Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

Undiagnosed Obstructive Sleep Apnea as Predictor of 90-Day Readmission for Brain Tumor Patients

BACKGROUND

Previously undiagnosed obstructive sleep apnea (OSA) is a known contributor to negative postoperative outcomes. The STOP-Bang questionnaire is a screening tool for OSA that has been validated in both medical and surgical populations. The authors have previously studied this screening tool in a brain tumor population at 30 days. The present study seeks to investigate the effectiveness of this questionnaire, for predicting 90-day readmissions in a population of brain tumor patients with previously undiagnosed OSA.

METHODS

Included for analysis were all patients undergoing craniotomy for supratentorial neoplasm at a multihospital, single academic medical center. Data were collected from supratentorial craniotomy cases for which the patient was alive at 90 days after surgery (n = 238). Simple logistic regression analyses were used to assess the ability of the STOP-Bang questionnaire and subsequent single variables to accurately predict patient outcomes at 90 days.

RESULTS

The sample included 238 brain tumor admissions, of which 50% were female (n = 119). The average STOP-Bang score was 1.95 ± 1.24 (range 0-7). A 1-unit higher increase in STOP-Bang score accurately predicted 90-day readmissions (odds ratio [OR] = 1.65, P = 0.001), 30- to 90-day emergency department visits (OR = 1.85, P < 0.001), and 30- to 90-day reoperation (OR = 2.32, P < 0.001) with fair accuracy as confirmed by the receiver operating characteristic (C-statistic = 0.65-0.76). However, the STOP-Bang questionnaire did not correlate with home discharge (P = 0.315).

CONCLUSIONS

The results of this study suggest that undiagnosed OSA, as evaluated by the STOP-Bang questionnaire, is an effective predictor of readmission risk and health system utilization in a brain tumor craniotomy population with previously undiagnosed OSA.

Perioperative Guidelines in Anesthesia

Agreement between surgical and anesthesia teams regarding appropriate perioperative management strategies is vital to delivering safe and effective patient care. Perioperative guidelines serve as a valuable reference in optimizing patients for surgery. The article provides a broad set of guidelines related to cardiovascular evaluation, medication reconciliation, and preoperative fasting and includes a framework for the care of patients with comorbidities, such as coronary artery disease and obstructive sleep apnea.

Obstructive sleep apnoea and its knowledge and attitude among Indian anaesthesiolgists - A survey study

BACKGROUND AND AIMS

Obstructive sleep apnoea (OSA) has an estimated prevalence of 2%-4% in adult population and is increasing. Most of these are detected late which is the cause for higher perioperative morbidity. This survey was aimed to seek the level of knowledge and attitude of Indian anaesthesiologists towards OSA.

METHODS

The OSA Knowledge and Attitude (OSAKA) questionnaire (23-statements) was distributed to the anaesthesiologists attending the difficult airway conference in December 2017. The first section has 18 statements pertaining to OSA knowledge. The second section consists of five statements to evaluate self-confidence in the management of OSA. Age, gender, professional title, type of hospital, years of experience, and bariatric experience were analysed.

RESULTS

205 out of 350 participants responded. In all, 201 (57.4%) fully completed responses were analysed. The mean ± standard deviation knowledge and attitude scores were 12.01 ± 2.88 (66.72% ± 16%) and 18.16 ± 3.75 (72.64% ± 15%) respectively. On exclusion of junior residents (n = 56), knowledge and attitude scores of qualified anaesthesiologists were 12.7 ± 2.55 (70.55% ± 14.16%) and 18.78 ± 3.91 (75.12% ± 15.64%), respectively. Anaesthesiologists with bariatric experience had a significantly higher attitude score when compared with those who do not practice bariatric surgeries (P < 0.01). There is weak but significant, positive linear correlation between knowledge and attitude score (rs= 0.370, P < 0.01).

CONCLUSION

Deficit of adequate knowledge about OSA exists among Indian anaesthesiologists. Experience of managing cases with OSA seems to improve knowledge and attitude towards OSA.

Trends in total knee and hip arthroplasty recipients: a retrospective cohort study

Background

Arthroplasty is one of the most commonly performed procedures in the USA with projections of continuous growth. As this field undergoes continuous changes, the goal of this study was to provide an analysis of patient-related and healthcare system-related trends. This is important as it allows practitioners, administrators and policy makers to allocate needed resources appropriately.

