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Ambulatory Anesthesia in Remote Locations

  • Ambulatory Anesthesia (GP Joshi, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The use of anesthesia services in non-operating room locations is increasing and ranges from minimal sedation–analgesia to general anesthesia. This review addresses important challenges encountered by anesthesia providers when working in remote locations.

Recent Findings

The reduced physical space, ergonomics, limited anesthesia resources, and isolation from the operating room areas make these remote locations hostile environments for the anesthesia provider. Evidence suggests that anesthetic complications in remote locations are more severe than those occurring in the operating room, are associated with suboptimal care, and are preventable by better monitoring.

Summary

Anesthesia providers need to be familiarized with the complexity and hazards of the environment and the type of procedures found in non-operating room locations. The standard of care for anesthesia delivery outside the operating room must be the same, despite the location where the anesthetic service is provided or the limitations of the location.

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References

Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. Ferrari LR. Anesthesia outside the operating room. Curr Opin Anaesthesiol. 2015;28(4):439–40.

    Article  PubMed  Google Scholar 

  2. Schubert A, Eckhout GV, Ngo AL, Tremper KK, Peterson MD. Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook. Anesth Analg. 2012;115(2):407–27.

    Article  PubMed  Google Scholar 

  3. Hansen TG. Sedative medications outside the operating room and the pharmacology of sedatives. Curr Opin Anaesthesiol. 2015;28(4):446–52.

    Article  CAS  PubMed  Google Scholar 

  4. • Parashchanka A, Schelfout S, Coppens M. Role of novel drugs in sedation outside the operating room: dexmedetomidine, ketamine and remifentanil. Curr Opin Anaesthesiol. 2014;27(4):442–7. Recent literature is reviewed regarding dexmedetomidine, ketamine and remifentanil for its use outside the operating room. Sedationists have to keep in mind the pharmacokinetics and pharmacodynamics of the currently used agents in adults and children.

  5. Chatman N, Sutherland JR, van der Zwan R, Abraham N. A survey of patient understanding and expectations of sedation/anaesthesia for colonoscopy. Anaesth Intensive Care. 2013;41(3):369–73.

    Article  CAS  PubMed  Google Scholar 

  6. Lai YC, Manninen PH. Anesthesia for cerebral aneurysms: a comparison between interventional neuroradiology and surgery. Can J Anaesth. 2001;48(4):391–5.

    Article  CAS  PubMed  Google Scholar 

  7. Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010;23(4):523–31.

    Article  PubMed  Google Scholar 

  8. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–38

  9. Turunen E, Miettinen M, Setala L, Vehvilainen-Julkunen K. An integrative review of a preoperative nursing care structure. J Clin Nurs. 2016.

  10. • Karamnov S, Sarkisian N, Grammer R, Gross WL, Urman RD. Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. J Patient Saf. 2014. doi:https://doi.org/10.1097/PTS.0000000000000135. The most common adverse event and unplanned intervention were oversedation leading to apnea and the use of reversal agents. Oversedation, hypoxemia, reversal agent use, and prolonged bag-mask ventilation were most common in cardiology and gastroenterology suites.

  11. Youn AM, Ko YK, Kim YH. Anesthesia and sedation outside of the operating room. Korean J Anesthesiol. 2015;68(4):323–31.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Boquet G, Bushman JA, Davenport HT. The anaesthetic machine–a study of function and design. Br J Anaesth. 1980;52(1):61–7.

    Article  CAS  PubMed  Google Scholar 

  13. Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology. 1990;73(5):995–1021.

    Article  CAS  PubMed  Google Scholar 

  14. Szalados JE. Anesthesia in remote locations: medicolegal risks and strategies for minimizing liability. Int Anesthesiol Clin. 2009;47(2):105–31.

