Obesity and Obstructive Sleep Apnea in the Ambulatory Patient

Association Between the Weight-Adjusted Waist Index and OSA Risk: Insights from the NHANES 2017-2020 and Mendelian Randomization Analyses

Background

Obesity is a significant risk factor for obstructive sleep apnea (OSA). The weight-adjusted-waist index (WWI) reflects weight-independent centripetal obesity. Our study aims to evaluate the relationship between WWI and OSA.

Methods

The data used in the current cross-sectional investigation are from the National Health and Nutrition Examination Survey (NHANES), which was carried out between 2017 and 2020. We utilized weighted multivariable-adjusted logistic regression to evaluate the relationship between WWI and the risk of OSA. In addition, we applied various analytical methods, including subgroup analysis, smoothing curve fitting, threshold effect analysis and the receiver operating characteristic (ROC) curve. To further explore the relationship, we conducted a MR study using genome-wide association study (GWAS) summary statistics. We performed the main inverse variance weighting (IVW) method along with other supplementary MR methods. In addition, a meta-analysis was conducted to provide an overall evaluation.

Results

WWI was positively related to OSA with the full adjustment [odds ratio (OR)=1.14, 95% confidence interval (95% CI): 1.06-1.23, P<0.001]. After converting WWI to a categorical variable by quartiles (Q1-Q4), compared to Q1 the highest WWI quartile was linked to an obviously increased likelihood of OSA (OR=1.26, 95% CI: 1.06-1.50. P=0.01). Subgroup analysis revealed the stability of the independent positive relationship between WWI and OSA. Smoothing curve fitting identified a saturation effect of WWI and OSA, with an inflection point of 11.62. In addition, WWI had the strongest prediction for OSA (AUC=0.745). Sensitivity analysis was performed to verify the significantly positive connection between WWI and stricter OSA (OR=1.18, 95% CI: 1.05-1.32, P=0.005). MR meta-analysis further supported our results (OR=2.11, 95% CI: 1.94-2.30, P<0.001). Sensitivity analysis confirmed the robustness and reliability of these findings.

Conclusion

WWI was significantly associated with the risk of OSA, suggesting that WWI could potentially serve as a predictor for OSA.

Impact of Body Mass Index on All-Cause Mortality in Adults: A Systematic Review and Meta-Analysis

Background: Obesity is a risk factor for many diseases, diagnosed by calculating body mass index (BMI). Methods: To find an association between BMI and mortality in adults, we searched PubMed for articles published in the 21st century. Our review included 82 original studies, comprising 2.7 million patients and 23.4 million patient years. Results: The meta-analysis showed a U-shaped relationship between BMI and all-cause mortality risk, with the lowest mortality in the BMI range of 25-30 kg/m2. Subgroup analysis showed a J-shaped relationship, with greater risk in the highest BMI range (>35 kg/m2). Among the elderly, BMI values <20 kg/m2 were associated with the highest risk. Among diabetic patients, a U-shaped relationship was noticed, again with the highest risk in the lowest (<20 kg/m2) and highest BMI range (>35 kg/m2). Among patients with cardiovascular disease, the risk increased with BMI values <25 kg/m2 but did not noticeably change for BMI exceeding that value. Among cancer patients, the relationship was less pronounced than in other subgroups, with a slightly higher risk (>35 kg/m2). Conclusions: Our results show that the lowest mortality is observed among patients with BMI 25-30 kg/m2. Reduction of body mass should not be a universal recommendation in clinical practice, but it should be individualized.

Patient selection in ambulatory surgery

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Morbid Obesity Not a Risk for Serious Complications Following Outpatient Surgery

Patients with class III obesity are often excluded from surgery in ambulatory surgery centers (ASCs). We hypothesize that class III obesity is not a risk factor for serious post-operative complications following outpatient operations. ACS-NSQIP database from 2012 to 2018 was queried. Patients undergoing outpatient inguinal hernia repair (IHR) and laparoscopic cholecystectomy (LC) were grouped by BMI. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. Of these, 79,916 patients underwent IHR and 107,471 patients underwent LC. Multivariable analysis in IHR showed increased odds of superficial SSIs in all classes of obesity compared to normal weight (P < .0001). In the LC group, there were higher rates of SSIs with obesity (P < .0001). For both surgeries, a higher rate of readmissions to the hospital were observed in class II and IIIa obesity (both P < .0001), although rates were relatively low (<3%). Class III obesity demonstrates a statistically significant increase in SSI following IHR and LC. Severe complications requiring readmission are not mirrored, suggesting the morbidly obese patients should be considered for routine surgical procedures in outpatient settings.

Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass in Patients with Well-Regulated Obstructive Sleep Apnea

INTRODUCTION

Same-day discharge after bariatric surgery is increasingly being performed. In current practice, patients with only minor comorbidities are considered eligible for same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB). Obstructive sleep apnea (OSA) is a common comorbidity in patients with morbid obesity, with a prevalence of around 70-80% among patients undergoing bariatric surgery. Continuous positive airway pressure (CPAP) is the current gold standard treatment for OSA. We aimed to investigate whether same-day discharge after RYGB is feasible for patients with compliant use of CPAP.

METHODS

In this single-center prospective feasibility study, patients were selected who were scheduled for RYGB and were adequately treated for OSA. Compliance on the use of CPAP had to be proved (> 4 h per night for 14 consecutive nights). There were strict criteria on approval upon same-day discharge. The primary outcome was the rate of successful same-day discharge. Secondary outcomes included short-term complications, emergency department presentations, readmissions, and mortality.

RESULTS

Forty-nine patients underwent RYGB with intended same-day discharge, of whom 45 (92%) were successfully discharged. Three patients had an overnight stay because of divergent vital signs and one patient due to a delayed start of the surgery. Two patients (4%) were readmitted in the first 48 h postoperatively, both due to intraluminal bleeding which was managed conservatively (Clavien-Dindo 2). There were no severe complications in the first 48 h after surgery.

CONCLUSION

Same-day discharge after RYGB can be considered feasible for selected patients with well-regulated OSA.

Reducing Risk for Perioperative Anesthesia Complications

Aging patients and outpatient settings add complexity to the anesthetic management of facial plastic surgery, which emphasizes a quiet surgical field and smooth perioperative journey, absent rocky emergence phenomena, postoperative nausea and vomiting, prolonged post-anesthesia care unit stays, or last-minute hospital admissions. Monitored anesthesia care can be ideal with proper patient selection and a conscientious provider, although overlooking potential risks has led to catastrophic consequences, including burns, hypoxic brain injury, and death. Inherently isolated, emergency preparedness is more crucial in outpatient settings, and includes emergency training and protocol availability along with the appropriate stock of emergency equipment and medication, including dantrolene and lipid emulsion.

Obstructive Sleep Apnea, Circadian Clock Disruption, and Metabolic Consequences

Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of apnea and hypopnea during sleep. It is associated with various cardiovascular and metabolic complications, including type 2 diabetes mellitus (T2DM) and obesity. Many pathways can be responsible for T2DM development in OSA patients, e.g., those related to HIF-1 and SIRT1 expression. Moreover, epigenetic mechanisms, such as miRNA181a or miRNA199, are postulated to play a pivotal role in this link. It has been proven that OSA increases the occurrence of circadian clock disruption, which is also a risk factor for metabolic disease development. Circadian clock disruption impairs the metabolism of glucose, lipids, and the secretion of bile acids. Therefore, OSA-induced circadian clock disruption may be a potential, complex, underlying pathway involved in developing and exacerbating metabolic diseases among OSA patients. The current paper summarizes the available information pertaining to the relationship between OSA and circadian clock disruption in the context of potential mechanisms leading to metabolic disorders.

Is esketamine-based opioid-free anesthesia more superior for postoperative analgesia in obstructive sleep apnea patients undergoing bariatric surgery? A study protocol

INTRODUCTION

Opioid-free anesthesia (OFA) can certainly prevent nausea and vomiting after bariatric surgery (BS), but its postoperative analgesic effect is still controversial. Obstructive sleep apnea (OSA) is a prominent feature of morbid obesity in BS and accounts for a very high proportion, which significantly increases the difficulty of patients' airway management. Those patients will be more representative and highlight the advantages of OFA. It is not clear whether esketamine can play a more prominent role in OFA for postoperative analgesia. Therefore, this study aims to explore the postoperative analgesic effect of esketamine-based OFA on BS patients with OSA.

