Non-OR Anesthesia (NORA)

Overview

More and more, anesthesia providers are asked to care for patients outside of traditional OR settings. This Non-Operating Room Anesthesia (NORA) rotation exposes you to these environments where anesthesia is provided to complex patients (GI, EP, IR, MRI, CT). In the past, the proceduralist provided the sedation, but has become not always adequate or safe as the complexity and acuity of patients continues to increase. As more advanced and complex procedures are introduced with ever-expanding indications and sicker patients, the need for Anesthesia services increases. Patients who previously were considered poor candidates for high-risk invasive procedures are now receiving these equally high-risk but minimally invasive procedures. Coordinating patient care in these settings is a challenge, not only because of the type of procedures and patient population, but also due to working with different non-OR team members in an unfamiliar environment, often lacking equipment anesthesia providers are accustomed to in the OR.

Cases may or may not start strictly on-time because of the coordination of other providers and specific equipment. As always, try to be available and ready for when they do decide to start the case. One dedicated anesthesia tech covers the NORA cases; however, they are typically also turning over rooms in the main OR. If you need special equipment, collect it for your first case, or notify them early on. Communication is incredibly important as you will be engaging with different RNs and physicians. Ask questions and make your needs known. For your daily assignment, please refer to the daily schedule email sent out. Sometimes, you will have to look past the cover sheet into the actual room assignments. Occasionally, your room assignment with be listed on the preprocedure tab in the top right along with the name of the procedure being done.

For this chapter, locations will be covered one by one given the distinct differences in workflow and locations.

HVC - IR/EP/Cath lab

The HVC is on AIP2 3rd floor. There are typically four anesthesia teams in this area for a normal day. We may be involved with IR, neuro-IR, interventional cardiology, and EP cases. The CT-guided ablations are typically a HVC team, although these occur in the basement CT scanner. On occasion, we provide anesthesia for vascular surgery, pulmonology (bronchoscopies), MSK (kyphoplasties), and the ECHO cardiology service (sedation for TEE) as well.

TIP

• The HVC anes tech phone is x8-7967
• The tube station is 645
• HVC pre/post tube station (687)

The culture in the HVC is quite different than the operating room. If you open a dialogue with folks generally you will find that they are very willing to help, but don’t know what to do. Try to engage the procedure room nurses when you are inducing and emerging. This will help them both learn what you need and allow them to be helpful in the case of emergency. Write your phone number and your attending’s phone number on the white board in the room. While this is the typical practice in the general OR, it is especially important in HVC as your attending can be far away and the rooms are not arranged with the anesthesia team in mind. Unlike in the main OR, the nurses in the HVC usually do not have an up-to-date phone list. It will take time for them to find your attending’s phone number if you need them to call for help!

Supplies:

• The anesthesia equipment room is next to procedure room 1, it is room #3365 (the code to get in is the room number). It should have things like a CMAC, level 1, etc. There are other random anesthesia goodies on a shelf in the back left corner (circuits, tubes, etc.…).

INFO

If your room does not have an anesthesia machine or cart when you get there in the morning, just call your tech (x8-7967) for assistance.

If you run into an emergency, CALL FOR EQUIPMNET EARLY as it may take some time to get there.

Medications:

• There is a pyxis in Rm 3.2319.; in-between the EP hallway and the hallway to the IR/Cath control room. The door code to 3.2319 is 3231#. If you forget what the code is, just remember is the first 4 numbers of the room number.
• You should plan to get most of the medications and boxes you need from the main OR pharmacy and pyxis.
• Other meds you need when you can’t go back downstairs can be sent to the HVC pre/post tube station (#687). If you request medications during a case, pharmacy will send it to the tube station rather than walk it to you like in the main OR. Tell one of the nurses that you’re waiting for a medication, and they will check for you.

IR Cookbook

Rooms 7, 8, 9, 10, 14, 16

Fistulogram

• MAC or GETA
• Supine, operative arm out
• Angioplasty is very painful
• Confirm last dialysis, K+

Embolization

• MAC or GETA
• supine
• For active bleeding, keep in mind longer transit times for labs and blood and prepare ahead!

