The development of new interventional procedures has increased the use of neuroanesthesia and moved some of those procedures out of the operating suite to remote locations in the hospital, creating challenges for general anesthesiologists. A Tuesday session will look at how to deal with the challenges of those procedures.

“We will be reviewing all of the problems anesthesiologists face outside of the operating room, but also focus on something general anesthesiologists may not be used to, which is neuroanesthesia, and what you would need to think about when you are not inside a conventional operating room,” said Rafi Avitsian, M.D.

“Neuroanesthesia in Remote Locations” is an interactive course that will examine how to overcome issues related to these new procedures, said Dr. Avitsian, the session moderator. He is a neuroanesthesiologist and Vice Chair for Professional Development in the Department of General Anesthesiology at Cleveland Clinic.

Neuroanesthesiologists are often involved in procedures on the brain, the peripheral nervous system and the spine, as well as neurointerventional procedures. Intraoperative MRIs (iMRIs) are being used more often in neurosurgical procedures. That means conventional craniotomies are being performed in the MRI suite, and patients may need to have an MRI during the procedure — sometimes more than once.

“In some centers, this is close to the main operating room area, and in some centers it is far away and is counted as remote anesthesia. Even though it is an operating room, it is not the usual operating area that the anesthesiologist is used to,” Dr. Avitsian said. “There are issues involved in these areas, and so we get a lot of questions about them, especially in hospitals that have recently started using these methods.”

Gamma knife procedures involve the use of gamma knife radiation to destroy tumor cells or vascular formations inside the head. One challenge is that they can involve moving an anesthetized patient for a CT scan, MRI and, sometimes, angiography before even starting the gamma knife radiation. The gamma knife environment inhibits adequate and on-the-spot access to the patient by the anesthesia provider, increasing the challenges. For these procedures, patients receive sedation or general anesthesia, but some may not be able to lie flat, and they may have shortness of breath and become anxious, he said.

“You need a plan for these patients, for transporting them from one area to another, especially if all of them are remote relative to the main operating room area,” Dr. Avitsian said.

The session will include the presentation of a difficult case, with audience members getting time to develop a neuroanesthesia plan and respond to the presentation.

“Recently, we have had a lot more procedures outside of the normal operating room. Some are neurosurgical procedures or procedures with patients who have neurological disabilities and disorders. General anesthesiologists should be prepared to face them if they are on call,” Dr. Avitsian said.

Presenting the session with Dr. Avitsian will be Deborah A. Rusy, M.D., of the University of Wisconsin School of Medicine and Public Health, Madison. She will present “Craniotomy Under MRI Guidance or iMRIs.”