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Abstract
PURPOSE OF REVIEW This review aims to familiarize with the most current findings regarding preoperative evaluation and preparation of morbidly obese patients prior to elective, noncardiac surgery. In the light of the increasing number of surgical patients being morbidly obese, the knowledge of evidence-based preoperative evaluation strategies is profound for a rational approach. RECENT FINDINGS Preoperative evaluation should be carried out with sufficient time before the day of surgery to allow modification of the perioperative management. Medical history-taking and physical examination ought to be performed following a standardized scheme especially focussing on the presence of obstructive sleep apnea. Routine testing for fasting glucose and lipoprotein levels should be performed in order to diagnose a metabolic syndrome. ECG recording should be limited to those patients having one or more additional cardiac risk factors or presenting clinical signs of cardiovascular disease or were planned for intermediate or high-risk surgery. Spirometry should be limited to those patients with obstructive sleep apnea or other respiratory findings. SUMMARY Synthesis of proper medical history-taking and physical examination as well as detailed search for obstructive sleep apnea and metabolic syndrome are key components of preoperative evaluation. Further testing should be based on the findings of these steps and comprise the cardiac risk of the surgical procedure.
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102
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Chung F, Chan MTV, Liao P. Perioperative nocturnal hypoxemia matters in surgical patients with obstructive sleep apnea. Can J Anaesth 2016; 64:109-110. [DOI: 10.1007/s12630-016-0755-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 10/12/2016] [Indexed: 11/29/2022] Open
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Melamed R, Boland LL, Normington JP, Prenevost RM, Hur LY, Maynard LF, McNaughton MA, Kinzy TG, Masood A, Dastrange M, Huguelet JA. Postoperative respiratory failure necessitating transfer to the intensive care unit in orthopedic surgery patients: risk factors, costs, and outcomes. Perioper Med (Lond) 2016; 5:19. [PMID: 27486512 PMCID: PMC4969722 DOI: 10.1186/s13741-016-0044-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/01/2016] [Indexed: 11/11/2022] Open
Abstract
Background Postoperative pulmonary complications in orthopedic surgery patients have been associated with worse clinical outcomes. Identifying patients with respiratory risk factors requiring enhanced monitoring and management modifications is an important part of postoperative care. Patients with unanticipated respiratory decompensation requiring transfer to the intensive care unit (ICU) have not been studied in sufficient detail. Methods A retrospective case-control study of elective orthopedic surgery patients (knee, hip, shoulder, or spine, n = 51) who developed unanticipated respiratory failure (RF) necessitating transfer to the ICU over a 3-year period was conducted. Controls (n = 153) were frequency matched to cases by gender, age, and surgical procedure. Patient and perioperative care factors, clinical outcomes, and cost of care were examined. Results Transfer to the ICU occurred within 48 h of surgery in 73 % of the cases, 31 % required non-invasive ventilation, and 18 % required mechanical ventilation. Cases had a higher prevalence of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and regular psychotropic medication use than controls. Cases received more intravenous opioids during the first 24 postoperative hours, were hospitalized 4 days longer, had higher in-hospital mortality, and had excess hospitalization costs of US$26,571. COPD, OSA, preoperative psychotropic medications, and anesthesia time were associated with risk of RF in a multivariate analysis. Conclusions Unanticipated RF after orthopedic surgery is associated with extended hospitalization, increased mortality, and higher cost of care. Hospital protocols that include risk factor assessment, enhanced monitoring, and a cautious approach to opioid use in high-risk patients may reduce the frequency of this complication.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care Medicine, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 USA
| | - Lori L Boland
- Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA
| | - James P Normington
- Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA
| | - Rebecca M Prenevost
- Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA
| | - Lindsay Y Hur
- Department of Pharmacy, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA
| | - Leslie F Maynard
- Chronic Pain Team, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA
| | - Molly A McNaughton
- Chronic Pain Team, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA
| | - Tyler G Kinzy
- Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA
| | - Adnan Masood
- Department of Critical Care Medicine, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 USA
| | - Mehdi Dastrange
- Internal Medicine Residency Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA
| | - Joseph A Huguelet
- Internal Medicine Residency Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA
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104
