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9, No: 2
Amrita Journal of Medicine July - Dec 2013. Page 1 - 44

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Anaesthesia care beyond Operating Rooms:

Newer opportunities & Challenges.
Ramkumar P

Technological progress in medical Despite the availability of detailed (8) An emergency cart with a defibril-
science leads to more interventional guidelines, a recent analysis of closed lator, emergency drugs, and other
procedures, with which we are able anaesthesia claims demonstrated emergency equipment.
to give symptom relief for sicker pa- greater injury severity and more
(9) A means of reliable two-way com-
tients who may not be a candidate substandard care than seen with
munication to request assistance.
for a major surgical procedure. The operating room closed claims. Drug
risk involved in providing anaes- interactions were the most common (10) Compliance of the facility with
thesia for the sicker patients for the associated factor, followed by drug all applicable safety and building
interventional procedure is much overdose, inadequate monitoring, in- codes.
more than the regular surgery. As a adequate skills for cardiopulmonary
It is the responsibility of the anaes-
critical care and resus-citation expert resuscitation, inadequate evalua-
thesiologist providing care to ensure
and with special skills/ knowledge tion before sedation and premature
that the anaesthetizing location in
of Anaesthesia, the services of the discharge from medical supervision
which that care is delivered meets all
anaesthe-siologists are demanded by were other incidents noted as con-
applicable standards.
non surgical specialists who do not tributory to the events in outside or
make use of the regular opera-tion procedures. Presence of a dedicated Patient population:
rooms for the work. person for monitoring the patient and
Wide range of patients from new
following the proper guidelines can
Providing anaesthesia care in out born to geriatric patients, healthy to
minimize the events.
of operating room situations may be critically sick patients will be subject-
challenging, as changed and variable Guidelines for anaesthetic care ed for the anaesthesia care outside or
environments pose unique problems. delivered outside the Operating Room procedures. Children, unconscious /
When providing care at such loca- American Society of Anaesthesiologists uncooperative or anxious patients, el-
tions, anesthesiologists must maintain (ASA) 1994 Guidelines for NonOper- derly or confused patients all require
the same high standard of anesthetic ating Room Anaesthetizing Locations anaesthesia care. The reasons may
care provided in the operating suite. in-clude recommendations for be needle phobia, claustrophobia,
The anaesthetizing location must be painful procedures or procedures
(1) A reliable oxygen source with
surveyed by the anaesthesiologist requiring absolute immobile patient,
backup as required.
to determine whether anaesthesia comorbidity requiring constant moni-
care can be delivered safely in that (2) A working suction source with toring and resuscitation during the
location before delivery of that care. all proper connections & suction procedure. When very advanced and
The requirements for anaesthesia and catheters. costly procedures are being carried
the patients underlying condition do out physicians and patients prefer
(3) Waste gas scavenging system.
not vary merely because of location, TOTAL CARE especially when the ad-
but the conditions under which the (4) Adequate monitoring equipment ditional expenditure for anaesthesia
anaesthesia care is delivered may to meet the standards for basic care is negligible compared to the
vary greatly because of the space anaesthesia monitoring and, in procedure charges.
and equipment available in these addition, a self-inflating hand
locations. Large, mobile pieces of resuscitator bag/ transport ven-
radiologic equipment, radiation tilator. ASA standards for basic anaes-
hazards, intense magnetic fields, thesia monitoring require presence
(5) Sufficient safe electrical outlets.
paramedical personnel not familiar of qualified anesthesia personnel
with the anaesthesia team, and other (6) Adequate illumination of the throughout conduct of the course of
factors may compromise the delivery patient and anaesthesia machine anesthesia and continuous evaluation
of quality anaesthesia care. with battery-powered backup. of the patients oxygenation, ventila-
(7) Sufficient space for the anaesthe- tion, circulation, and temperature.
sia care team. Provision is made for the absence of
Dept. of Pain & Palliative Care, AIMS, Kochi.

