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Khanna AK, Banga A, Rigdon J, White BN, Cuvillier C, Ferraz J, Olsen F, Hackett L, Bansal V, Kaw R. Role of continuous pulse oximetry and capnography monitoring in the prevention of postoperative respiratory failure, postoperative opioid-induced respiratory depression and adverse outcomes on hospital wards: A systematic review and meta-analysis. J Clin Anesth 2024; 94:111374. [PMID: 38184918 DOI: 10.1016/j.jclinane.2024.111374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/23/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The current standards of postoperative respiratory monitoring on medical-surgical floors involve spot-pulse oximetry checks every 4-8 h, which can miss the opportunity to detect prolonged hypoxia and acute hypercapnia. Continuous respiratory monitoring can recognize acute respiratory depression episodes; however, the existing evidence is limited. We sought to review the current evidence on the effectiveness of continuous pulse oximetry (CPOX) with and without capnography versus routine monitoring and their effectiveness for detecting postoperative respiratory failure, opioid-induced respiratory depression, and preventing downstream adverse events. METHODS We performed a systematic literature search on Ovid Medline, Embase, and Cochrane Library databases for articles published between 1990 and April 2023. The study protocol was registered in Prospero (ID: 439467), and PRISMA guidelines were followed. The NIH quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using the software R version 4.1.1 and the package meta. The stability of the results was assessed using sensitivity analysis. DESIGN Systematic Review and Meta-Analysis. SETTING Postoperative recovery area. PATIENTS 56,538 patients, ASA class II to IV, non-invasive respiratory monitoring, and post-operative respiratory depression. INTERVENTIONS Continuous pulse oximetry with or without capnography versus routine monitoring. MEASUREMENTS Respiratory rate, oxygen saturation, adverse events, and rescue events. RESULTS 23 studies (17 examined CPOX without capnography and 5 examined CPOX with capnography) were included in this systematic review. CPOX was better at recognizing desaturation (SpO2 < 90%) OR: 11.94 (95% CI: 6.85, 20.82; p < 0.01) compared to standard monitoring. No significant differences were reported for ICU transfer, reintubation, and non-invasive ventilation between the two groups. CONCLUSIONS Oxygen desaturation was the only outcome better detected with CPOX in postoperative patients in hospital wards. These comparisons were limited by the small number of studies that could be pooled for each outcome and the heterogeneity between the studies.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Akshat Banga
- Department of Internal Medicine, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brian N White
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Joao Ferraz
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Fredrik Olsen
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sweden
| | - Loren Hackett
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vikas Bansal
- Division of Nephrology and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Roop Kaw
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA.
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Shekhar S, Kaw R, Agrawal A, Isogai T, Lak H, Mahalwar G, Pampori A, Reed G, Menon V, Kapadia SR. Outcomes of obesity in cardiogenic shock patients requiring mechanical circulatory support. Catheter Cardiovasc Interv 2023; 102:914-916. [PMID: 37675980 DOI: 10.1002/ccd.30824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Roop Kaw
- Departments of Hospital Medicine and Anesthesiology Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hassan Lak
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gauranga Mahalwar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam Pampori
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Shekhar S, Kaw R, Agrawal A, Pampori A, Isogai T, Lak H, Mahalwar G, Krishnaswamy A, Puri R, Reed G, Yun J, Kapadia SR. Use of Balloon Aortic Valvuloplasty in Contemporary Era. Am J Cardiol 2023; 206:380-382. [PMID: 37743146 DOI: 10.1016/j.amjcard.2023.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/04/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - Roop Kaw
- Department of Hospital Medicine; Department of Anesthesiology Outcomes Research
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - Adam Pampori
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - Hassan Lak
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | | | | | - Rishi Puri
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - Grant Reed
- Department of Cardiovascular Medicine, Heart and Vascular Institute
| | - James Yun
- Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute
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Khanna AK, Moucharite MA, Benefield PJ, Kaw R. Patient Characteristics and Clinical and Economic Outcomes Associated with Unplanned Medical and Surgical Intensive Care Unit Admissions: A Retrospective Analysis. Clinicoecon Outcomes Res 2023; 15:703-719. [PMID: 37780944 PMCID: PMC10541084 DOI: 10.2147/ceor.s424759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose To characterize medical and surgical patient characteristics, as well as clinical and economic outcomes, associated with unplanned intensive care unit (ICU) admissions. Patients and Methods This was a retrospective matched cohort analysis that utilized the PINC AITM Healthcare Database, which collects deidentified data from 25% of United States (US) hospital admissions. Discharge records were assessed for medical and surgical admissions in 2021. An unplanned ICU admission was defined as direct transfer from a medical, surgical, or telemetry unit to the ICU. Patients with and without an unplanned ICU admission were 1:1 propensity score matched. Differences between patients with and without unplanned ICU admissions were assessed using two-sample t-tests for continuous measures and Chi-square tests for categorical measures. Results A total of 3,807,124 qualifying admissions were identified. Medical admissions with unplanned ICU transfers were more likely to be urgent/emergent (odds ratio [OR] 2.9, 95% confidence interval [CI 2.7-3.0], p<0.0001), with patient characteristics including male sex (1.4, [1.4-1.4], p<0.0001), obesity (1.7, [1.6-1.7], p<0.0001), and increased Charlson Comorbidity Index (CCI=1: 1.8, [1.8-1.9], p<0.0001; CCI≥5: 3.2, [3.1-3.3], p<0.0001). Surgical admissions with unplanned ICU transfers were more likely to be urgent/emergent (3.1, [2.9-3.2], p<0.0001) and with patients of higher CCI (2.5, [2.3-2.6], p<0.0001 to a CCI of≥5 (7.9, [7.4-8.4], p<0.0001). Between matched medical patients, mean differences in length of stay, cost, and mortality were 4.1 days (p<0.0001), $13,424 (p<0.0001), and 21% (p<0.0001), respectively. Between matched surgical patients, mean differences in these outcomes were 6.4 days (p<0.0001), $21,448 (p<0.0001), and 14% (p<0.0001), respectively. Conclusion Emergency care in patients with a higher co-morbid burden is more likely to lead to unplanned ICU admission, putting patients at a significantly increased chance of mortality, longer length of stay, and increased costs. Improving care and monitoring of patients outside the ICU may help detect early changes in pathophysiology and enable early intervention.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | | | | | - Roop Kaw
