REVIEW

CURRENT
OPINION Nonoperating room anesthesia for patients with
serious comorbidities
Reino Pöyhiä

Purpose of review
To provide aids to deal with increasing amount of several comorbidities in nonoperating room anesthesia
(NORA).
Recent findings
New indexes for assessment of comorbidities are described and guidelines for the care of patients with
obesity, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), diabetes and COVID19
in NORA summarized.
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Summary
In addition to ASA classification, such instruments as Charlson Comorbidity Index, Frailty Index, Surgical
Complexity Score and Revised Cardiac Risk could supplement the prospective assessment of the risk of
comorbidities. Using institutional protocols patients with significant obesity, obstructive sleep apnea, COPD,
diabetes and COVID19 can be safely cared in NORA. However, the individual functioning and the
severity are more important than only the number of diseases.
Keywords
ambulatory surgery, comorbidity, nonoperating room anesthesia, office-based surgery

INTRODUCTION Interesting new methods in the assessment of

&

The constant increase of surgeries and interven- comorbidities include Frailty Index [6 ], Cholecys-
tional procedures performed in offices and ambula- tectomy As A Day Case (CAAD) Score [7], Surgical
&&

tory facilities has brought sicker and sicker patients
for nonoperating room anesthesia (NORA) services.
Registry data from the USA show that the percen-
tages of patients of office-based surgeries for patients
in ASA classes 4–5 has increased from 19.3 to 32.8%
&&
from 2010 to 2014 [1 ]. Unfortunately, very little is
known about the influence of the comorbidities on
outcome in office-based or ambulatory surgery,
radiological, cardiological or other invasive proce-
dures because of lacking randomized and
prospective studies.
ASSESSING COMORBIDITIES
Recent retrospective studies [2 –4] have shown that
high Charlson Comorbidity Index (CCI) is associ-
ated with increased morbidity, postoperative com-
plications and unplanned hospital admissions.
Cut-off values of CCI for specific endpoints in
ambulatory surgery have not been defined exclu-
sively, but in a study by Fernandez-Cortinas et al.
&
[5 ] CCI more than 5 was associated with postoper-
ative mortality.
Complexity Score [8] and Revised Cardiac Risk [9 ],
which all have been shown to predict morbidity and
mortality. Compared with comorbidity indexes,
these measures take in account also functionality,
state of the disease, previous treatments and proce-
dure and anesthesia-related factors. They can be
generated even from the medical records and calcu-
lated rather easily electronically. It would be inter-
esting to see if they would be beneficial in
preoperative risk assessment. However, none of
these instruments includes combined information
of concomitant diseases, NORA settings, experience
of the staff and anesthesia resources. Naturally, the
facility for NORA matters, too: a surgical unit in a
downtown office is a very different environment
from that in a university hospital as an example.
Department of Anesthesiology and Intensive Care, University of Helsinki,
Helsinki, Finland
Correspondence to Reino Pöyhiä, Hietamäentie 2B, 02200 Espoo,
Finland. Tel: +358415458406; e-mail: reino.poyhia@helsinki.fi
Curr Opin Anesthesiol 2020, 33:594–600
DOI:10.1097/ACO.0000000000000890

www.co-anesthesiology.com Volume 33  Number 4  August 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Frailty Index, Surgical Complexity Score and Revised
Cardiac Risk and could be used together with ASA
classification in preoperative risk assessment
of comorbidities.
 Using defined protocols patients with juvenile diabetes,
obesity, OSA, and COPD can be safely accepted
for NORA.
 Both pathophysiological state and the number of
comorbidities must be considered carefully before and
treated properly after the surgery.
 Special arrangements are needed with COVID19.