Amrita Journal of Medicine

anaesthesia personnel from the immediate vicinity of Facility for post procedure care/ PACU.
the patient if required for safety (i.e., in the presence
of radiation hazards), provided that adequate patient Patient Evaluation:
monitoring is continued despite the physical separa- Clinicians should be familiar with the sedation-
tion of the anesthesiologist from the patient. Oxygen related aspects of the pa-tients medical history.
concentrations of inspired gas should be monitored
These include (1) abnormalities of major organ
with the use of a low-concentration alarm, blood oxy-
systems, (2) previous adverse effects with sedation and
genation should be monitored with pulse oximetry, and
general anesthesia, (3) drug allergies, current medica-
ventilation should be monitored by observation of the
tions, and drug interactions, (4) time and nature of oral
patient. When present, the position of the endotracheal
intake, and (5) history of tobacco, alcohol, or substance
tube must be verified by observation and by detec-
tion of end-tidal carbon dioxide. Continuous end-tidal
carbon dioxide analysis should be performed. When A focused physical examination including vital signs,
mechanical ventilation is used, a disconnect alarm with auscultation of the heart and lungs, and evaluation of
an audible signal must be present. Circulation is moni- the airway is recommended.
tored by continuous display of the electrocardiogram, as
Preprocedural Preparation:
well as by measurement of arterial blood pressure at a
minimal interval of 5 minutes, in addition to other assess- Patients should be informed of and agree to sedation,
ments such as auscultation, palpation of pulse, invasive including its risks, benefits, limitations, and alternatives.
blood pressure monitoring, or oximetry. When changes Sufficient time should elapse before a procedure to allow
in body temperature are anticipated or suspected, pa- gastric emptying in elective patients. Minimum fasting
tient temperature should be assessed. There should be periods of 2 hours (clear liquids), 4 hours (breast milk),
no hesitation to use invasive monitoring if the patient and 6 hours (infant formula, nonhuman milk, and light
condition warrants so in case for or procedure. meal), are recom-mended for healthy patients. If urgent,
emergent, or other situations impair gastric emptying,
the potential for pulmonary aspiration of gastric contents
The goals of sedation/ anaesthesia outside or can be must be considered in determining the tar-get level of
summarized as follows sedation, delay, or intubation.
Guard the patients safety and welfare Medications: Monitored anaesthesia care (MAC),
Minimize Physical discomfort and pain general anaesthesia (GA) or regional anaesthesia may be
Control anxiety, minimize psychological trauma required. Midazolam, Fentanyl, Propofol, and Ketamine
are frequently used drugs. Dexmedetomedine is useful
and maximize the potential for amnesia
for conscious sedation as well as for facilitating smooth
Control behavior and / or movement to allow safe anaesthesia and recovery when GA is needed.
completion of the procedure
A moderately sedated child who can respond to light
Return the patient to a state in which safe discharge touch can protect his or her airway and a deeply se-
from medical supervision is possible. dated child who can respond appropriately only to pain
Problems: may not be able to control the airway. The important
Unfamiliar locations and working conditions pose cer- assessment of the child is not response to stimulation
tain problems like but the ability to protect the airway. Different sedative
drugs have differing effects on analgesia versus airway
Related to physical layout of the facility obtundation. Propofol is not a profound analgesic but
Remoteness from available help. has profound effects on the airway. Conversely, the
Difficult or limited access to patients. sedative drug Dexmedetomidine may provide profound
Unfamiliar or outdated anaesthesia equipment. sedation with little depression of respiratory function.
Ketamine produces intense analgesia and most children
Untrained personnel.
maintain a patent airway and adequate respiratory effort.
General Precautions:
When Spinal anaesthesia is needed for day care pa-
Proper check up of anaesthesia machine & equipment
tients, ropivacaine is a better choice due to less motor
Availability of adequate number of gas cylinders block and early recovery.
Obsolete and poorly functioning equipment should
Combinations of Sedative/Analgesic Agents: Com-
be discarded. binations of sedative and analgesic agents may be
Proper grounding of electrical equipment administered as appropriate for the procedure being
Availability of adequate persons and materials for performed and the condition of the patient. Ideally,
the procedure and monitoring each component should be administered individually

Amrita Journal of Medicine Anaesthesia care beyond Operating Rooms:
Newer opportunities & Challenges.

