**3.3 The gastroenterology suite**

The gastroenterology suites conduct many procedures that can warrant the patient to be either sedated or anesthetized. These include edoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, esophageal or colonic dilatation and stenting, enteroscopies, and endoscopic sleeve gastroplasties. ERCP procedures need to be done with the patient in the prone position and in a fluoroscopy room. These rooms are usually small and crowded with equipment other than airway equipment. Apart from doing these under GA, these procedures have also been done under deep sedation with no adjunct airway device except supplemental oxygen via nasal prongs. One has to bear in mind the difficulty of airway access in these cases and plan airway management at the outset based on the expected duration of the procedure and expertise of the operator. Frequent suctioning of the oral cavity may be required in the unprotected airway.

**41**

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

**3.4 Electroconvulsive therapy (ECT) suite**

post procedure monitoring.

to increase the safe apneic time.

**3.6 Oncology**

airway kit.

**3.7 Cardiology**

relaxants are not necessary.

physiology in certain critical congenital heart lesions.

**3.5 The in-vitro fertilization (IVF) suite**

The gastroenterology suites have started doing more bariatric work than in the past. These include simple procedures like intra-gastric balloon insertions and removals, and also complicated longer procedures like the sleeve gastroplasties. Obesity is by itself a pointer of airway risk and this should be taken into consideration when planning to intubate these patients. This includes having trained staff familiar with the bariatric airway, proper preparation of the patient, positioning the patient well using a ramp, good pre-oxygenation, and having a skilled person for

ECT is still being used in patients who have severe major depression or bipolar disorders who have not responded to maximal medical management strategies. Small electrical currents are passed through the brain, intentionally triggering a brief seizure, which has been known to alter brain chemistry, reversing symptoms. This procedure requires a GA, with the patient given an induction agent and a small dose of muscle relaxant to prevent trauma during seizures. It is vital to establish that the patient is fasting (some patients do not have mental capacity and are not able to give proper history) to avoid aspiration of gastric contents. These are very brief procedures and do not usually require an extensive airway armamentarium, but backup airway equipment should be standard. Since suxamethonium, a depolarizing muscle relaxant is used to achieve safety during the brief period of seizure (and therefore a short period of apnea), it is vital to pre-oxygenate the patient well

The IVF suite usually requires sedation and analgesia for egg retrieval. Mild to moderate sedation is usually sufficient, but some patients slip into deep sedation and airway support may be warranted. These areas need to be equipped with a

Stand-alone oncology units do procedures that usually require general or spinal anesthesia, or at times deep sedation. These include brachytherapy and bone marrow aspirations, among other procedures. In spite of being a stand-alone facility for the immunocompromised, these areas usually have OR setups with the usual

The cardiac catheter lab provides an area for interventional procedures and has similarities to the neuro-interventional suite although deep sedation or general anesthesia is not usually necessary in adult patients. Apart from interventional cardiology, sedation is also given for Transesophageal Echocardiograms (TEE). This is similar to having an esophagogastroscopy and the airway needs are that of the gastroenterology suite. Cardioversions may be done in this area or as an emergency in the ED. These patients usually get a dose of sedative medication, but muscle

Ventilation in some patients needs the use of room air to study the blood gases

dedicated airway trolley as airway problems are not uncommon.

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

*Special Considerations in Human Airway Management*

sensors is vital to the safe conduct of anesthesia.

cavity may be required in the unprotected airway.

**3.2 The neuroradiology suite**

**Figure 2.**

exists in many hospitals these days.

**3.3 The gastroenterology suite**

of the cryogen that causes an immediate loss of superconductivity, to shut down the magnetic field) and if there is damage to the quench pipe, the build-up of helium within the scanning room could potentially lead to asphyxiation. The use of oxygen

*The MRI room with the patient's airway in the tunnel and not easily accessible to the operator.*

The neuroradiology suite would require a special mention, as they may be standalone from the rest of the radiology suite. These are very similar to the interventional radiology suites used by radiologists for other procedures, but the incidence of the patient needing intubation and a general anesthesia over just deep sedation is more here. Apart from the general risks of working in a dark environment with high radiation as is mentioned in the general risks below, these areas should be set up to mirror an OR as far as possible. It is comparable to the hybrid CT/MRI ORs that

The gastroenterology suites conduct many procedures that can warrant the patient to be either sedated or anesthetized. These include edoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, esophageal or colonic dilatation and stenting, enteroscopies, and endoscopic sleeve gastroplasties. ERCP procedures need to be done with the patient in the prone position and in a fluoroscopy room. These rooms are usually small and crowded with equipment other than airway equipment. Apart from doing these under GA, these procedures have also been done under deep sedation with no adjunct airway device except supplemental oxygen via nasal prongs. One has to bear in mind the difficulty of airway access in these cases and plan airway management at the outset based on the expected duration of the procedure and expertise of the operator. Frequent suctioning of the oral

**40**

The gastroenterology suites have started doing more bariatric work than in the past. These include simple procedures like intra-gastric balloon insertions and removals, and also complicated longer procedures like the sleeve gastroplasties. Obesity is by itself a pointer of airway risk and this should be taken into consideration when planning to intubate these patients. This includes having trained staff familiar with the bariatric airway, proper preparation of the patient, positioning the patient well using a ramp, good pre-oxygenation, and having a skilled person for post procedure monitoring.

