Much of what makes modern anesthesia carry a lower risk than the anesthetics of yesteryear relates to consistency: standard monitors, evidence based guidelines, the ready availability of equipment and personnel to be able to respond to an emergency. Few things are as dangerous as the removal of that consistency in the provision of anesthesia services, yet this is often what occurs in the catch-all world of anesthesia outside the operating room.
The very term “out of OR anesthesia” speaks to the varied lack of predictability and consistency in which safe patient care must nevertheless take place. From imaging suites such as CT or MRI, interventional radiology, endoscopy, to electroconvulsive therapy treatment, cardioversion and ICU procedures, we are increasingly expected to make our services portable, to reproduce the consistency of care we provide in the operating room with far fewer resources.
In lieu of a well-stocked drug cart or Pyxis dispenser, we often tote along a pared-down drug box. Instead of a difficult airway cart, glidescope and fiberoptic scope around the corner, we sometimes are equipped with whatever airway equipment we had the forethought to carry with us; on a good day we’ll have an LMA and a bougie in addition to the standard laryngoscope and endotracheal tubes. Depending on the location, suction or ambu bags may or may not be readily available. Anticipation is key, and we must often strike a balance between being well-prepared for common emergencies and getting bogged down in lugging along backup equipment and drugs for every contingency. What makes this somewhat difficult is that oftentimes, out of OR anesthesia can be relatively uneventful. The procedural risks are rarely high, and we find ourselves bringing less and less to “only a cardioversion” or “just an ECT.”
There are few guidelines directing how out of OR anesthesia should be performed. The ASA recommends such basic equipment as a backup oxygen source, access to a crash cart, suction and bag mask. Adequate staff and light source, as well as a scavenging system if volatile anesthetics are used, are also detailed.
Ultimately, it is at the discretion of the anesthesiology provider to determine their own threshold of safety for out of OR anesthesia. While more studies are being conducted regarding safety practices and optimal regimens for the various locations out of OR anesthesia covers, it is a relatively new frontier with a great deal to uncover. We owe it to our patients to be as mindful of our practice outside of the operating room as we are within it.