METHODS AND ANALYSIS

This single-center, prospective, randomized, controlled, single-blind study is planned to recruit 48 participants to undergo BS from May 2022 to April 2023. Patients will be randomly assigned to the OFA group and opioid-based anesthesia (OBA) group in a ratio of 1:1. The primary outcome is the Numeric Rating Scale (NRS) at different times postoperatively. Secondary outcomes include analgesic intake, the incidence and severity of postoperative nausea and vomiting (PONV), Leiden Surgical Rating Scale (L-SRS), postoperative agitation and chills, PACU stay time, EuroQol five-dimensional questionnaire (EQ-5D), length of hospital stay, intraoperative awareness, and hemodynamically unstable treatments.

DISCUSSION

The results of this study may explain the analgesic effect of esketamine-based OFA on patients undergoing BS combined with OSA, and provide evidence and insight for perioperative pain management.

ETHICS AND DISSEMINATION

This study is initiated by the Ethics Committee of The First Affiliated Hospital of Shandong First Medical University [YXLL-KY-2022(035)]. The trial results will be published in peer-reviewed journals and at conferences.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT05386979], identifier [NCT05386979].

Voluntary physical activity improves spatial and recognition memory deficits induced by post-weaning chronic exposure to a high-fat diet

Childhood and adolescent exposure to obesogenic environments has contributed to the development of several health disorders, including neurocognitive impairment. Adolescence is a critical neurodevelopmental window highly influenced by environmental factors that affect brain function until adulthood. Post-weaning chronic exposure to a high-fat diet (HFD) adversely affects memory performance; physical activity is one approach to coping with these dysfunctions. Previous studies indicate that voluntary exercise prevents HFD's detrimental effects on memory; however, it remains to evaluate whether it has a remedial/therapeutical effect when introduced after a long-term HFD exposure. This study was conducted on a diet-induced obesity mice model over six months. After three months of HFD exposure (without interrupting the diet) access to voluntary physical activity was provided. HFD produced weight gain, increased adiposity, and impaired glucose tolerance. Voluntary physical exercise ameliorated glucose tolerance and halted weight gain and fat accumulation. Additionally, physical activity mitigated HFD-induced spatial and recognition memory impairments. Our data indicate that voluntary physical exercise starting after several months of periadolescent HFD exposure reverses metabolic and cognitive alterations demonstrating that voluntary exercise, in addition to its known preventive effect, also has a restorative impact on metabolism and cognition dysfunctions associated with obesity.

A review on the beneficial effects of bariatric surgery in the management of obesity

INTRODUCTION

Obesity is a chronic disease with a complex interplay of multiple factors such as genetic, metabolic, behavioral, and environmental factors. The management of obesity includes; lifestyle modification, psychological therapy, pharmacological therapy, and bariatric surgery. To date, bariatric surgery is the most effective treatment for obesity by offering a long-term reduction in weight, remission of obesity-related complications, and improving quality of life. However, bariatric surgery is not equally effective in all patients. Thus, if we can predict who would benefit most, it will improve the risk versus benefit ratio of having surgery.

AREAS COVERED

In this narrative review, we explore the question on who will benefit the most from bariatric surgery by examining the recent evidence in the literature. In addition, we investigate the predisposing predictors of bariatric surgery response. Finally, we offer the best strategies in the clinic to explain the potential benefits of bariatric surgery to patients.

EXPERT OPINION

Bariatric surgery is an effective obesity management approach. Despite its efficacy, considerable variation of individual response exists. Thus, it is important to recognize patients that will benefit most, but at present very few predictors are available which can be clinically useful.

