NON OPERATING

ROOM ANAESTHESIA
(NORA)

PRESENTER : DR.RAVITEJA
MODERATOR:DR.VENKAT
GENERAL PRINCIPLES

 In recent years, the number of anesthetics

being delivered to patients in areas other than
the operating room has steadily increased.
 This is mainly related to the development of
large, complex equipment that cannot be
transported to the operating room for both
diagnostic and therapeutic procedures.
 The American Society of Anesthesiologists
(ASA) has developed practice guidelines for
sedation and analgesia by
nonanesthesiologists.
 Anesthesiologists undertake most of their
training in the operating room, surrounded
by familiar equipment and staff experienced
in the care of the anesthetized patient.
 Away from the operating room, the
anesthesiologist may not have this support.
 A simple three-step paradigm can be used to
approach an anesthetic assignment in an
alternate site.
 Anesthesiologists must maintain the same
high standard of anesthetic care provided in
the OR.

 The requirements for anesthesia and the pt's

underlying condition do not vary merely b/c
of location.

 The conditions under which the anesthetic

care is delivered vary greatly b/c of the
space and equipment available in these
locations.
GUIDELINES FOR ANESTHETIC CARE
DELIVERED OUTSIDE THE OPERATING
SUITE -ASA
1.a reliable oxygen source with backup

2. suction source;

3. waste gas scavenging;

4. adequate monitoring equipment to meet the standards for

basic anesthetic monitoring and a self-inflating hand
resuscitator bag;

5. sufficient safe electrical outlets;

(6) adequate illumination of the patient and
anesthesia machine with battery-powered
backup;

(7) sufficient space for the anesthesia care

team;
(8) an emergency cart with a defibrillator,
emergency drugs, and other emergency
equipment;

(9) a means of reliable two-way

communication to request assistance

(10) compliance of the facility with all

applicable safety and building codes.
 It is the responsibility of the
anesthesiologist providing care to ensure
that the anesthetizing location in which
that care is delivered meets all applicable
standards.
MONITORING:
 Appropriate pt monitoring is a universal
requirement for delivery of safe anesthetic care.

 The ASA standards for basic anesthetic

monitoring:

1.qualified anesthesia personnel -- present

throughout conduct of the course of anesthesia.

2.the pt’s oxygenation, ventilation, circulation,

and temperature be continually evaluated.
3.O2 conc. of inspired gas - monitored with the
use of a low-concentration alarm,

4.blood oxygenation - pulse oximetry,

5. ventilation -by observation of the pt.

6. the position of the ETT must be verified by

observation and by detection of ETCO2.

7.Continuous ETCO2 analysis should be performed.

8. When mechanical ventilation is used, a disconnect
alarm with an audible signal must be present.

9. Circulation -- ECG & measurement of arterial BP

( 5 minutes),

10. other assessments such as auscultation, palpation

of pulse, IBP monitoring, or oximetry.

11.When changes in body temperature are

anticipated patient temperature should be
assessed.
FACILITIES&EQUIPMENT:
 Many features of non–OR anesthetizing locations render
delivery of quality anesthetic care difficult.

 an awkward layout from the perspective of the

anesthesiologist,

 unfamiliar anesthetic equipment,

 the anesthetic implications of the procedure performed,

 the remoteness of available assistance,

 personnel less familiar than the usual personnel in the OR

with the anesthetic aspects of patient care.
 Access to the pt for anesthetic care is
hampered by diagnostic and therapeutic
equipment -- C-arms, other angiographic
equipment, u/s machines.

 Space for anesthesia equipment and drugs

may be limited and not conveniently
located.
 Piped-in gases, suction, and isolated power
are not always available in non–OR
anesthetizing locations.

 Anesthesia personnel must be familiar

with the gas cylinder supply for anesthesia
machines.

