Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea

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The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.

Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives

Healthcare increasingly is moving from volume- to value-based care, with an emphasis on linking a larger percentage of payments to the quality of care provided. There is a renewed interest in designing a focused, strategic approach to quality and safety education and engagement of trainees in hospital-wide quality, safety, and patient experience initiatives. Hospitals, trainees, and patients benefit as a result of engaging frontline learners in these activities. Hospitals can leverage the intelligence from the front line to contribute to improved hospital safety, increased employee and patient engagement, and better identification of vulnerable areas of safety risks. Trainees benefit from increased engagement by acquiring fundamentals in quality and safety; are able to satisfy Clinical Learning Environment Review recommendations; have an opportunity to practice a number of skill sets (leadership, communication, collaboration); and complete quality and safety hands-on projects. Patients benefit from a more engaged work force, safer environment for their healthcare, and an improved overall experience. In this article, the current state of the Johns Hopkins Department of Anesthesiology and Critical Care Medicine's efforts to engage its front line in quality, safety, and patient experience initiatives that are in evolutionary phases of implementation is presented. Evolutionary concepts relate to the Johns Hopkins Health System and the aim of its training program to continuously improve and innovate.

Prevalence of Undetected Sleep Apnea in Patients Undergoing Cardiovascular Surgery and Impact on Postoperative Outcomes

STUDY OBJECTIVE

We examined the prevalence of obstructive sleep apnea (OSA) among patients undergoing cardiac surgery and its impact on postoperative outcomes.

METHODS

Subjects were recruited from inpatient cardiovascular surgery units at two tertiary care centers. Crystal Monitor 20-H recorded polysomnograms preoperatively. Regression analyses were performed to explore associations between OSA using different apnea-hypopnea index (AHI) cutoffs and postoperative outcomes adjusting for key covariates. Prevalence of postoperative outcomes was compared among groups defined by AHI and left ventricle ejection fraction (LVEF) median cutoffs.

RESULTS

Of 107 participants, the AHI was ≥ 5 in 79 (73.8%), ≥ 10 in 63 (58.9%), ≥ 15 in 51(47.7%), and ≥ 30 in 29 (27.1%). Patients with AHI ≥ 15 had significantly lower LVEF (p < 0.001). Logistic regression analyses with OSA cutoffs as above adjusting for age, gender, race, BMI, and LVEF found no significant increase in odds for any postoperative outcomes. No significant differences were found in %Total sleep time (TST) with SpO2 < 90% between AHI or LVEF groups, or by presence/absence of complications. Patients with any amount of TST with SpO2 < 90% had greater BMI, longer OR tube time, and greater prevalence of prolonged intubation (p = 0.007, 0.035, 0.038, respectively).

CONCLUSIONS

OSA is highly prevalent in patients undergoing cardiovascular surgery. It could not be shown that OSA was significantly associated with adverse postoperative outcomes, but this may have been due to an insufficient number of subjects. AHI ≥ 15 was associated with lower LVEF. Larger samples are required to explore the impact of OSA on key postoperative outcomes that have clinical and economic importance in the care of cardiovascular surgery populations.

COMMENTARY

A commentary on this article appears in this issue on page 1081.

The impact of obesity on outcomes after critical illness: a meta-analysis

PURPOSE

To assess whether obesity is associated with mortality or other adverse intensive care unit (ICU) and post-ICU outcomes.

METHODS

A meta-analysis of studies from PubMed and EMBASE databases.

RESULTS

Twenty-two studies (n = 88,051 patients) were included. Pooled analysis demonstrated no difference in ICU mortality, but lower hospital mortality for obese and morbidly obese subjects (RR 0.76; 95% CI 0.59, 0.92; RR 0.83; 95% CI 0.66, 1.04, respectively) versus normal weight subjects. There was no association between obesity and duration of mechanical ventilation or ICU stay. Morbidly obese versus normal weight patients had longer hospitalizations. No study reported physical function, mental health, or quality of life outcomes after discharge.

CONCLUSIONS

Obesity is not associated with increased risk for ICU mortality, but may be associated with lower hospital mortality. There is a critical lack of research on how obesity may affect complications of critical illness and patient long-term outcomes.

