Introduction
As pediatric anesthesiology continues to evolve, non-operating room anesthesia (NORA) for neonates and infants has emerged as a critical and growing area of focus. These procedures, performed outside the traditional operating room, are becoming more frequent and complex, particularly in pediatric populations.[1],[2] Delivering safe, effective anesthesia in these settings requires clinicians to adapt to environments that often lack the resources, equipment, and support systems of the main OR.[3] For the most vulnerable patients, including neonates and infants, this creates significant clinical and logistical challenges. Meeting these demands calls for not only specialized expertise but also innovative technologies that enhance mobility, precision, and integration. In this article, we examine the unique challenges of pediatric NORA and explore how emerging solutions are helping anesthesia teams deliver high-quality care across diverse clinical settings.
Pediatric NORA by the numbers
Pediatric patients (under 18) account for approximately 15–20% of all anesthesia cases in the United States. [4] An increasing proportion of these cases occur in NORA settings, such as MRI suites, interventional radiology, and cardiac catheterization labs. According to data from US Anesthesia Partners (USAP), the share of pediatric NORA cases averaged 28.24% over a two-year period (2021–2022), rising slightly from 28.19% in 2021 to 28.28% in 2022, reflecting a continued upward trend in remote-site anesthetic procedures.4
Challenges of NORA
Providing anesthesia to neonates and infants in NORA environments presents a distinct set of challenges. These locations often lack the controlled conditions of the main OR, including pediatric-specific equipment, comprehensive monitoring tools, and trained support staff. Anesthesiologists must navigate unfamiliar room layouts, limited resources, and the heightened risk profiles of medically complex patients. The geographic dispersion of NORA sites across a hospital can stretch anesthesia teams thin, complicating staffing and response times. Communication becomes more difficult yet critically important, as clinicians must coordinate with proceduralists, nurses, and technicians who may not be familiar with pediatric protocols.[5] Without system-wide planning and standardization, these limitations can compromise safety and efficiency.
Adding to the complexity is the variability in provider experience. Pediatric anesthesia is delivered by a mix of clinicians—including board-certified pediatric anesthesiologists, fellowship-trained but non-certified anesthesiologists, and generalists, many of whom treat pediatric patients in less than 10% of their practice.4 This variability underscores the need for institutional support, standardized protocols, and ongoing training.
Addressing these challenges requires a proactive, multidisciplinary approach that emphasizes preparedness, adaptability, and institutional support.1
Best practices
As Dr. Jonathan Tan notes,1 delivering safe and effective anesthesia in NORA settings requires more than just the right equipment—it demands a coordinated, team-based approach grounded in preparation and communication. Best practices include conducting thorough pre-procedure assessments, confirming the availability and functionality of all necessary equipment, and clearly defining roles and responsibilities among team members. Establishing standardized protocols for patient monitoring, medication administration, and emergency response helps reduce variability and improve outcomes. Simulation-based training can further enhance team readiness by allowing clinicians to rehearse rare or high-risk scenarios in a controlled environment. Additionally, fostering strong communication channels between anesthesia providers, proceduralists, nursing staff, and support personnel is essential, particularly in geographically dispersed or resource-limited settings. These strategies help ensure that even in the most challenging environments, patient safety remains the top priority.
Summary of Dr. Tan’s recommendations:
- Conduct thorough pre-procedure assessments
- Ensure equipment readiness
- Define team roles and responsibilities
- Standardize protocols
- Incorporate simulation-based training
- Strengthen interdisciplinary communication
- Prioritize patient safety in every setting
Looking ahead
As the demand for pediatric NORA continues to grow, so too does the need for innovative solutions that support clinicians in delivering high-quality care beyond the OR. GE HealthCare remains committed to advancing anesthesia excellence through ongoing collaboration with clinical partners and the development of technologies that prioritize precision, portability, and integration. By equipping anesthesia teams with tools that adapt to a wide range of care environments, GE HealthCare aims to help healthcare systems meet the evolving needs of their youngest and most vulnerable patients. Looking forward, continued investment in training, standardization, and technology will be essential to ensuring that neonatal and pediatric patients receive safe, effective anesthesia—no matter where their care takes place.
References
[1] Tan, Jonathan. (2025). Optimizing Pediatric Anesthesia Care for Neonates and Infants. GE HealthCare, Clinical View. https://clinicalview.gehealthcare.com/article/optimizing-pediatric-anesthesia-care-neonates-and-infants
[2] Shih G, Bailey PD Jr. Nonoperating room anesthesia for children. Curr Opin Anaesthesiol. 2020 Aug;33(4):584-588. doi: 10.1097/ACO.0000000000000880. PMID: 32628407.
[3] Olivia Nelson and Philip D. Bailey, “Pediatric Anesthesia Considerations for Interventional Radiology,” Anesthesiology Clinics 35, no. 4 (December 2017): 701–14, https://doi.org/10.1016/j.anclin.2017.08.003.
[4] Dutton RP, Bryskin RB, Starks M, Shukla AS, Lounsbury O. Pediatric anesthesia in the community. Advances in Anesthesia. 2023;41(1):127-142. doi:10.1016/j.aan.2023.06.002
[5]Mary Landrigan-Ossar and Christopher Tan Setiawan, “Pediatric Anesthesia Outside the Operating Room: Safety and Systems,” Anesthesiology Clinics 38, no. 3 (September 2020): 577–86, https://doi.org/10.1016/j.anclin.2020.06.001.
Disclaimer: Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.
GE is a trademark of General Electric Company used under trademark license.
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