OTHER SITES

The need to provide anesthesia care in myriad non-OR "off-site" locations grows at a furious pace (see Chapter 69 ). As procedures become "less invasive" and do not need the facilities of an operating room, it is now easier to bring the anesthesia to the patient than the converse. Areas qualifying for the label "off the floor" or "in the outfield" encompass almost every specialty, including in vitro fertilization, lithotripsy, electroshock therapy, cardioversion, and, in the case of children, a variety of procedures for which sedation is often unsatisfactory (e.g., lumbar puncture, bone marrow biopsy, and various radiologic imaging procedures). These environments require special knowledge, equipment, and preparation. Strict adherence to practice standards in these non-surgical settings is critically important, and the ASA has developed a number of relevant standards of care. In this instance, "Guidelines for Nonoperating Room Anesthetizing Locations" (approved in 1994 and amended in 2003) is the appropriate guide.

Interventional neuroradiology, cardiac catheterization, and electrophysiologic laboratories are areas where new procedures seem to appear on a monthly basis. Radiology equipment, the need for shielding, and the fact that many of these laboratories were designed neither for the anesthesiologist nor with the necessary anesthesia equipment often make these procedures a special event. An exception to this is the fact that many of the newly constructed cardiac catheterization laboratories are designed with the ability to be converted to a complete operating room. On the other hand, the magnetic resonance imaging suite continues to be a less-than-hospitable place, whether we are called to care for a child, a trauma victim, or an inconsolable claustrophobic patient.

The cardiac electrophysiologic (EP) laboratory is a continual source of requests for care. Increasing knowledge of conducting systems of the heart permits electrical ablation of specific areas to control arrhythmias. Such procedures are extremely lengthy, and patients often become restless. Providing sedation and/or general anesthesia to these patients may be required. Additionally, the placement of implantable cardioverter-defibrillators, previously performed via a thoracotomy in the OR, is now carried out via the percutaneous route in the EP laboratory. Patients undergoing these procedures often have limited myocardial reserves and are being treated with a variety of antiarrhythmic drugs. Extensive knowledge of drug interactions in such cases is necessary, and the ability to support the circulation may be required.