#### **3.4 Electroconvulsive therapy (ECT) suite**

ECT is still being used in patients who have severe major depression or bipolar disorders who have not responded to maximal medical management strategies. Small electrical currents are passed through the brain, intentionally triggering a brief seizure, which has been known to alter brain chemistry, reversing symptoms. This procedure requires a GA, with the patient given an induction agent and a small dose of muscle relaxant to prevent trauma during seizures. It is vital to establish that the patient is fasting (some patients do not have mental capacity and are not able to give proper history) to avoid aspiration of gastric contents. These are very brief procedures and do not usually require an extensive airway armamentarium, but backup airway equipment should be standard. Since suxamethonium, a depolarizing muscle relaxant is used to achieve safety during the brief period of seizure (and therefore a short period of apnea), it is vital to pre-oxygenate the patient well to increase the safe apneic time.

#### **3.5 The in-vitro fertilization (IVF) suite**

The IVF suite usually requires sedation and analgesia for egg retrieval. Mild to moderate sedation is usually sufficient, but some patients slip into deep sedation and airway support may be warranted. These areas need to be equipped with a dedicated airway trolley as airway problems are not uncommon.

#### **3.6 Oncology**

Stand-alone oncology units do procedures that usually require general or spinal anesthesia, or at times deep sedation. These include brachytherapy and bone marrow aspirations, among other procedures. In spite of being a stand-alone facility for the immunocompromised, these areas usually have OR setups with the usual airway kit.

#### **3.7 Cardiology**

The cardiac catheter lab provides an area for interventional procedures and has similarities to the neuro-interventional suite although deep sedation or general anesthesia is not usually necessary in adult patients. Apart from interventional cardiology, sedation is also given for Transesophageal Echocardiograms (TEE). This is similar to having an esophagogastroscopy and the airway needs are that of the gastroenterology suite. Cardioversions may be done in this area or as an emergency in the ED. These patients usually get a dose of sedative medication, but muscle relaxants are not necessary.

Ventilation in some patients needs the use of room air to study the blood gases physiology in certain critical congenital heart lesions.

#### **3.8 ENT procedure room**

The Ear, Nose and Throat clinic usually has a procedure room to carry out minor procedures. Local anesthesia of the airway is usually used to access the laryngeal inlet for vocal cord injections. The clinic also performs tracheostomy tube changes and tracheostomy wound management. Routine tracheostomy changes must be done only during the daytime and during working hours except in an emergency. At least two trained practitioners are required during the tracheostomy tube change procedure. No drugs are usually given to hamper the patient's respiratory efforts, but the difficult airway trolley should always be available along with a good functioning suction machine.

#### **3.9 Emergency department**

The resuscitation areas in the ED are usually equipped to intubate and ventilate patients. In the other acute areas of the ED, procedures may be done for non-fasted patients (such as cardioversions, TEEs and fracture reductions). These areas should be well equipped with anesthetic machines and airway trolleys. One needs to keep in mind the need for a fiberoptic scope in case of airway swelling in severe allergies or burns.

#### **3.10 Wards and other areas**

The resuscitation team may need to intubate a patient in any area of the hospital. Basic airway kit and intubation equipment are available in all ward areas (**Figure 3**).

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**Figure 4.**

*A dimly-lit crowded interventional radiology room.*

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

**4. Challenges in these areas**

environment (**Figure 5**).

getting help quickly in case of a crisis.

very different to those available in the OR.

the OR.

Ventilation is usually achieved with the use of a bag-valve-mask device until a definite

Working in different areas outside the OR comes with its own difficulties. These may be specific to the area like the radiology suite or can be general differences to

**Dark rooms:** Rooms where fluoroscopy or ultrasound is used tend to have low lighting to enable visual clarity of the images for the operator (**Figure 4**). This makes it difficult to observe the patient and to monitor notes. An alternate source of light should always be available [2]. The monitor should be clearly visible in this

**Remote location:** When airway management is undertaken away from other trained personnel and specialist equipment, it is important to formulate a plan to

**Unfamiliar equipment:** Different areas are equipped with different airway kit. The anesthetic machines may be basic models with minimal monitors. It is important to familiarize oneself with the equipment available prior to use, as they may be

**Lack of skilled staff:** As mentioned above, skilled support staff may be at a distance, and having a plan to inform and seek help needs to be in place before starting. **Limited patient access during procedures:** Whether the patient is in the MRI tunnel or fully draped on the interventional radiology table, it is difficult to manipulate the patient's airway once the procedure has begun. The decision to maintain the patient's airway using a particular technique should be taken keeping this in mind. **Crowded rooms:** The rooms mentioned above can be very crowded with equipment essential to the procedure being performed (**Figure 4**). In the

portable ventilator is made available for transfer of the patient to the ICU.

**Figure 3.** *A resuscitation trolley with airway equipment on the ward.*

Ventilation is usually achieved with the use of a bag-valve-mask device until a definite portable ventilator is made available for transfer of the patient to the ICU.
