Sleep Apnea and Ambulatory Surgery

Authors:
Stierer TL, Collop NA.
Citation:
Perioperative Assessment and Management for Sleep Apnea in the Ambulatory Surgical Patient. Chest 2015;148:559-565.

The following are 10 points to remember about perioperative assessment and management for obstructive sleep apnea (OSA) in the ambulatory surgical patient:

Guidelines

  1. Same day discharge for surgical procedures can approach 70% of all procedures in some hospitals.
  2. Historically, known OSA patients were observed in the intensive care unit setting postoperatively. However, outside of the elective non-otolaryngologic procedure population, the best evidence today has not identified OSA as an independent risk for unanticipated hospital admission.
  3. The Society for Ambulatory Anesthesiology 2012 practice guidelines recommend that OSA patients with optimized comorbidities are acceptable risk for ambulatory surgery as long as they are able to comply with continuous positive airway pressure postoperatively.
  4. Current recommendations also include screening all ambulatory surgery patients for OSA (with a validated questionnaire), although no data to support screening will improve outcomes.

Preoperative Testing

  1. Polysomnography is the gold standard for diagnosing OSA, although there is no evidence that a higher apnea-hypopnea index (AHI) is linked to adverse outcomes, except in those with severe OSA (AHI >30 events/hour). Reasons may have to do with internight variability, varied scoring criteria among laboratories, and sleep position may impact scoring.
  2. Home sleep tests are more convenient and less costly, but have a failure rate approaching 20% due to lack of an attendant to correct signaling error.
  3. Even if OSA diagnosis is made preoperatively and treatment has begun, there is no evidence that outcomes are impacted.

Management

  1. Feared complications among severe OSA patients include: upper airway obstruction after sedation or during induction, failed intubation, negative pressure pulmonary edema, arrhythmias, or hypoxic cardiac arrest.
  2. No singular medication has been proven to be superior to induce anesthesia in the OSA population.
  3. More studies are needed to determine whether specific AHI level (marker of OSA severity) would benefit from longer observation in the postoperative setting.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Sleep Apnea

Keywords: Airway Obstruction, Sleep Apnea, Obstructive, Ambulatory Surgical Procedures, Apnea, Arrhythmias, Cardiac, Continuous Positive Airway Pressure, Heart Arrest, Perioperative Care, Polysomnography, Pulmonary Edema, Sleep Apnea Syndromes


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