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Non-OR Anesthesia (NORA) — MRI, GI, Cath Lab
TEXTSpecialty III · 9 min read
Remote locations + limited backup + procedure-specific physiology. NORA preparation is the difference between safe + sentinel.
After this lesson you can
3 min read9 sections- Plan anesthesia in remote locations.
- Identify MRI-specific safety concerns.
- Manage anesthesia at the cath lab + endoscopy suite.
- Document NORA case appropriately.
MRI safety zones
Projectile hazard: ferromagnetic items become missiles (O₂ cylinder, scissors, IV pole pulled into magnet = fatal).
All equipment MR-conditional or MR-safe.
Thermal injury risk from heated leads.
Pediatric + claustrophobic patients need sedation.
Emergency access plan + quench protocol if life-threatening.
Cath lab anesthesia
Pediatric cath: MAC sedation for simple diagnostic, GA for complex interventional (ASD/VSD closure, valvuloplasty).
Remote location considerations: emergency airway + meds + help.
Hemodynamic monitoring + transfusion ready.
Contrast nephropathy prevention.
Endoscopic procedure sedation
Capnography mandatory per ASA 2011 standard.
- left lateral for colonoscopy
- prone or LLD for ERCP
- supine for EGD
Aspiration risk in some patients.
NPO times standard.
- difficult airway predicted
- OSA + opioid-tolerant
- very long procedure
- full stomach concern
Remote-location preparation
- emergency airway equipment (laryngoscope + ETTs + LMA + bougie + suction)
- emergency medications (epi + atropine + sux + propofol + reversal + lipid emulsion)
- oxygen supply (wall + backup cylinder)
- full ASA monitor standard
- plan to call help
ASA closed claims show NORA cases more likely to have respiratory events from inadequate monitoring/preparation.
Treat as you would in OR.
ECT — electroconvulsive therapy
Methohexital 1 mg/kg (lowest seizure-threshold raise) or propofol 1 mg/kg or etomidate 0.2 mg/kg.
Succinylcholine 0.5-1 mg/kg to attenuate motor activity.
Bite block protects tongue.
Pre-O₂ + capnography.
Brief duration 5-10 min.
Cardiovascular monitoring + glycopyrrolate (vagal response from stimulus).
Continue antidepressants per psychiatry.
Series of treatments — vary technique per response.
Post-NORA recovery
Same discharge criteria as OR cases.
Hand-off to receiving team (PACU nurse, ICU, floor).
Document procedure + anesthetic technique + drugs + complications + recovery plan.
Some NORA locations have direct discharge home — verify escort + transportation + understanding of instructions.
Anesthesia 24-hr line available for problems.
Interventional radiology + neuro-IR
Anesthesia choice: GA for most adult neurointerventions (motion control critical), MAC for some peripheral vascular cases + adult cooperative thrombectomy patients (allows neuro exam during procedure).
RECENT TRIALS (GOLIATH, AnStroke, SIESTA) show GA vs MAC for stroke thrombectomy — equivalent functional outcomes when GA is delivered with strict hemodynamic protocol (avoid hypotension).
- contrast nephropathy
- anti-platelet/anticoagulation status
- sudden bleed during intervention
- sustained hyperdynamic state in some cases
Pediatric sedation outside OR
- MRI/CT (motion control)
- oncology procedures (lumbar puncture, bone marrow biopsy, port access)
- radiation therapy (daily sedation × weeks)
Standard technique: propofol bolus + infusion or ketamine + propofol (ketofol).
DEXMEDETOMIDINE bolus 1-2 mcg/kg increasingly used (preserves spontaneous breathing, less PONV).
NITROUS OXIDE with topical anesthesia for minor procedures.
Strict capnography + monitoring per ASA standards.
Pediatric airway emergency equipment + reversal drugs available.
Disaster + emergency NORA scenarios
What to do when something goes wrong in remote location: CODE CALL system + designated arrival of help (medics, code team, anesthesia backup), AMBU + O2 supply for hand-ventilation if pipeline fails, defibrillator + code drugs immediately available, intubation equipment + LMA if airway compromise, malignant hyperthermia cart accessible.
Many institutions now require pre-procedural verification of these resources before starting NORA cases.
Document the resource verification + emergency-response time test in QI metrics.
⚠ Common pitfalls
- Bringing ferromagnetic equipment into MRI — projectile risk.
- Inadequate monitoring + emergency backup in remote sites — same standards as OR apply.
- Long propofol drip without depth monitoring in remote — awareness + post-procedure delirium.
- Forgetting that anesthesia personnel may be alone — call-for-help slower.
💎 Clinical pearls
- MRI: ferromagnetic-safe everything (laryngoscope, syringes, pulse-ox cable).
- Cath lab: radiation exposure — lead apron + distance + dosimeter.
- Endoscopy: bite block on the patient, SGA or natural airway; propofol + low-dose opioid most common.
- All NORA needs ASA standard monitors + emergency cart + suction + scavenging.
Recap
- MRI: ferromagnetic-safe everything (laryngoscope, syringes, pulse-ox cable).
- Cath lab: radiation exposure — lead apron + distance + dosimeter.
- Endoscopy: bite block on the patient, SGA or natural airway; propofol + low-dose opioid most common.
- All NORA needs ASA standard monitors + emergency cart + suction + scavenging.
Mark each section done to complete the module.