Routine Postoperative Monitoring after Bariatric Surgery in Morbidly Obese Patients with Severe Obstructive Sleep Apnea: ICU Admission is not Necessary

Goucham, Amin B.; Coblijn, Usha K.; Hart-Sweet, Helga B.; Vries, Nico de; Lagarde, Sjoerd M.; Wagensveld, Bart A. van

doi:10.1007/s11695-015-1807-3

Cited by 30 publications

(20 citation statements)

References 29 publications

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“…Although several studies have found beneficial effects of postoperative treatment of OSA on weight loss after bariatric surgery compared to bariatric surgery alone 28–30 , long-term improvement of metabolic and cardiovascular comorbidities after bariatric surgery might be linked more closely to weight loss than CPAP treatment 31,32 . During the early perioperative period, retrospective studies in patients undergoing bariatric surgery reported no differences in overall postoperative morbidity 33 , as well as no cases of death, reintubation, or cardiopulmonary complications 34,35 , regardless of CPAP or AP treatment. CPAP was found to improve blood oxygenation in patients after open Roux-en-Y gastric bypass in some studies 36 , while other authors found severe and prolonged episodes of hypoxemia during the early postoperative period despite preoperative diagnosis and treatment of OSA, including use of CPAP following bariatric surgery 37 .…”

Section: Discussionmentioning

confidence: 99%

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

et al. 2016

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Background Bariatric surgery patients are vulnerable to sleep-disordered breathing (SDB) early after recovery from surgery and anesthesia. The authors hypothesized that continuous positive airway pressure (CPAP) improves postoperative oxygenation and SDB and mitigates opioid-induced respiratory depression. Methods In a randomized crossover trial, patients after bariatric surgery received 30% oxygen in the postanesthesia care unit (PACU) under two conditions: atmospheric pressure and CPAP (8 to 10 cm H2O). During 1 h of each treatment, breathing across cortical arousal states was analyzed using polysomnography and spirometry. Arousal state and respiratory events were scored in accordance with American Academy of Sleep Medicine guidelines. Data on opioid boluses in the PACU were collected. The primary and secondary outcomes were the apnea hypopnea index (AHI) and apnea after self-administration of opioids in the PACU. Linear mixed model analysis was used to compare physiologic measures of breathing. Results Sixty-four percent of the 33 patients with complete postoperative polysomnography data demonstrated SDB (AHI greater than 5/h) early after recovery from anesthesia. CPAP treatment decreased AHI (8 ± 2/h vs. 25 ± 5/h, P < 0.001), decreased oxygen desaturations (5 ± 10/h vs. 16 ± 20/h, P < 0.001), and increased the mean oxygen saturation by 3% (P = 0.003). CPAP significantly decreased the respiratory-depressant effects observed during wakefulness–sleep transitions without affecting hemodynamics. The interaction effects between CPAP treatment and opioid dose for the dependent variables AHI (P < 0.001), inspiratory flow (P = 0.002), and minute ventilation (P = 0.015) were significant. Conclusions This pharmacophysiologic interaction trial shows that supervised CPAP treatment early after surgery improves SDB and ameliorates the respiratory-depressant effects of opioids without undue hemodynamic effects.

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Section: Discussionmentioning

confidence: 99%

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

et al. 2016

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“…RYGB had higher rates than SG or LAGB . The risk for cardiac events after bariatric surgery may be increased with OSA and this risk mitigated with the use of CPAP , though other studies fail to demonstrate these associations . Parenthetically, even though bariatric surgeries involving senior‐level residents had more statistically significant morbidities, including postoperative cardiac events, this association is more likely related to perioperative rather than intraoperative care .…”

Section: Executive Summarymentioning

confidence: 93%

“…Hence, routine preoperative clinical screening for OSA with confirmatory polysomnography may be considered, with further diagnostic testing and treatment of appropriate at‐risk patients . However, the data are generally mixed in terms of overall benefit of screening, with several studies showing no risk reduction with OSA screening or treatment .…”

Section: Executive Summarymentioning

confidence: 99%

“…According to guidelines, patients with OSA who have had bariatric surgery should have continuous monitoring with pulse oximetry in the early postoperative period with minimization of sedatives and opioids . Since patients with OSA and adequate CPAP use are at low risk for cardiopulmonary complications after laparoscopic bariatric surgery, routine ICU admission in the immediate postoperative period is not necessary . However, there is a need for additional research to assess risk factors and impact of sleep‐associated desaturation, which is not unusual in patients after bariatric surgery .…”

Section: Executive Summarymentioning

confidence: 99%

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Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

322

464

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Objective The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. Methods Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. Results New or updated topics in this CPG include: contextualization in an adiposity‐based chronic disease complications‐centric model, nuance‐based and algorithm/checklist‐assisted clinical decision‐making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Conclusions Bariatric procedures remain a safe and effective intervention for higher‐risk patients with obesity. Clinical decision‐making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

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“…In a study involving a group of bariatric surgery patients, 30 of whom had severe OSA and were admitted in ICU for a 24-h postoperative observation, no relation between a high AHI and desaturations was found. Those findings could be explained by having one responsible nursing individual who may awaken the patients before the desaturation becomes severe (60). …”

Section: Clinical Observationsmentioning

confidence: 99%

A Brief Review of Non-invasive Monitoring of Respiratory Condition for Extubated Patients with or at Risk for Obstructive Sleep Apnea after Surgery

et al. 2017

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Obstructive sleep apnea (OSA) is one of the important risk factors contributing to postoperative airway complications. OSA alters the respiratory physiology and increases the sensitivity of muscle tone of the upper airway after surgery to residual anesthetic medication. In addition, the prevalence of OSA was reported to be much higher among surgical patients than the general population. Therefore, appropriate monitoring to detect early respiratory impairment in postoperative extubated patients with possible OSA is challenging. Based on the comprehensive clinical observation, several equipment have been used for monitoring the respiratory conditions of OSA patients after surgery, including the continuous pulse oximetry, capnography, photoplethysmography (PPG), and respiratory volume monitor (RVM). To date, there has been no consensus on the most suitable device as a recommended standard of care. In this review, we describe the advantages and disadvantages of some possible monitoring strategies under certain clinical conditions. According to the literature, the continuous pulse oximetry, with its high sensitivity, is still the most widely used device. It is also cost-effective and convenient to use but has low specificity and does not reflect ventilation. Capnography is the most widely used device for detection of hypoventilation, but it may not provide reliable data for extubated patients. Even normal capnography cannot exclude the existence of hypoxia. PPG shows the state of both ventilation and oxygenation, but its sensitivity needs further improvement. RVM provides real-time detection of hypoventilation, quantitative precise demonstration of respiratory rate, tidal volume, and MV for extubated patients, but no reflection of oxygenation. Altogether, the sole use of any of these devices is not ideal for monitoring of extubated patients with or at risk for OSA after surgery. However, we expect that the combined use of continuous pulse oximetry and RVM may be promising for these patients due to their complementary function, which need further study.

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Routine Postoperative Monitoring after Bariatric Surgery in Morbidly Obese Patients with Severe Obstructive Sleep Apnea: ICU Admission is not Necessary

Abstract: Patients with severe OSA and adequate CPAP use are at low risk of cardiopulmonary complications after (laparoscopic) bariatric surgery. Routine admission to an ICU might be superfluous. However, continuous digital oximetry remains essential.

Cited by 30 publications

References 29 publications

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

A Brief Review of Non-invasive Monitoring of Respiratory Condition for Extubated Patients with or at Risk for Obstructive Sleep Apnea after Surgery

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