NORA

Question 1

NORA unique challenges

Answer 1

• working with non-anesthesia personnel
• scheduling priorities = rushed prep
• equipment problems
• unfamiliar environment
• inadequate supplies, equipment, etc
• lax “check-in” policies
• stressful distance from the patien
• isolated from other anesthesia providers

Question 2

ASA statement on NORA locations about what is needed

Answer 2

• O2 source and back up
• suction meeting OR standards
• scavenging for volatiles and N2O
• self-inflating ambu bag with greater than 90% O2 ability, monitoring that meets “basics”, anesthesia machine at OR standards if volatiles and/or N2O being used
• adequate electrical outlets + emergency back-up
• adequate lighting + battery back-up
• adequate space for equipment and patient access
• crash cart with defibrillator, drugs, and CPR supplies
• adequately trained staff for anesthesia support
• dependable communication devices
• all building and safety codes must be followed
• trained staff for post-procedure care including transport personnel

Question 3

BIG deal communication requirement

Answer 3

dependable communication devices

Question 4

what are we doing in these places?

Answer 4

EVERYTHING

• bronchoscopy
• GI endoscopy
• cardiac (cath lab)
• diagnostic radiology
• interventional radiology
• ICU (pts too unstable to move)
• dental
• plastics
• ophthalmology

Question 5

higher frequency of _____ _____ and ______

Answer 5

severe injury and death

Question 6

> 50% NORA-related claims involving deaths: patients received sub-standard anesthesia care _________ by improved _______ techniques

Answer 6

preventable
monitoring

Question 7

sub-optimal ____ and failure to provide _____ _____ were the leading causes of poor outcomes

Answer 7

care
safe practice

Question 8

most claims were related to:

Answer 8

inadequate oxygenation and/or ventilation (loss of airway)

Question 9

______ most common cause - (___% of claims)

Answer 9

MAC (50% of claims)

Question 10

1/3 are due to _____-_____ leading to respiratory depression

Answer 10

over-sedation

Question 11

most claims are d/t over-sedation: limited _______ monitoring or no _______ monitoring at all

Answer 11

EtCO2
respiratory

Question 12

Mean age of NORA patients is ____ ____ _____ than OR patients

Answer 12

3.5 years greater

Question 13

this means more medically ______/more _______/less stable ______ ____

Answer 13

complex
comorbidities
surgical risk

Question 14

NORA has higher percent of ASA

Answer 14

ASA III-V patients (37.6% compared to 33%)

Question 15

because many NORA procedures are minimally invasive, patients are more likely to be _______ _____/____ _____

Answer 15

discharged early/same day

Question 16

general considerations, patient factors:

Answer 16

• ASA
• comorbidities
• airway
• level of sedation
• analgesia needed
• basic vs. advanced monitoring

Question 17

general considerations, environment:

Answer 17

• equipment (basic and ER), personnel, radiation/magnetic fields, temperature, portable monitoring, and O2
• more non-anesthesia trained personnel being licensed to administer sedation in NORA areas

Question 18

general considerations, procedure:

Answer 18

• diagnostic v. therapeutic
• expected duration
• positioning
• surgical back-up

Question 19

endoscopy

Answer 19

• airway compression/obstruction
• prone/semi prone positioning
• limited access to patient airway
• aspiration

Question 20

pulmonary

Answer 20

• neck positioning
• pre-procedure ABG
• shared airway
• apneic oxygenation
• local anesthesia/blunted airway reflexes

Question 21

cardiology

Answer 21

• high risk of dysrhythmias
• invasive monitoring (art line, CVP, PA)
• TTE/TEE

Question 22

pediatrics

Answer 22

• general vs. deep sedation with local/regional
• neuroapoptosis - “feed and wrap”
• airway obstruction, hypoxia, bradycardia

Question 23

fertility

Answer 23

• neuraxial
• regional
• sedation
• GA
• anesthetic agent accumulation in the follicular fluid

Question 24

magnets force ______ to align with magnetic field

Answer 24

protons

Question 25

radiofrequency current stimulates protons causing them to:

Answer 25

spin against the pull of the magnetic field

Question 26

when this current is turned off, MRI sensors detect the ______ ______ as the ______ ______

Answer 26

energy released protons realign

Question 27

the time and amount of energy released varies with the _________ and ________ chemistry

Answer 27

environment and tissue chemistry

Question 28

radiofrequency radiation emitted by MRI scanners is absorbed by the patient as ____ _____

Answer 28

heat energy

Question 29

magnet strength is measured in _____

Answer 29

teslas (T)

Question 30

most common magnet strength

Answer 30

1.5 T and 3T (the higher the number, the stronger the scale)

Question 31

now approved in the US is ____ T

Answer 31

7 T

Question 32

in the works:

Answer 32

10.5 T (weighs 3x more than a Boeing 737)

Question 33

MRI has ____ zones

Answer 33

4

Question 34

the zones are _____-_____ T

Answer 34

0.5-4 T

Question 35

anesthesia machine, monitors, stretchers, IV poles must be ____ compatible, and all staff must be _________

Answer 35

MRI de-magnetized

Question 36

NORA has _____ mortality rate than the OR

Answer 36

lower (0.02% compared to 0.04%)

Question 37

most common minor NORA adverse outcomes:

Answer 37

- PONV - inadequate pain control - hemodynamic instability

Question 38

most major complications:

Answer 38

- serious hemodynamic instability - upgrade of care

Question 39

highest NORA mortality categories:

Answer 39

cardiology and radiology (0.05%)

Question 40

significant NORA risk:

Answer 40

- over-sedation - inadequate ventilation and oxygenation all typically during MAC cases

Question 41

when providing NORA, the same ASA safety requirements must be _____ as those in the _____

Answer 41

met OR

Question 42

NORA includes specific challenges related to _____, ______, ______, and ______

Answer 42

environment, equipment, personnel, and isolation

Question 43

Many NORA adverse outcomes can be prevented with:

Answer 43

vigilant