NORA: Non-O.R. Anesthesia

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November 1, 2013 Volume 77, Number 11
NORA: Non-O.R. Anesthesia Charlotte Bell, M.D.
Chair, Committee on Equipment and Facilities
Member, Committee on Patient Safety and Education

Delivering anesthesia in areas remote to the O.R. results in some of the most unique and problematic issues of our specialty. Typically, routine anesthetic equipment is not stored in these locations and must be brought from central O.R. areas. Medical gases, scavenging, evacuation and electricity may not exist in convenient areas of the facility (or at all). Not only is equipment transported, but patients must also be transported, often from critical locations. And the support systems we most rely on, colleagues and technicians, are usually far away and need time to respond even in emergent situations.


Members of the Committee on Equipment and Facilities and their colleagues have described on the following pages some of the most interesting and difficult situations that occur during the process of delivering non-O.R. anesthesia (NORA). Topics include building productive working teams with our non-anesthesiology colleagues who are involved in performing the procedures and typically unfamiliar with O.R. practices; scavenging gases away from central O.R. scavenging systems; and problems identified from the perspective of our anesthesia techs who provide a critical lifeline in both routine and emergent situations. In addition, we have approached issues that exist specifically around the neurosuite, as this is often the location with the most critical procedures and patients. Not only are we challenged in this location by the patients and procedures, but the physical plant associated with neuroimaging poses additional hazards to patient and anesthesiologist – whether in the invasive neuroradiology suite or the MRI suite.


The high-magnetic field present in the MRI suite prohibits the use of any ferromagnetic equipment or materials that can potentially become airborne projectiles. However, in addition to this static magnetic field, MRI also uses two other types of energy: a varying magnetic field and, particularly important to us, radiofrequency, in order to form the images. Even if our monitors are non-ferromagnetic, the radiofrequency interferes with their normal function. Therefore, all monitoring equipment must be non-ferromagnetic and must also be housed inside a box which precludes RF interference.


Establishing anesthesia delivery in the MRI suite demands working with biomedical engineers, technologists, imaging nursing staff and radiologists (who are often not on site). Because of the hazards of the physical plant, anyone who enters the MRI suite is mandated to undergo a formal education process describing the unique problems and solutions pertaining to this environment. Safety measures have been described in detail in the American College of Radiology “ACR Guidance Document on Safe MR Practices: 2013,” which has been endorsed by ASA.1


This issue of the ASA NEWSLETTER does not include a separate article on anesthesia delivery in the MRI suite. Detailed information on this topic and others can be found in the 2012 ASA Operating Room Design Manual, written by the Committee on Equipment and Facilities, which can be found in its entirety on the ASA website.2 This fully downloadable book offers extensive information on the design process, environmental considerations, infrastructure, specialty O.R.s, communication and information management systems, and other pertinent topics, whether embarking on a new facility design or renovations of an existing facility.


Because of advancing technology coupled with the ubiquity of fixed complex diagnostic and therapeutic equipment, the future of medicine demands that more and more difficult procedures will take place outside of the domain of the classic operating theater. The contributors to this issue have shared their exceptional expertise and knowledge in discussing some of the challenges that are encountered routinely as our anesthetic practices expand to more areas of the medical center.

Charlotte Bell, M.D. is Attending Anesthesiologist, Milford Anesthesia Associates, Milford, Connecticut.


1. Kanal E, Barkovich AJ, Bell C, et al.; Expert Panel on MR Safety. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37(3):501-530. Accessed September 16, 2013.

2. Rogoski J. Remote and hazardous locations. In: Block FE, Helfman S, eds. Operating Room Design Manual. Park Ridge: American Society of Anesthesiology Committee on Equipment and Facilities; [2012]:84-91. Accessed September 16, 2013.