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
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Shekhar S, Kaw R, Ramu SK, Pampori A, Isogai T, Krishnaswamy A, Puri R, Reed G, Harb SC, Yun J, Kapadia SR. Outcomes After Isolated Aortic Valve Replacements in Patients With Chronic Obstructive Pulmonary Disease. Am J Cardiol 2023; 200:72-74. [PMID: 37302283 DOI: 10.1016/j.amjcard.2023.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 06/13/2023]
Affiliation(s)
| | - Roop Kaw
- Departments of Hospital Medicine; Departments of Anesthesiology Outcomes Research
| | | | | | | | | | | | | | | | - James Yun
- Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Chindamporn P, Wang L, Bena J, Zajichek A, Milinovic A, Kaw R, Kashyap SR, Cetin D, Aminian A, Kempke N, Foldvary-Schaefer N, Aboussouan LS, Mehra R. Obesity-associated sleep hypoventilation and increased adverse postoperative bariatric surgery outcomes in a large clinical retrospective cohort. J Clin Sleep Med 2022; 18:2793-2801. [PMID: 35959952 PMCID: PMC9713925 DOI: 10.5664/jcsm.10216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Although obesity hypoventilation syndrome (OHS) is associated with increased morbidity and mortality, post-bariatric surgery OHS risk remains unclear due to often nonsystematic OHS assessments. METHODS We leverage a clinical cohort with nocturnal CO2 monitoring during polysomnography to address the hypothesis that patients with obesity-associated sleep hypoventilation (OaSH; ie, stage II OHS) have increased adverse postoperative bariatric surgery outcomes. We retrospectively analyzed data from patients undergoing pre-bariatric surgery polysomnography at the Cleveland Clinic from 2011-2018. OaSH was defined by body mass index ≥ 30 kg/m2 and either polysomnography-based end-tidal CO2 ≥ 45 mmHg or serum bicarbonate ≥ 27 mEq/L. Outcomes considered were as follows: intensive care unit stay, intubation, tracheostomy, discharge disposition other than home or 30-day readmission individually and as a composite, and all-cause mortality. Two-sample t test or Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact test for categorical variables were used for OaSH vs non-OaSH comparisons. All-cause mortality was compared using Kaplan-Meier estimation and Cox proportional hazards models. RESULTS The analytic sample (n = 1,665) was aged 45.2 ± 12 years, 20.4% were male, had a body mass index of 48.7 ± 9 kg/m2, and 63.6% were White. OaSH prevalence was 68.5%. OaSH patients were older and more likely to be male with a higher BMI, apnea-hypopnea index, and glycated hemoglobin. The composite outcome was higher in OaSH vs non-OaSH patients (18.9% vs 14.3%, P = .021). Although some individual outcomes were respectively higher in OaSH vs non-OaSH patients, differences were not statistically significant: intubation (1.5% vs 1.3%, P = .81) and 30-day readmission (13.8% vs 11.3%, P = .16). Long-term mortality (median follow-up: 22.9 months) was not significantly different between groups, likely due to overall low event rate (hazard ratio = 1.39, 95% confidence interval: 0.56, 3.42). CONCLUSIONS In this largest sample to date of systematically phenotyped OaSH in a bariatric surgery cohort, we identify increased postoperative morbidity in those with sleep-related hypoventilation in stage II OHS when a composite outcome was considered, but individual contributors of intubation, intensive care unit admission, and hospital length of stay were not increased. Further study is needed to identify whether perioperative treatment of OaSH improves post-bariatric surgery outcomes. CITATION Chindamporn P, Wang L, Bena J, et al. Obesity-associated sleep hypoventilation and increased adverse postoperative bariatric surgery outcomes in a large clinical retrospective cohort. J Clin Sleep Med. 2022;18(12):2793-2801.
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Affiliation(s)
- Pornprapa Chindamporn
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Pulmonary and Critical Care Division, Phramongkutklao Hospital, Bangkok, Thailand
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alexander Zajichek
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alex Milinovic
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Roop Kaw
- Departments of Hospital Medicine and Anesthesiology Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Derrick Cetin
- Bariatric Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nancy Kempke
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Loutfi S. Aboussouan
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Shekhar S, Ajay A, Isogai T, Kaw R, Saad A, Agrawal A, Lak H, Kansara T, Mentias A, Krishnaswamy A, Svensson L, Kapadia SR. Utilization and outcomes of aortic valve replacements (from the United States readmissions database). Am Heart J Plus 2022; 19:100184. [PMID: 38558864 PMCID: PMC10978345 DOI: 10.1016/j.ahjo.2022.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 04/04/2024]
Abstract
Study objective Assess the utilization of aortic valve replacements (AVR). Design Retrospective analysis of the Nationwide Readmissions Database (2016-2018). Setting Nationwide. Participants Heart failure patients with concomitant aortic stenosis (CHF + AS cohort) or aortic stenosis with aortic regurgitation (CHF + AS+AR cohort). Interventions Transcatheter aortic valve implantation (TAVI), surgical aortic valve replacement (SAVR), no-AVR. Main outcome measures Utilization of treatment interventions. Results In the CHF + AS cohort, TAVI, SAVR and no-AVR were done in 9.3 %, 10.8 % and 79.9 % of patients respectively. Similarly, majority of CHF + AS+AR patients were managed with no-AVR (53.2 %). Of patients managed with no-AVR in the first six months of each year, only 7.9 % of CHF + AS and 11.8 % of CHF + AS+AR patients underwent AVR in the subsequent six months of the year. No-AVR patients had worse short-term outcomes in comparison to AVR recipients. Conclusion More studies are needed to understand the timing, indications and utilization of AVR in this population.