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Gavrilovic B, Bradley TD, Vena D, Lyons OD, Gabriel JM, Popovic MR, Yadollahi A. Factors predisposing to worsening of sleep apnea in response to fluid overload in men. Sleep Med 2016; 23:65-72. [PMID: 27692279 DOI: 10.1016/j.sleep.2016.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/03/2016] [Accepted: 05/22/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is highly prevalent in patients with fluid-retaining conditions. Using bioimpedance measurements, previous studies have shown that the greater the amount of fluid redistributed from the legs to the neck overnight, the greater the severity of OSA. Our objective was to investigate factors that predispose the development or worsening of OSA in response to experimental fluid overload. METHODS Fifteen normotensive and non-obese adult men with and without OSA underwent polysomnography (PSG) during which normal saline was infused intravenously at a minimal rate to keep the vein open (control) or as a bolus of 22 ml/kg body weight (approximately 2 L) in a random order and crossed over after a week. RESULTS AND CONCLUSIONS Before and after sleep, neck circumference and bioimpedance were measured to calculate neck resistance, reactance, phase angle, and fluid volume. Subjects who experienced more than a twofold increase in apnea-hypopnea index (AHI) or obstructive AHI from control to intervention and had an AHI>10 during intervention were considered susceptible to the development or worsening of OSA. Baseline neck circumference and phase angle before saline infusion were independently associated with increased susceptibility to developing or worsening OSA in response to saline infusion. In non-obese men, a larger neck circumference and bioimpedance phase angle of the neck, which may be associated with larger pharyngeal tissue content, is associated with increased susceptibility for worsening of OSA in response to fluid overloading.
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Affiliation(s)
- Bojan Gavrilovic
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Vena
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Owen D Lyons
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Joseph M Gabriel
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Milos R Popovic
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada.
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105
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Borg L, Walters TL, Siegel LC, Dazols J, Mariano ER. Use of a home positive airway pressure device during intraoperative monitored anesthesia care for outpatient surgery. J Anesth 2016; 30:707-10. [PMID: 27169990 DOI: 10.1007/s00540-016-2188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/04/2016] [Indexed: 11/28/2022]
Abstract
Perioperative positive airway pressure (PAP) is recommended by the American Society of Anesthesiologists for patients with obstructive sleep apnea, but a readily available and personalized intraoperative delivery system does not exist. We present the successful use of a patient's own nasal PAP machine in the operating room during outpatient foot surgery which required addition of a straight adaptor for oxygen delivery and careful positioning of the gas sampling line to permit end-tidal carbox dioxide monitoring. Home PAP machines may provide a potential alternative to more invasive methods of airway management for patients with obstructive sleep apnea under moderate sedation.
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Affiliation(s)
- Lindsay Borg
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Tessa L Walters
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - Lawrence C Siegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - John Dazols
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA.
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Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, Chung F, Memtsoudis SG. Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing. Anesth Analg 2016; 122:1321-34. [DOI: 10.1213/ane.0000000000001178] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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107
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Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg 2016; 122:1335-9. [DOI: 10.1213/ane.0000000000001169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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108
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Suboptimal Diagnostic Accuracy of Obstructive Sleep Apnea in One Database Does Not Invalidate Previous Observational Studies. Anesthesiology 2016; 124:1192-3. [DOI: 10.1097/aln.0000000000001037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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109
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110
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Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire. Chest 2016; 149:631-8. [DOI: 10.1378/chest.15-0903] [Citation(s) in RCA: 542] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/19/2015] [Accepted: 08/22/2015] [Indexed: 01/14/2023] Open
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111
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Development and Validation of a Morphologic Obstructive Sleep Apnea Prediction Score. Anesth Analg 2016; 122:363-72. [DOI: 10.1213/ane.0000000000001089] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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112
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Dawson D, Singh M, Chung F. The importance of obstructive sleep apnoea management in peri-operative medicine. Anaesthesia 2016; 71:251-6. [PMID: 26763386 DOI: 10.1111/anae.13362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- D Dawson
- Department of Anaesthesia and Sleep Medicine, Bradford Teaching Hospitals, Bradford, UK.
