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Out of Operating Room Anesthesia: A Comprehensive Review.

2086 www.anesthesia-analgesia.org June 2017 • Volume 124 • Number 6 DOI: 10.1213/ANE.0000000000002114 Over the past several decades, the evolution of procedures and technology, coupled with the expanding need to decompress operating room schedules, has led to the burgeoning demand to deliver anesthesia and sedation in nonoperating room anesthesia (NORA) locations. Providing anesthesia/sedation in these settings requires a comprehensive understanding of NORA policies, guidelines, procedures, and the patient population in order to maximize safety and efficiency. Out of Operating Room Anesthesia: A Comprehensive Review is a 477-page textbook that provides a comprehensive overview of all aspects of NORA and features authors from the United States, Ireland, Germany, and India. A total of 32 chapters have been organized into 8 sections: general concepts, safety, anesthesia for endoscopy, cardiac, neuroradiology, specialized situations (emergency department, cosmetic and ophthalmologic procedures, etc) and patients (eg, morbidly obese), anesthesia for other out of operating room procedures, and future directions. In the first section, “General Concepts,” the authors lay the foundation for the delivery and pharmacology of anesthesia and sedation in areas distant to the operating room. Section II presents preoperative patient evaluation and nil per os considerations in the context of organizing a NORA/sedation site that follows established guidelines. Sections III and IV provide an overview of the most commonly performed endoscopic and nonoperating room cardiac procedures. Important in these sections are the chapters that present airway and ventilation strategies, which may be useful in nonconventional situations. These chapters are structured similarly, beginning with an abstract, keywords, and introduction, followed by an overview of patient, procedural, anesthetic and sedation considerations, and anesthesia delivery options. The consideration of all of the various anesthesia delivery techniques is an important contribution of this book. The authors present the periproceduraland postproceduralassociated risks, complications, and management. They also tell readers how to optimize the patient before the procedure. Aside from the text of the abstract and the introduction of each chapter, the majority of chapters are formatted in a bulleted list so as to highlight the primary information and concepts. The presentation of and justification for the authors’ preferred techniques are valuable additions. Section V, “Anesthesia for Neuroradiology,” outlines the perioperative concerns for all possible procedures in the neurointerventional suite, a comprehensive overview of the anesthetic goals for ischemic stroke, intracranial hemorrhage, anticoagulation and reversal, neuroprotection, and renal protection. Sections VI and VII describe the management of selected special situations, including a pediatric update on anesthesia/sedation strategies for dental procedures, electroconvulsive therapy, cosmetic procedures, ophthalmologic surgery, and infertility treatment. Practical recommendations based on current literature and author experience are presented, and current practice guidelines are reviewed. The chapters on off-site anesthesia and procedural sedation for pediatric emergency medicine are both well researched and current. The final section of the textbook concludes with an eye toward the future, with chapters exploring new drug innovations and drug delivery systems and techniques, all intended to improve predictability and the safety and recovery profile. Also included are reflections on the current and future role and direction of NORA research. Although the chapter on regional techniques and their pitfalls may be of use for an overview of techniques, applications, and complications of a range of regional blocks, its applicability to the NORA provider is likely limited, and it seems out of place in this setting. Overall, this textbook is well organized and covers the most important aspects of anesthesia/sedation in NORA locations. It provides a general overview of all aspects of NORA. However, it ought not be used for detailed clinical care choices and management. This book is most useful if it is used as a handbook or an overview since it is not exhaustive with regard to references. There is also some duplication and overlap of the presented material, which is especially noticeable when reading the book from cover to cover. This repetition of material serves to solidify information for readers, and also allows them to be able to read individual chapters either out of sync or in isolation. This textbook can equip anesthesiologists with valuable strategies and practical insight based on clinical practice. It is a clinically applicable launching pad for the novice and seasoned anesthesiologist alike.