As advances in imaging techniques and interventional procedures are expanding across all hospital specialties, pediatric hospitals in particular are finding an exponential increase in the need for nonoperating room anesthesia (NORA) to help children receive the studies, scans, and procedures required for best care practices. NORA is now an established service in most hospitals and has its own unique practice requirements and guidelines, medications, challenges, and complications. As the service continues to grow in scope, it is imperative that organizations follow all protocols and standards set forward by governing bodies and that NORA personnel are well versed in the sedation continuum, methods of monitoring, and sedation scales. Due to its complexity, variability, and multiple venues, it requires such a different skill set that the American Board of Anesthesiologists (ABA) is now mandating education and experience in and testing of NORA for all anesthesia residency programs. NORA is such a fast-growing field that the next decade may find up to 50% of all anesthetics are done at NORA sites (Curr Opin Anaesthesiol 30:644–651, 2017 and 19:430-435). As a shift to nonoperating room locations continues and more widespread use of sedation by other practitioners follows, anesthesiologists should continue to be at the forefront in representing and advocating for the highest quality of care for all children receiving sedation. They should also champion accreditation of institutions and credentialing of practitioners, as well as support new and innovative technology which will make NORA even safer in the future.