 The machines themselves may be older

models relegated from the OR to areas
where their use is less frequent.
“GUIDELINES FOR DETERMINING
ANESTHESIA MACHINE OBSOLESCENCE.”
1.the anesthesia machine should have essential
safety features such as a minimum gas ratio
device and oxygen failure alarm,

2. not have unacceptable features such as

measured flow vaporizers,

3. maintained and serviced.

4.Anesthesia machines that do not meet these

standards should not be used in any
anesthetizing location.
5.Anesthesia personnel must perform
standard machine checks before delivering
anesthesia and should be familiar with
operation of the machine,

6.Ideally, familiarization and machine checks

should be performed before the
procedure.

7. Grounded power outlets are a minimum

electrical requirement.
PERSONNEL &STAFFING:
 Nonanesthesia personnel involved in pt
care in non–OR anesthetizing locations,
including circulating nurses and radiology
technicians are less familiar with the
management of patients under anesthesia.
 Open communication b/n care teams is
essential b/c skilled assistance for the
anesthesia care team may be some distance
away.

 the presence of an adequate number of

anesthesia personnel in the immediate vicinity
of the care site is vital.

 Educational programs for personnel in non–OR

anesthetizing locations may be helpful in this
regard.
 Organization of the anesthesia department to provide
services both within and outside the OR is key to
efficient provision of patient care.

 Non–OR anesthetic locations with high utilization might

have full-time assignment of anesthetic personnel.

 Areas with lower utilization may require block

assignments of anesthesia times.

 centralized scheduling with the anesthesiology group to

provide care in a timely& efficient manner.
MEDICATIONS:
 Anesthesia techniques used in non–OR
anesthetizing locations range from no
anesthesia; to minimal, moderate, or deep
sedation/analgesia; to GA.

 mainly depends on the desired level of

anesthesia, the patient's underlying
medical condition, and the procedure to be
performed.
SEDATION/ANALGESIA
 the level of anesthesia at which pts are
able to tolerate unpleasant procedures
through relief of anxiety, discomfort, or
pain and at which uncooperative patients
are able to tolerate procedures requiring
that they not move.
MODERATE
SEDATION/ANALGESIA
 the level of anesthesia at which the patient
retains purposeful responses to
stimulation, requires no airway
intervention, and can maintain adequate
ventilation and cardiovascular function.
 Combinations of benzodiazepines (e.g.,
midazolam, diazepam) and opiates (e.g.,
alfentanil or remifentanil) -- mainstay of iv
sedation/analgesia.

 These drugs are titratable, and antagonists

are available: flumazenil for antagonism of
benzodiazepine-induced sedation and
naloxone for antagonism of opiate effects.
 use of barbiturates or propofol for
analgesia/sedation can result in rapid onset
of GA.

 ketamine alters the signs of anesthetic

depth, as well as cause airway obstruction
and pulmonary aspiration –used with
caution.
ANESTHESIA OUTSIDE OR:
 Radiology suite
 CT
 MRI
 Interventional neuroradiology
 Interventional cardiology
 Gastroenterology
 ECT
 Dental surgery
RADIOLOGY:
 Radiologic procedures that may require
sedation/analgesia :
 radiological interventions: percutaneous drain placement,

 nephrostomy tube placement,

 percutaneous placement of feeding tubes,

 placement of intravascular access catheters,

 thrombolysis,

 dilation of stenotic vessels,

 embolization of tumors or arteriovenous malformations

(AVMs),
GENERAL CONSIDERATIONS:
 the patient must often remain immobile for
prolonged periods.

 Most procedures may be accomplished with

minimal to moderate sedation/analgesia.

 The work environment in the radiology suite is

frequently ill adapted to safe anesthetic care of
patients.

 The rooms may be crowded, especially in older

radiology suites
 Pts & equipment are frequently moved
during the procedures to facilitate imaging,
& airway devices or iv access may become
dislodged,

 and the patient, or even the anesthesia

provider, may be injured.

 High-voltage equipment or the presence of

intense magnetic fields may result in current
leakage being conducted to the patient.
 Lack of gas scavenging may limit the
options of the anesthesiologist should GA
prove necessary for the procedure.