    Article  PubMed  Google Scholar 

  15. Crosson JA. Keeping patients safe: the importance of collaboration. AORN J. 2015;101(2):279–81.

    Article  PubMed  Google Scholar 

  16. Biber JL, Allareddy V, Allareddy V, Gallagher SM, Couloures KG, Speicher DG, et al. Prevalence and predictors of adverse events during procedural sedation anesthesia-outside the operating room for esophagogastroduodenoscopy and colonoscopy in children: age is an independent predictor of outcomes. Pediatr Crit Care Med. 2015;16(8):e251–9.

    Article  PubMed  Google Scholar 

  17. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH. Pediatric Sedation Research C. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795–804.

    Article  CAS  PubMed  Google Scholar 

  18. Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087–96.

    Article  PubMed  Google Scholar 

  19. Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol. 2006;19(4):436–42.

    Article  PubMed  Google Scholar 

  20. Domino KB. Trends in anesthesia litigation in the 1990s: monitored anesthesia care claims. ASA Newsletter. 1997;61:15–7.

    Google Scholar 

  21. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009;22(4):502–8.

    Article  PubMed  Google Scholar 

  22. Domino KB. Office-based anesthesia: lessons learned from the closed claims project. ASA Newslett. 2001;65(9–11):5.

    Google Scholar 

  23. Organizations TJCoAoH. Procedure for intravenous conscious sedation. Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL1999. p. TX73–TX9.

  24. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Basic standards for preanesthesia care 2015. http://www.asahq.org/quality-and-practice-management/standards-and-guidelines. Accessed 16 June 2016.

  25. • Chang B, Urman RD. Non-operating Room Anesthesia: The Principles of Patient Assessment and Preparation. Anesthesiol Clin. 2016;34(1):223–40. Preoperative planning in the non-operating room setting should be focused on both a careful patient assessment and getting familiarized with the location and resources of the anesthetizing location.

  26. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol. 2010;23(4):494–9.

    Article  PubMed  Google Scholar 

  27. Evron S, Ezri T. Organizational prerequisites for anesthesia outside the operating room. Curr Opin Anaesthesiol. 2009;22(4):514–8.

    Article  PubMed  Google Scholar 

  28. Gross WL, Urman, R.D. Challenges of anesthesia outside the operating room. In: Urman RD, Gross WL, 1st edition. Anesthesia outside of the operating room. New York: Oxford University Press; 2011. p. 1–7.

  29. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Statement on nonoperating room anesthetizing locations 2013. Available from: http://www.asahq.org/quality-and-practice-management/standards-and-guidelines. Accessed 16 June 2016.

  30. Schenker MP, Martin R, Shyn PB, Baum RA. Interventional radiology and anesthesia. Anesthesiol Clin. 2009;27(1):87–94.

    Article  PubMed  Google Scholar 

  31. Watkinson AF, Francis IS, Torrie P, Platts AD. Commentary: the role of anaesthesia in interventional radiology. Br J Radiol. 2002;75(890):105–6.

    Article  CAS  PubMed  Google Scholar 

  32. Murselovic T, Adanic Mikloska I, Bajic Rifai M, Majeric Kogler V. Role of anesthesiologist in endovascular management of intracranial aneurysms. Acta Med Croatica. 2008;62(1):69–71.

    PubMed  Google Scholar 

  33. Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol. 2007;41(Suppl 3):S344–51.

    Article  PubMed  Google Scholar 

  34. Gonsalves M, Belli A. The role of interventional radiology in obstetric hemorrhage. Cardiovasc Intervent Radiol. 2010;33(5):887–95.

    Article  CAS  PubMed  Google Scholar 

  35. Guzzardi G, Fossaceca R, Divenuto I, Musiani A, Brustia P, Carriero A. Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula. Cardiovasc Intervent Radiol. 2010;33(4):853–6.

    Article  PubMed  Google Scholar 

  36. Miraglia R, Maruzzelli L, Piazza M, Gallo G, D’Amico M, Spada M, et al. Real-time ultrasound-guided placement of a pigtail catheter in supine position for draining pleural effusion in pediatric patients who have undergone liver transplantation. J Clin Ultrasound. 2016;44(5):284–9.