PREPARING FOR NONOPERATING ROOM
ANESTHESIA
It is very important to underline that all necessary
care for comorbidities should be provided also in
NORA. It is equally important to detect both the
number of comorbidities and their pathophysiolog-
ical state before NORA. Diabetes without complica-
tions carries certainly lower risks than a complicated
disease. The team should be trained to maintain the
vital functions, provide adequate monitoring and
treat comorbidities specific when needed. In addi-
tion, the care should be extended for recovery
period and transportation to home. NORA-service
providers have to be prepared also to handle with
the putative emergencies related to the comorbid-
ities such as intubation difficulties.
Unfortunately, very little evidence is available for
the disease-specific care in NORA. However, recent
updated reviews are useful for the care of patients
with obese, diabetes, and chronic obstructive pulmo-
nary disease (COPD), who are commonly presented
& & & & && &&
in NORA services [10 ,11 ,12 ,13 ,14 ,15,16 ]. Spe-
cial attention and new practices are needed with
COVID19. Most likely, these guidelines would be
very useful for institutional protocols to help anes-
thesiologist to take of patients with various comor-
bidities, which previously were considered as
&&
contraindications for NORA [1 ].
OBESITY AND OBSTRUCTIVE SLEEP
APNEA
Overweight and obesity are defined as abnormal or
excessive fat accumulation that presents a risk to
health. A body-mass index (BMI) at least 25 kg/m2
means overweight, a BMI at least 30 kg/m2 obesity
and finally a BMI at least 40 kg/m2 severe obesity.
The age-standardized prevalence of overweight was
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Nonoperating ro om anesthesia for patients Pöyhiä
39% and that of obesity 12.5% in 2015. The preva-
lence has increased 50–80% over the past 35 years,
mostly in Europe and USA [17].
Obesity is not an independent medical condi-
tion, but one that may affect multiple organ sys-
tems. Obese individuals have been found to have
many concomitant medical problems such as coro-
nary artery disease, hypertension, obstructive sleep
apnea (OSA), diabetes, and even cancer [18]. Obesity
may be associated with deteriorated pulmonary
functions, perioperative hemodynamic instability,
airway obstruction leading to hypoxia, or impaired
wound healing or dehiscence. Problems in airway
management, in bag-mask ventilation, in oxygen-
ation, and in tracheal intubation may occur and
laryngoscopy can be more difficult with obese
patients than with nonobese ones.
There are several studies to evidence that a BMI
between 30 and 40 kg/m2 is not a contraindication
for NORA and is not associate with unanticipated
emergency admission after ambulatory surgery
when compared to normal weight. Patients with
BMI more than 40, also, are not good candidates
for NORA. All obese patients should have a particu-
lar anesthetic plan, including preprocedural assess-
ment, airway protection strategy and wise use of
anesthetics and sedatives [1 ,10 ].
&& &
According to various studies 9–43% of adults
suffer from OSA. However, a matter of concern is
that 80–90% of surgical patients may appear in
NORA services without an established diagnosis
&
and any treatment [13 ]. Using STOP-Bang Question-
naire (Table 1), a validated screening tool to identify
patients at high risk is highly recommended [14 ].
&&
There are still controversies about the care
patients with OSA in NORA services [13 ]. In previ-
&
ous studies, patients with OSA had nearly a four-fold
Table 1. STOP-BANG questionnaire [14 ] &&
The STOP-BANG scoring can be used to identify the risk category
of patients with OSA: ‘yes’ ¼ 1 point, ‘no’¼ zero point. Low risk
with ‘Yes’ to 0–2 questions, moderate risk with ‘Yes’ to 3–4
questions, and high risk with ‘Yes’ to 5–8 questions:
1. Snoring: Do you snore more loudly (louder than talking or loud
enough to be heard through closed doors)?
2. Tired: Do you often feel tired, fatigued or sleepy during
daytime?
3. Observed: Has anyone observed you stop breathing during
your sleep?
4. Blood pressure: Do you have or are you being treated for high
blood pressure?