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Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Abhishek Ajay
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Roop Kaw
- Department of Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Anas Saad
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Hassan Lak
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Tikal Kansara
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amgad Mentias
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lars Svensson
- Department of Thoracic & Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Sohail MA, Luong P, Sedor J, Kaw R. Microangiopathic hemolytic anemia in a female patient with systemic lupus erythematosus. Cleve Clin J Med 2022; 89:130-138. [PMID: 35232825 DOI: 10.3949/ccjm.89a.21066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mohammad A Sohail
- Internal Medicine Residency Program, Cleveland Clinic, Cleveland, OH
| | - Peter Luong
- Case Western Reserve University, Cleveland, OH
| | - John Sedor
- Department of Kidney Medicine, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Roop Kaw
- Department of Hospital Medicine, Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Kaw R, Wong J, Mokhlesi B. Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure. Anesth Analg 2021; 132:1265-1273. [PMID: 33857968 DOI: 10.1213/ane.0000000000005352] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
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Affiliation(s)
- Roop Kaw
- From the Departments of Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Jean Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital.,Department of Anesthesiology and Pain Medicine, Women's College Hospital.,University Health Network, University of Toronto, Ontario, Canada
| | - Babak Mokhlesi
- Department of Medicine, University of Chicago, Chicago, Illinois
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Usama M, Wang L, Jin J, Milinovich A, Aylor J, Kaw R, Kashyap S, Cetin D, Aminian A, Kempke N, Mehra R, Aboussouan L. 476 Sleep-Disordered Breathing is More Predictive than Obesity of Increased Left Ventricular Mass Index in Bariatric Surgery Patients. Sleep 2021. [DOI: 10.1093/sleep/zsab072.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Obesity and obstructive sleep apnea (OSA) are associated with left ventricular hypertrophy and increased cardiovascular risk. Alternatively, the “obesity paradox” describes an improved prognosis from heart failure in obesity, though potentially attributable to confounding/bias. We sought to determine the contributions of obesity and sleep-disordered breathing (SDB) to left ventricular function and morphology in bariatric surgery candidates.
Methods
Patients undergoing polysomnography prior to bariatric surgery from 2011–2018 had demographic (age, gender, race), anthropometric (body mass index [BMI], neck circumference), comorbidities (atrial fibrillation, coronary artery disease, diabetes, hypertension, hyperlipidemia), echocardiographic and sleep-disordered breathing (apnea-hypopnea index [AHI], peak end-tidal CO2 [etCO2]) variables retrospectively examined. The echocardiographic visit closest to polysomnogram within two years was selected with missing values filled by available values within 6 months. Linear regression assessed the relationship of BMI, AHI, and etCO2 with left ventricular mass index (LVMI) after adjustment of demographics and comorbidities. Echocardiographic measures were logarithm transformed before regression analysis. Coefficients and 95% confidence intervals (CI) were calculated by exponential transformation. The analysis was performed based on an overall significance level of 0.05 using SAS software (version 9.4, Cary, NC).
Results
The total of 832 patients had 24% males, mean age 48.8±12, 60% white, and BMI:49.4±9.5kg/m2. Ejection fraction (%) was 60.0±7.0, and LVMI (g/m2): 80.9±23.7. In adjusted models, LVMI decreased by 2.1% for each 5kg/m2 increase in BMI (coefficient=0.979, 95%CI 0.961–0.997, p=0.022) and increased by 4.3% for each 5 mmHg increase in etCO2 (coefficient=1.043, 95%CI 1.013–1.073, p=0.005). Without adjustment, patients with AHI ≥ 5 had 15.3% higher LVMI than non-OSA group (coefficient=1.153, 95%CI 1.034–1.286, p=0.011) and moderate/severe OSA was associated with a 7.6% higher LVMI than those with AHI<15 (coefficient 1.076, 95%CI 1.003–1.153, p=0.040), but not statistically significant after adjustment.
Conclusion
In obese patients, nocturnal hypoventilation rather than obesity may have adverse influences on left ventricular morphology. Future studies should focus on clarifying whether obesity is truly protective in terms of LV mass, i.e. reflective of paradox versus a product of bias. The potential benefit of identifying/treating SDB in bariatric surgery candidates to mitigate cardiovascular risk also deserves further investigation.
Support (if any)
Cleveland Clinic Transformative Resource Neuroscience Award
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Affiliation(s)
- Muhammad Usama
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Jian Jin
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Joan Aylor
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
| | - Roop Kaw
- Medicine Institute, Cleveland Clinic
| | | | | | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic
| | - Nancy Kempke
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
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Heinzinger C, Chindamporn P, Bena J, Wang L, Milinovich A, Kaw R, Kashyap S, Cetin D, Aminian A, Kempke N, Foldvary-Schaefer N, Aboussouan L, Mehra R. 465 Evaluating the Impact of Sleep Disordered Breathing on Adverse Cardiovascular Outcomes After Bariatric Surgery. Sleep 2021. [DOI: 10.1093/sleep/zsab072.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Sleep disordered breathing (SDB), including obstructive sleep apnea (OSA) and obesity-associated sleep hypoventilation (OASH), has well-characterized adverse effects on the cardiovascular system and increases morbidity and mortality. Long-term impact on cardiovascular outcomes post-bariatric surgery, however, remains unclear. We hypothesize that patients with SDB have increased frequency of major adverse cardiovascular events (MACE) post-bariatric surgery than those without.
Methods
Patients undergoing polysomnography (PSG) prior to bariatric surgery at The Cleveland Clinic from 2011–2018 were retrospectively examined and followed up from date of last surgery to 2019, including the perioperative period. Primary predictors include moderate-severe OSA, i.e. apnea hypopnea index(AHI)>15, and OASH, i.e. body mass index (BMI)≥30kg/m2 and either end-tidal CO2≥45mmHg or serum bicarbonate≥27mEq/L. MACE (coronary artery events, cerebrovascular events, heart failure or atrial fibrillation)-free probability was compared using hazard ratios estimated from Cox proportional hazards models on four groups: OASH with moderate-severe OSA (N=492), OASH-only (N=442), moderate-severe OSA-only (N=203), and a reference group without OASH or moderate-severe OSA (N=243). Multivariable Cox proportional hazards models adjusting for age, sex, BMI were fit on MACE survival. Analysis was performed based on an overall significance level of 0.05, using SAS software (version 9.4, Cary, NC).
