Episode #120 Welcome to the Future of NORA

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are back for Part 4 of our series on the 2022 APSF Stoelting conference, “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA).” We hope that you will check out the first three parts of the series and we are glad you are tuning in again because there is still more to discuss when it comes to keeping patients safe during NORA care.

Before we dive into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Last week, we covered Session 2 from the conference which was all about Appropriate Patients and Procedures in locations that are outside of the hospital including ambulatory surgery centers, office-based practices, and dental procedures. Before we move on to session 3, let’s take some questions from the conference participants with answers from the session 2 speakers.

First, can one set of NORA guidelines fit all locations including NORA, Office-based practices, Dental Offices, and ambulatory surgery centers? This may be really challenging given the wide variety of these practice settings. The first step may be to start with the basics. At the minimum, at least 2 people are needed who are able to resuscitate a patient who receives sedation. The next step is very clear overarching principles for safe NORA care similar to the ASA guidelines which include required monitoring and the requirement that there is someone available to monitor and that person knows what the monitor means. From here, there may need to be different guidelines for different practice models.

The next question is about providing anesthesia care and the availability of anesthesia professionals given the current staffing shortages and expanded need for NORA care. How can we address this? Education is the key. Some considerations include better education for assistants as well as not offering anesthesia or sedation to everyone, especially if you can’t do it safely. In the future, there may be a role for increased technology, remember those smart assistant devices that we talked about last week, these devices may be able to help single providers and those who are less familiar with managing patients during and after sedation.

The next question is related to proper patient selection for each location. We really need to know “Should this patient be done with this procedure in this location?” Once again, it may be challenging to create a single statement for all sites, but a good starting point would be to implement a patient selection standard protocol for hospital outpatient, free-standing ambulatory surgery center, and office-based anesthesia practices.

Let’s talk about two additional keys for improved patient safety in these locations. The use of end-tidal CO2 monitoring should be mandatory for all patients who receive sedation. You may read guidelines that include the phrase “when feasible” but it is always feasible and must be required for any level of sedation. Remember, unrecognized ventilatory depression followed by a late intervention and then not being able to manage the airway may lead to anoxic brain injury.  In addition, the need for ACLS and PALS training should be required for more than just the anesthesia professional or the anesthesia permit holder. The office staff should have training and education to be able to help in an emergency as well. Keeping patients safe in NORA locations and during procedural sedation requires that anesthesia professionals own this space and be responsible for creating standards for patient triage, training, documentation, quality, and training.

There is no time for a commercial break because we are going to hear from one of the members of the planning committee for the 2022 Stoelting Conference, Patty Reilly, to talk about the most important takeaways from the conference and what she hopes to see going forward. Let’s take a listen now.

[Patty Reilly] Hi, my name is Patty Riley and I am a CRNA practicing at Chester County Hospital, Penn Medicine in West Chester, Pennsylvania. I am also on the board of Directors of the Anesthesia Patient Safety Foundation. For me, the passion and the interest of the audience around the topic of Nora. The discussion and sharing of experience and expertise was wonderful. The participants were engaged the entire time. There was discussion, there was debate, there was happiness about making changes and affecting the practice of the anesthesia, Nora, and there were questions around how do we do that and how long will it take?

What do I hope to see going forward? I hope to see clear guidelines adapted from the anesthesia patient safety foundation work, and the Stoelting conference. The recommendations which were well thought out, clear, concise, and very patient-centric, decided upon by a very engaged group of practitioners.”

[Bechtel] Thank you so much to Reilly for helping to plan the conference and contributing to the show today and for moderating the third session, “Designing NORA for Patient safety. Beyond Current State to a Future Best Practice?” Let’s dive in now.

First up, we have Jonathan Wanderer and his talk, “Using Data to Improve Care in the NORA Setting.” Wanderer kicks off his session by reviewing the transition between data to wisdom with stops at information and knowledge along the way. So, how do we make this journey? It starts with a data model. Some examples include MPOG, NACOR, and Caboodle in Epic. The next step is using reporting platforms to report on the data at different phases to look at different outcomes such as PONV. Data from patients including patient satisfaction surveys can be used to provide anesthesia professionals and the anesthesia department with a report. Wanderer also reviews data from the National Anesthesia Clinical Outcomes Registry (NACOR) related to NORA. Data from the registry between 2010 and 2013 of over 12 million cases reveals that compared to OR procedures, NORA procedures are performed on a higher percentage of patients greater than 50 years old with monitored anesthesia care and sedation performed more often. The most common minor complications in NORA locations include PONV, inadequate pain control, and hemodynamic instability with major complications of serious hemodynamic instability and need to upgrade care. I will include the citation to this study in the show notes. Using data from this registry it is possible to evaluate outcomes for patients undergoing procedures in NORA locations and it is vital that we continue to evaluate this data to help keep patients safe during NORA care going forward.

The next session is “The Future of NORA Medications May Include Newer Short Acting Sedatives” by  George Gilkey. Have you used remimazolam? This is a new medication approved for general anesthesia and procedural sedation in several countries starting in 2020 and 2021. This medication is similar to midazolam. It enhances GABA-A receptor activity to induce cell membrane hyperpolarization and increased chloride influx leading to sedation. Remimazolam is a very quick acting medication that is rapidly hydrolyzed to an inactive metabolite through a non-specific tissue esterase activity. The dose range is 2.5-5mg with onset time of 1-2 minutes and a duration of 10-12 minutes for an 8mg bolus. It is available for IV use only and may be re-dosed after 2 minutes. Where could we use this drug? Here are some considerations: GI Endoscopy for LVAD patients, ALS patients undergoing PEG tube placement, Feeding tube placement in patients with odynophagia; sick patients in the Cath lab, patients who need vascular access in interventional radiology with poor cardiovascular status, patients who need ultrasound guided procedures needing quick sedation, and certain Neurosurgical or Neuro IR procedures including trigeminal ablations. The benefits of this medication include minimal respiratory depression and hemodynamic changes when used as the sole agent and rapid emergence. On the flip side, remimazolam requires frequent dosing, IV compatibility, it is expensive, and it is important to manage provider expectations when using this new medication.

