4206 Litman-37.qxd

A large percentage of pediatric anesthesia practice takes place outside the traditional operating room (OR) environment. This practice presents unique challenges because of unfamiliar surroundings, lack of sufficient space, and ancillary personnel who are not familiar with anesthetic procedures and techniques. Furthermore, we are often scheduled in multiple locations throughout the institution on the same day. Therefore, equipment is transported and set up multiple times.This increases the risk of equipment-related problems. Although the physical locations differ, the anesthesiologist who provides care outside the OR must abide by the same safety and monitoring standards that are followed inside the OR (Box 37-1). It is not necessary to always have an anesthesia machine at the off-site anesthetizing location. Its presence will depend on the comfort of the anesthesiologist and the anticipated use of inhalational anesthetic agents.When one anticipates the use of capnography, it is often easier to transport the entire anesthesia machine that stores the capnograph device. Children who are expected to present a difficult airway should undergo induction of general anesthesia and full airway management in the OR environment, where personnel and equipment are readily available. Once tracheal intubation is safely accomplished, the child is then transported, while anesthetized, to the procedural area. There are numerous anesthetic techniques that are acceptable in off-site locations – the choice will primarily depend on the preference of the anesthesiologist and the type of procedure being performed. Children undergoing radiological procedures that are not painful are best managed by a hypnotic agent without analgesic properties, such as propofol or a barbiturate. Painful procedures are best managed using analgesics or inhalational anesthetics. It is possible to use high doses of a hypnotic agent during a painful procedure. However, for a severely painful procedure (e.g., bone marrow biopsy), few anesthetic agents will provide adequate analgesia and immobility without respiratory depression and the need for assisted ventilation (ketamine being a possible exception). Whatever the choice, the anesthesiologist should always have immediately available three syringes during and following each procedure: succinylcholine, atropine, and an induction agent of choice. Transport of the child to the postanesthesia care unit (PACU) at the completion of the procedure is a consideration that should be addressed proactively. If there are recovery facilities in the anesthetizing area, emergence and tracheal extubation can occur at that location, and standard discharge criteria then apply.When the PACU is a considerable distance from the anesthetizing location, the anesthesiologist can choose to either: (1) keep the child anesthetized during transport,with emergence and extubation occurring in the PACU; or (2) transport a child who is emerging from anesthesia. Ultimately, the personal preference of the anesthesiologist is the most important determinant. Either way, it is essential to have at least a pulse oximeter, reliable oxygen source, and a positive-pressure ventilation device en route. The cost efficiency of remote anesthesia presents an additional challenge. The daily schedule should reflect transport times between the anesthetizing location and the PACU, as well as between remote locations.The most common obstacle is delay, either because the remote