Results
The sample comprised 1380 patients: age: 43.5±12 years, BMI: 49±9 kg/m2, 17.7% male, 63.7% White. Risk of MACE across the groups bordered significance (p=0.051). Compared to the reference group, the OASH with moderate-severe OSA group had higher risk of MACE (HR2.53, 95%CI:1.07–6.00,p=0.035). Patients with moderate-severe OSA had higher risk of MACE than those with AHI<15 (HR1.94, 95%CI:1.20–3.13,p=0.007). Patients with severe OSA had higher risk of MACE than those AHI<30 (HR2.01, 95%CI:1.28–3.14,p=0.002). For every 5-unit AHI increase, risk of MACE increased by 6% (HR1.056, 95%CI:1.029–1.084,p<0.001) with slight reduction in point estimates in adjusted models.
Conclusion
Preliminary data from this largest-to-date sample of systematically phenotyped patients with SDB undergoing bariatric surgery show significant differences in risk of MACE and MACE-free survival mitigated after consideration of obesity. Further investigation to elucidate effect modification by obesity and metabolic factors is needed.
Support (if any)
Cleveland Clinic Transformative Resource Neuroscience Award
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Affiliation(s)
| | | | | | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Roop Kaw
- Medicine Institute, Cleveland Clinic
| | | | | | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic
| | - Nancy Kempke
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
| | | | | | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic
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Affiliation(s)
- Roop Kaw
- Department of Hospital Medicine and Department of Outcomes Research, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Anthony G Doufas
- Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Khanna AK, Bergese SD, Jungquist CR, Morimatsu H, Uezono S, Lee S, Ti LK, Urman RD, McIntyre R, Tornero C, Dahan A, Saager L, Weingarten TN, Wittmann M, Auckley D, Brazzi L, Le Guen M, Soto R, Schramm F, Ayad S, Kaw R, Di Stefano P, Sessler DI, Uribe A, Moll V, Dempsey SJ, Buhre W, Overdyk FJ. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial. Anesth Analg 2020; 131:1012-1024. [PMID: 32925318 PMCID: PMC7467153 DOI: 10.1213/ane.0000000000004788] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. METHODS PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. RESULTS One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring. CONCLUSIONS A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
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Affiliation(s)
- Ashish K. Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sergio D. Bergese
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, New York
| | | | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | | | - Simon Lee
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Lian Kah Ti
- Department of Anaesthesia, National University of Singapore, Singapore
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Carlos Tornero
- Department of Anesthesiology, Resuscitation and Pain Therapeutics, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leif Saager
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Toby N. Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Wittmann
- Department of Anaesthesiology, University Hospital Bonn, Bonn, Germany
| | - Dennis Auckley
- Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luca Brazzi
- Department of Anesthesia, Intensive Care and Emergency, University of Turin, Turin, Italy
| | - Morgan Le Guen
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | - Roy Soto
- Department of Anesthesiology, Beaumont Hospital, Royal Oak, Michigan
| | - Frank Schramm
- Department of Anesthesiology, Providence Regional Medical Center, Everett, Washington
| | - Sabry Ayad
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Roop Kaw
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Paola Di Stefano
- Medtronic Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
| | - Vanessa Moll
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Susan J. Dempsey
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- University of California, Los Angeles, School of Nursing, Los Angeles, California
| | - Wolfgang Buhre
- Department of Anesthesiology, University Medical Center, Maastricht, the Netherlands
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Kaw R. Letter to the Editor: Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery. J Am Soc Echocardiogr 2020; 33:1293-1294. [PMID: 32709476 DOI: 10.1016/j.echo.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Roop Kaw
- Cleveland Clinic, Cleveland, Ohio
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Chindamporn P, Bena J, Wang L, Zajichek A, Milinovich A, Kaw R, Kashyap S, Cetin D, Aminian A, Kempke N, Foldvary-Schaefer N, Aboussouan LS, Mehra R. 0583 Obesity-Associated Sleep Hypoventilation Syndrome and Adverse Post-Operative Bariatric Surgery Outcomes. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Although obesity hypoventilation syndrome (OHS) is associated with right ventricular dysfunction and increased mortality, its contribution to post-bariatric surgery risk remains unclear due to non-systematic OHS assessments. We hypothesize that patients with obesity-associated sleep hypoventilation (OASH) have increased adverse post-bariatric surgery outcomes than those without.
Methods
Patients undergoing polysomnography (PSG) prior to bariatric surgery at the Cleveland Clinic from 2011-2018 were retrospectively examined. OASH was defined by body mass index (BMI) ≥30kg/m2 and either PSG-based end-tidal CO2 ≥45mmHg or serum bicarbonate ≥27mEq/L. The following were considered individually and as a composite outcome: ICU stay, re-intubation, tracheostomy, discharge disposition or 30-day readmission. All-cause mortality was also examined. Outcomes were compared using two-sample t-test or Wilcoxon rank sum test and Chi-square or Fisher exact test. A multivariable logistic regression model included age, sex, BMI, apnea hypopnea index(AHI) and diabetes to examine OAHS and the composite outcome. All-cause mortality was compared using Kaplan-Meier estimation and hazard ratios from Cox proportional hazards models. SAS software (version 9.4) was used with overall significance level of 0.05.
Results
The sample comprised 1665 patients: age 45.2±12 years, 20.4% male, BMI=48.7±9 kg/m2, and 63.6% Caucasian. OASH prevalence was 68.5%. OAHS patients were older and more likely to be male with higher BMI, AHI and HbA1c. Although some individual outcomes were higher in OASH vs. non-OASH, findings were not statistically significant: re-intubation (1.5%vs.1.3%, p=0.81) and 30-day readmission (13.8% vs.11.3%, p=0.16). The composite outcome remained significantly associated with OAHS in the multivariable model: OR=1.36, 95%CI:1.005,1.845. Mortality was 2% in OASH and not significantly higher than non-OAHS (HR=1.39, 95%CI:0.56,3.42).
Conclusion
In this largest sample to date of systematically phenotyped OASH in patients undergoing bariatric surgery, we identify increased post-operative morbidity in those with OASH. Further study is needed to identify whether peri-operative treatment of OASH improves surgical outcomes.
