Articles Between Issues

Anesthesia Emergencies in Hybrid Operating Rooms: Multidisciplinary Crisis Resource Management

September 8, 2020

Hedwig Schroeck, MD; M. Dustin Boone, MD, MPH; Lisa A. Rubenberg, MSN, CRNA; Yvon F. Bryan, MD

Procedures performed in non-operating room (NORA) locations or hybrid operating rooms are associated with well-known challenges, but little is known about effective crisis resource management in NORA locations. After a near miss at our institution’s off-site intraoperative magnetic resonance imaging hybrid operating room, we developed cognitive aids and multidisciplinary crisis training. We believe that our experience can be helpful for other institutions facing an increase in complex procedures being performed outside of the regular operating room setting.

MRI Machine

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Non-operating room anesthesia (NORA) procedures are increasing in frequency and complexity.1 Anesthesia induction and emergence in particular are often challenging in NORA locations, but transporting ventilated patients to NORA after induction in the operating room is also fraught with risk.2 To overcome some of these problems, hybrid imaging-operating rooms are gaining popularity. Our institution built the “Center of Surgical Innovation” (CSI), a hybrid operating room suite capable of intraoperative magnetic resonance (MRI) and computed tomography (CT) imaging. While the theoretical implications of intraoperative MRI on safe anesthesia care are well described, the logistics of managing an emergency in this setting are not.3 We present a case of accidental extubation during a prone procedure in an infant. It took several minutes until additional anesthesia help arrived from the main operating room two floors away. Fortunately, both members of the anesthesia team (attending and CRNA) were present in the room. They immediately recognized the complication and stabilized the patient via mask ventilation, so no permanent harm occurred. Here, we describe how our institution used this event to improve crisis management in an off-site hybrid operating room.

The CSI was designed for innovative surgical technologies and scientific research. Cases were initially scheduled infrequently, with extensive preparation for each individual procedure. As case volume increased, primarily for neurosurgical and orthopedic procedures with intra-operative imaging, several crisis events occurred, including mucus plugging of the endotracheal tube in an infant and intraoperative hemorrhage necessitating a massive transfusion protocol. Several problems were uncovered, which differed from those encountered in the regular operating room (see Table 1).

Table 1: Challenges and Vulnerabilities encountered in the hybrid-operating room (CSI):

CSI (intra-op MRI) specific challenges Implication
Distance between patient (airway) and the anesthesia machine >1 person needed for airway management
OR table stabilizer (“CPR pole”) needed during CPR to avoid swinging of the imaging-compatible table > 1 person needed to adjust table position on pole prior to effective CPR
Hybrid OR team (circulator, scrub) less familiar with paging system Hybrid OR team ineffective in calling for anesthesia help
Access to airway or vascular line sites limited by positioning/draping Delay in diagnosis and troubleshooting.

> 1 person needed to hold/remove drapes.

MRI-related precautions Only MRI compatible equipment can be brought to the OR;

Responders need to know what is safe

Access to the CSI suite restricted to trained personnel Pool of CSI-trained personnel is limited;
untrained additional personnel will increase risk of introducing ferrous items inadvertently
Off-site (NORA) challenges Implication
Remoteness from main OR Delay until help/equipment arrives
Low frequency of crisis events NORA team unfamiliar with crisis “routines”
Differences in NORA and OR team clinical skill Uncertainty how to delegate tasks during a crisis

Abbreviations: CSI: Center for Surgical Innovation (a NORA location and hybrid operating room); MRI: magnetic resonance imaging; OR: operating room; CPR: cardiopulmonary resuscitation; NORA: non-operating room anesthesia location.

To address the safety concerns, a multidisciplinary task force including members of the anesthesia team convened to characterize the safety concerns and construct solutions. The most critical problems identified were emergent airway management and the need for additional personnel during a crisis. The presence of a mobile magnetic field in CSI necessitates avoidance of ferromagnetic contamination and radio-frequency shielding, which restrict the use of commonly used airway and communication devices. We developed an MRI-safe airway “grab bag” for single-rescuer ventilation and a laminated card with instructions for activating the emergency response system, along with implementing several changes (see Table 2). Mock crisis sessions were found to be critical to evaluate the effectiveness of these measures. Finally, we conducted crisis simulation training for all anesthesia, nursing, and technician personnel working in the hybrid suite. The primary goal was to increase familiarity with the site-specific aspects of crisis management, but in addition, the feedback generated from these training sessions informed additional improvements (see Table 2). Recurrent training will be mandated, to maintain skills and continually update team members of new developments. Our institutional efforts to create a site-specific crisis management protocol for a hybrid operating room has evolved based on feedback and effectiveness. Interestingly, we have started to observe “spill-over” effects in how clinicians prepare in other NORA locations: For example, cognitive aid cards with emergency phone numbers are in development for our endoscopy unit, and a workgroup of endoscopy technicians, nurses and anesthesia representatives is being assembled to discuss process flow and crisis planning. We believe that our experience can serve as a framework to other institutions facing similar challenges in a rapidly changing off-site landscape.

Table 2: Issues and Solutions (developed by a multidisciplinary task force and modified after feedback obtained during mock crisis training sessions)

Issue: Solution(s):
Airway management requiring multiple people
  • Airway grab-bag (self-inflating bag, adjuncts, SGA) to allow 1-person ventilation
  • Training of CSI support personnel to perform manual ventilation from the anesthesia machine
  • Addition of extension tubing on oxygen outlets
Calling for help different in CSI from regular OR
  • Creation of a “stat” page function, alerting all anesthesia clinicians with CSI training
  • Cognitive aid cards at each phone/computer
    – instructions for stat page
    – back-up instructions for overhead paging
Initiation of CPR time-consuming (requires 2 people to position CPR pole)
  • Clear role assignment (circulator and imaging tech)
  • practice runs; resulting in modifications:
    – shorter CPR pole
    – step stools always available
Code cart/code medications not available while magnet present in OR
  • Code medication pack of pre-filled syringes in each room
  • Defibrillator is not magnet safe, brought in after magnet removed.
Delay until external help arrives
  • “stat” page function created and tested
  • temporizing measures for airway management (see above)
Low frequency of crisis events and
differences in OR team skill set
  • Multidisciplinary crisis training
  • Expanded practice training: CSI support personnel trained to assist with airway
Unfamiliarity of responders with the CSI location and team
  • Departmental education and multidisciplinary crisis training
  • Non-ferrous name badges for CSI team1
  • Dry erase board in the CSI with names/roles1
Limited number of CSI trained personnel
  • Training of additional anesthesia and nursing personnel
  • Gate keeper role to screen for “magnet-safety” during a crisis

Abbreviations: SGA: supraglottic airway device; CSI: Center for Surgical Innovation; OR: operating room; CPR: cardiopulmonary resuscitation. 1: Implementation pending.


Hedwig Schroeck, MD
Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA

M. Dustin Boone, MD, MPH
Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA

Lisa A. Rubenberg, MSN, CRNA
Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA

Yvon F. Bryan, MD

The authors have no conflict of interest.


  1. Walls JD, Weiss MS. Safety in Non-Operating Room Anesthesia (NORA). APSF Newsletter. 2019;34:3-21.
  2. Algarra NN, Gravenstein N. Considerations for mechanical support of ventilation during patient transport. APSF Newsletter. 2019;34:47.
  3. Schroeck H, Welch TL, Rovner MS, Johnson HA, Schroeck FR. Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review. J Clin Anesth. 2019 May;54:89-101.