See Article, page 1149

Nearly every currently practicing anesthesiologist is familiar with the remarkable rise in procedures requiring anesthesia that are performed outside the operating room (OR). A 2017 review of the National Anesthesia Clinical Outcomes Registry observed a 30% increase in procedural volumes from 2011 to 2014 and noted that nonoperating room anesthesia (NORA) accounted for one-third of all anesthetics in the United States.1 Now 9 years later, the percentage of NORA is likely higher. At the University of Chicago, the percentage of cases performed out of OR has increased by 12% from 2014 to 2022. Although many factors contribute to this growth, improved surgical processes, increased demand for anesthesia for complex nonoperating room procedures such as electrophysiology ablations and transcatheter valve insertions, and greater efficiency of proceduralists when performing procedures in their preferred environment likely play major roles. Recently published closed claims analyses of nonoperating room anesthetics2 testify to an increasing interest and focus on anesthetics delivered outside the OR.

NORA may occasionally be administered in the intensive care unit (ICU) to facilitate procedures, such as tracheostomy, wound debridement, or vascular cannulation. In addition to greater efficiency, performing procedures in the ICU rather than the OR eliminates a potentially risky patient transport and allows the ICU service to manage enteral feedings, anticoagulation, continuous renal replacement therapy, and other continuously administered ICU therapies, which must be interrupted for an intraoperative procedure. Because such cases are often add-ons to a busy elective OR schedule, bringing the proceduralist to the patient (rather than vice versa) also allows the ICU service to schedule other diagnostic/therapeutic procedures more efficiently. And, although intensivists with anesthesia training clearly have the skills to manage an anesthetic for ICU-located procedures, intensivists in other specialties are increasingly familiar with managing intravenous sedatives likely to be adequate for most procedures suitable for an ICU setting.

Although a strategy of shifting procedures to the ICU when feasible sounds like a win-win, the devil is (as always) in the details. In this issue of Anesthesia & Analgesia, Karamchandani et al3 explore the advantages and disadvantages of performing procedures in the ICU rather than the OR. Their engaging Pro-Con format addresses many of the challenges and opportunities inherent in performing procedures in the ICU versus the OR and reviews the relevant literature. The result is worthwhile reading for intensivists, anesthesiologists, OR managers, and department leaders pondering how best to allocate scarce anesthesia resources.

Among the highlights is a list of procedures amenable to an ICU location, which includes not only expected procedures such as tracheostomy and gastrointestinal (GI) endoscopy but also more invasive procedures such as percutaneous feeding tube placement, tunneled central venous line insertion, fracture stabilization, wound debridement, and even laparotomy for abdominal compartment syndrome.

With respect to the “Pro” argument, Karamchandani et al3 note that in addition to facilitating ICU care, existing literature supports a shorter time from request to performance for in-ICU tracheostomy at some centers, and reduced procedure and anesthesia times.4 Subsequent studies support considerable potential cost savings when tracheostomies and percutaneous feeding tube insertions are performed in the ICU.4,5 When combined with the relative safety and decreased workload of not transporting a critically ill patient through the hospital, the case seems strong to move at least some procedures to the ICU.

The “Con” argument is a bit less obvious but every bit as relevant and well-articulated by Karamchandani et al.3 They note a series of pragmatic concerns, including space—likely to be limited in an ICU room where multiple support devices may limit easy mobility by surgical team members, sterility—in some hospitals, ICU rooms may have different airflow requirements than ORs, limitations in anesthetic options due to a lack of anesthesia machines and scavenging systems for inhaled anesthetics, and potential difficulty linking anesthesia information management systems to ICU monitors.

Karamchandani et al3 also astutely observe that the greater efficiency and more rapid completion of procedures in the ICU may be offset by reduced efficiency with respect to nurse staffing and system-wide anesthesia coverage. One underrecognized advantage of geographically grouping procedures is the ability to share resources between ORs and to allow anesthesiologists to cover multiple rooms. Although transporting a critically ill patient to the OR for a tracheostomy can be time-consuming, performing the procedure in the OR allows more efficient use of anesthesia resources as 1 anesthesiologist can potentially cover >1 OR. In contrast, assigning an anesthesia care team in the ICU allows that team to cover only a single location. Other advantages of performing procedures in dedicated OR locations include better lighting, usually more room, trained circulator and scrub nurses, greater availability of additional equipment and personnel, and potentially more sterile conditions. Existing data do not find differences in infection rates or outcomes between cases performed in and out of the OR.6,7 But, today’s clinicians likely select cases carefully for OR and non-OR locations, and more advanced NORA procedures such as wound debridement and exploratory laparotomy are as yet rare.

In their conclusion, Karamchandani et al3 argue that planning, preparation, and patient selection may limit the adverse consequences of performing surgical procedures in the ICU. However, another reasonable interpretation might be that any advantage to performing procedures in the ICU rather than the OR likely depends considerably on local geographic, staffing, and ICU environmental factors—and that each medical center may need to decide themselves which procedures are best performed in what patients in an ICU environment. Regardless, advances in surgical technology and equipment and overall trends in NORA make it increasingly likely that procedures such as tracheostomy and endoscopy will be performed in an ICU environment going forward. A core component of future intensivist training may thus be learning to manage such procedures from an anesthetic perspective. In the meanwhile, Karamchandani et al3 have done an excellent job of highlighting many potential issues that intensivists, anesthesiologists, and OR managers should consider when contemplating NORA in the ICU.

DISCLOSURES

Name: Avery Tung, MD, FCCM.

Contribution: This author conceived and wrote this manuscript.

Conflicts of Interest: A. Tung receives a salary stipend as Executive Section Editor for Critical Care in Anesthesia & Analgesia.

This manuscript was handled by: Thomas R. Vetter, MD, MPH, MFA.

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