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Dubin JA, Bains SS, Hameed D, Chen Z, Mayassi HA, Nace J, Delanois RE. The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total knee arthroplasty: a propensity score matched analysis. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05238-0. [PMID: 38758237 DOI: 10.1007/s00402-024-05238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/17/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited. METHODS A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years. RESULTS The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years. CONCLUSION Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group.
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Affiliation(s)
- Jeremy A Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Zhongming Chen
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Hani A Mayassi
- Department of Orthopaedic Surgery, WellSpan Health, York Hospital, York, PA, USA
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA.
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Oster B, Hameed D, Dubin JA, Bains SS, Shul C, Mont M, Delanois RE. The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total hip arthroplasty: A propensity score matched analysis. J Orthop 2024; 50:149-154. [PMID: 38283874 PMCID: PMC10819191 DOI: 10.1016/j.jor.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/17/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Obstructive sleep apnea (OSA) impacts approximately 936 million individuals globally and is known to complicate post-surgical recovery, particularly after total hip arthroplasty (THA). While continuous positive airway pressure (CPAP) is commonly recommended for managing OSA, its effect on THA recovery remains uncertain. The study aimed to assess the impact of CPAP use on post-THA outcomes in patients with OSA, focusing on medical complications and periprosthetic joint infection (PJI) at 90 days and 1 year. Methods A national, all-payer database was utilized to identify patients undergoing primary THA between 2010 and 2021. Patients with OSA were stratified based on CPAP use through propensity score matching. Three matched groups were formed: OSA without CPAP, OSA with CPAP, and no OSA. Medical and surgical complications were assessed at 90 days and 1 year post-THA. Results Patients with OSA using CPAP exhibited more baseline comorbidities than those without CPAP. CPAP use was associated with inferior outcomes, including higher odds of PJI, wound complications, and venous thromboembolism at 90 days and 1 year post-THA. These trends were consistent even after adjusting for confounders. Conclusion CPAP use, indicative of severe OSA, was linked to worse post-THA outcomes, emphasizing the importance of recognizing OSA severity preoperatively. The study does not advocate for or against CPAP use but underscores the heightened risk in this patient population, guiding clinicians in tailoring perioperative strategies and counseling patients about potential risks.
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Affiliation(s)
- Brittany Oster
- University of Maryland, Orthopedic Surgery Department, Baltimore, MD, USA
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Craig Shul
- University of Maryland, Orthopedic Surgery Department, Baltimore, MD, USA
| | - Michael Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ronald E. Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Champreeda V, Hu R, Chan B, Tomasek O, Lin YH, Weinberg L, Howard W, Tan CO. Nocturnal respiratory abnormalities among ward-level postoperative patients as detected by the Capnostream 20p monitor: A blinded observational study. PLoS One 2023; 18:e0280436. [PMID: 36662703 PMCID: PMC9858304 DOI: 10.1371/journal.pone.0280436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/01/2023] [Indexed: 01/21/2023] Open
Abstract
PURPOSE This prospective observational study aimed to establish the frequency of postoperative nocturnal respiratory abnormalities among patients undergoing major surgery who received ward-level care. These abnormalities may have implications for postoperative pulmonary complications (PPCs). METHODS Eligible patients underwent blinded noninvasive continuous capnography with pulse oximetry using the Capnostream™ 20p monitor over the first postoperative night. All patients received oxygen supplementation and patient-controlled opioid analgesia. The primary outcome was the number of prolonged apnea events (PAEs), defined as end-tidal carbon dioxide (EtCO2) ≤5 mmHg for 30-120 seconds or EtCO2 ≤5 mmHg for >120 seconds with oxygen saturation (SpO2) <85%. Secondary outcomes were the proportion of recorded time that physiological indices were aberrant, including the apnea index (AI), oxygen desaturation index (ODI), integrated pulmonary index (IPI), and SpO2. Exploratory analysis was conducted to assess the associations between PAEs, PPCs, and pre-defined factors. RESULTS Among 125 patients who had sufficient data for analysis, a total of 1800 PAEs occurred in 67 (53.4%) patients. The highest quartile accounted for 89.1% of all events. Amongst patients who experienced any PAEs, the median (IQR) number of PAE/patient was four (2-12). As proportions of recorded time (median (IQR)), AI, ODI, and IPI were aberrant for 12.4% (0-43.2%), 19.1% (2.0-57.1%), and 11.5% (3.1-33.3%) respectively. Only age, ARISCAT, and opioid consumption/kg were associated with PPCs. CONCLUSIONS PAE and aberrant indices were frequently detected on the first postoperative night. However, they did not correlate with PPCs. Future research should investigate the significance of detected aberrations.