Percutaneous gastrostomy

• MAC or GETA, light MAC strongly preferred for ALS patients
• supine
• NG will be placed for gastric insufflation
• Glucagon administered prior to gastrostomy, proceduralist will request dose at appropriate time
• Ultrasound and fluoroscopy guidance for percutaneous access to gastric lumen, then gastrostomy tube is placed, and NG tube removed

Kyphoplasty

• MAC or GETA
• Prone
• Bone cement used

Nephrostomy (PCN)

• MAC or GETA
• Prone

PTCA (Percutaneous Transhepatic Cholangiogram) and PTBD (Percutaneous Biliary Drain)

• Usually GETA, occasionally MAC
• Supine
• Procedure length dependent on whether bile duct is dilated
• High risk for intraop sepsis

TACE (Transarterial Chemoembolization) aka Y90

• GETA or light MAC (frequent breath holds needed)
• supine
• Chemotherapy is injected directly into the vessels supplying a liver tumor
• Decadron/Zofran usually ordered and administered pre-op, check the MAR, don’t double dose

TIPS

• GETA
• Supine, R IJ access, sometimes femoral as well
• For control or prevention of variceal hemorrhage and/or intractable ascites

WARNING

BRTO/CARTO sometimes done in conjunction with TIPS to reduce the risk of bleeding in gastric esophageal varices. Catheter is used to access the varices, coils are deployed to occlude flow at the distal end. A sclerosing agent is then injected into the varices to harden the tissue and prevent blood flow

Chest Port

• MAC
• These are usually done with RN administered moderate sedation
• Patients with history of OSA on CPAP require anesthesia consult prior to moderate sedation with RN. If pt is pending chemo initiation they are just scheduled with anesthesia to expedite their treatment rather than awaiting PPS visit. MAC is usually appropriate

Spinal Angiogram

• GETA, neuromonitoring
• Supine
• Post-op directly to Neuro ICU

Cerebral angiogram +/- embolization

• GETA, maintain paralysis
• Supine
• Administer heparin, check ACTs
• PO aspirin and Plavix taken pre-op, if not, will place NGT and administer ASA/Brilinta intraop
• If EVD in place, IR nurse will monitor Post-op directly to Neuro ICU

Stroke

WARNING

Emergent case, time = brain!

• GETA, consider TIVA
• IR staff will be prepping while we are inducing
• Femoral arterial access obtained, have Aline setup ready to transduce. Do not delay case start to place our own Aline
• Post-op directly to Neuro ICU

PE

• MAC with very minimal sedation vs GETA, proceduralists VERY strongly prefer no intubation
• With MAC, be very cautious to avoid hypoventilation

EP Cookbook

rooms: #2, 11, 12, and 13

General ablation notes

• Headsets are worn during procedures when one or more team members are working in the control room. Headsets will be given to anesthesia providers and need to be worn as this is how the team will communicate information relevant to the case and patient care.
• Communicate significant hemodynamic changes and initiation or escalation of pressor support with EP physicians. Pericardial effusion, cardiogenic shock, acute blood loss all must be considered with hemodynamic instability
• Communicate regarding anesthetic plan prior to administration of any medications, all anesthetics can be antiarrhythmic. Some arrhythmias require awake mapping prior to administration of sedation
• Limit fluids. Catheter ablation uses an irrigated catheter which can result in a large volume of fluid administered over the duration of a case (2-4+ liters). Lasix is often indicated for large positive fluid balance
• EP RN will monitor hourly I+O
• Heparin administered if working in left side of the heart. Dosing directed by proceduralist. Anesthesia administers boluses, EP RN maintains infusion and draws ACTs.
• If heparin indicated, anesthesia places 2nd PIV. Typically IV on Left side is designated for EP RN use, IV on Right side for anesthesia use
• Have soft bite block ready in case cardioversion or defibrillation is required

AFib/pulmonary vein isolation (PVI)

• GETA
• Supine, femoral access
• A-line only if patient condition warrants; 2nd PIV, heparinization indicated
• No paralysis redosed after induction. Ablation occurs near a branch of the phrenic nerve, need to avoid thermal injury. They will identify the location of the nerve by pacing and observing for diaphragm response.
• Place esophageal temperature probe. During ablation on the posterior wall, this is observed closely, and the room will determine who is responsible for monitoring. An increase of 0.1 degree Celsius needs to be reported. Increased esophageal temperature is associated with esophageal injury, including ulceration, perforation and atria-esophageal fistula
• Protamine at case end. Our EP physicians prefer we administer a 1 mg test dose. After ensuring no reaction to the test dose the rest of the protamine can be given slowly, at a rate of 5mg/min

