The suitability of ambulatory surgery for a patient with obstructive sleep apnea (OSA) remains controversial because of concerns of increased perioperative complications including postdischarge death. Therefore, a Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for ambulatory surgery. A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Although the studies evaluating perioperative outcome in OSA patients undergoing ambulatory surgery are sparse and of limited quality, they do provide useful information that can guide clinical practice. Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period. Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP-Bang questionnaire, and with optimized comorbid conditions, can be considered for ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques. On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for ambulatory surgery. What other guidelines are available on this topic? The American Society of Anesthesiologists (ASA) practice guidelines for management of surgical patients with OSA published in 2006. Why was this guideline developed? The ASA guidelines are outdated because several recent studies provide new information such as validated screening tools for clinical diagnosis of OSA and safety of ambulatory laparoscopic bariatric surgery in OSA patients. Therefore, an update on the selection of patients with OSA undergoing ambulatory surgery is warranted. How does this guideline differ from existing guidelines? Unlike the ASA guidelines, this consensus statement recommends the use of the STOP-Bang criteria for preoperative OSA screening and considers patients' comorbid conditions in the patient selection process. Also, current literature does not support the ASA recommendations that upper abdominal procedures are not appropriate for ambulatory surgery. Why does this guideline differ from existing guidelines? This consensus statement differs from existing ASA guidelines because of the availability of new evidence.

Background:An important requirement during functional endoscopic sinus surgery is to maintain a clear operative field to improve visualization during surgery and to minimize complications.Materials and Methods:We compared total intravenous anesthesia using propofol with inhalational anesthesia using isoflurane for controlled hypotension in functional endoscopic sinus surgery. It was a prospective study in a tertiary hospital in India. Forty ASA physical status I and II adult patients (16–60 years) were randomly allocated to one of two parallel groups (isoflurane group, n = 20; propofol group, n = 20). The primary outcome was to know whether total intravenous anesthesia using propofol was superior to inhalational anesthesia using isoflurane for controlled hypotension. The secondary outcomes measured were intraoperative blood loss, duration of surgery, surgeon's opinion regarding the surgical field and the incidence of complications.Results:The mean (±SD) time to achieve the target mean blood pressure was 18 (±8) minutes in the isoflurane group and 16 (±7) minutes in the propofol group (P = 0.66). There was no statistically significant difference (P = 0.402) between these two groups in terms of intraoperative blood loss and operative field conditions (P = 0.34).Conclusions:Controlled hypotension can be achieved equally and effectively with both propofol and isoflurane. Total intravenous anesthesia using propofol offers no significant advantage over isoflurane-based anesthetic technique in terms of operative conditions and blood loss.

An intracuff pressure of 80 cm H(2)O with the LMA Supreme is associated with a higher OLP compared with 60 cm H(2)O or 40 cm H(2)O without a greater incidence of postoperative pharyngolaryngeal adverse events. For a superior glottic seal when using the LMA Supreme, we recommend intracuff pressures up to 80 cm H(2)O.

Pregnancy induced hypertension is a hypertensive disorder, which occurs in 5% to 7% of all pregnancies. These parturients present to the labour and delivery unit ranging from gestational hypertension to HELLP syndrome. It is essential to understand the various clinical conditions that may mimic preeclampsia and the urgency of cesarean delivery, which may improve perinatal outcome. The administration of general anesthesia (GA) increases morbidity and mortality in both mother and baby. The provision of regional anesthesia when possible maintains uteroplacental blood flow, avoids the complications with GA, improves maternal and neonatal outcome. The use of ultrasound may increase the success rate. This review emphasizes on the regional anesthetic considerations when such parturients present to the labor and delivery unit.

The recent publications indicated that the majority of OSA patients may be done as ambulatory surgical patients with few adverse events. However, it may not be safe to do patients with severe OSA requiring postoperative narcotics as ambulatory surgical patients.

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The objective of this review is to determine the effects of perioperative sedatives and anesthetics in surgical patients with obstructive sleep apnea (OSA) on respiratory events, medication requirements, hemodynamics, pain, emergence, and hospital stay. We searched The Cochrane CENTRAL Register of Controlled Trials, Medline, Embase, and Cochrane Database of Systematic Reviews from 1950 to June 2010 for relevant articles. All prospective and retrospective studies were eligible for inclusion if the effects of perioperative administration of sedation and anesthetics on medication requirements, pain, emergence, hemodynamics, respiratory events, and length of hospital stay in OSA patients were reported. The search strategy yielded 18 studies of 1467 patients. Of these, 456 patients were documented as having OSA. Few adverse respiratory effects were reported. Eight out of 700 (1.14%) patients undergoing middle ear surgery with midazolam and fentanyl had impaired upper airway patency and were retrospectively diagnosed as having OSA by polysomnography. Also, intraoperative snoring causing uvular edema in the postoperative period was described in an OSA patient undergoing upper limb surgery when propofol was administered with midazolam and fentanyl for sedation. A decrease in oxygen saturation in the postoperative period was described with propofol and isoflurane in 21 OSA patients undergoing uvulo-palato-pharyngoplasty and tonsillectomy surgery (P<0.05). Perioperative alpha 2 agonists were shown to decrease the use of anesthetics (P<0.05), analgesics (P=0.008) and anti-hypertensives (P<0.001) in OSA patients. Contradictory reports regarding emergence occurred with intraoperative dexmedetomidine. Intraoperative opioids decreased the analgesic consumption (P=0.03) and pain scores (P<0.05) in the postoperative period. There was limited data on the length of hospital stay. There were few adverse effects reported when patients with known OSA underwent elective surgery with the currently available sedatives and anesthetics. Adverse events were reported with midazolam. However, the quality and number of patients in the studies were limited. There is a need for further trials with large numbers and uniform reporting of outcomes.

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