| | - M Singh
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - F Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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113
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Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the Perioperative Setting: Evidence of Support. Chest 2016; 149:586-597. [PMID: 26469321 PMCID: PMC5831563 DOI: 10.1378/chest.15-1777] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 09/27/2015] [Accepted: 09/28/2015] [Indexed: 12/18/2022] Open
Abstract
OSA is a commonly encountered comorbid condition in surgical patients. The risk of cardiopulmonary complications is increased by two to threefold with OSA. Among the different treatment options for OSA, CPAP is an efficacious modality. This review examines the evidence regarding the use of CPAP in the preoperative and postoperative periods in surgical patients with diagnosed and undiagnosed OSA.
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Affiliation(s)
- Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada.
| | - Mahesh Nagappa
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada
| | - Babak Mokhlesi
- Department of Medicine, Sleep Disorders Center and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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114
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Abstract
Depending on the subpopulation, obstructive sleep apnea (OSA) can affect more than 75% of surgical patients. An increasing body of evidence supports the association between OSA and perioperative complications, but some data indicate important perioperative outcomes do not differ between patients with and without OSA. In this review we will provide an overview of the pathophysiology of sleep apnea and the risk factors for perioperative complications related to sleep apnea. We also discuss a clinical algorithm for the identification and management of OSA patients facing surgery.
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Affiliation(s)
- Sebastian Zaremba
- Department of Anaesthesia Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, 02114, USA; Department of Neurology, Rheinische-Friedrich-Wilhelms-University, Bonn, D-53127, Germany; German Center for Neurodegenerative Diseases, Bonn, D-53127, Germany
| | - James E Mojica
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, 02114, USA
| | - Matthias Eikermann
- Department of Anaesthesia Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, 02114, USA; Department of Anaesthesia and Critical Care, University Hospital Essen, Essen, 45147, Germany
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115
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Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S, Mokhlesi B, Chung F. Validation of the STOP-Bang Questionnaire as a Screening Tool for Obstructive Sleep Apnea among Different Populations: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0143697. [PMID: 26658438 PMCID: PMC4678295 DOI: 10.1371/journal.pone.0143697] [Citation(s) in RCA: 361] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/09/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diagnosing obstructive sleep apnea (OSA) is clinically relevant because untreated OSA has been associated with increased morbidity and mortality. The STOP-Bang questionnaire is a validated screening tool for OSA. We conducted a systematic review and meta-analysis to determine the effectiveness of STOP-Bang for screening patients suspected of having OSA and to predict its accuracy in determining the severity of OSA in the different populations. METHODS A search of the literature databases was performed. Inclusion criteria were: 1) Studies that used STOP-Bang questionnaire as a screening tool for OSA in adult subjects (>18 years); 2) The accuracy of the STOP-Bang questionnaire was validated by polysomnography--the gold standard for diagnosing OSA; 3) OSA was clearly defined as apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) ≥ 5; 4) Publications in the English language. The quality of the studies were explicitly described and coded according to the Cochrane Methods group on the screening and diagnostic tests. RESULTS Seventeen studies including 9,206 patients met criteria for the systematic review. In the sleep clinic population, the sensitivity was 90%, 94% and 96% to detect any OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥15), and severe OSA (AHI ≥30) respectively. The corresponding NPV was 46%, 75% and 90%. A similar trend was found in the surgical population. In the sleep clinic population, the probability of severe OSA with a STOP-Bang score of 3 was 25%. With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the probability rose proportionally to 35%, 45%, 55% and 75%, respectively. In the surgical population, the probability of severe OSA with a STOP-Bang score of 3 was 15%. With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the probability increased to 25%, 35%, 45% and 65%, respectively. CONCLUSION This meta-analysis confirms the high performance of the STOP-Bang questionnaire in the sleep clinic and surgical population for screening of OSA. The higher the STOP-Bang score, the greater is the probability of moderate-to-severe OSA.
