NORA Nonoperating room anesthesia (NORA) refers to administration of sedationlanesthesia outside the operating room to patients undergoing painful or Uncomfortable procedures. Aka Anaesthesia al Remate Locations aka Out patient Ax aka OBA ie Orfce Based Ax Three step approach to NORA Patients soos Pars 09 ‘rece meted arses cate MA Chen conor eit ares and heap troup pears reneshet ce Interventional pulmonology +E, endobronchial ultrasound ransbronchial needle aspiration, balloon bronchoplasty, airway stents, bronchoalveolar lavages 1 Assess for risk factors fr unstablecenical spine Topical and/or nebulized lidocaine Selaioner genera anesthesia may berequred pending onthe procedure ‘Magnetic resonance imaging + Use MR compatible pumps or extension tubingto run infusions from outside the MRI zone + wen an emergency takes place, remove patient from MRI zone to zones ‘Typically minimal sedation ‘Sedation or general anesthesia patents who areclaustophobe, phonophobieor unable to remain motionless + Wen general anesthesia s required, perform Induction and airway ASA guidelines for non-operating room anesthesizing locations. Reliable O2 source Safe electrical = Emergency cart, [with backup supply outlets for Sefisrliater, drugs, Se. een, illumination, battery communication backup = Applicable facility Fegiscitation bat oe " wsutficient space for " safety codes met anaesthesia Appropriate personnel, postanaesthetic equipment management, + Problems in providing NORA | Equipment might be old, not regularly serviced and not in standard use as in the rest of the hospital = Monitoring standards may not adequate. = Piped gases may not be supplied, © Other personnel may be unaware of the problems facing the anesthetist Space may be limited by bulky equipment making access to patient difficult |= Poor environment conditions( e.g. Lightening, temperature) |= Recovery facilities may not be available. |= Inadequate ventilation/ scavenging causing pollution. = Problems related to transferring patients. NON-OPERATING ROOM ANESTHESIA PROCEDURES Endoscopy + Eg, esophagogastroduodenoscopy, endoscope retrograde cholangiopanereatogrephy Precence of ihe endoscope ants placement can cause extemal Compression and ead to upper alrway obstruction Way require patient tobe in he prone/semi-prone position ‘Topical lidocaineot benzoeaine can be applied the pharynx Propofol andimidazolamare commonly used Interventional radiology Mostly performed under general anesthesia ‘Many procedures can be done under light to moderate sedation and peripheral nerve blocks + E29, phrenie nerve block for CT-guided pulmonary biopsies, paravertebral block for biliary drainage Interventional cardiology E.g, percutaneous coronary intervention, percutaneous transcatheter aortic valve replacement, transcatheter mitral valve repair Monitor for hemodynamic changes Have external defibrillator pads readily available Sedation can reduce length of stay compared to general anesthesia ‘management ousideot the Mlzone IVF + Retrieval of cooytes can be performed under paracervica, epidural spinal, end general anesthesia, 2s vell as IV sedation Complication of NORA Major Complications Unintended patient awareness (gastroenterologic locatiot Anaphylaxis (radiology procedures and cardiology locatior Need for upgrade of care Serious hemodynamic instability Respiratory complications Need for resuscitation Central and peripheral nervous system injury (radiology procedures and cardiology locations) Vascular access-related complications (radiology procedur and cardiology locations) ‘Wrong patient/wrong site (radiology procedures and cardiology locations) Fall or bum (radiology procedures and cardiology locatior ‘Minor Complications (in order of frequency) Postoperative nausea and vomiting, Inadequate postoperative pain control Hemodynamic instabity ‘Minor neurologic complications such as postdural puncture headache (cardiology and radiologic locations) Miner espatry complications (arcklogy and radiologic cations) ‘Complications related to centralintravenous lines (cardiology locations) \Need for opioid reversal (cardiology and radiologic locations)