to achieve the desired effect (e.g., additional analgesic the resulting decrease in fat solubility markedly delays
medication to relieve pain; additional sedative medica- transport into the CNS (peak EEG effect 4.8 minutes
tion to decrease awareness or anxiety). The propensity for midazolam versus 1.6 minutes for diazepam .The
for combinations of sedative and analgesic agents to sedated child usually becomes compliant but does not
cause respiratory depression and airway obstruction lose consciousness. Children frequently move, and
emphasizes the need to appropriately reduce the dose another agent, such as an opioid, may be necessary if
of each component as well as the need to continually the child must not move to successfully accomplish the
monitor respiratory function. procedure. The benzodiazepines have the advantage of
antegrade amnesia in a significant number of patients.
Titration of Intravenous Sedative/Analgesic Medi-
The markedly prolonged and variable elimination
cations: Intravenous sedative/analgesic drugs should
half-life and active metabolite of diazepam (desmethyl-
be given in small, incremental doses that are titrated
diazepam) make midazolam a superior sedative drug
to the desired end points of analgesia and sedation.
in children, particularly infants. Time to peak effect
Sufficient time must elapse between doses to allow the
after intravenous administration of midazolam is 2 to 4
effect of each dose to be assessed before subsequent
minutes, and duration is 45 to 60 minutes. Midazolam
drug administration. When drugs are administered by
can be given intravenously, intranasally, sublingually,
nonintravenous routes (e.g., oral, rectal, intramuscular,
orally, or rectally. It is the only drug in this class ap-
transmucosal), allowance should be made for the time
proved for neonates. Benzodiazepines produce mild
required for drug absorption before supplementation is
respiratory depression and upper airway obstruction.
considered. Because absorption may be unpredictable,
Respiratory depression may become severe in compro-
administration of repeat doses of oral medications to
mised children or in children with tonsil hypertrophy.
supplement sedation/analgesia is not recommended.
Benzodiazepines must be given after appropriate guide-
Anesthetic Induction Agents Used for Sedation/ lines. The combination of benzodiazepines and opioids
Analgesia (Propofol, Methohexital, Ketamine): Even is particularly troubling because they can produce a
if moderate sedation is intended, patients receiving super additive effect on respiratory depression.
propofol or methohexital by any route should receive
Flumazenil is a specific benzodiazepine receptor
care consistent with that required for deep sedation.
antagonist and will rapidly reverse the seda-tive and res-
Accordingly, practitioners administering these drugs
piratory effects of benzodiazepines. It is the first specific
should be qualified to rescue patients from any level of
reversal agent for benzodi-azepines and rapidly reverses
sedation, including general anesthesia. Patients receiv-
CNS-induced unconsciousness, respiratory depression,
ing ketamine should be cared for in a manner consistent
sedation, amnesia, and psychomotor dysfunction. The
with the level of sedation that is achieved.
recommended dose of flumazenil is 10 g/kg up to 0.2
Anxiolytics/Sedatives mg every minute to a maximum cumulative dose of
1 mg intravenously. Antagonism begins within 1 to 2
The most commonly used anxiolytics/sedatives in
minutes and lasts approximately 1 hour. Because reseda-
pediatric sedation are chloral hydrate, diazepam, and
tion after 1 hour may occur, the child must be carefully
midazolam. Chloral hydrate is one of the most widely
monitored for at least 2 hours. Repeat flumazenil may
used sedatives in neonates and children younger than 3
be necessary. It should be noted that flumazenil will
years of age. It is widely used as a sedative to facilitate
not antagonize respiratory depression due to opioids.
nonpainful diagnostic procedures such as EEG and CT
Flumazenil should not be administered for the routine
or MRI. It is rapidly and completely absorbed when
reversal of the sedative effects of benzodiazepines but
given orally. Rectal administration is erratically absorbed
reserved for reversal of respiratory depression.
and therefore not recommended. Onset of sedation is
30 to 60 minutes, and the usual clinical duration is 1 Barbiturates:
hour. Although it has a long safety record, it can cause
Pentobarbital is the most commonly used interme-
respiratory depression due to airway obstruction, and
diateacting barbiturate for sedation. It has no analgesic
deaths have been associated with its use alone and when
effect and produces sedation, hypnosis, and amnesia.
combined with other sedating medications.
It has a long history of use during radiologic proce-
The benzodiazepines are commonly used in pedi- dures. Sedation starts in 3 to 5 minutes and peaks in
atric sedation. They are anxiolytic, amnestic, sedative 10 minutes. Studies have shown a low incidence of
hypnotics with anticonvulsant activities but no analgesic respiratory obstruction and transient desaturation as
properties. Their high lipid solubility at physiologic well as hypotension. The barbiturates tend to make
pH accounts for the rapid CNS effects. As opposed to children more sensitive to pain and should be combined
diazepam, midazolam is delivered in a water-soluble with analgesics when used during painful procedures.
form (pH 3.5), which markedly decreases the incidence Newer, shorter-acting, faster recovery drugs are quickly
of pain on injection and thrombophlebitis. However, replacing pentobarbital.

