Search Results (8)

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article

Non-operating room anesthesia (NORA) has emerged as one of the fastest-growing domains of modern anesthetic practice. Increasing procedural complexity and an aging, comorbid patient population demand analgesic strategies that enhance safety, comfort, and procedural success while minimizing physiological disturbance. Although systemic opioids and sedatives remain commonly used in NORA settings, their dose-dependent adverse effects may compromise patient safety and delay recovery, particularly in environments with limited postprocedural monitoring. Ultrasound-guided fascial plane blocks (FPBs) have therefore gained prominence as key components of opioid-sparing and opioid-free anesthetic strategies. By providing targeted regional analgesia with preserved hemodynamic stability, FPBs reduce systemic analgesic requirements and opioid-related side effects while improving patient comfort. This review summarizes the anatomical basis, proposed mechanisms of action, and current clinical evidence supporting the use of thoracic and abdominal fascial plane blocks in NORA settings, with particular emphasis on interventional cardiology and interventional radiology procedures. The expanding role of FPBs suggests that these techniques may become integral elements of standard analgesic protocols in contemporary non-operating room anesthesia practice. Full article

Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided vascular access under conditions of limited resources and support, underscores the need for simple, reproducible, and inherently safe techniques. The objective of this technical note is to describe a modified ultrasound-guided venipuncture technique for non-tunneled PICC insertion, specifically developed for NORA settings, aimed at reducing procedure-related complications and preserving patient safety in routine clinical practice. Methods: The proposed technique consists of controlled intraluminal advancement of the needle tip (approximately 0.3–0.5 cm) under continuous ultrasound visualization, combined with progressive reduction in the insertion angle to achieve stable central intraluminal alignment before guidewire insertion. The technique has been applied in routine clinical practice across multiple Italian centers over the last two years, within a large multicenter real-world experience exceeding 5000 non-tunneled PICC procedures. Results: Based on real-world clinical observations, the systematic application of the technique was associated with a low incidence of early mechanical complications, including failed guidewire advancement, multiple venipuncture attempts, local pain, and hematoma formation. During standardized post-procedural ultrasound follow-up of the catheterized upper-extremity veins, no cases of catheter-related deep vein thrombosis were detected. Conclusions: This modified ultrasound-guided venipuncture technique represents a feasible and reproducible procedural refinement for non-tunneled PICC insertion in NORA environments. By enhancing intraluminal needle stability during guidewire advancement, it may contribute to improving procedural reliability and supporting patient safety in routine clinical practice. Further prospective and comparative studies are warranted to confirm these findings and define the generalizability of this approach. Full article

Background: Efficient and safe discharge is critical in pediatric dental procedures performed under deep sedation in non-operating room anesthesia (NORA) settings. Traditional institutional criteria may delay discharge due to subjectivity. Objective: This study compared the Modified Aldrete Recovery Score (MAS) and institutional discharge criteria to determine which provides faster and reliable discharge decisions. Methods: In this prospective observational study, 100 children (ages 2–10, ASA I–III) undergoing deep sedation for dental treatment were evaluated. Two nurse anesthetists independently assessed discharge readiness every five minutes using either MAS or institutional criteria. Demographic data, BMI percentile, ASA class, anesthesia duration, and propofol dose were recorded. Discharge times were compared using Wilcoxon signed-rank and subgroup analyses and correlation tests. Results: MAS allowed significantly earlier discharge than institutional criteria (24.75 ± 7.33 vs. 36.79 ± 8.59 min, p = 0.01). The agreement between methods was poor (ICC = 0.06). Discharge time varied significantly by BMI percentile (p = 0.01); obese children had shorter recovery times, while time differences were greater in overweight children. No adverse events or readmissions occurred. Conclusions: MAS provides a quicker and equally safe discharge assessment in pediatric dental sedation. Its use may enhance workflow efficiency and standardize recovery decisions in NORA settings lacking formal PACUs. Full article

Non-operating room anesthesia (NORA) is a rapidly growing domain for anesthesia professionals due to advances in procedural technology and increased emphasis on patient comfort. The majority of these procedures are conducted under monitored anesthesia care (MAC) where patients receive varying levels of sedation. Analysis of the Anesthesia Closed Claims database suggests that adverse respiratory events continue to be the main cause of morbidity and mortality in patients undergoing NORA procedures. Most NORA claims occurred under MAC, with oversedation leading to respiratory depression coupled with inadequate monitoring making up the majority of claims. The American Society of Anesthesiologists (ASA) has released standards of pre-anesthesia, intraoperative monitoring, and post-anesthesia care, which apply to all anesthetizing locations including NORA. The ASA has also made recommendations in a statement on NORA to promote patient safety. Evidence suggests that patient characteristics, monitoring tools, physical constraints, and team familiarity play a role in the risk for adverse respiratory events. Future studies are required to further understand the challenges specific to NORA locations. Full article

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings. Full article

Introduction: Percutaneous ultrasound-guided radiofrequency ablation (RFA) is a well-studied treatment option for locally non-advanced hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLMs). Sedation is of crucial interest as it enables safe and pain-free procedures. Whether the type of sedation has an impact on procedural outcome is still not well investigated. Methods: We retrospectively collected data on patients undergoing liver RFA for various oncological conditions. Procedures were conducted in a non-operating room anesthesia (NORA) setting. Procedural-related complications and short-term oncological outcomes were analyzed. Results: Thirty-five patients (mean age 71.5 y, 80% male) were treated for HCC (26), CRLM (6) and gastric cancer metastases (3). Mean lesion size was 21 mm (SD ± 10.1 mm), and the most common tumor localization was the right hepatic lobe. RFA was performed in a step-up sedation approach, with subcutaneous lidocaine injection prior to needle placement and subsequent deep sedation during ablation. No anesthesia-related early or late complications occurred. One patient presented with pleural effusion due to a large ablation zone and was treated conservatively. Local tumor-free survival after 1 and 6 months was 100% in all cases where a curative RFA approach was intended. Conclusions: NORA for liver RFA comes with high patient acceptance and tolerance, and optimal postoperative outcomes and oncologic results. Full article

Background: Uncooperative children require sedative approach for dental treatment. The aim was to assess the effectiveness of Propofol in “Non-Operating Room Anesthesia” (NORA) for paediatric dental treatment; intraoperative side effects; postoperative side effects; post-discharge effects. Methods: a prospective study, involving 109 uncooperative children undergoing sedation in NORA using Propofol for dental treatment, was performed. Working sessions, success/failure, intraoperative and postoperative side effects, number of treatment; type of procedure were assessed. Parents completed a post-discharge questionnaire on: pain; crying; fever; vomiting; headache; drowsiness; excitability; irritability; ability to eat; drugs and medical care needing. Results: Success: 96.7%. Intraoperative side effects: 33.3%. Postoperative side effects: 6.4%. Statistically significant association between: intraoperative side effects and age (p = 0.001), health status (p = 0.0007), weight (p = 0.038), respectively; intraoperative side effects and number/ type of dental treatment (p = 0.0055) and scaling (p = 0.0001), respectively. For post-discharge questionnaires, statistically significant association between: age and crying (p = 0.0001) and headache (p = 0.002), respectively; health status and crying (p = 0.015) and drugs needing (p = 0.04), respectively; weight and crying (p = 0.0004); extraction and pain (p = 0.0001) and crying (p= 0.0073), respectively; scaling and crying (p = 0.04), excitability and irritability (p = 0.03), respectively. Conclusion: Propofol in NORA was effective with minimal side effects. Full article