Preclinical and clinical evaluation of sulforaphane for chemoprevention in the breast

Consumers of higher levels of Brassica vegetables, particularly those of the genus Brassica (broccoli, Brussels sprouts and cabbage), reduce their susceptibility to cancer at a variety of organ sites. Brassica vegetables contain high concentrations of glucosinolates that can be hydrolyzed by the plant enzyme, myrosinase, or intestinal microflora to isothiocyanates, potent inducers of cytoprotective enzymes and inhibitors of carcinogenesis. Oral administration of either the isothiocyanate, sulforaphane, or its glucosinolate precursor, glucoraphanin, inhibits mammary carcinogenesis in rats treated with 7,12-dimethylbenz[a]anthracene. In this study, we sought to determine whether sulforaphane exerts a direct chemopreventive action on animal and human mammary tissue. The pharmacokinetics and pharmacodynamics of a single 150 mumol oral dose of sulforaphane were evaluated in the rat mammary gland. We detected sulforaphane metabolites at concentrations known to alter gene expression in cell culture. Elevated cytoprotective NAD(P)H:quinone oxidoreductase (NQO1) and heme oxygenase-1 (HO-1) gene transcripts were measured using quantitative real-time polymerase chain reaction. An observed 3-fold increase in NQO1 enzymatic activity, as well as 4-fold elevated immunostaining of HO-1 in rat mammary epithelium, provides strong evidence of a pronounced pharmacodynamic action of sulforaphane. In a subsequent pilot study, eight healthy women undergoing reduction mammoplasty were given a single dose of a broccoli sprout preparation containing 200 mumol of sulforaphane. Following oral dosing, sulforaphane metabolites were readily measurable in human breast tissue enriched for epithelial cells. These findings provide a strong rationale for evaluating the protective effects of a broccoli sprout preparation in clinical trials of women at risk for breast cancer.

Demographics and diagnosis of obstructive sleep apnea

This article reviews the terminology of obstructive sleep apnea and the associated diagnostic tests and provides an overview of the risk factors for this chronic condition. Sleep apnea affects 2% to 4% of middle-aged working adults in the general population, however, a considerable number of affected individuals remain undiagnosed. Patients with the disease may be at a higher risk for adverse perioperative outcomes. Knowledge of factors associated with an increased risk of obstructive sleep apnea is vital to the perioperative assessment and anesthetic plan.

Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review

In this systematic review we focused on postoperative recovery and complications using four different anesthetic techniques. The database MEDLINE was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or "desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery. However, early recovery was faster with desflurane compared with propofol and isoflurane and with sevoflurane compared with isoflurane. A minor difference was found in home readiness between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache, and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P < 0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the propofol group. We conclude that the differences in early recovery times among the different anesthetics were small and in favor of the inhaled anesthetics. The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent with propofol.

IMPLICATIONS

A systematic analysis of the literature comparing postoperative recovery after propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. The incidence of nausea and vomiting were less frequent with propofol.

The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial

OBJECTIVE

To evaluate the validity of preoperative cardiac stress testing using clinical predictors from the American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation before Noncardiac Surgery in patients undergoing vascular surgery.

DESIGN

Prospective, randomized pilot study.

SETTING

Academic medical center.

PARTICIPANTS

Patients undergoing elective abdominal aortic, infrainguinal, and carotid vascular surgery.

INTERVENTIONS

After stratification by American College of Cardiology/American Heart Association (ACC/AHA) Guideline parameters, 99 patients were randomized to preoperative cardiac stress testing or to no stress testing and followed for up to 12 months postoperatively for adverse cardiac outcomes.

MEASUREMENTS AND MAIN RESULTS

Before hospital discharge of 46 patients who underwent preoperative stress testing, 7 (15%) had inducible ischemia with no adverse postoperative cardiac outcomes, whereas only 1 (3%) of 39 patients (85%) with no ischemia had a nonfatal adverse cardiac outcome (p = not significant). Of 53 patients without preoperative stress testing, only 2 (4%) had a nonfatal adverse postoperative cardiac outcome. There were no cardiac deaths. At 12-month follow-up in 79 (80%) patients, there was 1 nonfatal adverse cardiac outcome (no stress test) and 1 cardiac death (abnormal stress test), reflecting a 1% 12-month cardiac morbidity and mortality.

CONCLUSION

In this small prospective, randomized study evaluating the validity of preoperative cardiac stress testing using ACC/AHA Guidelines before major vascular surgery, preoperative cardiac stress testing offered no incremental value for determining postoperative adverse cardiac outcomes. Larger randomized clinical trials are needed to confirm these findings.

Challenging patients in an ambulatory setting

An increasing number of surgical procedures are now performed on an ambulatory basis. This article reviews these conditions and defines the appropriate preoperative evaluation and perioperative management. Our goal is to define those patients who would benefit in having care in an inpatient setting or those who require more intensive medical evaluation or preparation prior to outpatient surgery.