Amrita Journal of Medicine

Opioids: effects of opioids but reserved for reversal of respiratory

Opioid analgesics are rarely used alone for diagnos- depression / respiratory arrest. Naloxone may be given
tic and therapeutic procedures in children. These potent intravenously, intramuscularly, or subcutaneously. The
analgesics are important during painful diagnostic and initial dose for respiratory depres-sion is 0.01 mg/kg
therapeutic procedures. They bind with four primary titrated to effect every 2 to 3 minutes. Ten to 100 g/kg
opioid receptor types (mu, kappa, delta, and sigma) up to 2 mg may be required for reversing respiratory ar-
that are located in the brain, spinal cord, and periphery. rest. Adverse reactions from reversal of analgesia include
Serious effects of opioids include respiratory depression, nausea, vomiting, tachycardia, hypertension, delirium,
bradycardia, hypotension, seizures, and opioid-induced and pulmonary edema. Patients on long-term opioid
glottic/ chest wall rigidity. therapy should be given opioid reversal agents in low
doses and with extreme caution because withdrawal
Morphine may be considered for painful procedures seizures and delirium may occur. If naloxone is used,
(>1hour) or when the child will also be in pain after the then the patient should be observed for a minimum of
procedure. The duration of action is 3 to 5 hours after 2 hours. Repeat naloxone may be necessary. Nalmefene
intravenous administration. Morphine may be given (Revex) has a longer half-life (~10 hours) than naloxone.
orally (0.2 to 0.5 mg/kg), intravenously (0.05 to 0.1 mg/ Its half life outlasts the effects of fentanyl and negates
kg [maximum 0.3 mg/kg]), or intramuscularly (0.1 to the treatment of pain with opioids for several hours.
0.2 mg/kg). Time to peak effect for oral, intravenous, or
intramuscular administration is 60 minutes, 3 to 5 min- Systemic Anesthetics
utes, and 10 to 30 minutes, respectively. Its slow onset These drugs should be used only by anesthesiolo-
and prolonged duration have caused it to be replaced gists or other practitioners who have specific training
by shorter acting opioids when used for sedation and in their use and have advanced airway management
analgesia for procedures. skills because airway obstruction, apnea, and cardiovas-
Fentanyl has replaced morphine as the opioid of cular instability may quickly and unpredictably occur.
choice for analgesia/sedation for procedures in children. Ketamine is one of the few sedatives that produce both
Intravenous fentanyl is a potent pure opioid (i.e., 100 amnesia and analgesia. The clinical appearance is that of
times more potent than morphine) with no amnesic a patient who has opened eyes (usually with horizontal
properties. Its high lipid solubility allows for onset within nystagmus) but does not respond to pain. Ketamine has
30 seconds and a peak effect at 2 to 3 minutes. It has a been shown to preserve cardiovascular function in most
