What do you need for sleep apnea patients?
What do you need for sleep apnea patients?
New guidelines address outpatient cases
According to new practice guidelines from the American Society of Anesthesiologists, when patients are at increased perioperative risk from obstructive sleep apnea (OSA), the facility should have emergency difficult airway equipment, respiratory care equipment [nebulizers, continuous positive airway pressure (CPAP) equipment, and ventilators], radiology facilities (for portable X-rays), and clinical laboratory facilities (for blood gases and electrolytes).
"Perhaps a patient that would have severe OSA would not be an ideal patient to do in a freestanding center where you don’t have those facilities," says Constance Hill, MD, clinical professor of anesthesiology at State University of New York (SUNY) Downstate, Brooklyn.
The capabilities of the outpatient facility are just one of nine factors for outpatient surgery programs to consider when deciding whether outpatient surgery should be performed on a patient with OSA, according to the guidelines. The other factors are: sleep apnea status, anatomic and physiologic abnormalities, nature of surgery, type of anesthesia, need for postoperative opioids, patient age, adequacy of post-discharge observation, and status of coexisting diseases, they say. For example, determine if "they have diseases that are impacting on organ systems, particularly cardiovascular pulmonary systems," she advises.
The guidelines contain significant recommendations for the preoperative evaluation of OSA patients, for postoperative management, and for selection of appropriate patient/procedure/anesthesia combinations that are suitable for outpatient care.
"These patients should not be discharged from the recovery area to an unmonitored setting (i.e., home or unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression," according to the guidelines.1 "Because of their propensity to develop airway obstruction or central respiratory depression, this may require a longer stay as compared to non-OSA patients undergoing similar procedures." Outpatient surgery staff can document whether their post-operative respiratory function is adequate by observing patients in an unstimulated environment, preferably while they appear to be asleep, to establish that they are able to maintain their baseline oxygen saturation while breathing room air, the guidelines suggest.
In compiling the guidelines, the ASA used a panel of expert consultants to examine which surgical procedures could be performed safely on OSA patients as outpatients. While there was disagreement regarding some procedures, the consultants agreed that superficial surgery with local or regional anesthesia, minor orthopedic surgery with local or regional anesthesia, and lithotripsy could be safely performed outpatient on patients with OSA. (For complete list of procedures, see table.)
While the practice guidelines serve a valuable function, these recommendations are based almost entirely on expert opinion, as there is very little relevant literature, says David O. Warner, MD, professor of anesthesiology at the Mayo Clinic College of Medicine in Rochester, MN. "Indeed, the assumption that these patients are at increased risk for perioperative complications is exactly that — an assumption that has not yet been rigorously tested," Warner says.
The few studies are primarily retrospective using clinical information systems, and they are equivocal, he says. For example, Warner points to study he co-authored that was not included in the literature review in the practice guideline but is relevant to the question of whether patients with OSA can be safely managed as outpatients.2 His study found that the preoperative diagnosis of OSA was not a risk factor for unanticipated hospital admission or for other adverse events among patients undergoing outpatient surgical procedures in a tertiary referral center.
"The question of what factors may preclude outpatient surgery in patients with OSA thus still is very much open, and the practice guide-line appropriately does not provide definitive recommendations," Warner says. "Further research studies are urgently needed to determine whether patients with OSA are at increased risk for perioperative complications, and, if so, what characteristics may be predictive of such risk."
References
- American Society of Anesthesiologists Task Force on Perioperative Management of Patient with Obstructive Sleep Apnea. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Park Ridge, IL; 2005.
- Sabers C, Plevak DJ, Schroeder DR, et al. The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery. Anesth Analg 2003; 96:1,328-1,335.
Source/Resource
For more information on the guidelines, contact:
- Constance Hill, MD, Clinical Professor of Anesthesiology, Department of Anesthesiology, State University of New York Downstate, 450 Clarkson Ave., Box 6, Brooklyn, NY 11203. E-mail: [email protected].
The guidelines are available on the web at www.asahq.org. Click on "Clinical Information" on the left, then "Practice Parameters" on the right.Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea."
According to new practice guidelines from the American Society of Anesthesiologists, when patients are at increased perioperative risk from obstructive sleep apnea (OSA), the facility should have emergency difficult airway equipment, respiratory care equipment [nebulizers, continuous positive airway pressure (CPAP) equipment, and ventilators], radiology facilities (for portable X-rays), and clinical laboratory facilities (for blood gases and electrolytes).Subscribe Now for Access
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