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Affiliation(s)
- Vichaya Champreeda
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Brandon Chan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Owen Tomasek
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Yuan-Hong Lin
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Will Howard
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong O. Tan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
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The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00017. [PMID: 35442925 PMCID: PMC9022776 DOI: 10.5435/jaaosglobal-d-21-00248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA.
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Cozowicz C, Chung F, Doufas AG, Nagappa M, Memtsoudis SG. Opioids for Acute Pain Management in Patients With Obstructive Sleep Apnea. Anesth Analg 2018; 127:988-1001. [DOI: 10.1213/ane.0000000000003549] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Naqvi SY, Rabiei AH, Maltenfort MG, Restrepo C, Viscusi ER, Parvizi J, Rasouli MR. Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty. J Arthroplasty 2017; 32:2680-2683. [PMID: 28583758 DOI: 10.1016/j.arth.2017.04.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/05/2017] [Accepted: 04/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aims to evaluate the effect of sleep apnea (SA) on perioperative complications after total joint arthroplasty (TJA) and whether the type of anesthesia influences these complications. METHODS Using the ninth and tenth revisions of the International Classification of Diseases, coding systems, we queried our institutional TJA database from January 2005 to June 2016 to identify patients with SA who underwent TJA. These patients were matched in a 1:3 ratio based on age, gender, type of surgery, and comorbidities to patients who underwent TJA but were not coded for SA. Perioperative complications were identified using the same coding systems. Multivariate analysis was used to test if SA is an independent predictor of perioperative complications and if type of anesthesia can affect these complications. RESULTS A total of 1246 patients with SA were matched to 3738 patients without SA. Pulmonary complications occurred more frequently in patients with SA (1.7% vs 0.6%; P < .001), confirmed using multivariate analysis (odds ratio = 2.91; 95% confidence interval, 1.58-5.36; P = .001). Use of general anesthesia increased risk of all but central nervous system complications and mortality (odds ratio = 15.88; 95% confidence interval, 3.93-64.07; P < .001) regardless of SA status compared with regional anesthesia. Rates of pulmonary and gastrointestinal complications, acute anemia, and mortality were lower in SA patients when regional anesthesia was used (P < .05). CONCLUSION SA increases risk of postoperative pulmonary complications. The use of regional anesthesia may reduce risk of pulmonary complications and mortality in SA patients undergoing TJA.
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Affiliation(s)
- Syed Y Naqvi
- Department of Internal Medicine, Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Amin H Rabiei
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad R Rasouli
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Verbraecken J, Hedner J, Penzel T. Pre-operative screening for obstructive sleep apnoea. Eur Respir Rev 2017; 26:26/143/160012. [PMID: 28049125 DOI: 10.1183/16000617.0012-2016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/02/2016] [Indexed: 01/04/2023] Open
Abstract
Sleep disordered breathing, especially obstructive sleep apnoea (OSA), has a high and increasing prevalence. Depending on the apnoea and hypopnoea scoring criteria used, and depending on the sex and age of the subjects investigated, prevalence varies between 3% and 49% of the general population. These varying prevalences need to be reflected when considering screening for OSA. OSA is a cardiovascular risk factor and patients are at risk when undergoing medical interventions such as surgery. Screening for OSA before anaesthesia and surgical interventions is increasingly considered. Therefore, methods for screening and the rationale for screening for OSA are reviewed in this study.
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Affiliation(s)
- Johan Verbraecken
- Dept of Pulmonary Medicine and Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Jan Hedner
- Dept of Sleep Medicine, Pulmonary Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Penzel
- Sleep Medicine Center, Dept of Cardiology CC11, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Lyons MM, Bhatt NY, Kneeland-Szanto E, Keenan BT, Pechar J, Stearns B, Elkassabany NM, Memtsoudis SG, Pack AI, Gurubhagavatula I. Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility. Biomark Med 2016; 10:265-300. [PMID: 26925513 DOI: 10.2217/bmm.16.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity.