Support
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Affiliation(s)
- P Chindamporn
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - J Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - L Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - A Zajichek
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - A Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - R Kaw
- Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - S Kashyap
- Endocrinology, Cleveland Clinic, Cleveland, OH
| | - D Cetin
- Obesity Medicine Specialist, Bariatric Metabolic Institute, Cleveland Clinic, Cleveland, OH
| | - A Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - N Kempke
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - N Foldvary-Schaefer
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - L S Aboussouan
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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16
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Mokhlesi B, Masa JF, Brozek JL, Gurubhagavatula I, Murphy PB, Piper AJ, Tulaimat A, Afshar M, Balachandran JS, Dweik RA, Grunstein RR, Hart N, Kaw R, Lorenzi-Filho G, Pamidi S, Patel BK, Patil SP, Pépin JL, Soghier I, Tamae Kakazu M, Teodorescu M. Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 200:e6-e24. [PMID: 31368798 PMCID: PMC6680300 DOI: 10.1164/rccm.201905-1071st] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, 2) stable ambulatory patients with OHS receive positive airway pressure (PAP), 3) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, 4) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2–3 mo), and 5) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Conclusions: Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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Affiliation(s)
- Melda Sonmez
- Medical Student, Koc University School of Medicine, Istanbul, Turkey
| | - Loutfi S Aboussouan
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA.,Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Carol Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.,Professor of Pathology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA.,Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Roop Kaw
- Departments of Hospital Medicine and Outcomes Research Anesthesiology, Cleveland Clinic, Cleveland, OH, USA. .,Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, OH, USA
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Kaw R, Nagarajan V, Jaikumar L, Halkar M, Mohananey D, Hernandez AV, Ramakrishna H, Wijeysundera D. Predictive Value of Stress Testing, Revised Cardiac Risk Index, and Functional Status in Patients Undergoing Noncardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:927-932. [DOI: 10.1053/j.jvca.2018.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Indexed: 11/11/2022]
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19
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Affiliation(s)
- Roop Kaw
- Departments of Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, Ohio, Center for Sleep Disorders, Respiratory Institute, Heart and Vascular Institute, Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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Kadri AN, Kaw R, Al-Khadra Y, Abuamsha H, Ravakhah K, Hernandez AV, Tang WHW. The role of B-type natriuretic peptide in diagnosing acute decompensated heart failure in chronic kidney disease patients. Arch Med Sci 2018; 14:1003-1009. [PMID: 30154881 PMCID: PMC6111357 DOI: 10.5114/aoms.2018.77263] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/26/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). MATERIAL AND METHODS We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR-, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP. RESULTS We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3-4, BNP < 155 pg/ml rules out ADHF (Sn90%, LR- = 0.26 and DOR = 5.75), and BNP > 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71-0.87). In contrast, in those with HFrEF with CKD stages 3-4, BNP < 412.5 pg/ml rules out ADHF (Sn90%, LR- = 0.19 and DOR = 9.37), and BNP > 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69-0.86). All LRs and DOR were statistically significant. CONCLUSIONS BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3-4, with moderate discriminatory diagnostic ability.
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Affiliation(s)
| | - Roop Kaw
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Hasan Abuamsha
- St. Vincent Charity Medical Center – Case Western Reserve University, Cleveland, Ohio, USA
| | - Keyvan Ravakhah
- St. Vincent Charity Medical Center – Case Western Reserve University, Cleveland, Ohio, USA
| | - Adrian V. Hernandez
- University of Connecticut, Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
- School of Medicine, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru
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Sirijanchune P, Kaw R, Wang L, Herbert M, Mehra R, Aboussouan LS. 0455 Determinants of Hypercapnia in Obesity Hypoventilation Syndrome with Obstructive Sleep Apnea. Sleep 2018. [DOI: 10.1093/sleep/zsy061.454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - R Kaw
- Cleveland Clinic, Cleveland, OH
| | - L Wang
- Cleveland Clinic, Cleveland, OH
| | | | - R Mehra
- Cleveland Clinic, Cleveland, OH
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Kaw R, Mehra R. Sleep disordered breathing and post-cardiac surgery atrial fibrillation. J Thorac Dis 2017; 9:E867-E868. [PMID: 29221363 PMCID: PMC5708439 DOI: 10.21037/jtd.2017.08.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Roop Kaw
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesia Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, Patrawala S, Lam D, Kumar A, Joshi GP, Fleetham J, Ayas N, Collop N, Doufas AG, Eikermann M, Englesakis M, Gali B, Gay P, Hernandez AV, Kaw R, Kezirian EJ, Malhotra A, Mokhlesi B, Parthasarathy S, Stierer T, Wappler F, Hillman DR, Auckley D. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2017; 123:452-73. [PMID: 27442772 PMCID: PMC4956681 DOI: 10.1213/ane.0000000000001416] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. 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.
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Affiliation(s)
- Frances Chung
- From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; ‡Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; §Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph's Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph's Health care, Western University, London, Ontario, Canada; ‖Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; ¶Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; #Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; **Department of Medicine, University of California San Diego, San Diego, California; ††Sparrow Hospital, Lansing, Michigan; ‡‡Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; §§Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; ‖‖University of British Columbia, Vancouver, BC, Canada; ¶¶Department of Medicine, Emory University, Atlanta, Georgia; ##Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; ***Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; †††Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‡‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §§§Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; ‖‖‖School of Medicine, Universidad Peruana de Ciencias Apl
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Velez VJ, Kaw R, Hu B, Frankel RM, Windover AK, Bokar D, Rish JM, Rothberg MB. Do HCAHPS Doctor Communication Scores Reflect the Communication Skills of the Attending on Record? A Cautionary Tale from a Tertiary-Care Medical Service. J Hosp Med 2017; 12:421-427. [PMID: 28574531 DOI: 10.12788/jhm.2743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores measure patient satisfaction with hospital care. It is not known if these reflect the communication skills of the attending physician on record. The Four Habits Coding Scheme (4HCS) is a validated instrument that measures bedside physician communication skills according to 4 habits, namely: investing in the beginning, eliciting the patient's perspective, demonstrating empathy, and investing in the end. OBJECTIVE To investigate whether the 4HCS correlates with provider HCAHPS scores. METHODS Using a cross-sectional design, consenting hospitalist physicians (n = 28), were observed on inpatient rounds during 3 separate encounters. We compared hospitalists' 4HCS scores with their doctor communication HCAHPS scores to assess the degree to which these correlated with inpatient physician communication skills. We performed sensitivity analysis excluding scores returned by patients cared for by more than 1 hospitalist. RESULTS A total of 1003 HCAHPS survey responses were available. Pearson correlation between 4HCS and doctor communication scores was not significant, at 0.098 (-0.285, 0.455; P = 0.619). Also, no significant correlations were found between each habit and HCAHPS. When including only scores attributable to 1 hospitalist, Pearson correlation between the empathy habit and the HCAHPS respect score was 0.515 (0.176, 0.745; P = 0.005). Between empathy and overall doctor communication, it was 0.442 (0.082, 0.7; P = 0.019). CONCLUSION Attending-of-record HCAHPS scores do not correlate with 4HCS. After excluding patients cared for by more than 1 hospitalist, demonstrating empathy did correlate with the doctor communication and respect HCAHPS scores. Journal of Hospital Medicine 2017;12:421-427.
