3.

Cardiovascular System
Cardiopulmonary events are the most feared complications during procedures, and
therefore, a thorough assessment should be performed. Although most non-OR pro-
cedures can be performed under less invasive means and do not require a general
anesthetic, any anesthetic may turn into a general anesthetic and any procedure
may require emergent resuscitation and transport to the OR for a surgical intervention.

Box 3
Basic elements of patient assessment

Age
Height
Weight
Allergies: reactions to allergens
Current medications, including over-the-counter medications and herbal supplements
Smoking status: how frequent, how long, and when was the last use
Illicit substance use: how frequent, how long, and when was the last use
Alcohol use: how frequent, how long, and when was the last use
Family history
Previous hospitalizations
Previous surgeries
Pregnancy status
Current medical conditions
Functional status
Focused physical examination
Airway examination
 Mouth opening
 Mallampati score
 Thyromental distance
 Dental condition
 Neck mobility
 Prior anesthesia records
232 Chang & Urman

According to the most recent American College of Cardiology and the American Heart
Association Guidelines for cardiovascular evaluation for noncardiac surgery, the pa-
tient should be cleared for the OR based on their disease status and current condition
of disease, risk factors, and the type and urgency of the procedure.32 Active cardiac
conditions include acute myocardial ischemia (within 7 days of onset), unstable or se-
vere angina, decompensated heart failure, severe valvular disease, or significant
arrhythmia.

CARDIOVASCULAR ASSESSMENT

Approximately one American experiences a coronary event every 34 seconds, and

coronary disease has caused approximately 1 of every 7 deaths in the United States
in 2011.33 The spectrum of symptoms range from asymptomatic to unstable, frequent
angina, and functional impairment. Each patient’s cardiovascular record should be
requisitioned with prior echocardiography, electrocardiography, and stress tests.
Baseline blood pressure and heart rate should be recorded, and these parameters
should be maintained within 10% of baseline under anesthesia. Patients with concern-
ing symptoms or risk factors without recent evaluation should receive an electrocar-
diogram, and further testing may be considered. The benefits of coronary
revascularization before a procedure are controversial, and the risks need to be
balanced with the risks of a procedure with significant disease burden.
Revascularized patients typically have either bare-metal or drug-eluting stents that
require a period of antiplatelet therapy that may cause increased bleeding risks during
procedures. Current guideline for therapy recommends at least a 1-month duration for
bare-metal stents and a 6-month duration for drug-eluting stents, although the optimal
period of therapy is still not completely clear.34 Many patients are maintained on these
medications for much longer than the officially suggested duration, and the risk of
holding these medications before instrumentation needs to be considered against
each patient’s risk factors. For patients who are anticipating surgery, there may be dis-
cussions with the cardiology team regarding the patient’s candidacy for bare-metal
stents due to the shorter mandatory therapy time. Elective procedures should be post-
poned until this period of therapy has been reached to prevent complications. Aspirin
should be continued during the perioperative period with the exception of certain pro-
cedures on closed spaces such as neurosurgical/neurologic interventional proce-
dures. These concerns should be discussed with the procedural team. Both
invasive and noninvasive procedures can increase a patient’s risk of stent thrombosis,
which is associated with high mortality.
Patients with congestive heart failure should be assessed for the presence of
decompensation based on both symptoms and physical examination. Prior echocar-
diograms should be evaluated to determine anatomic dysfunction. Although systolic
cardiac dysfunction is often the most worrisome type of heart failure, more than half
of all heart failure incidences are caused by diastolic failure. These patients should
be on salt restriction, b-blockers, and angiotensin-converting enzyme medications
and should have a well-managed blood pressure.
Severe valvular dysfunction often manifests with symptoms of heart failure. These
patients will require a thorough assessment of functional status and symptoms.
With severe valvular conditions, changes in either heart rate or blood pressure may
cause sudden and severe cardiac dysfunction. Maintenance of normal sinus rhythm
for atrial kick, volume status, heart rate, and blood control needs to be tailored for
the specific valvular abnormality. Finally, some patients may require endocarditis pro-
phylaxis during the procedure; the latest guidelines are outline in Box 4.
 Non-operating Room Anesthesia 233

Box 4
Conditions requiring endocarditis prophylaxis

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Prior history of infective endocarditis
Congenital heart disease (CHD)
 Unrepaired cyanotic CHD
 Completely repaired CHD with prosthetic material or device during the first 6 months after
the procedure
 Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or
prosthetic device
Cardiac transplant patients who develop cardiac vavulopathy

Adapted from Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis:
guidelines from the American Heart Association: a guideline from the American Heart Associ-
ation Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovas-
cular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular
Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary
Working Group. Circulation 2007;116(15):1745.

