Nonoperating Room Anesthesia (NORA)

Nonoperating room anesthesia (NORA) refers to the administration of anesthesia or sedation outside the operating room (OR).1 The popularity of NORA is increasing, with proportions of NORA cases (out of all anesthesia cases) rising from 28.3 percent in 2010 to 35.9 percent in 2014.2 Common NORA procedures fall under radiology, gastrointestinal imaging such as colonoscopy or endoscopy, diagnostic/therapeutic interventions, pediatric cardiac catheterization, psychiatric treatment and dentistry.1 As NORA becomes more commonplace, anesthesia providers must adapt their practices to fit the equipment, personnel and facilities associated with these procedures.1 Each non-OR site has its own anesthetic challenges and may be unfamiliar to the anesthesiology practitioner, causing technical, communication and operational issues.3 When providing patient care, anesthesia professionals should consider NORA-related procedure preparation and complications specific to NORA.1,4

Preparing for a NORA procedure may be unfamiliar to an anesthesia provider, but it is crucial to patient safety.1 As NORA procedures may be far from hospitals, anesthesiologists must ensure that the location has reliable sources of oxygen and suction; systems for scavenging waste anesthetic gases; resuscitation devices; anesthesia drugs, supplies and equipment for the required care; monitoring equipment; electrical outlets; proper illumination; sufficient space; and appropriate staff.1 Additionally, anesthesia providers should familiarize themselves with new devices and choose appropriate equipment based on the particular non-OR environment.4 The choice of anesthesia itself may also be different for a NORA procedure. For example, Lin and Weigel suggest that use of propofol sedation for low-risk, non-OR procedures may allow the allocation of scarce anesthesia resources to more complex surgeries.5 On the other hand, a review by Knigge and Hahnenkamp found that propofol use in non-OR endoscopic procedures may be concerning.6 The authors recommend that non-OR propofol be provided in a limited dose, along with careful titration, the addition of supplements like ketamine and dexmedetomidine, monitoring of anesthetic depth and vigilant airway control.6 Walls et al. emphasize that with the rapid growth of NORA, anesthesia providers should be more cautious than ever in preventing human error.7 Overall, NORA requires ample preparation of the non-OR location and of the anesthetic team.

Many complications can occur during the induction of NORA. These include, but are not limited to, wheezing, coughing, aspiration, allergic reaction, apnea, airway obstruction, delirium, IV-related complications, inadequate anesthesia supply, vomiting, requirement of emergency anesthesia consultation, hypothermia, unplanned admission to hospital, unexpected changes in vital signs and—in some cases—death.1 Though many of these complications could also occur in the OR, they are made more complex by the distance between non-OR settings and the hospital and other health professionals.1 A review by Tao and Oprea showed that issues such as chronic oral anticoagulation can cause risk of bleeding in non-OR procedures, making the anesthesiologist’s job more difficult.8 A review by Clark demonstrated higher severity of injury in non-OR procedures compared to those in the OR, with the most common complication being oversedation.3 Lin and Weigel cited NORA complications such as difficulties in endotracheal tube placement and the potential need to move to an OR.5 NORA may be useful in saving time, money or supplies,5 but it may present unique and difficult complications.8

The use of NORA is becoming more common, and it has various advantages and disadvantages. While NORA is helpful for various imaging and dental procedures, it comes with added challenges. Anesthesia providers must ensure the non-OR location and anesthetic team are adequately prepared for a procedure, and they may need to alter selection of anesthesia. Additionally, clinicians should be aware of the added complications that could arise during NORA induction. In the future, NORA facilities should standardize their equipment in order to preventable complications. Anesthesiology practitioners can take the lead in consistent NORA provision to improve patient outcomes and reduce adverse events.1

1.         Youn AM, Ko Y-K, Kim Y-H. Anesthesia and sedation outside of the operating room. Korean Journal of Anesthesiology. 2015;68(4):323–331.

2.         Nagrebetsky A, Gabriel RA, Dutton RP, Urman RD. Growth of Nonoperating Room Anesthesia Care in the United States: A Contemporary Trends Analysis. Anesthesia & Analgesia. 2017;124(4):1261–1267.

3.         Clark C. Non-operating Room Anesthesia. In: Sikka PK, Beaman ST, Street JA, eds. Basic Clinical Anesthesia. New York, NY: Springer New York; 2015:421–428.

4.         Mandel JE. Recent advances in respiratory monitory in nonoperating room anesthesia. Current Opinion in Anesthesiology. 2018;31(4):448–452.

5.         Lin OS, Weigel W. Nonoperating room anesthesia for gastrointestinal endoscopic procedures. Current Opinion in Anesthesiology. 2018;31(4):486–491.

6.         Knigge S, Hahnenkamp K. Nonoperating room anesthesia for endoscopic procedures. Current Opinion in Anesthesiology. 2017;30(6):652–657.

7.         Walls JD, Bramble WJJ, Weiss MS. Safety in the nonoperating room anesthesia suite is not an accident: Lessons from the National Transportation Safety Board. Current Opinion in Anesthesiology. 2019;32(4):504–510.

8.         Tao J, Oprea AD. Periprocedural Anticoagulation Management For Nonoperating Room Anesthesia Procedures: A Clinical Guide. Seminars in Cardiothoracic and Vascular Anesthesia. 2019;23(4):352–368.

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