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Affiliation(s)
- Vicente J Velez
- Department of Hospital Medicine, Medicine Institute, Center for Excellence in Healthcare Communication, Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio
| | - Roop Kaw
- Department of Hospital Medicine, Medicine Institute, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bo Hu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Richard M Frankel
- Indiana University School of Medicine, Cleveland Clinic Education Institute, Cleveland, Ohio
| | - Amy K Windover
- Center for Excellence in Healthcare Communication, Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio
| | - Dan Bokar
- Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio
| | - Julie M Rish
- Office of Patient Experience, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic Medicine Institute, Cleveland Clinic, Cleveland, Ohio
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Mehta H, Wang L, Kaw R, Mehra R, Aboussouan LS. 0433 IMPACT OF PULMONARY PHYSIOLOGIC AND METABOLIC FACTORS ON ARTERIAL CARBON DIOXIDE LEVELS IN OBESITY HYPOVENTILATION SYNDROME. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kaw R, El Zarif S, Wang L, Bena J, Blackstone EH, Mehra R. Obesity as an Effect Modifier in Sleep-Disordered Breathing and Postcardiac Surgery Atrial Fibrillation. Chest 2017; 151:1279-1287. [PMID: 28300569 DOI: 10.1016/j.chest.2017.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/06/2017] [Accepted: 03/01/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Because the interrelationships of objectively ascertained sleep-disordered breathing (SDB), postcardiac surgery atrial fibrillation (PCSAF), and obesity remain unclear, we aimed to further investigate the interrelationships in a clinic-based cohort. METHODS Patients with polysomnography and cardiac surgery (coronary artery bypass surgery and/or valvular surgery) within 3 years, from January 2009 to January 2014, were identified, excluding those with preexisting atrial fibrillation. Logistic models were used to determine the association of SDB (apnea hypopnea index [AHI] per 5-unit increase) and secondary predictors (central sleep apnea [CSA] [central apnea index ≥ 5] and oxygen desaturation index [ODI]) with PCSAF. Models were adjusted for age, sex, race, BMI, and hypertension. Statistical interaction and stratification by median BMI was performed. ORs and 95% CIs are presented. RESULTS There were 190 patients who comprised the analytic sample (mean age, 60.6 ± 11.4 years; 36.1% women; 80% white; BMI, 33.3 ± 7.5 kg/m2; 93.2% had an AHI ≥ 5; 30% had PCSAF). Unlike unadjusted analyses (OR, 1.06; 95% CI, 1.01-1.1), in the adjusted model, increasing AHI was not significantly associated with increased odds of PCSAF (OR, 1.04; 95% CI, 0.98-1.1). Neither CSA nor ODI was associated with PCSAF. A significant interaction with median BMI was noted (P = .015). Effect modification by median BMI was observed; those with a higher BMI > 32 kg/m2 had 15% increased odds of PCSAF (OR, 1.15; 95% CI, 1.05-1.26; P < .003). CONCLUSIONS SDB was significantly associated with PCSAF in unadjusted analyses, but not after taking into account obesity; those with both SDB and obesity may represent a vulnerable subgroup to target to reduce PCSAF and its associated morbidity.
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Affiliation(s)
- Roop Kaw
- Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Samer El Zarif
- Sleep Disorders Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - James Bena
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; Respiratory Institute and Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
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Kaw R. Cardiac Risk Stratification Among Ambulatory Patients Undergoing Non-Cardiac Surgery. Curr Anesthesiol Rep 2016. [DOI: 10.1007/s40140-016-0188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Kaw R, Bhateja P, Paz y Mar H, Hernandez AV, Ramaswamy A, Deshpande A, Aboussouan LS. Postoperative Complications in Patients With Unrecognized Obesity Hypoventilation Syndrome Undergoing Elective Noncardiac Surgery. Chest 2016; 149:84-91. [DOI: 10.1378/chest.14-3216] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Foldvary-Schaefer N, Kaw R, Collop N, Andrews ND, Bena J, Wang L, Stierer T, Gillinov M, Tarler M, Kayyali H. Prevalence of Undetected Sleep Apnea in Patients Undergoing Cardiovascular Surgery and Impact on Postoperative Outcomes. J Clin Sleep Med 2015; 11:1083-9. [PMID: 26094932 DOI: 10.5664/jcsm.5076] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/25/2015] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
| | - Roop Kaw
- Cleveland Clinic Department of Hospital Medicine and Anesthesiology Outcomes Research, Cleveland, OH
| | | | | | - James Bena
- Cleveland Clinic Quantitative Health Sciences, Cleveland, OH
| | - Lu Wang
- Cleveland Clinic Quantitative Health Sciences, Cleveland, OH
| | - Tracey Stierer
- Johns Hopkins Department of Anesthesiology, Baltimore, MD
| | - Marc Gillinov
- Cleveland Clinic Department of Cardiac and Thoracic Surgery, Cleveland, OH
| | - Matt Tarler
- Cleveland Medical Devices Inc., Cleveland, OH
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Affiliation(s)
- Roop Kaw
- Cleveland Clinic, Cleveland, Ohio, USA (R.K.)
