Non-Operating Room Anesthesia

(NORA)
A Beginner’s Guide

Prepared by: Nadine Abi Younes ‘21

This is a summary you can use to ease your transition from
OR to non OR settings in order to maximize patient safety
and efficiency.
Introduction

 Sedation, especially in ambulatory sites, should not be

taken lightly. It may seem like a less risky and easier
approach than general anesthesia, but that is a
misconception.

 If your patient and environment are not assessed

properly and thoroughly prior to initiating the procedure,
extremely drastic situations can arise which may not be
as easily and quickly handled if not fully equipped.
Patient Factors
It goes without question that you should take a full pre-operative
history on all your patients. It is even more crucial in some
circumstances to know some details when you decide to sedate
as opposed to using a general anesthesia approach.
 Comorbidities
Obstructive Sleep Apnea (consider a quick screen if patient not
diagnosed previously)

Obesity

Severe GERD

Cardiac Conditions
• Any Prior Ischemia/Stents/CABG surgery (how recent, if on
any anticoagulation, if still symptomatic)
• If any devices: ICD/Pacemakers (ensure cardio team is on
board to check the device if cautery will be used)
• Heart Failure
• Arrhythmias
• If on any Betablockers ,antiarrhythmics (do not stop
perioperatively),
Recent or Current Upper Respiratory Tract Infections (especially
in pediatric populations)

NPO status
Be strict with these!
Aspiration is highly probable in sedation and disastrous if it
occurs, so ask and ask again to ensure proper NPO status before
initiating)
Airway
• Fully examine airway as well as question patient for any prior
episodes of difficult intubation
• Check for any anatomical or range of motion abnormalities to
anticipate difficult airways (dental, craniofacial, neck)
• Ensure all equipment needed should you face a difficult
airway is present and accessible to you (LMA, Ambu bag,
Video Laryngoscope)

Allergies (ex. Contrast)

Environmental Factors
Once you step out of the operating room, you will
immediately feel out of your comfort zone. Scan the
procedure room to familiarize yourself with it. You and your
therapist should both be comfortable and familiar with the
environment before you start.
Make sure that these factors are accounted for:

 Presence of oxygen source

 Suction (make sure this is ready and connected before you

start!)

 Lay out of room: try to ensure that during the procedure you
will have easy access to airway as well as any equipment
you should need if further problems arise)

 A monitor should be present which includes the basic

monitoring (spo2, ecg, end tidal CO2, NIBP) → this can be
present at the site, or brought as a portable monitor by you
and your therapist depending on locations
Materials/Readying the trolley:

 Usually the therapist will gather all materials needed for the day. It is
also your responsibility to ensure that nothing is forgotten so always
double check your trolley before heading out!

 Checking you trolley before you leave will also help you rapidly
locate any emergency equipment should you need to respond to
a situation quickly.

 Ensure you have

 Ambu bags/Laryngoscopes of all sizes (for adults and pediatrics

patients) and make sure you and the Therapist know where they
are

 Intubating Tubes/LMAs of multiple sizes

Emergency Medications

Atropine

Adrenaline (Ready dilutions for ease of access

should you need them quickly)

Ephedrine

Neosynephrin

Nitroglycerin

Adenosine/Amiodarone

Naloxone
Procedural Factors
You will have to tailor your anesthetic plan according to the
type of procedure. Below are some tips regarding some
common procedures we perform at our institution.
Obviously choices of anesthetics can vary highly due to
anesthesiologists’ preferences as well as patient and
procedure conditions.
GI procedures

 Involving upper airway (Endoscopy/ERCPs): Ensure

deeper sedation to prevent any laryngospasm,
coughing, or irritation once the scope is inserted into the
mouth.

 Obviously this should be done with caution to prevent

any apneic episode

 If no upper airway involvement (colonoscopy): ensure

adequate sedation and analgesia. This can be titrated
based on each patient, does not need to be very deep.
Lumbar puncture/Bone-marrow
Aspirate

 Note that BMAs are much more painful and stimulating

than Lps so ensure you deepen your patient more for
these procedures as well as include an analgesic.

 (Lp’s wont necessarily need the addition of an analgesic,

but you may need to include them if your patient is
tolerant to regular sedatives and needs a combination of
medications.)
 ECT
One of the most unique experiences outside of the OR.

 The psychiatry team will put a tight band on the patients toe (this will be to prevent
neuromuscular block from reaching the toe and monitor onset/offset of seizure)

 You will be asked to sedate and paralyze the patient. You will sufficiently ventilate the
patient until you announce to psychiatry that the patient is deep enough to initiate
procedure.

 You will remove your airway and insert the bite guard instead (do not forget this!)

 Once you give the ok, the team will induce a seizure. It will be for a very short time.

 Possible complications post the ECT include a drastic increase in BP (so have
medications ready to counteract this quickly, some clinicians give them empirically),
and arrhythmias.

(to note: this is a very brief summary of what to expect during ECT)
Cardiac Cath

 Ensure that the pads are placed correctly and

connected to a defibrillator should you need to shock
the patient.

 Some adult cardiac cases can be done under local +

sedation. However others need to be done under
general anesthesia.

 All pediatric cardiac cath cases are done under general

anesthesia for multiple reasons.
Complications
Some complications to keep an eye out for (not an extensive list):

 Aspiration

 Airway Obstruction

 Respiratory Depression

 Hypoxemia

 Hypercarbia

 Hypotension

 Arrhythmias
Logistics
Due to different procedures having to be done in different
locations of the hospital, at different times, and in accordance
with different team members, coordinating the logistics of
each procedure to ensure you stay on schedule can be a
hassle.

 The teams we deal with regularly have gotten better at

being on time, ensuring the patient gets there on time and
with the correct NPO status, and are more understanding of
the variable nature of our availability and scheduling.

 Samer Itani is an especially useful asset with regards to these

issues and can be involved when needed to ease the
process of communicating with several teams and
scheduling etc.. (Don’t tell him I told you so)
 Specific Tips:
 Radiotherapy: Some of these cases start 7:30 am and they page you early
to inform you patient has arrived. A lot of the patients come daily, so the
radiotherapy team usually has knowledge about positioning requirements
and how the patient usually responds to sedation + anxiety. Ask them if you
need additional info! They’re usually very Helpful.

 XRAY Room 4: usually ERCP’s are done in this room to follow the GI cases.

 GI Suite Usually Reem deals with scheduling. Patients start coming in at

around 8:30 am

 ECT/Psychiatry: Now perfomed in the Recovery room of the CT/Radio Area

 St Jude Out (Lp’s/Bone Marrow Aspirates): Randa usually calls you at

around 11am to ask if you’ll be available at 1pm (+/- 1 hours: usually the
children are not ready before then)
Extensions
Radiotherapy 5097,5100

Radiotherapy: 5087,5100

XRAY Room 5: 5055

XRAY Room 4: 5054

GI Suite 7400, 5403:

St Jude Out (Randa): 8111

St Jude In: 7645

MRI: 5193

CT : 5042

US: 7590

Samer ☺: 6800
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