Nonoperating room anesthesia in the ICU: current practice and considerations

PURPOSE OF REVIEW: ICU procedures are increasingly complex, often requiring deeper sedation or general anesthesia, and are increasingly performed at the bedside to avoid transport risk. This trend has expanded the role of anesthesiologists in ICU nonoperating room anesthesia (NORA). This review summarizes practical anesthetic considerations for these procedures, focusing on optimization, monitoring, and systems issues. RECENT FINDINGS: ICU patients frequently have shock, hypoxemia, right ventricular failure, metabolic acidosis, organ dysfunction, and neurologic injury that change anesthetic pharmacokinetics and hemodynamic responses. Bedside tracheostomy, percutaneous endoscopic gastrostomy, extracorporeal membrane oxygenation cannulation, bronchoscopy, thoracic interventions, and selected neurosurgical and interventional radiology procedures are feasible in the ICU but carry higher rates of cardiorespiratory events than operating room cases, largely because of illness severity and environmental constraints. Short-acting sedatives, noninvasive respiratory support, point-of-care ultrasound, and structured checklists, simulation, and dedicated ICU NORA pathways can reduce complications. Emerging artificial intelligence and machine learning tools that process physiologic and waveform data may further improve risk stratification, early detection of instability, and decision support. SUMMARY: Bedside ICU procedures blur the boundaries between sedation, monitored anesthesia care, and general anesthesia. Effective practice requires individualized plans, clear rescue pathways, and coordination between anesthesia, ICU, and procedural teams, supported by advanced monitoring and data-driven decision support.