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sobieraj DM, Coleman CI, Pasupuleti V, Deshpande A, Kaw R, Hernandez AV. Comparative efficacy and safety of anticoagulants and aspirin for extended treatment of venous thromboembolism: A network meta-analysis. Thromb Res 2015; 135:888-96. [DOI: 10.1016/j.thromres.2015.02.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/06/2015] [Accepted: 02/24/2015] [Indexed: 01/07/2023]
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Kaw R, Pasupuleti V, Wayne Overby D, Deshpande A, Coleman CI, Ioannidis JP, Hernandez AV. Inferior vena cava filters and postoperative outcomes in patients undergoing bariatric surgery: a meta-analysis. Surg Obes Relat Dis 2014; 10:725-33. [DOI: 10.1016/j.soard.2014.04.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/21/2014] [Accepted: 04/09/2014] [Indexed: 12/20/2022]
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Cho JH, Kutti Sridharan G, Kim SH, Kaw R, Abburi T, Irfan A, Kocheril AG. Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis. BMC Cardiovasc Disord 2014; 14:64. [PMID: 24884693 PMCID: PMC4029836 DOI: 10.1186/1471-2261-14-64] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 05/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated whether right ventricular dysfunction (RVD) as assessed by echocardiogram can be used as a prognostic factor in hemodynamically stable patients with acute pulmonary embolism (PE). Short-term mortality has been investigated only in small studies and the results have been controversial. METHODS A PubMed search was conducted using two keywords, "pulmonary embolism" and "echocardiogram", for articles published between January 1st 1998 and December 31st 2011. Out of 991 articles, after careful review, we found 12 articles that investigated the implications of RVD as assessed by echocardiogram in predicting short-term mortality for hemodynamically stable patients with acute PE. We conducted a meta-analysis of these data to identify whether the presence of RVD increased short-term mortality. RESULTS Among 3283 hemodynamically stable patients with acute PE, 1223 patients (37.3%) had RVD, as assessed by echocardiogram, while 2060 patients (62.7%) had normal right ventricular function. Short-term mortality was reported in 167 (13.7%) out of 1223 patients with RVD and in 134 (6.5%) out of 2060 patients without RVD. Hemodynamically stable patients with acute PE who had RVD as assessed by echocardiogram had a 2.29-fold increase in short-term mortality (odds ratio 2.29, 95% confidence interval 1.61-3.26) compared with patients without RVD. CONCLUSIONS In hemodynamically stable patients with acute PE, RVD as assessed by echocardiogram increases short-term mortality by 2.29 times. Consideration should be given to obtaining echocardiogram to identify high-risk patients even if they are hemodynamically stable.
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Affiliation(s)
- Jae Hyung Cho
- Department of Hospital Medicine, Cleveland Clinic, OH, 9500 Euclid Avenue, M2-Annex, Cleveland, OH 44195, USA.
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Kaw R. ACP Journal Club. In patients with obstructive sleep apnea and resistant hypertension, CPAP reduced 24-hour blood pressure. Ann Intern Med 2014; 160:JC10. [PMID: 24733215 DOI: 10.7326/0003-4819-160-8-201404150-02010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Memtsoudis SG, Stundner O, Rasul R, Chiu YL, Sun X, Ramachandran SK, Kaw R, Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118:407-418. [PMID: 24445639 DOI: 10.1213/ane.0000000000000051] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite the concern that sleep apnea (SA) is associated with increased risk for postoperative complications, a paucity of information is available regarding the effect of this disorder on postoperative complications and resource utilization in the orthopedic population. With an increasing number of surgical patients suffering from SA, this information is important to physicians, patients, policymakers, and administrators alike. METHODS We analyzed hospital discharge data of patients who underwent total hip or knee arthroplasty in approximately 400 U.S. Hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics and outcomes such as mortality, complications, and resource utilization were compared among groups. Multivariable logistic regression models were fit to assess the association between SA and various outcomes. RESULTS We identified 530,089 entries for patients undergoing total hip and knee arthroplasty. Of those, 8.4% had a diagnosis code for SA. In the multivariate analysis, the diagnosis of SA emerged as an independent risk factor for major postoperative complications (OR 1.47; 95% confidence interval [CI], 1.39-1.55). Pulmonary complications were 1.86 (95% CI, 1.65-2.09) times more likely and cardiac complications 1.59 (95% CI, 1.48-1.71) times more likely to occur in patients with SA. In addition, SA patients were more likely to receive ventilatory support, use more intensive care, stepdown and telemetry services, consume more economic resources, and have longer lengths of hospitalization. CONCLUSIONS The presence of SA is a major clinical and economic challenge in the postoperative period. More research is needed to identify SA patients at risk for complications and develop evidence-based practices to aid in the allocation of clinical and economic resources.
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Affiliation(s)
- Stavros G Memtsoudis
- From the *Department of Anesthesiology, Hospital for Special Surgery, †Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, New York; ‡Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan; §Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio; and ‖Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York
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Kaw R, Pasupuleti V, Abhishek D, Modha K, Hernandez A. IVC Filters and Postoperative Outcomes in Patients Undergoing Bariatric Surgery: A Meta-analysis. Chest 2013. [DOI: 10.1378/chest.1703210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Minai OA, Yared JP, Kaw R, Subramaniam K, Hill NS. Perioperative Risk and Management in Patients With Pulmonary Hypertension. Chest 2013; 144:329-340. [DOI: 10.1378/chest.12-1752] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Jaimchariyatam N, Dweik RA, Kaw R, Aboussouan LS. Polysomnographic determinants of nocturnal hypercapnia in patients with sleep apnea. J Clin Sleep Med 2013; 9:209-15. [PMID: 23493528 DOI: 10.5664/jcsm.2480] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Identify polysomnographic and demographic factors associated with elevation of nocturnal end-tidal CO2 in patients with obstructive sleep apnea. METHODS Forty-four adult patients with obstructive sleep apnea were selected such that the maximal nocturnal end-tidal CO2 was below 45 mm Hg in 15 studies, between 45 and 50 mm Hg in 14, and above 50 mm Hg in 15. Measurements included mean event (i.e., apneas or hypopneas) and mean inter-event duration, ratio of mean post- to mean pre-event amplitude, and percentage of total sleep time spent at an end-tidal CO2 < 45, 45-50, and > 50 mm Hg. An integrated nocturnal CO2 was calculated as the sum of the products of average end-tidal CO2 at each time interval by percent of total sleep time spent at the corresponding time interval. RESULTS The integrated nocturnal CO2 was inversely correlated with mean post-apnea duration, with lesser contributions from mean apnea duration and age (R (2) = 0.56), but did not correlate with the apnea-hypopnea index, or the body mass index. Mean post-event to mean pre-event amplitude correlated with mean post-apnea duration (r = 0.88, p < 0.001). Mean apnea duration did not correlate with mean post-apnea duration. CONCLUSIONS Nocturnal capnometry reflects pathophysiologic features of sleep apnea, such as the balance of apnea and post-apnea duration, which are not captured by the apnea-hypopnea index. This study expands the indications of capnometry beyond apnea detection and quantification of hypoventilation syndromes.
