Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol

Bolden, Norman; Smith, Charles E.; Auckley, Dennis

doi:10.1016/j.jclinane.2008.08.023

Cited by 30 publications

(12 citation statements)

References 20 publications

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“…The surgical patient with confirmed or suspected OSA requires a number of specialized services from anesthesiologists, including thorough preoperative evaluation, intubation and extubation protocols, and careful postoperative monitoring [1,4]. Retrospective series have found that patients with OSA are roughly twice as likely to experience a postoperative complication as those without OSA [5,6].…”

Section: Discussionmentioning

confidence: 99%

“…The 2006 ASA guidelines state that OSA patients who use CPAP prior to surgery or who suffer frequent apneic events should have CPAP applied as soon as is feasible after surgery unless contraindicated by the surgical procedure [1,4]. To increase patient compliance and decrease associated costs, these guidelines also suggest that patients bring their personal machines at the time of surgery.…”

Section: Discussionmentioning

confidence: 99%

“…We propose a clarification of the OSA perioperative management algorithm as described by Bolden et al [4]. Specifically, postoperative CPAP and/or BiPAP use may be contraindicated in cases where positive airway pressure may result in breakdown of the operative repair or pathological introduction of air into potential spaces.…”

Section: Discussionmentioning

confidence: 99%

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Pneumocephalus with BiPAP use after transsphenoidal surgery

Kopelovich

Garza

Greenlee

et al. 2012

Journal of Clinical Anesthesia

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While the benefits of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for patients with obstructive sleep apnea are well described, reports in the literature of complications from its use are rare. A patient who received postoperative BiPAP after undergoing transsphenoidal craniopharyngioma resection developed severe pneumocephalus and unplanned intensive care unit admission. Although the pneumocephalus resolved with conservative management over two weeks, we propose caution in the use of CPAP postoperatively in patients undergoing procedures of the head and neck.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Pneumocephalus with BiPAP use after transsphenoidal surgery

Kopelovich

Garza

Greenlee

et al. 2012

Journal of Clinical Anesthesia

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“…24 In the non-pregnant adult population with OSA, local and national protocols have been proposed for screening, diagnosis, therapy and general peri-anesthetic care. 25 allow researchers to trace the epidemiologic course of the condition, both its genesis and its path into chronicity. We believe that the time has come for our profession to wake up to this diagnosis.…”

Section: Gestational Sleep Apnea: Have We Been Caught Napping?mentioning

confidence: 99%

Gestational sleep apnea: have we been caught napping?

Karan

Ginosar

2016

International Journal of Obstetric Anesthesia

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“…As a result, the development of a postoperative protocol for treatment of these patients has been advocated by the American Academy of Sleep Medicine and the American Society of Anesthesiologists. 13 This has sparked initiatives in hospitals around the country that have recently been heightened by legal cases involving sudden death in the postoperative period. When managing OSA patients on labor and delivery, early placement of regional anesthesia may prevent the need for general anesthesia if emergent cesarean delivery becomes necessary and may obviate the need for parenteral opioids to manage labor pain.…”

Section: Are There Any Intrapartum Concerns In Women With Obstructivementioning

confidence: 99%

Management of Obstructive Sleep Apnea in Pregnant Women

Louis

Auckley

Bolden

2012

Obstetrics & Gynecology

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A 32-year-old woman, gravida 6 para 5004, at 37 0/7 weeks of gestation presented for a repeat cesarean delivery. The patient's pregnancy was complicated by morbid obesity (body mass index [calculated as weight (kg)/[height (m)] 2 ] 53.1), chronic hypertension, and obstructive sleep apnea (OSA) but not pregestational or gestational diabetes. Her antenatal course was uneventful. Her OSA was diagnosed 2 years before this pregnancy but she failed to initiate therapy. A repeat polysomnogram performed at 20 weeks confirmed her OSA with an apnea-hypopnea index of nine events per hour, indicating mild sleep apnea. Her lowest oxygen saturation on the overnight polysomnogram was 76% and she spent 3.9% of her total sleep time with an SpO 2 level less than 90%. After multiple visits for evaluation and continuous positive airway pressure (CPAP) adjustment, she initiated CPAP treatment at 12 cm H 2 O at 26 weeks of gestation. She reported nightly compliance thereafter.The patient underwent an uncomplicated repeat cesarean delivery and a tubal ligation under combined spinalepidural (12 mg bupivacaine, 20 g fentanyl, 0.2 mg morphine). The neonate weighed 3,148 grams and Apgar scores at 1 and 5 minutes were 9 and 9, respectively. Secondary to our departmental postoperative sleep apnea protocol ( Fig. 1), she was monitored on labor and delivery for 24 hours after her cesarean delivery. The patient declined CPAP. Within the first 4 hours postoperatively, the patient was noted to have intermittent hypoxemia with a pulse oximetry nadir of 83%. At that time, her lungs were clear, there was no tachycardia, and she denied chest pain. Therefore, venous thromboembolism or pulmonary edema was deemed unlikely. Subsequently, her pulse oximetry ranged between 93% and 94%. Given her sleep apnea, she was kept on continuous pulse oximetry monitoring for the remainder of her admission. No narcotics beyond the spinal narcotics administered by anesthesia intraoperatively could be administered for the first 24 hours without permission from the anesthesia service (per our neuraxial opioid standing orders). There were no standing orders for opioid medications (intravenous or oral) in the postoperative period beyond 24 hours. Rather, physician assessment of vital signs was required before narcotic administration and ketorolac was used for analgesia. The hypoxemia was most profound in the first 24 hours. On postoperative day 2, her oxygen saturation was consistently approximately 96% with a nadir of 93%. By postoperative day 3, the patient's pulse oximetry returned back to her preoperative baseline of 98% with no desaturations (on room air). Given her long-standing history of sleep apnea, an echocardiogram was performed to evaluate for the presence of pulmonary hypertension and was noted to be normal. The remainder of the patient's course was uneventful and she was discharged home on postoperative day 4.Obstructive sleep apnea is a sleep-related breathing disorder that is characterized by recurrent episodes of partial (hypopnea) or complete (apnea) airw...

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Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol

Cited by 30 publications

References 20 publications

Pneumocephalus with BiPAP use after transsphenoidal surgery

Pneumocephalus with BiPAP use after transsphenoidal surgery

Gestational sleep apnea: have we been caught napping?

Management of Obstructive Sleep Apnea in Pregnant Women

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