 Familiarity of the anesthesia personnel

with the environment in the anesthetizing
location is essential to provide safe patient
care.
RADIATION SAFETY:
 A unique hazard in the radiology suite is radiation
exposure .

 potentially harmful- its somatic effects

( leukemia) & genetic injury- fetal abnormalities
-damage to gonadal cells or the developing fetus.

 In the radiology suite, anesthesia personnel must

be aware of radiation safety and take precautions
when possible to avoid radiation exposure.

 Dosimeters should be worn to monitor exposure.

 the maximal permissible radiation dose for
occupationally exposed persons is 50
millisieverts (mSv) annually,

 a lifetime cumulative dose - 10 mSv × age,

 monthly exposure of 0.5 mSv -pregnant

women.
 Radiation exposure can be limited --by
wearing appropriate lead aprons &thyroid
shields, using movable leaded glass screens
& applying innovative techniques such as
video monitoring.

 Open communication and adequate

warning of initiation of imaging by the
radiology team.
IODINATED CONTRAST MEDIA:
 Adverse reactions :range from mild to immediately life
threatening,

 causes :direct toxicity, idiosyncratic reactions, allergic

reactions, either anaphylactic or anaphylactoid .

 Predisposing factors :h/o bronchospasm, h/o allergy,

underlying cardiac disease, hypovolemia, hematologic
disease, renal dysfunction, extremes of age, anxiety,
β-blockers, aspirin, and NSAIDS.
COMPUTED TOMOGRAHY:
CT –USES:
 to evaluate the status of a neoplastic process in the
thorax or abdomen.

 to visualize drainage of a liver abscess.

 Contrast studies of vascular malformations and tumors.

 Certain pulmonary neoplasms- metastases not suitable

for surgical resection, are amenable to CT-guided RF
ablations.
COMPUTED TOMOGRAPHY:
 inaccessibility of the pt during the procedure.

 With anesthetized patients, ensure that the sides of

the scanning tunnel do not occlude or dislodge the
breathing circuit or monitoring leads during the
procedure.

 exposure to ionizing radiation occurs during CT

scans.--The pt can be monitored visually through a
lead glass window/closed circuit TV.

 radiation-monitoring badges and protective lead

aprons and thyroid shields must be worn.
MAGNETIC RESONANCE
IMAGING:
MAGNETIC RESONANCE
IMAGING:
 MRI can reveal subtle differences between areas of dissimilar
anatomy, physiology, and pathology .
 Other advantages :

1. MRI can obtain images in any plane (transverse, saggittal, coronal,

or oblique).
 
2.  provides excellent soft tissue contrast.

3. provides intravascular contrast without the need for iv contrast

media.  

4. Very little patient preparation is required.

5. does not produce ionizing radiation, is noninvasive, and

6. does not in itself produce biologically deleterious effects.

HAZARDS &LIMITATIONS OF MRI:
1.Imaging is time consuming,

2. Any pt & physiologic motion (e.g., cardiac and vascular

pulsations, CSF flow , respiratory excursion, and peristalsis )
produce artifacts on the image.

3. when imaging the CVS, the signal acquisition is

synchronized or “gated” with phases of the cardiac cycle
[ECG] R wave) to virtually freeze cardiac motion.

4. Obese patients cannot be examined in this small magnetic

bore,

5. Switching the RF generators on and off produces loud noises

(>90 dB). Hearing protection is mandatory .
 The most significant risk in the MRI suite
-effect of the magnet on ferrous objects.

 Dislodgement and malfunction of implanted

biologic devices or other objects containing
ferromagnetic material occurs.

 shrapnel, vascular clips and shunts, wire

spiral ETTs, pacemakers, automatic
implantable cardioverter-defibrillators
(ICDs), mechanical heart valves, and
implanted biologic pumps.
 Pts with such devices should not undergo
MRI examination.

 Tattoo ink-- contain high conc.of iron

oxide.

 Burns at tattoo sites have been reported.

