Evidence-Based Patient Safety Advisory: Patient Assessment and Prevention of Pulmonary Side Effects in Surgery. Part 1—Obstructive Sleep Apnea and Obstructive Lung Disease:

Preoperative Evaluation: Estimation of Pulmonary Risk Including Obstructive Sleep Apnea Impact

One in 4 deaths occurring within a week of surgery are related to pulmonary complications, making it the second most common serious morbidity after cardiovascular events. The most significant predictors of the postoperative pulmonary complications (PPCs) are American Society of Anesthesiologists physical status, advanced age, dependent functional status, surgical site, and duration of surgery. The overall risk of PPCs can be predicted using scores that incorporate readily available clinical data.

Evidence based development of bedside clinical drug rules for surgical patients

BACKGROUND

Surgical adverse events constitute a considerable problem. More than half of in-hospital adverse events are related to a surgical procedure. Medication related events are frequent and partly preventable. Due to the complexity and multidisciplinary nature of the surgical process, patients are at risk for drug related problems. Consistent drug management throughout the process is needed.

OBJECTIVE

The aim of this study was to develop an evidence-based bedside tool for drug management decisions during the pre- and postoperative phase of the surgical pathway.

SETTING

Tool development study performed in an academic medical centre in the Netherlands involving an expert panel consisting of a surgeon, a clinical pharmacist and a pharmacologist, all experienced in quality improvement.

METHOD

Relevant medication related problems and critical pharmacotherapeutic decision steps in the surgical process were identified and prioritised by a team of experts. The final selection comprised undesirable effects or unintended outcomes related to surgery (e.g. pain, infection) and comorbidity related hazards (e.g. diabetes, cardiovascular diseases). To guide patient management, a list of bedside surgical drug rules was developed using international evidence-based guidelines.

MAIN OUTCOME MEASURE

55 bedside drug rules on 6 drug categories, specifically important for surgical practice, were developed: pain, respiration, infection, diabetes, cardiovascular diseases and anticoagulation.

RESULTS

A total of 29 evidence-based guidelines were used to develop the Bedside Surgical Drug Rules tool. This tool consist of practical tables covering management regarding (1) the most commonly used drug categories during surgery, (2) comorbidities that require dosing adjustments and, (3) contra-indicated drugs in the perioperative period.

CONCLUSION

An evidence-based approach provides a practical basis for the development of a bedside tool to alert and assist the care providers in their drug management decisions along the surgical pathway.

Cardiorespiratory complications of neuraxial opioids in patients with obstructive sleep apnea: a systematic review

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.

Asystole in young athletic women during breast augmentation: a report of three cases

Reported herein are three cases of spontaneous bradycardia progressing to asystole during routine breast augmentation in healthy, adult female patients with a history of endurance training and resting bradycardia (heart rate <60 beats per minute). The incidence of this phenomenon is minimally reported and virtually unexplained in literature. Our goal is to alert the plastic surgery community of the possibility of these events occurring without warning in athletic patients, attempt to explain these findings, and provide a plan of action to minimize morbidity and mortality in these patients. The most severe case was that of a 38-year-old female who became severely bradycardic progressing to asystole during routine breast augmentation. She had no history of any medical problems, but did have a resting heart rate of <60. Glycopyrrolate, an antimuscarinic agent, was given and chest compressions started. After 10-20 s of chest compressions the patient's normal sinus rhythm resumed. Two other cases are also reported, although these patients responded to antimuscarinic agents without requiring chest compressions. Both were endurance athletes with a resting heart rate of <60. Bradycardia caused by a vagal response during surgery is not uncommon and routinely treated successfully with administration of atropine-like agents. Bradycardia progressing to frank asystole is rare and has not been reported in young, otherwise healthy, aesthetic surgery patients. This report should serve to alert the plastic surgeon to the possibility of this situation occurring and how to treat it successfully, especially in the outpatient or office-based surgery setting. Level of Evidence V This journal requires that authors assign a level of evidence to each article.

Respiratory perioperative management of patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has become a major public health problem in the United State and Europe. However, perioperative strategies regarding diagnostic options and management of untreated OSA remain inadequate. Preoperative screening and identification of patients with undiagnosed OSA may lead to early perioperative interventions that may alter cardiopulmonary events associated with surgery and anesthesia.(1) Hence, clinicians need to become familiar with the preoperative screening and diagnosis of OSA. Perioperative management of a patient with OSA should be modified and may include regional anesthesia and alternative analgesic techniques such as nonsteroidal anti-inflammatory drugs that may reduce the need for systemic opioids. Additionally, supplemental oxygen and continuous pulse oximetry monitoring should be utilized to maintain baseline oxygen saturation. Postoperatively patients should remain in a semi-upright position and positive pressure therapy should be used in patients with high-risk OSA.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Prevalence of comorbid obstructive sleep apnea and metabolic syndrome: syndrome Z and maxillofacial surgery implications

PURPOSE

To determine the prevalence of the recently identified syndrome Z (SZ), which is the co-occurrence of obstructive sleep apnea (OSA; hypoxia, systemic and pulmonary hypertension, nocturnal arrhythmias) and metabolic syndrome (MetS; increased abdominal girth, hypertriglyceridemia, decreased high-density lipoprotein, hypertension, increased fasting glucose), which places the surgical patient at heightened risk of perioperative complications (myocardial infarction, stroke, pneumonia, wound infection).

MATERIALS AND METHODS

Electronic medical records of 296 male veterans were assessed for the presence of SZ using the American Academy of Sleep Medicine definition of OSA and a modified Adult Treatment Panel III definition of MetS, where obesity was defined by a body mass index of at least 30 kg/m(2) rather than by waist circumference.

RESULTS

SZ was diagnosed in 59% of patients. These individuals commonly exhibited severe OSA and least commonly mild OSA. The more severe the OSA, the more likely (60%) that patients manifested moderate (4 risk markers) or severe (5 risk markers) MetS. Furthermore, with increasing apnea-hypopnea index values, the more severe were the MetS elements.

CONCLUSIONS

The results of this study demonstrate the high prevalence rate of MetS in patients with OSA seeking treatment. Given the risk of perioperative complications, it is suggested that all patients scheduled for maxillofacial surgical procedures to treat OSA be evaluated for SZ.