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Affiliation(s)
- Mahesh Nagappa
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pu Liao
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States of America
| | - Satya Krishna Ramachandran
- Department of Anesthesiology, University of Michigan Health System, East Medical Center Drive, Michigan, United States of America
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, United States of America
| | - Babak Mokhlesi
- Department of Medicine, Sleep Disorders Center and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, United States of America
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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116
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Duggan E, Collop N. Building a Perioperative Sleep Apnea Algorithm: Applying the Literature to Your Practice. Bariatr Surg Pract Patient Care 2015. [DOI: 10.1089/bari.2015.0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elizabeth Duggan
- Department of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Nancy Collop
- Department of Medicine, Emory University Hospital, Atlanta, Georgia
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117
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Baudin F, Wallet F, Marret E, Payen JF, Fusciardi J, Piriou V. A French national survey of obstructive sleep apnoea screening. Anaesth Crit Care Pain Med 2015; 34:305-6. [PMID: 26608353 DOI: 10.1016/j.accpm.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Florent Baudin
- Department of Anaesthesia and Intensive Care, CHU Lyon-Sud, 69310 Pierre-Benite, France
| | - Florent Wallet
- Department of Anaesthesia and Intensive Care, CHU Lyon-Sud, 69310 Pierre-Benite, France
| | - Emmanuel Marret
- Department of Anaesthesia and Intensive Care, CHU Tenon, 75020 Paris, France
| | - Jean-Francois Payen
- Department of Anaesthesia and Intensive Care, CHU de Grenoble, 38700 La Tronche, France
| | - Jacques Fusciardi
- Department of Anaesthesia and Intensive Care, hôpital Trousseau, CHU de Tour, 37170 Chambray-lès-Tours, France; CFAR (French College of Anaesthesia and Intensive Care), 75016 Paris, France
| | - Vincent Piriou
- Department of Anaesthesia and Intensive Care, CHU Lyon-Sud, 69310 Pierre-Benite, France.
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118
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In Reply. Anesthesiology 2015; 123:230-1. [PMID: 26510197 DOI: 10.1097/aln.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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119
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Perioperative management of patients with obstructive sleep apnea: a survey of Canadian anesthesiologists. Can J Anaesth 2015; 63:16-23. [DOI: 10.1007/s12630-015-0512-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/08/2015] [Indexed: 11/29/2022] Open
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120
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Casey KR, Teodorescu M. Postoperative Complications in Patients with Obstructive Sleep Apnea: Where Do We Stand? J Clin Sleep Med 2015; 11:1081-2. [PMID: 26414991 DOI: 10.5664/jcsm.5074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/11/2015] [Indexed: 11/13/2022]
Affiliation(s)
- Kenneth R Casey
- William S. Middleton Memorial Veterans Hospital, Madison WI; Wisconsin Sleep, Madison, WI; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mihai Teodorescu
- William S. Middleton Memorial Veterans Hospital, Madison WI; Wisconsin Sleep, Madison, WI; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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121
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Wong JK, Maxwell BG, Kushida CA, Sainani KL, Lobato RL, Joseph Woo Y, Pearl RG. Obstructive Sleep Apnea Is an Independent Predictor of Postoperative Atrial Fibrillation in Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1140-7. [DOI: 10.1053/j.jvca.2015.03.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Indexed: 01/11/2023]
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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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123
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Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg 2015; 1:17-27. [PMID: 29204536 PMCID: PMC5698527 DOI: 10.1016/j.wjorl.2015.08.001] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022] Open
Abstract