Patients with pacemakers and implantable cardioverter-defibrillators are seen with

increasing frequency in procedural rooms. Each anesthesiologist should be familiar
with the setting of each pacer, the patient’s condition that required its placement,
and the level of their pacemaker dependence. Each patient should be queried about
the frequency of defibrillation, and if there are any concerns, the pacemaker should be
interrogated. Each device reacts differently to magnet placement, including some that
do not revert to its original settings after magnet placement, making it even more
important to understand this function. Not all procedures require the placement of a
magnet, and this decision must be made on an individual basis, depending on the pa-
tient’s device dependence and location of the procedure. For patients who are
pacemaker-dependent, having the device changed to an asynchronous mode instead
of a sensed mode by a cardiologist on the day of surgery is recommended. Magnets
should only be used as a last resort during emergencies. In the devices with both
pacemaker and defibrillation capabilities, magnet placement may cause variable
changes in function. In many devices, only the antitachyarrhythmia function is
disabled without changes to the underlying pacemaker function. Therefore, reliance
on magnet placement is not recommended, and actual interrogation and disabling
of functions by cardiologists should be performed. Any device that has been deacti-
vated by a magnet should be interrogated and re-enabled before the patient leaves
the recovery room.35

PULMONARY ASSESSMENT

Despite the focus given to perioperative cardiac complications, pulmonary complica-

tions can contribute significantly to perioperative morbidity and mortality. Hypoxia and
desaturation are the most common occurrences seen in the perioperative period. Risk
factors include advanced age, chronic obstructive pulmonary disease (COPD), smok-
ing (current and prior history), heart failure, higher ASA class, impaired sensorium,
functional dependency, and obstructive sleep apnea.36 Surgical risk factors include
upper abdominal surgeries and any abdominal surgeries, duration of procedure, gen-
eral anesthesia, and emergent procedures. Elective procedures should be postponed
for patients with active respiratory disease for 6 weeks to decrease the risk of
234 Chang & Urman

pulmonary events. Patients with asthma or COPD should be assessed for medical
optimization and functional status. Although pulmonary function tests, radiographs,
and arterial blood gas provide information on a patient’s baseline status, these tests
are not necessary to perform during the preoperative assessment and have demon-
strated little benefit. Patients with severe disease and functional limitations may be
candidates for regional or neuraxial anesthesia in an effort to avoid airway manipula-
tion as well as perioperative bronchodilator therapy. Patients with sleep apnea should
be instructed to bring with them their home continuous positive airway pressure de-
vices on the day of the procedure.

GASTROINTESTINAL ASSESSMENT

Patients should be evaluated for conditions causing decreased gastric motility or full
stomach precautions. Severity of gastroesophageal reflex should be determined and
acid suppressants should be taken on the day of the procedure. Patients with con-
cerns for delayed gastric emptying, such as intestinal obstruction, gastroparesis,
trauma, emergent procedures, full stomachs, or opioid use, should be assessed for
rapid sequence inductions and the need for gastric decompression after induction.
For example, although many of the diagnostic gastrointestinal endoscopies (upper
endoscopy, colonoscopy) are performed while maintaining a natural airway, some
of these patients may pose a higher aspiration risk.

RENAL ASSESSMENT

Many non-OR procedures involve the use of fluoroscopy and IV dye, which can increase
the risk of renal injury. Contrast-induced nephropathy (CIN) has been associated with
up to 11% of all hospital-acquired acute renal failure. CIN is defined as a greater than
0.5 mg/dL increase in creatinine in patients with baseline creatinine less than 1.9 mg/
dL occurring within 48 to 72 hours after contrast administration in the absence of other
causes for renal injury.37 Patients without history of renal disease have very low risk of
CIN and do not require routine monitoring or prophylaxis.38,39 The single most important
risk factor for CIN is chronic kidney disease (serum creatinine >1.5 mg/dL), which im-
parts more than 20 times the risk compared with patients with normal renal function.
Additional risk factors include diabetes, male gender, diabetes, volume of contrast
agent, and renal impairment.40 Procedures that are most commonly associated with
CIN include coronary angiograms, angioplasties, and computed tomographic scans.37
Strategies for prevention of CIN are outlined in Table 1.
Dialysis-dependent patients should have dialysis on the day before the procedure
but generally avoid dialysis on the day of procedure because of concerns for electro-
lyte abnormalities and volume depletion.