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Affiliation(s)
- M Melanie Lyons
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biobehavioral Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Nitin Y Bhatt
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Kneeland-Szanto
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan T Keenan
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne Pechar
- Department of Penn Orthopaedics, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Branden Stearns
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology & Public Health, Weill Cornell Medical College & Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Allan I Pack
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Sleep Medicine, CMC VA Medical Center, Philadelphia, PA, USA
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Affiliation(s)
- James T Ninomiya
- Department of Orthopaedic Surgery, FMLH Specialty Clinics Building, Medical College of Wisconsin, 5200 West Wisconsin Avenue, Milwaukee, WI 53226. E-mail address:
| | - John C Dean
- West Texas Orthopedics, 10 Desta Drive, Suite 100E, Midland, TX 79705
| | - Stephen J Incavo
- Houston Methodist Hospital, Smith Tower, 6550 Fannin Street, Suite 2600, Houston, TX 77030
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Obstructive sleep apnea as a risk factor after shoulder arthroplasty. J Shoulder Elbow Surg 2013; 22:e6-9. [PMID: 24045126 DOI: 10.1016/j.jse.2013.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 05/26/2013] [Accepted: 06/01/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) has been identified as an important risk factor in perioperative orthopaedic surgery outcomes despite limited evidence. Screening systems are being instituted in increasing frequency to prevent morbidity and mortality. Our objective was to determine if patients with OSA have a higher likelihood of postoperative in-hospital complications, length of stay, or increased costs after shoulder arthroplasty. METHODS We utilized the Nationwide Inpatient Sample (NIS) to analyze 22988 patients undergoing TSA or hemiarthroplasty. Of these patients, 1983 (5.9%) were diagnosed with OSA. Multivariate analysis with logistic regression modeling was used to compare patients with and without OSA for various outcomes. RESULTS Patients with obstructive sleep apnea had overall similar in-hospital mortality and complications including PE compared with those without OSA. OSA was not associated with increased postoperative charges ($39,741 in patients with OSA vs. $39,334 in those without OSA) and resulted in a shorter length of stay (mean, 2.61 vs. 2.91 days; P < .0001). CONCLUSION This study does not support OSA as a significant risk factor for in-hospital morbidity and mortality following shoulder arthroplasty. Our results suggest that a diagnosis of OSA does not increase perioperative morbidity and mortality including perioperative complications. Given the results of this study, further research is warranted to attempt to keep patient screening costs down while optimizing outcomes.
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Orlov D, Ankichetty S, Chung F, Brull R. Cardiorespiratory complications of neuraxial opioids in patients with obstructive sleep apnea: a systematic review. J Clin Anesth 2013; 25:591-9. [PMID: 23994284 DOI: 10.1016/j.jclinane.2013.02.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 02/14/2013] [Accepted: 02/15/2013] [Indexed: 11/28/2022]
Abstract
We sought to determine the rate of cardiorespiratory complications following neuraxial opioid administration in the setting of obstructive sleep apnea (OSA). This systematic review of the leading biomedical databases originated from a university-affiliated, tertiary-care teaching hospital. A systematic search of Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the International Pharmaceutical Abstracts Database (1970 - September 2011) was undertaken. Cardiorespiratory complications were stratified into minor and major based on existing OSA literature. Five studies, including a total of 121 patients, were selected for analysis. All studies comprised low-quality evidence. Six major cardiorespiratory complications were reported among 5 (4.1%) patients and included three deaths, one cardiorespiratory arrest, and two episodes of severe respiratory depression. Five of these complications occurred during continuous fentanyl-containing epidural infusions and without concurrent positive airway pressure treatment. The rate of cardiorespiratory complications following the administration of neuraxial opioids to surgical patients with OSA is difficult to determine.