Methods

The study included total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures from 2006 to 2016. Demographic information, comorbidities and complications were extracted and analyzed from the Premier Healthcare database.

Results

The surgical volume increased annually over the observation period by an average of 5.54% for TKA and 7.02% for THA, respectively. The average age of the patient population and the types of anesthesia used remained relatively consistent over time. Comorbidity burden increased, especially for obesity (16.52% in 2006 and 29.77% in 2016 for TKA, 11.15% in 2006 and 20.92% in 2016 for THA), obstructive sleep apnea (OSA) (6.82% in 2006 and 17.03% in 2016 for TKA, 4.69% in 2006 and 12.72% in 2016 for THA) and renal insufficiency (2.81% in 2006 and 7.01% in 2016 for TKA, 2.78% in 2006 and 6.43% in 2016 for THA). Minor trends of increases were also observed in the prevalence of liver disease, depression and hypothyroidism. All postoperative complications were trending lower except for acute renal failure, where an increase was noted (4.39% in 2006 and 8.10% in 2016 for TKA, 4.99% in 2006 and 8.42% in 2016 for THA).

Discussion

Significant trends in the care of patients who undergo TKA and THA were identified. Individuals undergoing these procedures presented with a higher prevalence of comorbidities. Despite these trajectories, complications declined over time. These data can be used to inform future research and to allocate resources to address changes in populations cared for and complications encountered.

Perioperative considerations and anesthesia management in patients with obstructive sleep apnea undergoing ophthalmic surgery

Obstructive sleep apnea (OSA) is a disorder characterized by breathing cessation caused by obstruction of the upper airway during sleep. It is associated with multiorgan comorbidities such as obesity, hypertension, heart failure, arrhythmias, diabetes mellitus, and stroke. Patients with OSA have an increased prevalence of ophthalmic disorders such as cataract, glaucoma, central serous retinopathy (detachment of retina, macular hole), eyelid laxity, keratoconus, and nonarteritic anterior ischemic optic neuropathy; and some might require surgery. Given that OSA is associated with a high incidence of perioperative complications and more than 80% of surgical patients with OSA are unrecognized, all surgical patients should be screened for OSA (eg, STOP-Bang questionnaire) with comorbidities identified. Patients suspected or diagnosed with OSA scheduled for ophthalmic surgery should have their comorbid conditions optimized. This article includes a review of the literature and highlights best perioperative anesthesia practices in the management of ophthalmic surgical patients with OSA.

Obesity and Obstructive Sleep Apnea in the Ambulatory Patient

Obesity and obstructive sleep apnea (OSA) are often associated with increased perioperative risks and challenges for the anesthesiologist. This article addresses the current controversies surrounding perioperative care of morbidly obese patients with or without OSA scheduled for ambulatory surgery, particularly in a free-standing ambulatory center. Topics discussed include preoperative selection of obese and OSA patients for ambulatory surgeries, intraoperative methods to reduce perioperative risk, and appropriate postoperative care.

Association of Unrecognized Obstructive Sleep Apnea With Postoperative Cardiovascular Events in Patients Undergoing Major Noncardiac Surgery

Importance

Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain.

Objectives

To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery.

Design, Setting, and Participants

Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations.

Exposures

Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring.

Main Outcomes and Measures

The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications.

Results

Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome (adjusted hazard ratio [HR], 1.49 [95% CI, 1.19-2.01]; P = .01); however, the association was significant only among patients with severe OSA (adjusted HR, 2.23 [95% CI, 1.49-3.34]; P = .001) and not among those with moderate OSA (adjusted HR, 1.47 [95% CI, 0.98-2.09]; P = .07) or mild OSA (adjusted HR, 1.36 [95% CI, 0.97-1.91]; P = .08) (P = .01 for interaction). The mean cumulative duration of oxyhemoglobin desaturation less than 80% during the first 3 postoperative nights in patients with cardiovascular complications (23.1 [95% CI, 15.5-27.7] minutes) was longer than in those without (10.2 [95% CI, 7.8-10.9] minutes) (P < .001). No significant interaction effects on perioperative outcomes were observed with type of anesthesia, use of postoperative opioids, and supplemental oxygen therapy.

Conclusions and Relevance

Among at-risk adults undergoing major noncardiac surgery, unrecognized severe obstructive sleep apnea was significantly associated with increased risk of 30-day postoperative cardiovascular complications. Further research would be needed to assess whether interventions can modify this risk.