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

Abstract

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.