brief clinical duration of 20 to 40 minutes when given in cases and to have limited effects on respiratory mechan-
small doses owing to its rapid redistribution to skeletal ics and allows for spontaneous respirations. Ketamine is
muscle, fat, and other inactive sites. Unlike morphine associated with nonpurposeful motion, which limits its
it has no active metabolites. Fentanyls clearance is usefulness when immobility is necessary (e.g., use dur-
decreased and its half-life is increased in preterm and ing CT). Ketamine can markedly increase cerebral blood
term infants. It is fully reversed by opioid antagonists flow and is contraindicated in patients with increased
and is frequently used with a short-acting anxiolytic intracranial pressure. Other contraindications include
(midazolam). Intravenous doses usually start at 0.5 to 1 those with head injury, open globe injury, hypertension,
g/kg and are titrated every 5 minutes to effect but not to and psychosis. Ketamine can decrease the response to
exceed 5 g/kg. Doses must be given in small aliquots hypercarbia, as well as cause laryngospasm, coughing,
and carefully titrated to avoid chest wall and glottic and apnea. No antagonist is available. Typical starting
rigidity. Close post-procedural observation is required doses are 1 to 2 mg/kg intramuscularly, 0.25 to 1.0 mg/
because respiratory depression can outlast analgesia. kg intravenously, or 4 to 6 mg/kg orally. The onset after
intramuscular injection is 2 to 5 minutes, with a peak of
Remifentanil is the newest rapid-acting opioid. This 20 minutes; duration can be 30 to 120 minutes. Onset
rapid onset, extremely potent, lipophilic short-duration after intravenous administration occurs in less than 1
opioid is metabolized by plasma cholinesterase. minute, with a peak effect in several minutes and dura-
Remifentanil has been used for intraoperative sedation tion of action of approximately 15 minutes. Oral doses
by anesthesiologists and in intubated children in the of 4 to 6 mg/kg are usually combined with atropine
ICU. Remifentanil is associated with a high incidence and have an effect in 30 minutes and last up to 120
of apnea and chest wall rigidity and should not be used minutes. Larger doses or supplementation with other
by the non-anesthesiologist for pediatric sedation. sedatives or opioids may produce deep sedation/general
Opioid antagonists specifically reverse the res- anesthesia. Ketamine should be administered with an
piratory and analgesic effects of opioids and should be antisialagogue (atropine, 0.02 mg/kg, or glycopyrrolate,
readily available when opioids are used. Naloxone is the 0.01 mg/kg) because copious secretions from ketamine
most commonly used an-tagonist. Opioid antagonists alone may induce laryngospasm. Although initially
should not be used for routine reversal of the sedative thought to maintain airway reflexes, this is not always