OBSTETRIC ASSESSMENT

Pregnant patients should be assessed for the current status of their pregnancy, com-
plications, and need for intervention. Because of the potentially devastating complica-
tions associated with pregnancy, elective procedures should be postponed until after
delivery or until the second trimester. Procedures and medications administered dur-
ing the first trimester coincide with fetal organogenesis and they are best avoided,
while more invasive procedures during the third trimester may precipitate premature
labor.42 Abdominal procedures increase this risk.
All women of child-bearing age should be assessed for the possibility of pregnancy.
This assessment of the possibility of pregnancy is especially important for procedures
 Non-operating Room Anesthesia 235

Table 1
Guidelines for prevention of contrast-induced nephropathy

Glomerular filtration rate (GFR) >60 mL/min, Low risk for CIN, no follow-up or prophylaxis
normal or near normal renal function required
GFR <45–59 mL/min Low risk for CIN without risk factors, no
specific prophylaxis or follow-up required
If intra-arterial contrast is administered,
preventative measures are recommended
GFR <45 mL/min Moderate risk for CIN, preventative measure
recommended
CIN prevention strategies41 IV hydration
 For inpatients, 0.9% saline solution at
1 mL/kg/h for 12 h before the procedure
and 12 h after the procedure
 For outpatients, isotonic saline or sodium
bicarbonate solution at 3 mL/kg/h, a
minimum of 1 h before the procedure
and 6 h after the procedure is a
reasonable abbreviated alternative
N-acetylcysteine: inconclusive results but often
administered due to low cost and lack of
major adverse effects
Discontinue nephrotoxic medications 8 h
before administration of contrast
Avoid dehydration
Avoid high osmolar contrast
Dialysis patients do not require fluid hydration
before contrast administration

Adapted from Nicola R, Shaqdan KW, Aran K, et al. Contrast-induced nephropathy: identifying the
risks, choosing the right agent, and reviewing effective prevention and management methods.
Curr Probl Diagn Radiol 2015;44(6):503.

that involve high levels of radiation exposure. A pregnancy test should routinely be a part
of each assessment if there is any uncertainty about the woman’s menstrual history.

PROCEDURAL ASSESSMENT

Many procedures performed in the non-OR setting involve creative techniques and
maneuvering to access anatomic locations that may not be amendable for surgery.
A careful discussion of the planned procedure, the involved components, the need
for immobility, duration, and positioning should occur among the care team members.
The need for IV contrast, medications, and invasive blood pressure monitoring should
be ascertained before the procedure so that preventative measures can be taken.

DIAGNOSTIC TESTING

Diagnostic testing before each procedure must be individualized based on patient risk
factors and the procedure itself. For patients without baseline laboratory tests in
whom there are possible bleeding risks or renal injury risks, baseline laboratory tests
assessing coagulation status, hemoglobin, and renal function should be drawn and
blood typing should be obtained. Dialysis patients should have electrolyte levels
drawn after their last dialysis run. Diabetics should have documented preoperative
glucose levels on the day of the procedure, and glucose levels should be monitored
during the procedure, depending on its duration. Patients with concerns for cardiac
236 Chang & Urman