Objective To provide an overview of the healthcare and societal consequences and costs of untreated obstructive sleep apnea syndrome. Data sources PubMed database for English-language studies with no start date restrictions and with an end date of September 2014. Methods A comprehensive literature review was performed to identify all studies that discussed the physiologic, clinical and societal consequences of obstructive sleep apnea syndrome as well as the costs associated with these consequences. There were 106 studies that formed the basis of this analysis. Conclusions Undiagnosed and untreated obstructive sleep apnea syndrome can lead to abnormal physiology that can have serious implications including increased cardiovascular disease, stroke, metabolic disease, excessive daytime sleepiness, work-place errors, traffic accidents and death. These consequences result in significant economic burden. Both, the health and societal consequences and their costs can be decreased with identification and treatment of sleep apnea. Implications for practice Treatment of obstructive sleep apnea syndrome, despite its consequences, is limited by lack of diagnosis, poor patient acceptance, lack of access to effective therapies, and lack of a variety of effective therapies. Newer modes of therapy that are effective, cost efficient and more accepted by patients need to be developed.
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Lyons PG, Zadravecz FJ, Edelson DP, Mokhlesi B, Churpek MM. Obstructive sleep apnea and adverse outcomes in surgical and nonsurgical patients on the wards. J Hosp Med 2015; 10:592-8. [PMID: 26073058 PMCID: PMC4560995 DOI: 10.1002/jhm.2404] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/11/2015] [Accepted: 05/20/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) has been associated with clinical deterioration in postoperative patients and patients hospitalized with pneumonia. Paradoxically, OSA has also been associated with decreased risk of inpatient mortality in these same populations. OBJECTIVES To investigate the association between OSA and in-hospital mortality in a large cohort of surgical and nonsurgical ward patients. DESIGN Observational cohort study. SETTING A 500-bed academic tertiary care hospital in the United States. PATIENTS A total of 93,676 ward admissions from 53,150 unique adult patients between November 1, 2008 and October 1, 2013. INTERVENTION None. MEASUREMENTS OSA diagnoses and comorbidities were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Logistic regression was used to control for patient characteristics, location prior to ward admission, and admission severity of illness. The primary outcome was in-hospital death. Secondary outcomes included rapid response team (RRT) activation, intensive care unit (ICU) transfer, intubation, and cardiac arrest on the wards. MAIN RESULTS OSA was identified in 5,625 (10.6%) patients. Patients with OSA were more likely to be older, male, and obese, and had higher rates of comorbidities. OSA patients had more frequent RRT activations (1.5% vs 1.1%) and ICU transfers (8% vs 7%) than controls (P < 0.001 for both comparisons), but a lower inpatient mortality rate (1.1% vs 1.4%, P < 0.05). OSA was associated with decreased adjusted odds for ICU transfer (odds ratio [OR]: 0.91 [0.84-0.99]), cardiac arrest (OR: 0.72 [0.55-0.95]), and in-hospital mortality (OR: 0.70 [0.58-0.85]). CONCLUSIONS After adjustment for important confounders, OSA was not associated with clinical deterioration on the wards and was associated with significantly decreased in-hospital mortality.
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Affiliation(s)
| | - Frank J. Zadravecz
- University of Chicago Medicine, Department of Medicine, Section of Hospital Medicine, Chicago, IL
| | - Dana P. Edelson
- University of Chicago Medicine, Department of Medicine, Section of Hospital Medicine, Chicago, IL
| | - Babak Mokhlesi
- University of Chicago Medicine, Department of Medicine, Section of Pulmonary and Critical Care Medicine, Chicago, IL
| | - Matthew M. Churpek
- University of Chicago Medicine, Department of Medicine, Section of Pulmonary and Critical Care Medicine, Chicago, IL
- Corresponding author and requests for reprints (Matthew M Churpek), University of Chicago, Section of Pulmonary and Critical Care, 5841 S Maryland Avenue, MC 6076, Chicago, IL 60637,
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Abstract
Abstract
Background:
Health administrative (HA) databases are increasingly used to identify surgical patients with obstructive sleep apnea (OSA) for research purposes, primarily using diagnostic codes. Such means to identify patients with OSA are not validated. The authors determined the accuracy of case-ascertainment algorithms for identifying patients with OSA with the use of HA data.