Amrita Journal of Medicine Anaesthesia care beyond Operating Rooms:
Newer opportunities & Challenges.

the case; ketamine may not protect against aspiration. with a peak effect in 3 to 5 minutes and very rapid return
Unpleasant dysphoric reactions (so-called emergence to baseline when discontinued. A premixed tank of no
reactions) (up to 12%) can be severe but are usually more than 50% N2O is available (Entonox). Adminis-
mild. The prophylactic use of midazolam does not tration of N2O can be used for minimal sedation. (1)
decrease this incidence. only ASA-PS I or II patients; (2) only 50% nitrous oxide
or less is used; (3) inhalation equipment must have the
Etomidate produces sedation/anesthesia, anxiolysis,
capacity to deliver 100% oxygen and never less than
and amnesia similar to the barbiturates and propofol. Its
25% oxygen; and (4) a calibrated oxygen analyzer must
major advantage is its lack of adverse cardiovascular ef-
be used. Although N2O in 50% concentration with
fects. Loss of consciousness occurs in 15 to 20 seconds,
oxygen usually produces minimal sedation, the addi-
and recovery is due to redistribution and occurs in 5
tion of any sedatives/hypnotics may rapidly produce a
to 10 minutes. Etomidate has been used in adults and
deeper level of sedation and require increased monitor-
children for procedural sedation, although the end point
ing and vigilance.
of sedation is not well described and often is general
anesthesia. Transient adrenal suppression can occur Dexmedetomidine is an imidazole 02 agonist that
after multiple doses and after single dose administra- is similar to clonidine but with an even higher 02 : 01
tion. Propofol is an anesthetic that is widely used for specificity ratio of 1600 : 1. Its elimination half-life in
pediatric sedation and anesthesia. Its onset is within 30 children is 2 hours. The drug is highly lipid soluble and
seconds. It is highly lipid soluble and the lipid solubility quickly crosses the blood-brain barrier. Its CNS effect is
makes the drug effect diminish extremely quickly (5- to stimulate receptors in the medullovasomotor center,
15 minutes). It has no analgesic properties, but it does which decreases sympathetic tone. It also stimulates
have antiemetic and antipruritic properties. Although central parasympathetic outflow and decreases sympa-
small doses of propofol (25-50 g/kg/min) can provide thetic outflow from the locus ceruleus of the brainstem.
moderate sedation in adults, deep sedation and airway The decreased outflow from the locus ceruleus allows
obstruction quickly occur in children. Dosing in adults for increased activity of the inhibitory GABA neurons,
for sedation is recommended at 25 to 200 g/kg/min, which cause sedation and analgesia. Dexmedetomidine
whereas many children require considerably higher is approved for sedation of ventilated adult patients in
doses. Propofol is a profound respiratory depressant the ICU but not in children. When administered in clini-
and can lead to rapid airway obstruction and apnea. cal doses it causes limited effects on ventilation in adults
Other adverse reactions include increased salivary and and may mimic natural rapid-eye-movement sleep. The
tracheobronchial secretions, myoclonic movements, initial dose must be given over 10 minutes, followed by
anaphylactic reactions, and bacterial contamination. an infusion. When given in the recommended fashion
Pain on injection can be lessened by the addition of it decreases blood pressure and heart rate in adults. It
lidocaine to the solution. Hypotension is mild and usu- should be used with caution in children with preexist-
ally not clinically significant in normal healthy patients. ing bradycardia, atrioventricular conduction defects,
Durations of propofol for more than 5 hours have been hypotension, and decreased cardiac output. Dexme-
associated with propofol infusion syndrome but not detomidine may provide safe sedation for procedures
during shorter procedures for sedation. Patients should with minimal effect of the airway and therefore markedly
be assumed to be deeply sedated or anesthetized when improve safety.
using this drug, and it should be administered only by
Patient transport to Recovery Room/ post anaesthe-
practitioners with advanced airway skills. Propofol
sia care unit:
procedural sedation delivered by nonanesthesiologists
is growing rapidly in intensive care units, emergency The patient must be medically stable before trans-
departments, dentistry, oral surgery, and gastroenterol- port. The patient must be accompanied to the recovery
ogy suites. The dosing recommendations for use in area by the individual providing the anesthesia or seda-
procedural sedation in these areas frequently do not tion/analgesia care, and moni-toring used according to
cause seda-tion but rather anesthesia. (Procedural the patients medical condition must be maintained.
sedation is defined as a depressed level of conscious- Provision of oxygen delivery and monitoring while the
ness but one that allows the patient to maintain airway patient is on the transport cart may be required. Appro-
control independently and continuously. ) However, priate recovery facilities and staff must be provided. In
multiple studies show that propofol procedural sedation the recovery area, the patients condition must be docu-
frequently causes anesthe-sia with inability to maintain mented and continually assessed. Immediate availability
the airway. The controversy over whom and under what of personnel trained in ad-vanced cardiac life support
conditions propofol (or other potent sedatives) should should be ensured. Patients should not be discharged
be administered for procedural sedation needs to be until they have met specific discharge criteria. Clear
addressed and agreed upon on a national level. directions are to be given in writing and explained to
the care taker at the time of discharge.
Nitrous oxide (N2O) is a potent inhalation analgesic

