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Non-Operating Room Anesthesia

Non-operating room anesthesia (NORA or “off-site” anesthesia) involves sedation and anesthesia provided by the Department of Anesthesiology for procedures occurring in locations outside the traditional operating room. Types of procedures falling into this category include radiological imaging and interventional procedures, gastrointestinal endoscopy, interventional cardiology and office-based procedures for both children and adults. As these procedures have become more complicated and technically challenging, the demand for high quality anesthesia has exploded. Meeting this rapid growth in a safe and efficient manner has been a challenge for anesthesiologists, both on a national basis and here at DHMC.

Patient Care

NORA cases have been separated into two distinct entities: pediatric cases done as a part of the Children’s Hospital at Dartmouth (CHaD) PainFree program and adult cases. While there are many similarities in the care of both children and adults, the NORA service primarily involves adult patients while pediatric NORA care is under the umbrella of pediatric anesthesiology. Demand for NORA care continues to grow rapidly. At this time, NORA (including PainFree) represents about 30% of the overall anesthetic case volume. This growth represents both a challenge and an opportunity for the department.


Resident physicians play an integral role in the provision of NORA care at DHMC. While there is no specific NORA rotation, residents are often assigned to NORA cases during the ambulatory surgery rotation and, to a lesser extent, on the general surgery rotation. On pediatric rotations, residents are, at times, assigned to work with the PainFree program. In addition, as part of the transition to practice rotation, CA-3 residents are assigned to NORA cases to foster independent practice and directly supervise CRNAs at NORA locations. Residents receive plenty of exposure to the unique needs and requirements of NORA and learn to work as part of a care team outside of the traditional operating room. Upon residency completion, graduates should feel comfortable handling the challenges of NORA care.