5. BMI > 35 kg/m2?
6. Age > 50 y?
7. Neck circumference > 40 cm?
8. Male sex?
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Nonoperating room anesthesia
higher incidence of pulmonary complications, rein-
tubation and cardiac dysrhythmias after surgery,
and the patients with high-risk OSA were not rec-
ommended eligible to ambulatory surgery. How-
ever, newer studies have provided evidence of the
safety of ambulatory or office-based surgery for
patients with OSA. A recent large retrospective study
&&
by Szeto et al. [19 ] found increased incidence of
immediate postoperative complications in patients
with high-risk OSA but no difference in the hospi-
talization or length of hospital stay between high- or
moderate risk OSA patients undergoing ambulatory
surgery. However, this study has been criticized
because the population may not have representative
(less males than usually among patients with OSA)
and it was executed only in one center with good
availability of respiratory therapists. The authors
recommended the respiratory therapists’ consulta-
tion both prior to and immediately after the surgery.
A new comprehensive review about the intra-
&&
operative care of patients with OSA [14 ] underlines
the risk of respiratory depression because of ana-
tomic difficulties in airway management and mask
ventilation, administration of sedative agents and
anesthetics, inadequate use of neuromuscular block-
ing agents and opioids in the perioperative. The risk
of residual neuromuscular blockade should be
avoided in all ways. Although evidence is lacking
about the method-of-choose for the anesthetic tech-
nique, regional anesthesia is highly recommended
for these patients, whenever possible. Long-acting
opioid analgesics should be avoided in all circum-
stances. Propofol can increase the likelihood of
respiratory depression and should be used with
heightened vigilance for procedural sedation of
patients with OSA. In terms of rapid recovery, sevo-
flurane may be better than propofol and desflurane
better than sevoflurane during general anesthesia
&&
for ambulatory surgery [14 ].
&
In addition, Gupta and Pyati [13 ] propose that
the full intubation equipment including difficult
devices (fiberoptic scope, LMAs, and so on), an
oxygen source, vasoactive drugs, and reversal agents
(such as sugammadex, neostigmine, naloxone)
should always be available for patients with OSA
in NORA setting. Furthermore, in these patients
should be monitored for respiratory rate, heart rate,
blood pressure, EKG, and continuous spo2 at least
for additional hour in the PACU unit. The preferred
position is nonsupine after the surgery to reduce
apnea. Patients with OSA would allowed to leave the
surgical unit only they have met the modified
Aldrete criteria for discharge. In the case of recurring
adverse respiratory events (SpO2 <90% on nasal O2
supply, RR <8 breaths per minute, apnea lasting
more than 10s, or pain-sedation mismatch),
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extended monitoring and admission should be con-
sidered. Finally, patients having CPAP device at
home should have this apparatus in hands in PACU
and at home.
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
COPD is a heterogeneous and multisystemic disease,
which causes increased morbidity and mortality [20].
About 10% of adult people has COPD. Patients with
COPD have many comorbidities, hypertension,
hyperlipidemia, and anxiety disorder being the com-
monest ones and affecting over 35% of patients.
Regardless where the surgery is performed, the
patients with COPD should preoperatively be
assessed for severity of disease, need of preproce-
dural improvement or optimization of COPD, risk of
perioperative respiratory complication, and the
organization of postoperative surveillance
& &
[11 ,12 ]. It has been proposed that stable patients
GOLD1–2 respiratory status (FEV1 65%) and room
air SpO2 greater than 95% can be eligible for NORA
(Table 2). Moderate to deep sedation should be
possible for these patients in the presence of experi-
enced anesthesia provider. However, all procedures
to patients with more advanced GOLD2 status or
GOLD3–4 respiratory status should be performed
& &
only in hospital setting [11 ,12 ].
Severe COPD is characterized with increased V/
Q-mismatch, hypoxemia, and hypercapnia at base-
line. Inadequate administration of oxygen may
worsen hypercapnia because of increased dead space
and rightward shifting of the CO2–dissociation
curve (Haldane effect). The current recommenda-
tion is to maintain oxygen saturation 88–92% to
avoid hypoxemia and excessive hypercapnia in
patients with severe COPD. For patients with less
severe COPD, oxygen can be administrated, so that
pulse oximetry level is well less than 99%. In emer-
gency situation saturation of 100% is naturally
&
accepted [12 ].
Production of surfactant, mucociliary responses,
and clearance decrease, and airway permeability
increases during intubated general anesthesia. How-
ever, if general anesthesia will be chosen and the
patient must be intubated, lung protective ventilation
must be applied by setting tidal volumes 5–8 ml/kg
Table 2. GOLD classification [21]
I (mild): FEV1  80% predicted
II (moderate): FEV1 ¼50%–79% predicted
III (severe): FEV1 ¼30%–49% predicted
IV (very severe): FEV1 < 30% predicted
Volume 33  Number 4  August 2020

of ideal body weight and keeping plateau airway
pressures 15–20 cmH2O. In addition, an inspira-
tory-to-expiratory ratio of 1:3, proper expiratory time
and careful use of PEEP at 5–10 cmH2O would pre-
vent hyperinflation of lungs and air trapping. At least
when breathing spontaneously, sitting or slight semi-
recumbent position is usually better tolerated by
these patients, because diaphragm moves easily
and secretions can be managed. Laryngeal mask
may not be optimal for patients with COPD because
of bronchial secretion and coughing. Long-acting
opioids should be replaced with short-acting ones
&
in the anesthesia [12 ].
During the recovery, the sitting or semirecumbent
position should be prioritized to prevent atelectasis
and ease breathing, oxygen supplementation should
be discontinued if possible, and postprocedural
pain should be effectively treated without opioids.
DIABETES
The current global prevalence of all types of diabetes
is 9.3% and it is believed to increase to 10.9% by year
1945 [22]. In France, over 45% of surgeries to
patients with diabetes are performed in NORA-envi-
ronments [15]. Both type 1 and 2 patients can be
eligible to office-based or ambulatory surgery.
The French Society for the study of Diabetes has
recently published comprehensive guidelines about
preoperative and perioperative care of a patient with
&&
diabetes in ambulatory surgery [15,16 ]. In short,
the glycemic control, putative intubation difficul-
ties, and organ complications should be assessed in
all patients with diabetes before any type of surgery.
Surgery should be postponed if HbA1c is less than
6.0% or higher than 8.0%. Adjustment of diabetic
control may be necessary by a general practitioner or
diabetologist, if there is a recent history of hypogly-
cemic events (>2/last week) and great variation in or
lack of daily blood glucose measurements.
Diabetes is often associated with severe multi-
organ dysfunction, which may influence on the
perioperative care and the outcome of surgical pro-
cedures. All patients with diabetes should be
assessed at least for three comorbidities: gastropa-
resis, cardiovascular state, and intubation difficul-
ties. Gastroparesis is common in association with
diabetic neuropathy affecting 30–50% of patients
with both juvenile and adult diabetes. Gastroparesis
may present as abdominal pain, nausea or vomiting,
early satiety, or slowing of digestion. Delayed emp-
tying of stomach increases the risk of aspiration in
the induction of anesthesia. Because about 75%
patients with diabetes die because of cardiovascular
complications, it is very important to check the
history of cardiovascular events, medications, and
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Nonoperating ro om anesthesia for patients Pöyhiä
symptoms prior to surgery. Glycated collagen may
sequester in atlanto-occipital or temporomandibu-
lar joints leading to difficulties in endotracheal
intubation. This is called ‘stiff-join syndrome’ and
may be detected as a ‘prayer sign’: unability to
approximate the palmar surfaces of the fingers when
putting the palms together. Another consequence of
abnormal glycosylation is diabetic scleroderma,
thick skin, which may make intravenous cannula-
tion difficult [15].
The French guidelines recommend no changes
in the administration of insulin and eating in the
preoperative evening. In the morning of the proce-
dure, no food nor antidiabetic medications should
be taken. Glucose containing fluids can be taken
orally 2 h before anesthesia, if blood glucose falls too
low. The further instructions depend on the
planned course of the day.
Scheduling the patients with diabetes as first in
the surgical morning list is always preferred, because
it would necessitate the least changes in the routine
diabetic care. If the surgery is short and the patient
leaves the recovery room by 10 am, regular morning
medications can be taken with a breakfast after
the procedure.
If the patient leaves the recovery room at 10–12
am, the morning drugs are given on arrival at hos-
pital and G10% infusion 40 ml/h is initiated until
the next meal is given with insulin or insulin secre-
tor medication (glinide/sulphonamide).
If the procedures starts later and the patient is
aimed to leave the recovery room in the afternoon, a
light breakfast (including solids) is allowed with
morning medication. A peripheral intravenous line
is inserted, but not necessary with glucose. This
treatment is continued until next meal.
In all cases it is recommended to open an intra-
venous access, but infusion of glucose is warranted
as mentioned above or for hypoglycemia. Treatment
of postoperative pain, nausea, and vomiting is nat-
urally important. Both oral and written instruction
should be given to the patient and his/her caretaker
for the preoperative and postoperative management
&&
of diabetes [16 ].
During the surgery or interventional procedure,
the blood glucose should be kept in the range of 5–
10 mmol/l (0.90–1.80 g/l). There is plenty of evi-
dence to document that hyperglycemia (blood glu-
cose >10 mmol/l ¼ 1. 8 g/l) is associated with
increased morbidity at least in conjunction with
major surgery. Blood glucose should be tested every
1–2 h during and after the surgery or interventional
&&
procedure [15,16 ]. Instructions for postoperative
control of blood glucose are given in Table 3.
Antidiabetic medications could be given as reg-
&&
ularly before NORA procedure [16 ]. The exception
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Nonoperating room anesthesia
Table 3. Instructions for postoperative care of blood glucose (adapted from 16)
B-gluc Actions
10 mmol/l (1.8 g/l) Resume regular treatments
>10 mmol/l (1.8 g/l) Remain in hospital for intermittent injections of corrective subcutaneous insulin until B-gluc glucose
levels 5–10 mmol/l (0.9 and 1.8 g/l).
>16.5 mmol/l (3 g/l) No discharge home, but admission to hospital for intravenous insulin therapy
might sulphonamides, which may cause significant
hypoglycemia if oral intake of carbohydrates is
restricted. In principle, the basal requirement of
insulin should be continued.
There is unfortunately a huge lack of prospective
studies about the management of patients with
diabetes in office-based or ambulatory surgery. Con-
tinuous blood sugar measurement or insulin pump
has not been studied at all so far.
COVID19
In many countries elective surgery is currently put
on hold in the ambulatory or office-based facilities
and their resources are removed to hospitals for
caring infected patients during COVID19 pandemia.
However, many procedures are unavoidable and
must be carried out during the pandemia too.
Guidelines and recommendations about performing
the essential cardiological and radiological interven-
tions for infected patients have been recently pub-
lished [23–26]. On the other hand, moving some
surgical and diagnostic procedures from hospital to
ambulatory or office-based facilities, would provide
more hospital capacity for patients with COVID19.
In such a case, the most suitable facilities would
undoubtedly be the hospital-based ambulatory or
day surgery units but not free-standing units. Exam-
ples of interventions which could be performed in
ambulatory facilities, would be appendicectomy,
laparoscopic surgery, cancer-related or urological
procedures preventing obstruction or infection,
and trauma-related interventions (such as fractures,
tendon repairs, and deliberation of compartment
syndrome, vascular compromise, postoperative
&&
wound dehiscence) [27 ].
Some examples of organizing nonoperating
room services lines for patients with COVID19 have
been published recently. Valdivia et al. [28]
described an endoscopic facility with clean and
contaminated areas: the infected pathway has a
separate entrance, recovery area, and reprocessing
room for endoscopes. They also have a dedicated
team working only in the infected pathway.
Another creative and interesting option has been
established in Paris: a mobile endoscopy unit with
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devices and protected staff which provides services
&
in departments of infected patients [29 ].
The facility should have negative isolation rooms,
dedicated areas for infected patients, and appropriate
protection available for the staff (N95 respirators, face
shields, gowns, and gloves). The excellent guidelines
for anesthesiologists by the American and European
anesthesia societies [30,31] are applicable also for
NORA and are highly recommended.
Providing NORA services to patients with
COVID19 requires careful assessment of the patients
and planning the procedures. Although the corona
virus infection may asymptomatic, the most com-
mon symptoms are fever, cough, fatigue, and dys-
pnea. The patients with COVID19 often have other
diseases. The most prevalent comorbidities were
hypertension, diabetes, cardiovascular, and pulmo-
nary diseases. In a meta-analysis including 46 248
patients the odds ratios for lung diseases and hyper-
tension were 2.36 (95% CI, 1.46–3.83) and 2.46
(95% CI, 1.76–3.44), respectively [32]. Patients with
severe symptoms because of or at high risk of COVID
19 are not eligible for NORA.
There should be a plan for transfer to hospital,
home care, or nursing facility after the procedure.
Similar screening protocols should be applied at
NORA as in the hospital. At a telephone interview
24 h prior to surgery, patients should be asked about
exposure to COVDI19 contamination (recent trav-
els, travels of closest persons, contacts to COVID19
positive individuals). On the day of the procedure
rescreening should be performed and temperature
&&
measured before entering to the facility [27 ].
Both patient and safety-related issues should be
considered when choosing the anesthetic tech-
nique. General anesthesia, deep sedation, airway
manipulation, and administration of high-flow oxy-
gen should be avoided, if possible, in order to mini-
mize coronavirus transmission through aerosolized
droplets. Spinal and epidural anesthesia can be rec-
ommended even for laboring patients with
COVID19 [33,34]. Regional anesthesia with mini-
mal or no sedation is recommended patients with
confirmed or suspected COVID19 infection.
Patients should wear surgical mask and low-flow
&
oxygen could be given via nasal cannula [35 ].
Volume 33  Number 4  August 2020

However, if general anesthesia cannot be
avoided, endotracheal intubation is prioritized over
supraglottic devices to reduce ambient leaks of
exhaled gases. Rapid sequence intubation, avoiding
mask pressurization ventilation before the loss of
consciousness, a small volume tidal volume of lung
protective ventilation, and short-acting anesthetics
may reduce likelihood of coughing, avoid ventila-
tor-induced lung trauma, and provide fast recovery.
During the recovery period, aggressive treatment of
PONV with combinations of different medications
and pain without opioids is very important to
& &
reduce coughing [35 ,36 ]. The most important
thing is to prevent the transmission of the virus.
CONCLUSION
The pathophysiological states of various comorbid-
ities should be carefully examined and risk evalua-
tion performed prior to surgery regardless where the
procedures will be done. Both the number of comor-
bidities and the functionality of the patient are
important. Recently published NORA guidelines
for COPD, obesity, OSA, and diabetes are very useful
tools but will not reduce the need of institutional
protocols. International and national guidelines
help caring patients during the COVID19 pandemia.
NORA facilities should include possibilities for
appropriate postprocedural surveillance and proto-
cols for hospital admission for patients with severe
comorbidities. Further prospective studies are
needed how to estimate the eligibility of patients
with various comorbidities in NORA services.
Acknowledgements
None.
Financial support and sponsorship
This work was supported by the The Paulo Foundation,
Finland, and the Department of Anesthesia, Medical
University of Sapporo, Japan.
Conflicts of interest
There are no conflicts of interest.
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Volume 33  Number 4  August 2020