Amrita Journal of Medicine

1. Anaesthesia for diagnostic neuroradiological ROPIVACAINE and FENTANYL works for the period of
procedures: complete treatment and avoids involuntary movement of
Computed Tomography (CT) the lower limbs causing displacement of the applicator
/ implants and if there is any misplacement it allows to
Magnetic Resonance Imaging (MRI)
correct the applicators after confirming under IMAGE.
4. Coronary angiography and cardiac catheterization,
Angiography: Includes mainly spinal cord and
5. Anaesthesia for electroconvulsive therapy (ECT),
cerebral angiography
6. Anaesthesia in Emergency Room/ Trauma care Unit,
Patients in the radiology suite may have severe un-
7. Anaesthesia in Ophthalmology and Dental clinics :
derlying medical conditions such as cardio-vascular,
Details of the above situations 4/5/6 &7 not included
pulmonary, or neurologic disease. Indeed, they may
due to space limitations.
be in the radiology suite, as op-posed to the operating
suite, precisely because their severe underlying disease 8. Anaesthesia for IVF & GIFT: To be aware of the
precludes oper-ative intervention. Finally, anesthesiolo- Ovarian Hyper Stimulation Syndrome.
gists may be summoned relatively late in the care, after 9. Anaesthesia for ERCP & Endoscopy: Risk of manag-
failure of sedation/analgesia administered by the radiolo- ing patients with deranged Liver function.
gist or nonanaesthesia personnel. Clearly, this situation 10. Anaesthesia for children in Oncology/ Rheumatol-
is undesirable, and open communication between the ogy/ Nuclear Medicine etc.
departments of radiology and anesthesiology is essential.
Special precautions should be taken in MRI due to the Anaesthesia care in remote locations: These include
effect of magnetic field on ferrous objects. war fronts and other mass casualties, including disasters
and terrorist violence etc. The guiding principles of
2. Anaesthesia for interventional radiology. care are same as envisaged in minimum monitoring
Angiograms, angioplasty and angio-embolization are and safety standards, advocated by the ISA. There is
becoming a regular work in many radiology labs. Most no justification in giving anaesthesia (other than field
of the procedures can be done as a Monitored Anaesthe- and local blocks) without ensuring the availability
sia Care and moderate sedation / Conscious Sedation, of a reliable oxygen source, facilities to establish de-
but some require complete immobilization and require finitive airway and pulse oximetry. On the other hand
General Anaesthesia with controlled ventilation. Radio resuscitation for basic and advanced life support and
Frequency Ablation of the solid tumour mass in the comprehensive trauma life support (CTLS) should be
lungs, Liver and bones is another area where similarly undertaken whenever and wherever necessary and
anaesthesia service could be utilized. Some of the RFA feasible. The techniques and extent of the life support
patients will benefit from continuous regional block with instituted will depend upon the place, available facilities
catheter for Post procedural pain relief. The iodinated and resuscitators expertise.
contrast media used in the radiology and neuroradiology Conclusion: The role of anaesthesia outside the oper-
suites, as well as the cardiac catheterization laboratory, ating rooms is rapidly expanding and evolving along
may cause significant adverse reactions, and patients with the advances in interventional radiology and other
receiving contrast media require close monitoring. invasive modalities. However, we must understand that
3. Anaesthesia for radiotherapy there are many constraints, as the co-morbid conditions
of the patients are similar and often more severe than
Intra Operative Radiation Therapy (IORT) & external what we face in the operating rooms, and in-creasingly
beam radiation: MAC or moderate to deep sedation may complex diagnostic and therapeutic procedures are
be needed for anxious patients to keep without moving being performed on sicker patients. Understanding the
during the CT simulation and External RT especially anaesthetic constraints and complexities and keeping
in paediatric patients who may require 5/7 days seda- abreast with the current developments are crucial in en-
tion/ TIVA that too for a month or so depends upon the suring the maximal benefits to and safety of the patients.
number of fractions needed. Peripherally inserted CV
Access will be useful in these patients. Suggested reading:

Intra Cavitary Radio Therapy (ICRT/ BRACHY- Millers Anesthesia Seventh edition: Ronald D Miller
THERAPY): Compared to Low Dose Rate therapy et al, Chapter 79 Anesthesia at Remote Locations,
taking nearly 24 hours time the High Dose Rate with Paul E.Stensrud
Iridium 192 the treatment time is only 20 minutes and A Practice of anesthesia for Infants and Children:
the whole process will be over in 3-4 hours time. ICRT Charles J Cote et al, Chapter 48 Sedation for Diagnos-
will be used in Carcinoma Cervix patients and these tic and Therapeutic Procedures Outside the Operating
patients could be managed as Day Care patients under Room: R. F Kaplan, J P Cravero, M Yasterand C J Cote
regional anaesthesia /CS/GA. Subarachnoid Block with (pages 1024-1048)