    Article  PubMed  Google Scholar 

  37. Trotteur G, Stockx L, Dondelinger RF. Sedation, analgesia and anesthesia for interventional radiological procedures in adults. Part I. Survey of interventional radiological practice in Belgium. JBR BTR. 2000;83(3):111–5.

    CAS  PubMed  Google Scholar 

  38. Yilmaz M, Mamanov M, Yener M, Aydin F, Kizilkilic O, Eren A. Acute ischemia of the parotid gland and auricle following embolization for epistaxis. Laryngoscope. 2013;123(2):366–8.

    Article  PubMed  Google Scholar 

  39. Fontalvo LF, Amaral JG, Temple M, Chait PG, John P, Krishnamuthy G, et al. Percutaneous US-guided biopsies of peripheral pulmonary lesions in children. Pediatr Radiol. 2006;36(6):491–7.

    Article  PubMed  Google Scholar 

  40. Molla N, AlMenieir N, Simoneau E, Aljiffry M, Valenti D, Metrakos P, et al. The role of interventional radiology in the management of hepatocellular carcinoma. Curr Oncol. 2014;21(3):e480–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Naumann H, Pittaway A, Lynn AM, Vo NJ. CT-guided percutaneous lung biopsy under general anesthesia: a pediatric case series and literature review. Paediatr Anaesth. 2012;22(5):469–75.

    Article  PubMed  Google Scholar 

  42. Uller W, Wohlgemuth WA, Hammer S, Knoppke B, Goessmann H, Loss M, et al. Percutaneous treatment of biliary complications in pediatric patients after liver transplantation. RoFo. 2014;186(12):1127–33.

    Article  CAS  PubMed  Google Scholar 

  43. • Courbon C, Bize P, Chollet Rivier M, Denys A. High-frequency jet ventilation for HIFU. Cardiovasc Intervent Radiol. 2014;37(5):1397–8. Interventional radiology procedures in organs close to the diaphragm can be facilitated in selected patients by general anesthesia with high-frequency jet ventilation, which provides immobility of internal organs.

  44. Denys A, Lachenal Y, Duran R, Chollet-Rivier M, Bize P. Use of high-frequency jet ventilation for percutaneous tumor ablation. Cardiovasc Intervent Radiol. 2014;37(1):140–6.

    Article  PubMed  Google Scholar 

  45. Bryson EO, Frost EA. Anesthesia in remote locations: radiology and beyond, international anesthesiology clinics: CT and MRI. Int Anesthesiol Clin. 2009;47(2):11–9.

    Article  PubMed  Google Scholar 

  46. •• Committee on S, Practice P. Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the american society of anesthesiologists task force on anesthetic care for magnetic resonance imaging. Anesthesiology. 2015;122(3):495–520.This article describes the updated ASA guidelines for safe anesthetic practice in magnetic resonance imaging suites.

  47. Wynnychenko TM, Szokol JW, Murphy GS. Infusion pump use in the MRI. Anesth Analg. 2000;91(1):249–50.

    CAS  PubMed  Google Scholar 

  48. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring (Approved by the ASA House of Delegates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011). https://www.asahq.org/quality-and-practice-management/standards-and-guidelines/. Accessed on 16 June 2016.

  49. Mason KP, Burrows PE, Dorsey MM, Zurakowski D, Krauss B. Accuracy of capnography with a 30 foot nasal cannula for monitoring respiratory rate and end-tidal CO2 in children. J Clin Monit Comput. 2000;16(4):259–62.

    Article  CAS  PubMed  Google Scholar 

  50. Henneberg S, Hok B, Wiklund L, Sjodin G. Remote auscultatory patient monitoring during magnetic resonance imaging. J Clin Monit. 1992;8(1):37–43.