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Affiliation(s)
- Nattapong Jaimchariyatam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
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Hernandez AV, Kaw R, Pasupuleti V, Bina P, Ioannidis JP, Bueno H, Boersma E. ASSOCIATION BETWEEN OBESITY AND POSTOPERATIVE ATRIAL FIBRILLATION IN PATIENTS UNDERGOING CARDIAC SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)60278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012; 109:897-906. [PMID: 22956642 DOI: 10.1093/bja/aes308] [Citation(s) in RCA: 279] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is often undiagnosed before elective surgery and may predispose patients to perioperative complications. METHODS A literature search of PubMed-Medline, Web of Science, Scopus, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to November 2010 was conducted. Our search was restricted to cohort or case-control studies in adults diagnosed with OSA by screening questionnaire, oximetry, or polysomnography. Studies without controls, involving upper airway surgery, and with OSA diagnosed by ICD-9 codes alone were excluded. The primary postoperative outcomes were desaturation, acute respiratory failure (ARF), reintubation, myocardial infarction/ischaemia, arrhythmias, cardiac arrest, intensive care unit (ICU) transfer, and length of stay. RESULTS Thirteen studies were included in the final analysis (n=3942). OSA was associated with significantly higher odds of any postoperative cardiac events [45/1195 (3.76%) vs 24/1420 (1.69%); odds ratio (OR) 2.07; 95% confidence interval (CI) 1.23-3.50, P=0.007] and ARF [33/1680 (1.96%) vs 24/3421 (0.70%); OR 2.43, 95% CI 1.34-4.39, P=0.003]. Effects were not heterogeneous for these outcomes (I(2)=0-15%, P>0.3). OSA was also significantly associated with higher odds of desaturation [189/1764 (10.71%) vs 105/1881 (5.58%); OR 2.27, 95% CI 1.20-4.26, P=0.01] and ICU transfer [105/2062 (5.09%) vs 58/3681 (1.57%), respectively; OR 2.81, 95% CI 1.46-5.43, P=0.002]. Both outcomes showed a significant degree of heterogeneity of the effect among studies (I(2)=57-68%, P<0.02). Subgroup analyses had similar conclusions as main analyses. CONCLUSIONS The incidence of postoperative desaturation, respiratory failure, postoperative cardiac events, and ICU transfers was higher in patients with OSA.
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Affiliation(s)
- R Kaw
- Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative Complications in Patients With Obstructive Sleep Apnea. Chest 2012; 141:436-441. [DOI: 10.1378/chest.11-0283] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Kaw R, Chung F, Pasupuleti V, Mehta J, Gay P, Hernandez A. Obstructive Sleep Apnea and Postoperative Outcome. Chest 2011. [DOI: 10.1378/chest.1111087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Collop N, Foldvary-Schaefer N, Kaw R, Weimer S, Kayyali H. Reliability of Sleep Questionnaires in Detecting SDB in Cardiac Surgery Patients. Chest 2011. [DOI: 10.1378/chest.1119083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kaw R, Hernandez AV, Masood I, Gillinov AM, Saliba W, Blackstone EH. Short- and long-term mortality associated with new-onset atrial fibrillation after coronary artery bypass grafting: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2011; 141:1305-12. [DOI: 10.1016/j.jtcvs.2010.10.040] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 09/20/2010] [Accepted: 10/24/2010] [Indexed: 10/18/2022]
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Kaw R, Pasupuleti V, Deshpande A, Hamieh T, Walker E, Minai OA. Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med 2010; 105:619-24. [PMID: 21195595 DOI: 10.1016/j.rmed.2010.12.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 12/06/2010] [Accepted: 12/07/2010] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Perioperative risk associated with pulmonary hypertension (PH) in patients undergoing non-cardiac surgery (NCS) remains poorly defined. We report perioperative outcomes in a large cohort of patients undergoing NCS, comparing those with and without PH. METHODS Patients undergoing NCS at our institution between January 2002 and December 2006, were cross matched with a Right Heart Catheterization (RHC) database for the same period. Patients were excluded if they were <18 years old and if they underwent cardiac surgery prior to NCS or minor procedures using local anesthesia or sedation. Controls were defined as patients who underwent similar NCS with mean pulmonary arterial pressure (MPAP) ≤ 25 mmHg. RESULTS 173 patients underwent RHC and NCS during the specified period and were included in the analysis. Of these 96 (55%) had PH. Mean pulmonary arterial pressure (p = 0.001), American Association of Anesthesiology Class (p = 0.02), and chronic renal insufficiency (p = 0.03) were determined as independent risk factors for post-operative morbidity. Patients with PH were more likely to develop congestive heart failure (p < 0.001; OR: 11.9), hemodynamic instability (p < 0.002), sepsis (p < 0.0005), and respiratory failure (p < 0.004). Patients with PH needed longer ventilatory support (p < 0.002), stayed longer in the ICU (p < 0.04), and were more frequently readmitted to the hospital within 30 days (p < 008; OR 2.4). CONCLUSIONS In addition to the traditionally known risk factors for outcomes after NCS such as coronary artery disease, diabetes mellitus, chronic renal insufficiency, American Society of Anesthesiology class, the presence of underlying PH can have a significant negative impact on perioperative outcomes.
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Affiliation(s)
- Roop Kaw
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Lerner College of Medicine, Desk A13, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kaw R, Cai O. ACP Journal Club. Review: Preoperative brain natriuretic peptide level is an independent predictor of adverse cardiovascular events after noncardiac surgery. Ann Intern Med 2010; 152:JC3-12. [PMID: 20231554 DOI: 10.7326/0003-4819-152-6-201003160-02012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Roop Kaw
- Cleveland Clinic, Cleveland, Ohio, USA
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Mokhlesi B, Saager L, Kaw R. Should we routinely screen for hypercapnia in sleep apnea patients before elective noncardiac surgery? Cleve Clin J Med 2010; 77:60-1. [DOI: 10.3949/ccjm.77a.09105] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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