1. Copyright © 2015 Mark S Weiss All Rights Reserved HOW TO FEEL MORE AT HOME WHEN OUT OF YOUR COMFORT ZONE Non-OR Anesthesia - Stepping outside of the OR - Copyright © 2015 Mark S Weiss All Rights Reserved

2. What is NORA? Non-operating room (OR) anesthesia, or “NORA,” involves sedation and monitoring for procedures performed outside of the traditional operating room NORA has become routinely necessary for patients undergoing procedures or tests in:  Gastroenterology/Endoscopy  Electrophysiology (EP) and catheterization labs  Interventional radiology  Neuroradiology  MRI and CT scan suites, among others The need for NORA services continues to expand  new challenges for interventionalists, anesthesiologists, and patients Copyright © 2015 Mark S Weiss All Rights Reserved

3. Rise of NORA Complex (and not so complex) interventions are amenable to minimally invasive approaches  often provides substantial advantages over traditional open surgical alternatives, particularly in more medically complex or unstable patients Improvements in anesthesia technology & safety allows for surgical innovation Heavy operating room volume forces interventions to the “periphery” or remote locations Patient satisfaction Copyright © 2015 Mark S Weiss All Rights Reserved

4. Copyright © 2015 Mark S Weiss All Rights Reserved

5. Challenges Fewer resources, facilities often retrofitted for anesthesia care Greater variation in physical set-ups and anesthesia and monitoring equipment Decreased practitioner familiarity (environment, staff, organization) Patient comorbidities often unique to the particular specialty Physical access to patient may vary Shared airway Copyright © 2015 Mark S Weiss All Rights Reserved

6. Challenges, continued Interpersonal/design issues in OR become magnified in OR setting  Proceduralists/Nursing/Staff  support personnel may not follow rigorous pre-procedure check-in or safety processes  Language/Teamwork/Culture  Volume/Time management/ Efficiency without sacrificing safety Fewer ancillary staff available for help if needed Copyright © 2015 Mark S Weiss All Rights Reserved

7. Addressing challenges Potential difficulties can be addressed in advance by cooperative interdepartmental planning Some shortcomings can be identified by staff in the remote location before the anesthesia provider delivers the anesthetic Other challenges require the anesthesia provider’s ongoing attention when preparing for case and while providing patient care Copyright © 2015 Mark S Weiss All Rights Reserved

8. How to thrive in NORA?  Diligence & vigilance  Maintenance of same ASA standards & quality as expected in main operating room  Communication and collaboration with facility team  Strict patient selection criteria, including thorough preoperative evaluation and screening  Adequate staffing and recovery care protocols Copyright © 2015 Mark S Weiss All Rights Reserved

9. Preparing for the worst When things go wrong… Metzner J 1, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8. Copyright © 2015 Mark S Weiss All Rights Reserved