IDENTIFYING PATIENTS AT RISK AT ASC’S

• OSA disrupts sleep by constricting the airway and causing the sufferer to stop breathing briefly. The implications for surgery under anesthesia are that the patient is at risk for oxygen deprivation during and after the procedure.

• “Identifying patients with OSA is the first step in preventing postoperative complications due to OSA,”

THE QUESTION FOR SURGERY CENTERS IS “Wh ich on es?”

The only sure way to identify OSA is through polysomnography, an overnight sleep lab procedure. Few
prospective patients are willing to do this, Dr Chung has found.

Dr Chung estimates that 80% of men and 93% of women with moderate or severe OSA have NOT been diagnosed
The CHALLENGE for ASCs is to identify those individuals and then to assess the severity of their condition
which will determine if they can safely undergo surgery outside of a hospital with emergency facilities

HEIGHTENED RISK

Patients with OSA are more sensitive to sedatives, which can lead to upper airway
collapse. Both midazolam and propofol may cause upper airway obstruction, but recovery
from propofol is more rapid.
Sometimes, obese patients who showed no previous signs of sleep apnea develop
airway obstruction during sedation.
Meena S. Desai, MD, Nova Anesthesia Professionals-Villanova,PA

STRESS OF SURGERY

The stress of surgery itself may increase the risk or severity of apnea.
“OSA, particularly unrecognized OSA, not obesity, is more likely to cause problems.
We advise ASCs to screen all patients for signs of OSA.

Girish P. Joshi, MD, professor of Anesthesiology & Pain Management
University of Texas Southwestern Medical Center in Dallas

THE NEED TO SCREEN

Administrator Russell Uhrmacher, RN, CNOR, credits the policy with the center’s strong track record for avoiding complications

• EPWORTH SLEEPINESS SCALE

• STOPBANG

Educating the physicians has helped reduce the number of patients rejected at the time of screening

FEWER DRUGS,FEWER MONITORING

The presence (or strong suspicion) of OSA requires efforts to minimize the risk of airway
collapse. The ASA recommendations and the advice of OSA specialists include reducing use of opioids
and sedatives during surgery because they will continue to depress respiration after surgery.
“To alert all health care providers to the risks of sedatives and opioids in the patient with known
or suspected OSA, the charts of these patients will be flagged with ‘OSA Precautions’,” the ASA advises.

RECOMMENDATIONS

In selecting anesthetics, IF possible, use local anesthesia or peripheral nerve blocks or regional anesthesia.
If a patient is given sedation, monitor ventilation with capnography (CO2 measurement).
Consider using nonsteroidal anti-inflammatory medications to reduce the need for opioids.
In the recovery room, keep OSA patients fully or partially upright if possible.
Monitor continuously with pulse oximetry following surgery.

Give supplemental oxygen continuously until the patient can maintain baseline oxygen
saturation while breathing room air; do not depend on traditional measures
of respiratory rate to detect hypoxemia.

If the patient repeatedly experiences airway obstruction or hypoxemia, consider
transferring the patient to an inpatient facility for observation.
CPAP before and after surgery may also reduce OSA risks.
Prescribe postdischarge narcotics in smaller-than-normal doses

POSTOP CARE

It is essential to monitor ventilation, and to administer CPAP during moderate sedation.
• During recovery at home, she has found that despite the risk of oxygen desaturation
in apnea patients, continued CPAP protects against further complications.
Advise patients with CPAP equipment to use it at home.
Suggest a sleep study for those patients who are believed to have OSA

References