Methods:
Clinical data derived from an academic health sciences network within a universal health insurance plan were used as the reference standard. The authors linked patients to HA data and retrieved all claims in the 2 yr before surgery to determine the presence of any diagnostic codes, diagnostic procedures, or therapeutic interventions consistent with OSA.
Results:
The authors identified 4,965 patients (2003 to 2012) who underwent preoperative polysomnogram. Of these, 4,353 patients were linked to HA data; 2,427 of these (56%) had OSA based on diagnosis by a sleep physician or the apnea hypopnea index. A claim for a polysomnogram and receipt of a positive airway pressure device had a sensitivity, specificity, and positive likelihood ratio (+LR) for OSA of 19, 98, and 10.9%, respectively. An International Classification of Diseases, Tenth Revision, code for sleep apnea in hospitalization abstracts was 9% sensitive and 98% specific (+LR, 4.5). A physician billing claim for OSA (International Classification of Diseases, Ninth Revision, 780.5) was 58% sensitive and 38% specific (+LR, 0.9). A polysomnogram and a positive airway pressure device or any code for OSA was 70% sensitive and 36% specific (+LR, 1.1).
Conclusions:
No code or combination of codes provided a +LR high enough to adequately identify patients with OSA. Existing studies using administrative codes to identify OSA should be interpreted with caution.
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Chung F, Liao P, Yang Y, Andrawes M, Kang W, Mokhlesi B, Shapiro CM. Postoperative Sleep-Disordered Breathing in Patients Without Preoperative Sleep Apnea. Anesth Analg 2015; 120:1214-24. [DOI: 10.1213/ane.0000000000000774] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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127
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Nagappa M, Mokhlesi B, Wong J, Wong DT, Kaw R, Chung F. The Effects of Continuous Positive Airway Pressure on Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Surgery. Anesth Analg 2015; 120:1013-1023. [DOI: 10.1213/ane.0000000000000634] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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128
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Obesity, orthopaedics, and outcomes. J Am Acad Orthop Surg 2015; 23:210-1. [PMID: 25808684 DOI: 10.5435/jaaos-d-15-00098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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129
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Relationship between Chronic Intermittent Hypoxia and Intraoperative Mean Arterial Pressure in Obstructive Sleep Apnea Patients Having Laparoscopic Bariatric Surgery. Anesthesiology 2015; 122:64-71. [DOI: 10.1097/aln.0000000000000457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Abstract
Background:
Recurrent nocturnal hypoxemia in obstructive sleep apnea enhances sympathetic function, decreases baroreceptor sensitivity, and weakens peripheral vascular responses to adrenergic signals. The authors hypothesized that the percentage of total sleep time spent at oxyhemoglobin saturation (Sao2) less than 90% and minimum nocturnal Sao2 on preoperative polysomnography are associated with decreased intraoperative mean arterial pressure.
Methods:
The authors examined the records of all patients who had laparoscopic bariatric surgery at Cleveland Clinic between 2005 and 2009 and an available polysomnography study. The authors assessed the relationships between the percentage of total sleep time spent at Sao2 less than 90% and minimum nocturnal Sao2, and the time-weighted average of mean arterial pressure. The authors used multivariable regression models to adjust for prespecified clinical confounders.
