Remote locations

The number of diagnostic, therapeutic, and interventional procedures performed outside of the operating room (OR) environment in remote locations has increased exponentially over the past 20 years. An explosion of technologic advances, constraints on OR time, and the desire of patients for sedation and lack of recall all contribute to the greater popularity of anesthesia in remote areas. A remote site generally refers to a location which is distant from the main OR. Anesthetizing patients in a familiar environment, with familiar equipment and readily available assistance, is important to delivering safe anesthesia. These principles may be compromised, however, when anesthesiologists are asked to provide anesthesia in sites remote from the traditional OR. Pediatric diagnostic and therapeutic procedures take place in remote locations, where airway management and conduction of general anesthesia might prove challenging. In addition, an aging population and the prolonged survival of patients with complicated disease states have changed both the complexity of the interventions performed and the acuity of the patient population. The majority of these interventions can be performed with monitored anesthesia care (MAC) and standard monitoring. Longer procedures however may require general anesthesia as well as management of unstable hemodynamics. Data from an American Society of Anesthesiologists (ASA) closed claims project review reported that claims related to patients in remote locations occurred in older and sicker individuals (20% greater than 70 years, 69% ASA 3-5) compared to patients in operating rooms (Metzner et al., Curr Opin Anaesthesiol 22(4):502-508, 2009). The severity of injury was greater, inadequate oxygenation and ventilation occurred more frequently, and the risk of death was almost double in remote location claims compared to OR claims. Moreover, the injuries in remote locations were more often judged as preventable had there been better monitoring. Maintaining a safe and procedurally optimal environment in a nontraditional setting is a challenge. This environment represents a key element in maintaining a high level of patient care with minimal complications in the evolving modern-day delivery of anesthesia in remote locations. Precision and excellent communication between anesthesia and the proceduralist are necessary to ensure an optimal outcome. The anesthesiologist should take a leadership role in developing monitoring and sedation standards in remote anesthetizing locations (Metzner et al., Curr Opin Anaesthesiol 22(4):502-508, 2009; Robbertze et al., Curr Opin Anaesthesiol 19(4):436-42, 2006).