Table 2
Perioperative medication administration

Medication Perioperative Administration Instruction

Aspirin Continue unless contraindicated by the
procedure (ie, neurologic, ophthalmic
interventions) or by the proceduralist
b-Blockers —
Angiotension converting enzyme inhibitors Hold 12–24 h before procedure due to concerns
and angiotension receptor blockers of causing vasoplegia
Other antihypertensives Continue the day of surgery
Diuretics Hold on the day of surgery
Pulmonary inhalers Continue the day of surgery, bring to the
preoperative assessment center and
administer before the procedure
Gastrointestinal reflex medications Continue on the day of surgery
Neurologic therapies (dementia, Parkinson, Continue the day of surgery
seizure prophylaxis)
Antianxiety medications Continue on the day of procedure
Monoamine oxidase inhibitors Continue on the day of procedure unless risk
for serotonin syndrome is high and patient at
low risk for rebound from discontinuation.
Complete clearance requires 3 wk
Autoimmune and immunosuppressant Continue the day of procedure
medications
Steroids Continue the day of procedure
Patients using 5 mg a day of prednisone
equivalent for 3 wk have low risk of adrenal
suppression
5–20 mg per day of prednisone equivalent for
3 wk may cause adrenal suppression
20 mg/d for 3 wk will cause adrenal
suppression that may continue for a year
after cessation
Insulin Administer 1/3 to 1/2 dose the evening or
morning of procedure depending on
frequency of dosing. Hold short-acting
insulin
If insulin pump, continue lowest basal night
time rate
Measure blood glucose the morning of
procedure. These patients should be
scheduled as the first morning cases
Opioid and pain medications Take normal morning dose before procedure
Hold nonsteroidal anti-inflammatory
medications 48 h before procedure
Oral antiglycemic medications Hold on the day of surgery
Hold metformin on the day of surgery, risk of
lactic acidosis most prominent in renal or
hepatic failure
Herbal medication and supplements Hold for 7–14 d before procedure
 Non-operating Room Anesthesia 237

disease should have an electrocardiogram, whereas further testing should be decided

based on patient’s symptoms. Routine preoperative tests have rarely been shown to
impact patient management and improve patient care.31 In fact, instances of harm
have been documented due to pursuit of otherwise unknown abnormalities based
on these tests. Tests should only be ordered if they will impact the care provided.11

PREPROCEDURAL MEDICATION MANAGEMENT

The patient’s current medication list should be carefully examined to make sure it is up
to date, the dosages correspond to the actual amount of each medication taken, and
instructions by the patient’s providers, including the proceduralist, have been fol-
lowed. Some medications should be continued on the day of surgery, while others
should be held before the procedure, as outlined in Table 2. The risk of stopping
certain medications should be weighed against the risk of continuing them during
the periprocedural period; this is especially true for the management of anticoagulants
and antiplatelet medications.43

FUTURE DIRECTIONS

As non-OR procedures increase in frequency and complexity, a scientific approach to

triaging patients for proper selection of sedation by nonanesthesiologists or anesthesia
care needs to be developed. Algorithms that identify patient and procedural risk factors
that would benefit from further assessment or the presence of anesthesia staff will aid
physicians in providing the best care for each patient. Ideally, risk stratification strate-
gies can be developed that take patient, procedural, anesthesia, and location factors
into consideration. National standards and protocols for non-OR anesthetics for each
subspecialty and procedure will need to be further developed and evaluated against
patient outcomes. The standardization of patient assessment should be a result of inter-
disciplinary efforts by proceduralists, anesthesiologists, nurses, and hospital adminis-
trators. Lastly, there is a need to develop financial models to demonstrate the value of
NORA evaluation process and how creating an infrastructure for this process can posi-
tively impact periprocedural efficiency and patient outcomes.

SUMMARY

As the pioneers of patient safety, anesthesiologists should strive to maintain the same
standard of care throughout all anesthetizing locations. As the demand for NORA con-
tinues to increase, it is becoming more important than ever for the anesthesiologist to
deliver the same standard of care that is expected in the OR. In the NORA environ-
ment, where both proceduralists and support staff may have limited knowledge of
the patient’s history and anesthetic needs, an increased emphasis on proper patient
triaging and preoperative assessment by the anesthesia care team becomes impera-
tive. As procedures and techniques rapidly evolve, preoperative assessments need to
adapt concurrently. Oftentimes, this means that novel and unique management plans
need to be tailored to each patient for each specific procedure. Communication and
teamwork in these locations are equally important because many unknowns may arise
due to increasingly complex techniques and comorbidities. In this exciting new era of
medical advancement, anesthesiologists need to be at the forefront of promoting
patient safety. In collaboration with medical specialists of all specialties, anesthesiol-
ogists are ushering in a new era of improved patient care where they can add signif-
icant value.
238 Chang & Urman

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