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Affiliation(s)
- David Orlov
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada, M5T 2S8
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Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 2012; 27:95-8. [PMID: 22917083 DOI: 10.1016/j.arth.2012.03.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 03/15/2012] [Indexed: 02/01/2023] Open
Abstract
Although current evidence is limited, obstructive sleep apnea (OSA) has been suggested as a risk factor for morbidity after primary joint arthroplasty. Our objective was to determine if patients with OSA have a higher likelihood of postoperative in-hospital complications or increased costs after revision arthroplasty. The Nationwide Inpatient Sample was used to identify 258,455 patients who underwent revision total hip arthroplasty or revision total knee arthroplasty between 2006 and 2008. Of these patients, 16,608 (6.4%) had been diagnosed with OSA. Multivariate analysis with logistic regression modeling was used to compare patients with and without OSA. Obstructive sleep apnea was associated with increased in-hospital mortality (odds ratio, 1.9; P = .002), pulmonary embolism (odds ratio, 2.1; P = .001), wound hematomas or seromas (odds ratio, 1.36; P < .001), and increased postoperative charges ($61,044 vs $58,813; P < .001). Further research is warranted.
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Macintyre PE, Loadsman JA, Scott DA. Opioids, Ventilation and Acute Pain Management. Anaesth Intensive Care 2011; 39:545-58. [DOI: 10.1177/0310057x1103900405] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Despite the increasing use of a variety of different analgesic strategies, opioids continue as the mainstay for management of moderate to severe acute pain. However, concerns remain about their potential adverse effects on ventilation. The most commonly used term, respiratory depression, only describes part of that risk. Opioid-induced ventilatory impairment (OIVI) is a more complete term encompassing opioid-induced central respiratory depression (decreased respiratory drive), decreased level of consciousness (sedation) and upper airway obstruction, all of which, alone or in combination, may result in decreased alveolar ventilation and increased arterial carbon dioxide levels. Concerns about OIVI are warranted, as deaths related to opioid administration in the acute pain setting continue to be reported. Risks are often said to be higher in patients with obstructive sleep apnoea. However, the tendency to use the term ‘obstructive sleep apnoea’ to encompass the much broader spectrum of sleep- and obesity-related hypoventilation syndromes and the related misuse of terminology in papers relating to obstructive sleep apnoea and sleep-disordered breathing remain significant problems in discussions of opioid-related effects. Opioids given for management of acute pain must be titrated to effect for each patient. However, strategies aiming for better pain scores alone, without highlighting the need for appropriate monitoring of OIVI, can and will lead to an increase in adverse events. Therefore, all patients must be monitored appropriately for OIVI (at the very least using sedation scores as a ‘6th vital sign’) so that it can be detected at an early stage and appropriate interventions triggered.
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Affiliation(s)
- P. E. Macintyre
- Acute Pain Service, Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia; Sydney Medical School, University of Sydney and Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales; Department of Anaesthesia, St Vincent's Hospital and Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Acute Pain Service, Department of Anaesthesia, Royal Adelaide Hospital
| | - J. A. Loadsman
- Acute Pain Service, Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia; Sydney Medical School, University of Sydney and Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales; Department of Anaesthesia, St Vincent's Hospital and Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital
| | - D. A. Scott
- Acute Pain Service, Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia; Sydney Medical School, University of Sydney and Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales; Department of Anaesthesia, St Vincent's Hospital and Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anaesthesia, St Vincent's Hospital
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Berend KR, Ajluni AF, Núñez-García LA, Lombardi AV, Adams JB. Prevalence and management of obstructive sleep apnea in patients undergoing total joint arthroplasty. J Arthroplasty 2010; 25:54-7. [PMID: 20580192 DOI: 10.1016/j.arth.2010.04.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 04/30/2010] [Indexed: 02/01/2023] Open
Abstract
Obstructive sleep apnea (OSA) may be a risk factor for complications after total joint arthroplasty (TJA). We sought to determine the prevalence of OSA in patients undergoing TJA, and the safety and effectiveness of intrathecal narcotic (IN) in these patients. We retrospectively reviewed 1255 consecutive patients undergoing 1463 TJA at one hospital. All patients underwent routine screening for OSA and IN anesthesia, with 109 patients (134 TJA) identified with OSA (8.7%). Compared with 127 randomly selected patients (141 TJA) without OSA, OSA patients were significantly heavier and had higher American Society of Anesthesiologists scores, more comorbidities, longer length of stay, more transient hypoxia, more transfusions, and more medical variances. Despite more minor variances, with appropriate screening and management, OSA patients did not have a higher rate of significant or major complications. Length of stay, although longer, was only 2.3 days in OSA patients, demonstrating the safety and efficacy of IN anesthesia in these patients.
