الفهرس 
Introduction and Aim of the WorkOnly 14 pages are availabe for public view
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Abstract
There is an increasing demand for non–operating room (OR) anesthesia in remote locations. These remote locations offer challenges to the provider beyond those found in the traditional OR suite.
American Society of Anesthesiology (ASA) definition of MAC is: ”Monitored anesthesia care refers to instances in which an anesthesiologist has been called upon to provide specific anesthesia services to a particular patient undergoing a planned procedure, in connection with which a patient receives local anesthesia, or in some cases, no anesthesia at all. In such a case, the anesthesiologist is providing specific services to the patient and is in control of the patient’s non-surgical or non-obstetrical medical care, including the responsibility of monitoring the patient’s vital signs, and is available to administer anesthetics or provide other medical care as appropriate. Facilities to secure the airway should always be immediately available.
The aim of conscious sedation is to alleviate pain or discomfort, anxiolysis, and help the patient to lie still. Many procedures can be performed easily with minimal pain; however, the procedure may be stressful to the patient. The patient may experience discomfort from long periods of lying still on a hard cold table or claustrophobia from the confines of the room, these patients need sedation.
Services are requested at many different locations for a diverse range of procedures. These may be elective or emergency, diagnostic or potentially lifesaving interventions, and may last from seconds (e.g. cardioversion) through to all-day affairs in the electrophysiology laboratory. The patient group is equally diverse, covering all ages and co-morbidities.
Risk related to sedation and anesthesia outside the OR can be broken down into inadequate sedation, oversedation/adverse response to sedatives, and failure to rescue. This may lead to unscheduled admissions to the hospital, or unplanned admission to an intensive care unit as a direct result of the sedation or anesthesia (ie, because of protracted emesis, prolonged sedation, or respiratory or cardiac complication).
The two basic requirements for all anesthetics are:
1. The continuous presence of an anesthetist - where hazards exist (e.g. during CT), they may be outside with remote observation and monitoring.
2. The continual monitoring of vital signs by a combination of clinical methods and monitoring devices.
For all GAs, pulse oximetry (SpO2), non-invasive blood pressure (NIBP), electrocardiography (ECG) and CO2 monitoring are mandatory. The use of an anesthetic machine or ventilator requires additional monitoring. Sedation requires a minimum of SpO2 and when appropriate ECG and NIBP
Desaturation is a late sign of hypoventilation/apnoea, and clinical assessment may be difficult in remote settings. The American Society of Anesthesiology now recommends the use of CO2 monitoring whenever propofol is used.
The risks associated with anesthesia in the non-theatre environment should be minimized by proper planning and anesthetic service provision. where appropriate, the guidelines for anesthesia in remote sites should be followed. Whenever possible all anesthetic equipment should be standardized across all areas providing anesthetic services. Monitoring and anesthetic equipment should comply with the national standards stipulated for use in operating theatres. These should include the routine use of capnography in any situation where anesthesia is induced.
We discussed briefly best anesthesia practice in specific extramural sites as:
A. Anesthesia in radiology suites:
• Anesthesia for CT scanning
• Magnetic Resonance Imaging (MRI)
• Interventional neuroradiology
• Nuclear medicine
• External beam radiation therapy
• Stereotactic Radiosurgery.
B. Interventional cardiology.
C. Electroconvulsive therapy (ECT)
D. Gastro Intestinal procedures