 Intraocular ferromagnetic foreign bodies
may migrate within the MRI field, and MRI
examination of patients with suspected
ferromagnetic ocular foreign bodies should
not be undertaken.
 rapid movement is possible when Fe-containing items are
brought into the vicinity of the magnetic field of the MRI .

 Typical objects include scissors, pens, keys, and gas cylinders.

 When brought into the vicinity of the MRI, the intense magnetic
field may attract them into the scanner bore at high velocity.

 The result when a pt is present in the scanner bore may be fatal.

 health personnel, maintenance workers, or visitors to the MRI

suite might be injured by objects flying at high velocity toward
the scanner.

 For this reason, ferromagnetic items must never be allowed in

the vicinity of the MRI magnet.
 the anesthesiologists caring for patients
-understand the restrictions in place on
access to the MRI suite and the reasons for
these restrictions.

 Anesthesia personnel who provide pt

care in the MRI suite should complete the
formal training program to become
recognized MRI personnel.
ANESTHETIC MANAGEMENT FOR
MRI:UNIQUE PROBLEMS
1.Limited patient access and visibility .

2.    Absolute need to exclude ferromagnetic components  

 
3.    Interference/malfunction of monitoring equipment by the
changing magnetic field &RF currents  

4.    Potential degradation of the imaging caused by the stray RF

currents produced by the monitoring equipment and leads

5.    The necessity to not move the anesthetic and monitoring

equipment when the examination has started to prevent
degradation of magnetic field homogeneity

  6.    Limited access to the MRI suite for emergency personnel .

 MRI-compatible anesthetic machines,Various
breathing circuits –are available.

 pt's airway is not easily accessed & pt

assessment and communication are limited
with MRI scanning, deep sedation/analgesia
is not advisable.

 Pts requiring more than moderate

sedation/analgesia are administered a GA
with airway control -ETT/LMA.
 induce anesthesia in an induction area
adjacent to the MRI suite by using
conventional equipment with the pt on a
MRI transport table (not ferromagnetic).

 the patient is shifted into the MRI suite,

where anesthesia and monitoring are
continued with MRI-compatible devices.
 The MRI transport table -- used to remove
the pt rapidly from the scanner if an
emergency arises.

 This is important b/c the ferromagnetic

equipment used for pt resuscitation must
never be brought into the MRI scanner
room.
MONITORS IN MRI:
 ECG:ST&T wave changes occurs,

 Pulse oximetry:thermal injury b/c of wires,

 NIBP,capnography,temperature monitoring–
effective.
 At the end of the examination, the pt is
transferred back to the induction area and
awakened .

 Pts are discharged when they are

documented to have met conventional
discharge criteria.
INTERVENTIONAL CARDIOLOGY:
 Interventional cardiology procedures :
coronary angiography and cardiac
catheterization,
 coronary artery angioplasty/stenting,
 valvotomy,
 endovascular closure of intracardiac
defects,
 endovascular cardiac valve replacement,
 electrophysiologic studies with pathway
ablation, and cardioversion.
 Cardiac catheterization is performed in children
with congenital heart disease for both
hemodynamic assessment and interventional
procedures.
 Careful cardiac assessment is essential, and the
presence of a trained pediatric anesthesiologist
is desirable.
 Patients often present with cyanosis, dyspnea,
congestive heart failure, and intracardiac shunts.
 Hypoxia, hypercarbia, and sympathetic
stimulation as a result of anxiety may exacerbate
cardiopulmonary abnormalities
 In patients with a patent ductus arteriosis, high
oxygen tension can lead to premature closure
and should be avoided.
 Prostaglandin infusions are often used to
maintain duct patency.
 Meticulous attention must be paid to preventing
air bubbles entering intravenous lines because
they may cross to the arterial circulation via a
right-to-left shunt.
 Diagnostic, noninterventional studies are often
performed with sedation, and local anesthetic is
injected at the site of femoral puncture
 Oral sedation techniques include chloral
hydrate, 75 to 100 mg/kg, or a mixture of
meperidine, promethazine, and
chlorpromazine.
 Intravenous agents include midazolam,
morphine, and ketamine.
 Ketamine is useful in children with
myocardial depression and can be used as an
infusion together with propofol.
 Fentanyl, midazolam, and etomidate are
alternatives.
 General anesthesia is necessary when
children cannot tolerate sedation techniques
and/or have significant cardiac or other
morbidity, and when the procedure involves
severe hemodynamic disturbances such as
ventricular septal defect occlusion.
INTERVENTIONAL
NEURORADIOLOGY
 commonly performed interventional
neuroradiologic procedures:
 embolization of cerebral and dural AVMs,