    Article  CAS  PubMed  Google Scholar 

  51. Tse ZT, Dumoulin CL, Clifford GD, Schweitzer J, Qin L, Oster J, et al. A 1.5T MRI-conditional 12-lead electrocardiogram for MRI and intra-MR intervention. Magn Reson Med. 2014;71(3):1336–47.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Bashein G, Syrory G. Burns associated with pulse oximetry during magnetic resonance imaging. Anesthesiology. 1991;75(2):382–3.

    Article  CAS  PubMed  Google Scholar 

  53. Dempsey MF, Condon B, Hadley DM. Investigation of the factors responsible for burns during MRI. J Magn Reson Imaging. 2001;13(4):627–31.

    Article  CAS  PubMed  Google Scholar 

  54. Dujovny M, Kossovsky N, Kossowsky R, Valdivia R, Suk JS, Diaz FG, et al. Aneurysm clip motion during magnetic resonance imaging: in vivo experimental study with metallurgical factor analysis. Neurosurgery. 1985;17(4):543–8.

    Article  CAS  PubMed  Google Scholar 

  55. Edwards MB, Taylor KM, Shellock FG. Prosthetic heart valves: evaluation of magnetic field interactions, heating, and artifacts at 1.5 T. J Magn Reson Imaging. 2000;12(2):363–9.

    Article  CAS  PubMed  Google Scholar 

  56. Hug J, Nagel E, Bornstedt A, Schnackenburg B, Oswald H, Fleck E. Coronary arterial stents: safety and artifacts during MR imaging. Radiology. 2000;216(3):781–7.

    Article  CAS  PubMed  Google Scholar 

  57. Wagle WA, Smith M. Tattoo-induced skin burn during MR imaging. AJR Am J Roentgenol. 2000;174(6):1795.

    Article  CAS  PubMed  Google Scholar 

  58. • Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, 3rd, Freedman RA, Gettes LS, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2013;127(3):e283–352. This article provides updated recommendations for pacing and Implantable Cardioverter-Defibrillator Therapy in adults and children.

  59. Shook DC, Savage RM. Anesthesia in the cardiac catheterization laboratory and electrophysiology laboratory. Anesthesiol Clin. 2009;27(1):47–56.

    Article  PubMed  Google Scholar 

  60. Boccalandro F, Baptista E, Muench A, Carter C, Smalling RW. Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect. Am J Cardiol. 2004;93(4):437–40.

    Article  PubMed  Google Scholar 

  61. Carroll JD, Dodge S, Groves BM. Percutaneous patent foramen ovale closure. Cardiol Clin. 2005;23(1):13–33.

    Article  PubMed  Google Scholar 

  62. Martinez MW, Mookadam F, Sun Y, Hagler DJ. Transcatheter closure of ischemic and post-traumatic ventricular septal ruptures. Catheter Cardiovasc Interv. 2007;69(3):403–7.

    Article  PubMed  Google Scholar 

  63. Bryson EO, Sejpal D. Anesthesia in remote locations: radiology and beyond, international anesthesiology clinics: gastroenterology: endoscopy, colonoscopy, and ERCP. Int Anesthesiol Clin. 2009;47(2):69–80.

    Article  PubMed  Google Scholar 

  64. Ramsay MA, Newman KB, Jacobson RM, Richardson CT, Rogers L, Brown BJ, et al. Sedation levels during propofol administration for outpatient colonoscopies. Proc Bayl Univ Med Cent. 2014;27(1):12–5.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd; MC 9202, Dallas, TX, 75390, USA

    Eric B. Rosero

  2. Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA

    Girish P. Joshi

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  1. Eric B. Rosero
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Correspondence to Eric B. Rosero.

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Conflict of Interest

Eric B. Rosero declares that he has no conflict of interest. Girish P. Joshi has received honoraria from Baxter, Merck, Pacira, and Mallinckrodt Pharmaceuticals.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Ambulatory Anesthesia.

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Rosero, E.B., Joshi, G.P. Ambulatory Anesthesia in Remote Locations. Curr Anesthesiol Rep 6, 412–419 (2016). https://doi.org/10.1007/s40140-016-0181-6

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