Results:
Two hundred eighty-one patients were included in the analysis. The average change in the time-weighted average of mean arterial pressure was −0.02 (97.5% CI, −0.08, 0.04) mmHg for each 1% absolute increase in the percentage of sleep time spent at Sao2 less than 90% (P = 0.50). The average change was −0.13 (97.5% CI, −0.27, 0.01) mmHg, for each 1% absolute decrease in the minimum Sao2 (P = 0.04 > significance criterion of 0.025, Bonferroni correction). An unplanned analysis estimated 1% absolute decrease in minimum Sao2 was associated with −0.22 (98.75% CI, −0.39, −0.04) mmHg, change in mean arterial pressure (P = 0.002) in the time period between endotracheal intubation and trocar insertion.
Conclusion:
Recurrent nocturnal hypoxemia in obstructive sleep apnea is not a risk marker for intraoperative hypotension.
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Stundner O, Opperer M, Memtsoudis SG. Obstructive sleep apnea in adult patients: considerations for anesthesia and acute pain management. Pain Manag 2015; 5:37-46. [DOI: 10.2217/pmt.14.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Obstructive sleep apnea (OSA) represents a challenge in the perioperative period for both physicians and the health care system alike. A number of studies have associated OSA with increased risk for postoperative complications. This is of particular concern in the face of this disease remaining vastly underdiagnosed. In this context, current guidelines and established concepts such as the use of continuous positive airway pressure or the level of postoperative monitoring, lack strong scientific evidence. Other interventions such as the use neuraxial/regional anesthesia may however offer added benefit. This review aims to address considerations for physicians in charge of OSA patients in the perioperative setting and to give an outlook for current and future research on this topic.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Mathias Opperer
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
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Ramachandran SK. Can intravenous fluids explain increased postoperative sleep disordered breathing and airway outcomes? Sleep 2014; 37:1587-8. [PMID: 25197801 DOI: 10.5665/sleep.4062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/03/2022] Open
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132
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Abstract
Abstract
Background:
Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications. The authors investigated whether preoperative diagnosis and prescription of continuous positive airway pressure therapy reduces these risks.
Methods:
Matched cohort analysis of polysomnography data and Manitoban health administrative data (1987 to 2008). Postoperative outcomes in adult OSA patients up to 5 yr before (undiagnosed OSA, n = 1,571), and any time after (diagnosed OSA, n = 2,640) polysomnography and prescription of continuous positive airway pressure therapy for a new diagnosis of OSA, were compared with controls at low risk of having sleep apnea (n = 16,277). Controls were matched by exact procedure, indication, and approximate date of surgery. Procedures used to treat sleep apnea were excluded. Follow-up was at least 7 postoperative days. Results were reported as odds ratio (95% CI) for OSA or subgroup versus controls.
Results:
In multivariate analyses, the risk of respiratory complications (2.08 [1.35 to 3.19], P < 0.001) was similarly increased for both undiagnosed and diagnosed OSA. The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (P = 0.009) between undiagnosed OSA (2.20 [1.16 to 4.17], P = 0.02) and diagnosed OSA patients (0.75 [0.43 to 1.28], P = 0.29). For both outcomes, OSA severity, type of surgery, age, and other comorbidities were also important risk modifiers.
Conclusions:
Diagnosis of OSA and prescription of continuous positive airway pressure therapy were associated with a reduction in postoperative cardiovascular complications. Despite limitations in the data, these results could be used to justify and inform large efficacy trials of perioperative continuous positive airway pressure therapy in OSA patients.
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Corso RM, Gregoretti C, Braghiroli A, Fanfulla F, Insalaco G. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: Navigating through Uncertainty. Anesthesiology 2014; 121:664-5. [DOI: 10.1097/aln.0000000000000354] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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135
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Postoperative complications associated with obstructive sleep apnea: time to wake up! Anesth Analg 2014; 118:251-253. [PMID: 24445625 DOI: 10.1213/ane.0000000000000067] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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