 coil embolization of cerebral aneurysms,

 angioplasty of atherosclerotic lesions, and

 thrombolysis of acute thromboembolic

stroke.
 These procedures may involve deliberate
hypotension,

 deliberate hypercapnia, or deliberate cerebral

ischemia as part of the procedure;

 a requirement for rapid transition between

deep sedation/analgesia and the awake,
responsive state;

 and severe potential procedural complications.

ANESTHETIC CONSIDERATIONS:
 Sedation may be accomplished with a
number of drugs alone or in combination:
benzodiazepines, opiates,
dexmedetomidine, or propofol.

 GA - volatile to TIVA , - with prompt,

gentle emergence to allow neurologic
evaluation and avoid complications.
 Heparin is commonly administered during these
procedures, with a target activated clotting time
(ACT) of 2 to 2.5 times the baseline value.

 Deliberate hypotension-embolization of AVMs to

decrease flow to feeding vessels,- esmolol,
labetalol.

 Deliberate hypertension- cerebral ischemia to

maximize collateral flow- Phenylephrine-to increase
SBP 30% to 40% above baseline.

 Vasopressin may be a superior alternaive.

GASTROENTEROLOGY
UPPER GASTROINTESTINAL ENDOSCOPY

 Patients may have a number of

comorbidities, including disease of the
esophagus and stomach, with a risk of reflux,
biliary, and hepatic disease with esophageal
varices, hepatic dysfunction, coagulopathy,
and ascites.
 The procedure is tolerated without sedation in 66
to 81% of patients, and conscious sedation is usually
sufficient in the remainder.
 With general anesthesia, patients usually require
endotracheal intubation to protect the airway and
facilitate passage of the endoscope.
 The LMA has also been used successfully in adults
and children as an alternative device for airway
management.
 Local anesthetic is sprayed into the oropharynx to
facilitate passage of the endoscope; this can
abolish the gag reflex, increasing the risk of
aspiration
 A bite block is inserted to prevent the
patient from biting down on the endoscope
and damaging both the teeth and the
endoscope.
 Procedures are performed in the prone or
semiprone position with the patient's head
rotated to the side.
 This position makes the airway less
accessible.
 Care and attention should also be paid to
pressure areas, particularly the eyes, lips,
and teeth.
 Extreme rotation of the neck should be
avoided. Most procedures are brief, lasting
10 to 30 minutes, and are generally painless.
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

 ERCP is important in the diagnosis and treatment

of both biliary and pancreatic disease.
 During the procedure, the endoscope is
advanced via the mouth into the stomach, and
then into the duodenum where the ampulla of
Vater is visualized.
 The biliary and pancreatic duct systems may then
be instrumented, and therapeutic maneuvers
such as the passage of stents or removal of
stones carried out.
 Sphincter of Oddi manometry may also be
performed.
 Patients usually experience discomfort
during ERCP, particularly with
instrumentation and stenting of the biliary
and pancreatic ducts.
 Conscious or deep-sedation techniques are
recommended for the procedure, which
usually lasts between 20 and 80 minutes.
 Only 5 to 8% of patients require general
anesthesia.
 ERCP in the prone position can be particularly
problematic if careful attention is not paid to
maintenance of a patent airway.
 If sphincter of Oddi manometry is being
performed, glycopyrrolate, atropine, and
glucagon should be avoided because they effect
sphincter pressure.
 Opioids, particularly morphine and fentanyl,
cause spasm of the sphincter of Oddi, which
may be relieved with naloxone.
 Meperidine, in contrast, reduces the frequency
of sphincter of Oddi contractions.
 Patients presenting for emergency ERCP may
have significant comorbidity, including acute
cholangitis with septicemia, jaundice with
liver dysfunction and coagulopathy, bleeding
from esophageal varices resulting in
hypovolemia.
 Intravenous hyoscyamine given as a 0.5-mg
bolus before the procedure has been shown
to reduce the incidence of spasm, shorten
the procedure, and improve patient comfort;
sinus tachycardia may occur.
DENTAL SURGERY