Our next stop is the future of NORA postoperative pain management with our third speaker, Girish Joshi to talk about “The Future of NORA Post-Op Pain Control May Include New Non-Opioid Analgesics and Regional Blocks.” We have already talked about sedation for patients undergoing NORA procedures, but what about appropriate analgesia.  If we look broadly at the goals for safe NORA care which include improve patient acceptance and cooperation, minimize pain and discomfort, facilitate the procedure, expedite discharge, and avoid treatment-related complications, it becomes clear that pain management is an important consideration.  Anesthesia professionals have an important role to engage with the patient and provide education about the procedure, sedation, and analgesia options and risks as well as preoperative instructions for prescription medications. One option may be to safely reduce the fasting period keeping in line with current guidelines and continue hydration while fasting. It is important to set goals and expectations for sedation so that patients know that they should not experience pain, but they may feel touch and pressure. Let’s talk about options for postoperative analgesia. Pharmacological options may include non-opioids including acetaminophen and NSAIDS especially since the combination is superior to either drug alone. There are several safety considerations for NSAIDS. For patients with normal renal function, a short course of NSAIDS likely does not lead to acute kidney injury. Also, there is no conclusive evidence for increased risk for cardiovascular events, GI complications, and decreased bone healing following a short duration of NSAIDS. Opioids may be used for rescue if needed. Non-pharmacologic options may include music, virtual reality, and reassurance. Have you seen the randomized-control trial that showed that music may decrease postoperative pain and anxiety and improved patient satisfaction? Don’t worry, I will include the citation in the show notes. Cue the relaxing music…

Ah, that’s better. Now, its time to review several non-opioid adjuncts. Here we go:

1. Dexamethasone with the benefits of reduce pain and opioid requirements, antiemetic properties, improved functionality, and no safety concerns from the literature related to delayed wound healing or infection or hyperglycemia. It is likely safe to use this medication for patients with well-controlled diabetes.
2. Gabapentinoids need to be considered carefully due to conflicting analgesic effects and concerns for serious side effects of sedation, dizziness, visual disturbances, and respiratory depression and should likely only be used for patients are already taking it.
3. Ketamine has the benefit of reduced propofol and opioid requirements with side effects of hallucinations and nightmares. Keep in mind these contraindications which may include poorly controlled CV disease, hepatic dysfunction, high intracranial and intraocular pressures, active psychosis, and pregnancy.
4. Dexmedetomidine which may not be as safe as you think. Do you use this medication in NORA locations? Considerations include similar upper airway collapsibility to Propofol, bradycardia and hypotension that may delay discharge and require close hemodynamic monitoring.
5. Lidocaine infusions have been studied for different procedures, but with the expansion of regional anesthesia techniques, there is less of a role for IV lidocaine.
6. Regional anesthetic techniques provide excellent pain relief and may be used for pre-op blocks or for rescue.

What about a novel opioid? Have you heard of Oliceridine? It is the first of a new class of opioid agonists that preferentially activates G-protein signaling over beta-arrestin leading to improved analgesia with less risk of side effects. This drug is approved by the Food and Drug Administration to treat moderative to severe acute pain. Studies have revealed that Oliceridine is effective for pain control but additional research is needed to determine if there are less adverse effects. We will have to be on the lookout for this.

It’s time to move on to our next session, “Medication Safety: Pre-Filled Syringes, Drug Labeling, Infusion Pumps” by Elizabeth Rebello. There are some challenges to medication safety in NORA locations starting with the location that is far from the OR, limited availability of medications and supplies especially given the ongoing supply issues, the physical and lighting limitations, challenges in monitoring, and lack of familiarity with procedures and medications. If we look a little closer at medication errors, this may be due to incorrect dosing and substitution and administration is the most frequent error phase and does the most harm. There are some opportunities for improved mediation safety which may include color-coded syringes, barcode scanners, labels, and two provider checks as well as constraints such as smart pump guard rails, standard pharmacy concentrations, pre-filled syringes, and standardized layouts. Constraints are important for medication safety to help eliminate steps and extra options. Let’s look a little closer at labeling. In 2004, the first statement, Labeling of Pharmaceuticals for Use in Anesthesiology from the ASA was released by the ASA followed by a revised statement in 2020 to help reduce medication errors and improve patient safety. I will include a link in the show notes as well. Infusion pumps are common devices used during anesthesia care in the OR and in NORA locations. There are some safety concerns with infusion pumps which have led to more than 50,000 adverse events over a 7 year period in one study. Using smart infusion pumps may help to prevent inadvertent drug overdose. Improving medication safety during NORA care requires a team effort between the pharmacy and healthcare professionals to program infusion pumps with appropriate rates and concentrations. Rebello reminds us that medication safety begins with us. We are the last line of defense.

We still have more to talk about from the 2022 Stoelting Conference, so tune in next week for the exciting conclusion. We will talk about teamwork, communication, a culture of wellness, and disruptors and innovations in NORA.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Did you know that you can tune in to the entire conference online for free. That’s right, head over to APSF.org and click on the conferences and events heading. Second one down is APSF Stoelting Conference 2022. There you will find the recordings of all of these great sessions. I will include the link in the show notes, and we hope that you will check it out. If you are on twitter, check out the conference hashtag #APSF2022 to continue to learn about NORA patient safety all week long.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation