Sedation in Non Operating Room Anesthesia (NORA): A Narrative Review

Asfandiar Shah Rukh Hijaz — Sun, 23 Nov 2025 00:00:00 +0000

As procedural care increasingly shifts beyond the traditional operating room, Non-Operating Room Anesthesia (NORA) now accounts for up to half of anesthetic delivery in some institutions. These environments such as endoscopy suites, interventional radiology, cardiac electrophysiology labs, MRI units, and dental clinics present unique challenges due to limited space, restricted airway access, variable staffing, and inconsistent monitoring infrastructure. NORA patients are often older, frailer, and more medically complex than operating room populations, increasing the risk of sedation-related complications. A narrative review of PubMed literature (1990–2025) was conducted using search terms related to NORA and procedural sedation. Twenty-three high-quality studies met criteria; 15 were selected for synthesis, including guidelines, trials, and major reviews. Effective NORA sedation requires comprehensive pre-procedure evaluation with special attention to airway risk, comorbidities, and procedure-specific hazards. OR equivalent monitoring, particularly capnography, is essential due to high rates of hypoventilation and apnea. Sedation strategies vary by setting, with propofol, ketofol, and dexmedetomidine commonly used; each offers distinct advantages and physiologic considerations. Adverse events remain more frequent in NORA than in OR anesthesia, including airway obstruction, hypoventilation, hypotension, aspiration, and arrhythmias. Pediatric NORA carries particularly elevated respiratory risk. A three pillar safety framework: patient factors, environment/equipment, and provider expertise emphasizes that deficiencies in any domain increase morbidity. NORA sedation is safe when delivered with OR-level standards, meticulous preparation, and coordinated team communication. Standardized protocols, availability of airway-rescue equipment, capnography for moderate-to-deep sedation, and clear plans for conversion to general anesthesia are critical. Future innovations such as emerging sedatives, improved risk-stratification tools, and AI enhanced monitoring may further enhance safety and efficiency as NORA continues to expand across healthcare systems.

Essential Foundation Skills in Surgery: A Practical Guide for Junior Trainees

Praveen Subbiah — Sun, 07 Dec 2025 00:00:00 +0000

Surgery is built on a foundation of precise manual skills, disciplined technique, and consistent attention to patient safety. Before trainees can progress to complex operative procedures, they must first become confident in the fundamental abilities that support every aspect of surgical care. These core skills are not optional, they are the bedrock upon which all future surgical competence is developed.

Early mastery of essential skills allows junior trainees to enter the clinical environment with clarity and confidence. When trainees understand how to prepare a sterile field, suture a wound, tie secure knots, handle tissues gently, and perform catheterisation safely, they become valuable and reliable members of the surgical team. These competencies reduce the likelihood of errors, limit unnecessary tissue trauma, and promote smooth and efficient workflow in both operative and procedural settings.

The purpose of this book is to provide a structured, practical guide to these foundational skills. Drawing on established surgical principles and contemporary training standards, it outlines the abilities every junior surgical trainee is expected to acquire during early training.

THE STETHO

Sedation in Non Operating Room Anesthesia (NORA): A Narrative Review

Essential Foundation Skills in Surgery: A Practical Guide for Junior Trainees