 General anesthesia may be required during

more complicated or prolonged cases and
when patients are uncooperative, phobic, or
mentally challenged.
 Patients may also present for dental
clearance prior to undergoing cardiac surgery
or heart transplantation with severe
cardiomyopathy or valvular abnormalities.
Down syndrome is commonly encountered, and
the anesthesiologist should be aware of
1. cardiac abnormalities, including conduction
abnormalities and structural defects,
2. the risk of atlanto-occipital dislocation,
3. a variety of potential airway problems,
including macroglossia, hypoplastic maxilla,
palatal abnormalities, or mandibular
protrusion.
 If the patient is positioned head-up in the
dental chair, vasodilation and myocardial
depressant effects of anesthetics can be
pronounced, especially in patients with
cardiovascular diseases.
 Patients with neuromuscular diseases may
have a history of aspiration and episodes of
chronic recurrent pneumonitis that must be
addressed before dental surgery.
 During and after dental surgery blood, saliva,
and dental debris are present in the upper
airway.
 A throat pack is used to help protect the
airway, and this must be removed at the end
of surgery.
 Tracheal intubation, often via the nasal
route, is required to protect the airway,
although the LMA has been used successfully
for both adults and children undergoing
dental surgery.
 The immediate postoperative complications
include bleeding, airway obstruction, and
laryngeal spasm.
 Reanesthetizing the patient for treatment of
dental hemorrhage can be very difficult
because of the presence of blood in the
airway and the risk of pulmonary aspiration.
 Later complications in ambulatory patients
include drowsiness, nausea and vomiting,
and pain.
ELECTROCONVULSIVE THERAPY
(ECT)
 ECT is used to treat depression, mania, and
affective disorders in schizophrenic patients,
as well as a number of other psychiatric
disorders.
INDICATIONS FOR ECT
 Severe depression: if drug treatment fails
or is not tolerated ( i.e. elderly with
Parkinson's disease )
 Bipolar disorder: manic or depressed
phase
 Acute or Catatonic Schizophrenia
 Depression in pregnancy: with acute
mania
 ECT RISKS
 Sympathetic stimulation leads to dysrhythmias,
hypertension and tachycardia with myocardial ischemia in
at-risk patients.
 Cerebral oxygen consumption increases up
to 7 fold..
 Muscle pain is common and fractures are
possible with inadequately relaxed patients
 Memory loss and dis-orientation are
common side effects..
CONTRAINDICATIONS TO ECT
ABSOLUTE RELATIVE
 CV
 Recent MI < 3 months;  Pregnancy
 Severe angina, CHF  Thyrotoxicosis
 Aneurysm of major vessel
 Cardiac
 Pheochromocytoma
dysrhythmias
 CNS
 Glaucoma
 Cerebral tumor or
aneurysm  Retinal detachment

