Background: Obstructive sleep apnea (OSA) is prevalent in the surgical population, and it has been suggested that preoperative patients should be screened and treated for OSA. However, it remains unclear whether patients diagnosed with OSA in the preoperative period adhere to prescribed CPAP therapy. Objective: Our aim was to objectively quantify CPAP adherence, investigate predictors of poor CPAP adherence, and to establish an optimal CPAP setting in a cohort of presurgical patients diagnosed with OSA as part of the preoperative work-up. Methods: In a retrospective observational study, we collected data on all adult presurgical patients seen by the Anesthesia Perioperative Medicine Clinic (APMC) who screened positive for OSA on the STOP-Bang questionnaire and underwent an in-laboratory diagnostic polysomnogram (PSG) before surgery. CPAP was offered to patients with moderate or severe OSA. Objective CPAP adherence was recorded during the perioperative period. Factors associated with reduced CPAP adherence were delineated. Patient characteristics were compared between those with STOP-Bang scores of 3-4 and those with higher scores (STOP-Bang score ≥ 5). Results: During a 2-year period, 431 patients were referred and 211 patients completed a PSG. CPAP therapy was required in 65% of patients, and the optimal level was 9 ± 2 cm H 2 O. Objective CPAP adherence was available in 75% of patients who received CPAP therapy; median adherence was 2.5 h per night, without any signifi cant difference between the STOP-Bang subgroups. African American race, male gender, and depressive symptomatology were independent predictors of reduced CPAP adherence. Severe OSA was signifi cantly more prevalent in patients with a STOP-Bang score ≥ 5 than those whose score was 3-4 (55.1% versus 34.4%, p = 0.005). However, optimum CPAP pressure levels and adherence to therapy did not differ between the 2 STOP-Bang groups. Conclusions: Adherence to prescribed CPAP therapy during the perioperative period was extremely low. African American race, male gender, and depressive symptoms were independently associated with reduced CPAP usage. Further research is needed to identify and overcome barriers to CPAP acceptance and adherence in the perioperative setting.
S C I E N T I F I C I N V E S T I G A T I O N SS ince its initial description more than 40 years ago, OSA has been gaining more interest among anesthesiologists, and there is accumulating evidence that moderate to severe OSA can increase perioperative complications.1-3 Given the important implications of untreated OSA, 4-9 the American Society of Anesthesiologists (ASA) recommends screening presurgical patients for OSA and implementing treatment if signifi cant OSA is present. 10 There is lack of consensus on the most appropriate method of screening, diagnosis, and timing of therapy implementation.11 Although most studies have focused on screening and diagnosis of OSA, less is known about CPAP therapy and adherence during the perioperative period.In this study we aimed to objectively quantif...
Many medications have been used to prevent the hypertensive response to the induction of general anesthesia and laryngoscopy in preeclamptic patients, with varying results. In this focused review, we summarize the available data and pharmacologic profiles of these drugs. Several different drug classes may be used safely; however, magnesium bolus, lidocaine, calcium channel antagonists other than nicardipine, and hydralazine are not recommended. Further research is warranted into the hemodynamic impact of varying the induction drug dose or combining different classes of drugs.
F or the hypertensive disorders of pregnancy, with their 15% maternal mortality rate, cesarean delivery (CD) is often required. Most CDs are performed using neuraxial anesthesia, but some patients require general anesthesia because of maternal or fetal conditions. Many strategies have been used to control the hemodynamic response to laryngoscopy and intubation in the general surgical population, but fewer studies have examined preeclamptic patients. The drugs used should have a fast, predictable onset, be quickly cleared, cause no serious maternal adverse effects, have minimal placental transfer or no notable fetal/ neonatal effects, and be widely available and stable at room temperature without the need for reconstitution or dilution. This review was performed to examine drugs used to control the hypertensive response to laryngoscopy and tracheal intubation in preeclamptic patients receiving general anesthesia.Of the β-adrenergic antagonists, only esmolol and labetalol have been investigated in women with preeclampsia. Esmolol is a selective β1 antagonist with a short onset time and elimination half-life. It prevents the hemodynamic response to laryngoscopy and intubation in nonpregnant patients when given as an infusion or bolus after thiopental induction. In 1 randomized controlled trial (RCT) of preeclamptic women having CD, after thiopental induction, esmolol at a dose of 2 mg/kg suppressed heart rate and arterial blood pressure (ABP) increases during airway manipulation, but 1 mg/kg of esmolol required the addition of lidocaine at 1.5 mg/kg to be effective. Esmolol has few serious maternal adverse effects, but transient bradycardia or heart block can occur. Its fetal/maternal (F/M) ratio is 0.2. Although case reports indicated decreases in fetal heart rate after use of esmolol, favorable Apgar scores and no fetal bradycardia occurred with periinduction bolus doses ranging from1 to 2 mg/kg in women with preeclampsia. Labetalol is a mixed β1 and β2 receptor antagonist, with some α-adrenergic receptor antagonism. It is rapid acting with an onset time of several minutes and duration of 2 to 3 hours after an intravenous (IV) bolus. It is a first-line therapy for emergency treatment of elevated ABPs in preeclamptic patients and does not compromise placental blood flow. Potential maternal adverse effects are postinduction hypotension and bronchospasm. It crosses the placenta, with an F/M ratio of 0.38. Transient mild neonatal hypotension or hypotension and bradycardia can occur.Among the direct vasodilators, nitroglycerin (NTG) is a rapid-acting drug that decreases ABP by smooth muscle relaxation. Its onset time after an IV bolus is immediate, and duration of effect is 3 to 5 minutes. One small RCT in 19 preeclamptic patients found that an NTG infusion, titrated to decrease mean ABP by 20% immediately before induction with thiopental, improved peri-induction ABP. Nitroglycerin crosses the placenta with an F/M ratio of 0.18. No adverse fetal effects have been noted with peri-induction doses. Maternal adverse effect...
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