SVT/AFlutter ablation

• MAC (GETA in some cases, depending on complexity of procedure and patient assessment)
• Supine, femoral access
• Most SVTs and typical AFlutter are ablated in the right atrium. Some areas can be painful during ablation
• If left atrial access is needed, heparinization is indicated

PVC ablation

• MAC (discuss with proceduralist before ANY meds administered, often they begin with mapping while fully awake)
• Supine, femoral access

VT ablation

• GETA most common, MAC in some cases
• Supine
• Aline indicated
• Endocardial approach is most common (femoral vein/artery access). Epicardial access is sometimes indicated (subxiphoid approach is typically used)

Typical procedure:

1. Voltage mapping in sinus rhythm
2. Programmed stimulation with goal of arrhythmia induction
3. Activation mapping in VT if hemodynamically tolerated (pressor support often indicated, communicate with EP physician) If hemodynamically unstable, VT can be terminated by internal pacing or external cardioversion
4. Ablation, can be extensive
5. End-point assessment (often performed multiple times before case end). Can include re-induction of arrhythmia, pacing various sites that have been ablated, repeat mapping.

Implanted devices (pacemakers and ICDs)

• MAC
• sometimes a venogram on the operative side is indicated. We may need to place an IV for this

Subcutaneous ICD

• GETA
• Very stimulating when leads are tunneled
• VF will be induced to test device, external defibrillation if device fails (have bite block ready)

Leadless pacemaker

MAC, groin access

Cardioversions

Room 2 or sometimes bedside

EP Lab #13

WARNING

• This is an MRI room. Stereotaxis navigation system has a low Tesla magnet that is always on.

• MRI screening forms for patients and staff are only needed if the navigation system will be used
• MRI compatible machine and monitors are present in this room
• Monitor in room and in control room must both be off Standby
• Monitor has wireless EKG and pulse oximeter. Battery charging dock is in the control room.
• Ventilator data (TV, PIP, PEEP) will not automatically transfer, needs to be manually entered
• Temperature is usually monitored by EP and manually entered, but the anesthesia monitor does have temperature capability
• Massimo pulse oximeter is present to use as a backup if monitor fails
• Computer is NOT MRI compatible, if moved too close to the magnet it may shut off
• The anesthesia cart and its contents including airway equipment are NOT MRI compatible. Keep the NON-MRI compatible equipment outside the lines indicated on the floor
• Additional anesthesia supplies are in the rolling cart beside the anesthesia cart

INFO

• Standard MRI: 1-3 Tesla
• Stereotaxis system in Navigate position: 0.7 Tesla at magnet cover
• Stereotaxis system in stowed position: 0.2 Tesla at magnet cover
• Stereotaxis system in stowed position: 0.0005 Tesla outside brown circle marked on floor

Misc

• Typically, time out is performed prior to starting your anesthetic with the procedure and anesthesia teams. Use this time to confirm that everyone is on the same page if you haven’t already.
• Once you are done with induction / starting sedation, tell the team. They don’t always realize when you’re ready for them to start.
• Specific to EP, when you take over a case, ask for a timeout. Use this as a chance to introduce yourself and review management issues with the EP proceduralist and current (leaving) anesthesia provider. Be sure to discuss any significant BP support being administered. Document the time out in the anesthesia record. ALWAYS wear the headset they give you; this is how everyone communicates, and you will miss important things without it. There have been many near misses when people have not used it. Just make sure that it’s on mute if you are signing out, complaining, etc.
• EP Room 13 has a notoriously bad reputation, because it is technically an MRI room (low-tesla magnet), and the EPIC/Vitals monitor interface is very finnicky, resulting in the need to manually enter vitals. Make sure your attending gives you a primer on the room before you start your case. There is also a laminated “how to EP room 13” sheet on the vent – give it a look over on the first day you're in the room.
  • The EKG monitor and pulse have batteries that can be found in the room. When you arrive in the morning, one of the first things you should do is make sure that that batteries got taken out of the wireless monitors and put on the charger overnight. If not, get them on the charger ASAP. Also, the anesthesia machine in this room is MRI safe and thus not like the typical GE machines found elsewhere. Make sure to familiarize yourself with the machine the first time you use it.