 Recent CVA <1 month

 Respiratory System
 Severe respiratory failure
ANESTHETIC CONSIDERATIONS

 Patients presenting for ECT are often

elderly, with a number of coexisting
conditions; therefore, a thorough
preoperative assessment and workup should
be performed.
 Patients may be taking a variety of drugs,
which can have important interactions with
the anesthetic agents.
 The monoamine oxidase inhibitors have the
most significant interactions.
ANESTHETIC REQUIREMENTS
 amnesia
 airway management
 prevention of bodily injury from the seizure
 control of hemodynamic changes
 smooth, rapid emergence
INDUCTION AGENTS

 methohexital Sodium : 0.5-1 mg/kg

 thiopental: 2-4 mg/kg
 ketamine: 0.5-2 mg/kg
 propofol: 1.5-3 mg/kg
 etomidate: 0.15-0.3 mg/kg
INDUCTION AGENTS
An ideal agent:
 rapid unconsciousness, painless on
injection, no hemodynamic effects, no anticonvulsant
properties, rapid recovery, and inexpensive
 methohexital Sodium : 0.5-1 mg/kg
 thiopental: 2-4 mg/kg
 ketamine: 0.5-2 mg/kg
 propofol: 1.5-3 mg/kg
 etomidate: 0.15-0.3 mg/kg
MUSCLE RELAXANTS
 Objective:
-to improve injuries to musculo skeletal systems.
-to improve airway.
 Principle:

- moderate relaxation
- Usually half the induction dose.
MUSCLE RELAXANTS
Succinylcholine: 0.3-1.5 mg/kg.

Atracurium, 0.3-0.5 mg/kg

Mivacurium, 0.15-0.2 mg/kg

Rocuronium, 0.45-0.6 mg/kg

 Anesthesia is induced and the patient is ventilated
with 100% oxygen using an oral airway and a self-
inflating bag and mask.
 Moderate hyperventilation is beneficial prior to the
ECT to improve the quality and duration of
seizures, and it has been suggested that the LMA
may be useful to improve ventilation during ECT.
 Before administering the seizure, a bite guard is
placed to protect the teeth.
 The parasympathetic effects of ECT, salivation,
transient bradycardia, and asystole can be
prevented by premedication with glycopyrrolate or
atropine
 A number of drugs have been used to attenuate
the hypertensive and tachycardic responses
that accompany ECT.
 Labetalol (0.3 mg/kg) and esmolol (1 mg/kg)
both have been shown to ameliorate the
hemodynamic responses, although esmolol has
a lesser effect on seizure duration than
labetalol.
 The calcium channel antagonists nifedipine,
diltiazem, and nicardipine all attenuate the
hemodynamic responses to ECT, particularly in
combination with labetalol.
 The α2-adrenergic receptor agonists
clonidine,and more recently,
dexmedetomidine(1 µg/kg administered over
10 minutes just before induction of
anesthesia) have been shown to be effective
in controlling blood pressure without
affecting seizure duration.
TRANSPORT OF PATIENTS

 Patients who receive anesthesia or sedation

at alternate sites may need to be
transported to the PACU at the end of the
procedure; this may be some distance away.
 During transport, patients should be
accompanied by a member of the anesthesia
team.
 Portable ventilators are useful for transport;
however, these are often oxygen-powered,
and adequate supplies of oxygen must be
available for the transfer, as well as a
manual self-inflating bag to allow hand
ventilation in the event of ventilator failure.
 Similarly, the infusion pumps and portable
monitors should have adequate battery
power to allow them to continue working in
transit.
 The anesthesiologist should carry spare
anesthetic and emergency drugs, equipment
for intubation or reintubation, portable
suction.
 It is useful to notify persons in the
destination area that the patient is in transit
so appropriate preparations to receive the
patient can be made in advance.
SUMMARY

 The number and complexity of procedures that

are performed at alternate sites is steadily
increasing.
 This has led to an expansion of anesthesia
services in areas remote from the operating room
that may not be familiar to anesthesia providers.
 In preparing to administer anesthesia or sedation
in an alternate site, a simple three-step approach
involves giving careful consideration to the needs
of the patient, the particular problems posed by
the procedure, and the hazards and limitations of
the environment.
 In all cases, the standards of anesthesia care
and monitoring should be no different than
those provided in the conventional operating
room.
REFERENCES:
 MILLER’SANESTHESIA
 BARASCH
THANK YOU!