Explore this issue:July 2011
Minneapolis, Minn.—For patients undergoing surgery, identification of known or suspected obstructive sleep apnea (OSA) is critical to avoid or minimize surgical complications that are increased in these patients, experts said here last month at SLEEP 2011, the 25th Annual Meeting of the Associated Professional Sleep Societies.
Tracey Stierer, MD, medical director at the Johns Hopkins Medicine Outpatient Center, director of the division of ambulatory anesthesia and assistant professor of anesthesiology and critical care medicine at Johns Hopkins University in Baltimore, discussed the importance of screening surgical patients for OSA. She used the 2006 practice guidelines by the American Society of Anesthesiologists (ASA) as the template for her talk (Anesthesiology. 2006;104(5):1081-1093). Although the guidelines are not evidence-based, she said they provide a starting point to draw attention to the need to screen surgical patients for OSA and may provide some help on specific issues.
Among these issues is a way to score the severity of OSA to determine the risk of increased postoperative morbidity and mortality, along with the appropriate post-care location. The guidelines, for example, strongly recommend against sending to an unmonitored environment any patient who has had airway surgery, has a history of OSA or is suspected to have OSA.
In patients with known or suspected OSA, Dr. Stierer recommended that surgery be scheduled early in the day to allow for ample postoperative observation time. She also emphasized the importance of communication between the anesthesia and surgical teams to determine the approach to airway management and postoperative disposition. “Specifically, those patients with other co-morbidities such as overlap syndrome, pulmonary hypertension or compensated heart failure might be better served in an inpatient venue as opposed to an ambulatory surgical center,” she said.
Dr. Stierer also discussed an algorithm that has been used by Johns Hopkins Hospital in Baltimore, Md., for the past 15 years to determine postoperative care for OSA patients. Dr. Stierer, for example, has her patients who have previously been treated with continuous positive airway pressure (CPAP) bring their CPAP devices to the hospital on the day of surgery so they can use the devices postoperatively. For patients unable to use CPAP on the first night because of the nature of the surgical procedure, she urged high-level postoperative observation in an intensive care setting.
Another issue, is the need to maintain a high level of vigilance for obstruction in the immediate postoperative period. If a patient has been prescribed an oral narcotic to use at home after surgery, she said, Johns Hopkins physicians typically administer the first dose before discharge so they can observe the patient and determine fitness for discharge to home or an unmonitored environment.