Obesity and outcomes in patients undergoing upper airway surgery for obstructive sleep apnea

Objective

Obesity is frequently debated as a factor associated with increased postoperative complications. Specifically, upper airway surgeries for obstructive sleep apnea (OSA), a common comorbidity among obese patients, may be complicated by obesity’s impact on intraoperative ventilation. The aim of this retrospective study was to analyze the association of various degrees of obesity with postoperative outcomes in patients undergoing surgery for OSA.

Methods

The American College of Surgeons National Surgical Quality Improvement database between 2015 and 2019 was used to create a sample of patients diagnosed with OSA who underwent uvulopalatopharyngoplasty, tracheotomy, and surgeries at the base of tongue, maxilla, palate, or nose/turbinate. Inverse probability-weighted logistic regression and unadjusted multivariable logistic regression were used to compare outcomes of non-obese and obesity class 1, class 2, and class 3 groups (World Health Organization classification). Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications, and a secondary outcome was all-cause same-day hospital admission.

Results

There were 1929 airway surgeries identified. The inverse probability-weighted regression comparing class 1, class 2, and class 3 obesity groups to non-obese patients showed no association between obesity and composite outcome and no association between obesity and hospital admission (all p-values > 0.05).

Conclusion

These results do not provide evidence that obesity is associated with poorer outcomes or hospital admission surrounding upper airway surgery for OSA. While these data points towards the safety of upper airway surgery in obese patients with OSA, larger prospective studies will aid in elucidating the impact of obesity.

Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting.

RECENT FINDINGS

NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19.

SUMMARY

The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.

Impact of Upper Airway Characteristics on Disease Severity and CPAP Therapy in Chinese Patients With OSA: An Observational Retrospective Study

Objective

The characteristics of the upper airway (UA) are important for the evaluation and treatment of obstructive sleep apnea (OSA). This study aimed to investigate the association of UA characteristics with OSA severity, titration pressure, and initiation of and 3-month compliance with continuous positive airway pressure (CPAP).

Methods

This retrospective study included consecutive patients examined using a semi-quantitative UA evaluation system (combination with physical examination and awake endoscopy) during 2008–2018 at the Department of Respiratory and Critical Care Medicine, Peking University First Hospital. First, the differences in UA characteristics were compared between patients with simple snorers and mild OSA and those with moderate-to-severe OSA. Then, the effect of UA characteristics on the initiation to CPAP therapy and 3-month adherence to CPAP was conducted.

Results

Overall, 1,002 patients were included, including 276 simple snorers and patients in the mild OSA group [apnea-hypopnea index (AHI) <15] and 726 patients in the moderate-to-severe OSA group (AHI ≥15). Tongue base hypertrophy, tonsillar hypertrophy, mandibular recession, neck circumstance, and body mass index (BMI) were independent risk factors for moderate-to-severe OSA. Among those patients, 119 patients underwent CPAP titration in the sleep lab. The CPAP pressures in patients with thick and long uvulas, tonsillar hypertrophy, lateral pharyngeal wall stenosis, and tongue hypertrophy were higher than those of the control group (P < 0.05, respectively). The logistic regression analysis showed that nasal turbinate hypertrophy, mandibular retrusion, and positive Müller maneuver in the retropalate and retroglottal regions were independent predictors for the initiation of home CPAP treatment.

Conclusion

Multisite narrowing and function collapse of the UA are important factors affecting OSA severity, CPAP titration pressure, and the initiation of home CPAP therapy. Clinical evaluation with awake endoscopy is a safe and effective way for the assessment of patients with OSA in internal medicine.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Machine learning-based preoperative datamining can predict the therapeutic outcome of sleep surgery in OSA subjects

Increasing recognition of anatomical obstruction has resulted in a large variety of sleep surgeries to improve anatomic collapse of obstructive sleep apnea (OSA) and the prediction of whether sleep surgery will have successful outcome is very important. The aim of this study is to assess a machine learning-based clinical model that predict the success rate of sleep surgery in OSA subjects. The predicted success rate from machine learning and the predicted subjective surgical outcome from the physician were compared with the actual success rate in 163 male dominated-OSA subjects. Predicted success rate of sleep surgery from machine learning models based on sleep parameters and endoscopic findings of upper airway demonstrated higher accuracy than subjective predicted value of sleep surgeon. The gradient boosting model showed the best performance to predict the surgical success that is evaluated by pre- and post-operative polysomnography or home sleep apnea testing among the logistic regression and three machine learning models, and the accuracy of gradient boosting model (0.708) was significantly higher than logistic regression model (0.542). Our data demonstrate that the data mining-driven prediction such as gradient boosting exhibited higher accuracy for prediction of surgical outcome and we can provide accurate information on surgical outcomes before surgery to OSA subjects using machine learning models.

