Radiation Therapy Removes Anesthesia Provider from the Treatment Room

Timothy W. Martin, MD, MBA

Letter to the Editor:

To the Editor:

I am writing to comment on a letter which appeared in the Summer 2005 issue of the
APSF Newsletter titled “Stand Nearby in the MRI” and the ASA basic monitoring standard pertaining to the continuous presence “in the room” of qualified anesthesia personnel throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care. I agree with Dr. Kempen that anesthesiologists and nurse anesthetists should remain within the MRI suite, or “magnet room,” at the patient’s side throughout the conduct of general anesthesia or sedation during the conduct of MRI procedures.

However, as a pediatric anesthesiologist I am aware of at least 2 specific types of anesthetic cases in which it is unsafe and frankly contrary to radiation safety and health department standards to physically remain “in the room” with a patient throughout the entire anesthetic or sedation case: use of radiation therapy using high-energy x-rays to treat various types of tumors and malignancies, and the use of what is known as a “gamma knife” (focused and directed gamma radiation from radioisotopes) to treat different tumors and vascular lesions. In both instances, when anesthesia or deep sedation is required (usually for pediatric patients), the anesthesiologist must “remotely” monitor the patient via an adjoining room, but beyond sealed doors using a combination of electronic physiologic monitors (including all basic and standard ASA monitors) and either a closed circuit video camera that is aimed at the patient and monitors in the treatment room or a specially prepared window.

Having participated in a number of these cases, I am convinced that the spirit of appropriate ASA monitoring standards is being met, and in fact, the anesthesiologist is typically even more vigilant than normal because of the forced separation and distance from the patient. I have discussed the complex regulatory issues and standards with our colleagues in radiation oncology, and it appears clear that an anesthesiologist would be in violation of a variety of standards* to attempt to remain physically with a patient in a radiation therapy or “gamma knife” room, not to mention the likely and predictable health risks that the anesthesiologist would incur. This is particularly true in the case of radiation therapy using high energy x-rays, as patients who undergo this therapy generally require daily treatment for a period of weeks. I believe it would be completely inappropriate to deny children (and likely a few adults) who require radiation therapy this palliative or curative treatment because of an apparent conflict with the ASA basic monitoring standard on the issue of continuous presence “in the room” throughout the conduct of all anesthetics.

As we look to the future and various technological advances that may be on the horizon, I think it is likely there will be other types of procedures for which the anesthesiologist or other anesthesia care provider will not be able to physically remain “in the room” with the patient throughout the anesthetic. Perhaps it is time that the ASA consider revising the wording of the basic monitoring standard on anesthesia provider presence to acknowledge and allow for alternative monitoring arrangements when physical presence is unsafe and contrary to other regulations and standards.

Timothy W. Martin, MD, MBA
Little Rock, AR

*The Nuclear Regulatory Commission apparently regulates the safe use, handling, and exposure to radioisotopes. The various state health departments regulate exposure to high energy x-rays produced in an accelerator for radiation therapy, and although the standards vary from state to state, the radiation oncologists I spoke with were not aware of any state where a person other than the patient is permitted to remain within the actual treatment room during exposure of the patient to therapeutic x-rays.