Labs

• For ABGs/ Blood Gas labs, from 0700 – 1900 someone from HVC must walk it to the OR lab (our stat lab personnel from the main OR are not expected to come pick up from HVC) or send it through the tube station; from 1900-0700, call 85309 and someone will walk from Leprino to pick it up. Let the nighttime person know if you will be sending repeated/frequent labs. All TEGs must be walked down, the sample cannot be used if it’s been sent by tube.

Computers

• The IP addresses for the data ports on the booms in the HVC expire if not used after 30 days. This means that if you are doing an anesthetic in a room that we don’t use often (like cath lab 5 or cath lab 6) there will not be internet access without a call to the computer help desk. This is primarily an issue for interventional cardiology. IF you see that you are scheduled to do a case in an infrequently used room, such as cath lab 5 or cath lab 6, please reach out ahead of time to the nurses in that area and ask that the data port be issued a new IP address. Interventional Cardiology will try to be pro-active with this, but please do your part by helping folks remember or make the call yourself.

ECT

Location

The ECT suite is located inside the secured psychiatry ward on the 5th floor at AIP3. Make sure you have badge access to the locked ward prior to going on the NORA rotation. If taking Teal Service Elevators (the first set of elevators that you encounter coming in from the resident garage), the entrance to the psychiatry ward pre/post unit is directly across from the elevator lobby on the 5th floor. If coming from the Yellow Staff Elevators (by pre-op), make a right once you’ve exited the elevator lobby (walk away from the OBGYN ward), you should reach a front desk area where there will be staff members and a security guard. Proceed straight past the counter and through the double doors, the entrance to pre/post is to your right.

Chart preparation

All new ECT patients should have been seen by PPS unless they are transferred/referred from OSH or if they were admitted directly to inpatient. Returning patients will have their previous ECT anesthesia medications listed in the blue sticky note. Most likely the same regimen will be used again unless there are some dose titrations, which the attendings on both teams will discuss. If patient is new, the psychiatry team will have to perform their own pre-ECT eval and consent which could take some time.

Equipment

All necessary equipment and meds are located inside the ECT suite, including a stocked Pyxis. Each patient will need an Ambu bag and a foam bite block. Make sure to have airway adjuncts nearby and ready.

Medications

Prior to the patient being brough into the suite, the anesthesia and psychiatry team jointly determines the dose adjustments between treatments if required. The goal is to achieve a therapeutic level seizure that doesn't last too long, while maintaining reasonable hemodynamics. Benzodiazepines may be held on the DOS because they increase the seizure threshold, this will be managed by the psychiatry team. Check their notes for recommendations. Below is a list of common drugs you’ll encounter in the ECT suite

Preop seizure threshold modulationAnesthesia induction meds

• Methohexital
• Etomidate
• Ketamine Muscle relaxation during seizure
• Succinylcholine
• Rocuronium Post-procedural
• Propofol
• Midazolam
• Lorazepam
• Ketorolac
• Ondansetron, diphenhydramine, dexamethasone, scop

MRI

You may anesthetize patients in the MRI adjacent to OR 25 (3T) or in the basement MRI (1.5T). You need to fill out an MRI screening form annually while in residency that will be kept on file. If you have not done this, arrive early to one of the MRI rooms and notify the MRI tech, and they will be able to get you the paperwork to be allowed to enter the MRI. They will give you a small card to designate you have done this – it’s good for a year, put it with your badge so you always have it!

Prior to entering the MRI room, don’t forget to remove ALL metal objects as well as other things that will be damaged by the magnet; you can leave these in the control room. The MRI Tech will typically have a plastic bucket for you to place your belongings. This includes many things that you may not even think of (pens, bobby pins/hair clips, watches, cell phone, all credit cards or badges, etc.). Oddly enough, rings and the needles on your syringes are ok.

The MRI tech will always be present when you have access to the MRI room. In the basement, there is usually a tech around; however, they only come up for scheduled scans (with or without our involvement) upstairs. The phone number to the upstairs control room is x81690. The anesthesia tech also relies on the MRI tech to get into the room to set up your machine and cart.