Implementation of contextualized, emergency management cognitive aids in a periodontics clinic

BACKGROUND

Emergencies in outpatient clinics are rare. However, potentially catastrophic events can be challenging to manage due to a variety of factors, including limited equipment and staff. The purpose of this quality improvement project was to improve the staff knowledge and familiarity with critical performance elements for emergencies encountered in the setting of a periodontics clinic.

METHODS

Emergency cognitive aids tailored to the clinic's resources were created for anaphylaxis, airway obstruction, and sublingual hemorrhage. The project pre-post-test repeated measures design evaluated the effectiveness of cognitive aids using a combination of hands-on simulation, written knowledge assessments, and self-efficacy surveys. Training sessions and simulations were provided to the clinic's existing care teams made up of a periodontist and two dental assistants with an anesthetist who was present for simulations involving sedation. Due to the small sample size (N = 14) and non-normal distribution, all metrics were evaluated using non-parametric statistics.

RESULTS

Significant improvements were found in knowledge assessment (-2.310, P = 0.021) and self-efficacy (-2.486, P = 0.013) scores when retention after a training session before and after the introduction of cognitive aid was compared. The mean simulation scores and times improved steadily or reached maximum scores during the project progression.

CONCLUSION

Training sessions before and after cognitive aid introduction were effective in improving knowledge, self-efficacy, and simulation performance. Future projects should focus on validating the process for creating contextualized cognitive aids and evaluating the effectiveness of these cognitive aids in larger samples.

Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings

BACKGROUND

Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses.

RESULTS

A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77).

CONCLUSIONS

This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.

Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry

STUDY OBJECTIVE

Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities.

DESIGN

We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data.

SETTING

NACOR from 2012 to 2017.

PATIENTS

From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336.

INTERVENTIONS

None.

MEASUREMENTS

To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons.

MAIN RESULTS

Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701-3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117-151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion.

CONCLUSIONS

Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Using Abnormal Respiratory Motion on Myocardial Perfusion Scintigraphy as an Opportunity to Screen for Obstructive Sleep Apnea

A pilot study was performed to determine whether the raw data from routinely obtained upright and supine myocardial perfusion scan (MPS) imaging could be used as an opportunity to screen for obstructive sleep apnea (OSA). We hypothesized that abnormal respiratory motion seen only on supine imaging (not upright imaging) corresponds with OSA. MPS supine-only respiratory motion was compared with known OSA diagnoses and with risk factors known to be associated with OSA. Methods: We reviewed 154 consecutive MPS studies from patients at our institution, including both exercise and chemical stress testing. All examinations were obtained because there was clinical suspicion of myocardial ischemia. We used the MPS panogram to assess for respiratory motion on supine stress or upright rest or stress imaging. We obtained the age, sex, body mass index, hypertensive history, and continuous positive airway pressure or OSA diagnosis history. Results: We compared the patients who had supine, stress-only respiratory motion with the remaining patients, assessing their OSA risk factors and known OSA diagnoses. In total, 65 patients (42.2%) had 3 or more OSA risk factors and 26 patients (16.9%) had a known OSA diagnosis. A similar percentage of patients with abnormal supine-only respiratory motion and patients with 3 or more OSA risk factors had a known OSA diagnosis, 9 (16.7%) and 14 (21.5%), respectively. Conclusion: We found a similar prevalence of known OSA diagnoses in patients with abnormal supine-only respiratory motion on MPS studies and patients with 3 or more OSA risk factors. The pilot study suggests that assessment of motion on MPS studies may provide an opportunity to also screen for OSA.