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Affiliation(s)
- Keith R Berend
- Joint Implant Surgeons, Inc, New Albany, Ohio 43054, USA
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15
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Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol. J Clin Anesth 2009; 21:286-93. [DOI: 10.1016/j.jclinane.2008.08.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Revised: 07/21/2008] [Accepted: 08/02/2008] [Indexed: 11/15/2022]
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Mears DC, Mears SC, Chelly JE. Two-Incision Hip Replacement in the Morbidly Obese Patient. ACTA ACUST UNITED AC 2007. [DOI: 10.1053/j.sart.2007.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pawlik MT, Hansen E, Waldhauser D, Selig C, Kuehnel TS. Clonidine premedication in patients with sleep apnea syndrome: a randomized, double-blind, placebo-controlled study. Anesth Analg 2005; 101:1374-1380. [PMID: 16243997 DOI: 10.1213/01.ane.0000180194.30741.40] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients with sleep apnea often present with cardiac diseases and breathing difficulties, with a high risk of postoperative respiratory depression. We conducted a randomized, double-blind, prospective study in 30 adult patients with obstructive sleep apnea, undergoing elective ear-nose-throat surgery. The patients were randomly assigned to receive placebo or clonidine (2 microg/kg oral) the night before and the next morning 2 h before surgery. Spo2, heart rate, mean arterial blood pressure, snoring, and oronasal airflow were monitored for 36 h. A standard anesthesia was used consisting of propofol and remifentanil. Anesthetic drug consumption, postoperative analgesics, and pain score were recorded. In the clonidine group, mean arterial blood pressures were significantly lower during induction, operation, and emergence from anesthesia. Both propofol dose required for induction (190 +/- 32.2 mg) and anesthesia (6.3 +/- 1.3 mg . kg(-1).h(-1)) during surgery were significantly reduced in the clonidine group compared with the placebo group (induction 218 +/- 32.4, anesthesia 7.70 +/- 1.5; P < 0.05). Piritramide consumption (7.4 +/- 5.1 versus 14.2 +/- 8.5 mg; P < 0.05) and analgesia scores were significantly reduced in the clonidine group. Apnea and desaturation index were not different between the groups, whereas the minimal postoperative oxygen saturation on the day of surgery was significantly lower in the placebo than in the clonidine group (76.7% +/- 8.0% versus 82.4% +/- 5.8%; P < 0.05). We conclude that oral clonidine premedication stabilizes hemodynamic variables during induction, maintenance, and emergence from anesthesia and reduces the amount of intraoperative anesthetics and postoperative opioids without deterioration of ventilation.
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Affiliation(s)
- Michael T Pawlik
- Departments of *Anesthesiology and †Otorhinolaryngology, Universitätsklinik Regensburg; and ‡Department of Anesthesiology, Universitätsklinik Ulm, Germany
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Taylor S, Kirton OC, Staff I, Kozol RA. Postoperative day one: a high risk period for respiratory events. Am J Surg 2005; 190:752-6. [PMID: 16226953 DOI: 10.1016/j.amjsurg.2005.07.015] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 07/20/2005] [Accepted: 07/20/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day. METHODS We performed a retrospective case-control analysis identifying 62 postoperative patients who had a respiratory event. A respiratory event was defined as respiratory depression caused by narcotic use in the postoperative period that was reversed by naloxone. Sixty-two postoperative patients with no such event were chosen randomly and frequency matched based on surgical procedure and diagnosis-related group. Risk factors for an event were identified. RESULTS Of the cases, 77.4% had a respiratory event in the first 24 hours postoperatively. Significant risk factors for an event were as follows: 65 years of age or older, having chronic obstructive pulmonary disease, having 1 or more comorbidities, and being placed on hydromorphone. CONCLUSIONS The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day.
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Affiliation(s)
- Shiv Taylor
- Department of Surgery, University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
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Abstract
Patient-controlled analgesia was introduced as a technique that would allow greater flexibility in opioid delivery for the management of acute pain. However, so far, any benefit compared with conventional methods of pain relief appears to be small. This article reviews some of the factors that could limit the usefulness of intravenous patient-controlled analgesia in the clinical setting and what strategies might allow patient-controlled analgesia to become more effective.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Acute Pain Service, Hyperbaric and Pain Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, 5000 Australia.
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