Pre-op

• Make sure the patient has filled out their MRI screening form before you give any sedation and go back to the room. Many of these patients are receiving anesthesia because they are claustrophobic. No proceduralist will be there because the scan was ordered by an outpatient provider.
• Non-sedated patients can walk into the MRI suite and get onto the bed themselves. Otherwise, park the gurney in the control room, the MRI tech will bring the MRI bed out and then help you wheel that in once the patient is on it. You will typically induce on this bed next to the MRI, the tech can help lower/raise/etc.

Monitors

There are instructions on which monitor to enter into MonCap on the computer (UCHOR iMRI). This will not acquire your vitals unless the screen in the control room is turned on. Many of these monitors have special components to them (I.e., MRI safe EKG stickers, finger pulse ox probe is specific to the wireless monitor, etc.). Just ask the MRI techs to help you locate these if you cannot find them.

During the scan

Once the scan has started, you may be able to enter the room between sequences, however if something happens in the middle of a sequence, the only way to get to the patient (administer meds, etc.) is to interrupt it then restart from the beginning once you’re done. Be sure to communicate with the MRI tech if there’s something you need, and they will pause/stop for you.

Misc

• The MRI compatible pump is a giant pain. There are instructions for troubleshooting that should be with it. If possible, have someone walk you through getting it set up and get it working well before you actually need to use it. Typically, if you are running infusions, you just leave a non-MRI compatible pump outside the actual MRI room and run long extension tubing (ask the MRI tech for this tubing).
• Make sure to ask the MRI techs for the extra-long IV extension tubing if using the non-MRI compatible pump outside the room. Do keep in mind that this tubing has about 12 cc of fluid between the pump and the patient and as such changes made on the pump take a while to get to the patient unless you crank up the rate of your carrier

PACU

You must call PACU at 86203 to let them know you are bringing your patient to them. In the OR, typically the circulator RN handles this for you. Call 15-20 min before you anticipate arriving. They will want to know the patient's name and whether they are going home after recovery.

TIP

If it is your first day there or you feel uncomfortable, let the MRI techs know! They are incredibly helpful, and they will help you through the day and all the small but important nuances of MRI safety.

Radiology

Aka the basement

You will sometimes go downstairs to the basement to sedate patients for LP or for procedures in the CT scanner. Overall, this is very similar to MRI (and the 1.5T MRI is down here, as discussed above), however you have access to these rooms without a tech. Make sure you have lead for yourself, particularly for the CT ablations and things where you’ll be in and out during the procedure and scanning. Don't give sedation until you're downstairs (often the proceduralist has not consented while your patient is in preop even though you have). These monitors don't always pull vitals into Epic, when this is the case, you will have to chart everything manually.

TIP

As above, call PACU at 86203 to let them know to expect you. Depending on the procedure pre/post may be on the 2nd floor by the ORs or on 3 by CVC.

• Talk to your attendings about positioning specific to the procedure – sometimes it’ll be a surprise (i.e., radiology likes to have patients prone for LPs).
• The anesthesia tech will set up your machine and cart. They usually know when things are scheduled here but check in and keep them updated if scheduling changes. I would suggest calling them first thing of that day.

GI

GI is adjacent to the East ORs. There are a couple of suites as well as a small pre/post area between the GI suites and the East OR. Medications:

• The AOP pharmacy covers this area, their phone number is 81391. Similar to East OR, in the morning the pharmacy will have med bags pre-prepared for all your booked cases. You can pick up some or all bags in the morning, just remember that you can expect very fast room turnovers (~20 min), so find a system to keep up with administering and wasting medications for the correct patient, including when you get a break, or your attending gets something out of the top drawer.
• Some cases are simply done on the patient’s gurney while others will be done on a procedure table. The anesthesia tech will turn over your room, their number is on the anesthesia machine.
• As with some subspecialties, there are some minor differences in the anesthesia carts here (Unasyn instead of Ancef, glucagon in top drawer, albumin 500cc in bottom drawer).
• In general, you can anticipate to performing GETAs for: ERCPs and small bowel endoscopies. You will typically perform MAC for EGDs, colonoscopy, and some stent removals, however, as always, ultimately this depends on the pertinent details for that case or patient.