TY - CHAP M1 - Book, Section TI - ACC/AHA Guideline Summary on Preoperative Hypertension A1 - Bailin, Michael A1 - Spanakis, Spiro PY - 2000 T2 - Guidelines AB - |PrintPerioperative Management of Adult Patients with Obstructive Sleep ApneaComments by Mark Dershwitz, MD, PhDOrganization: American Society of AnesthesiologistsSource: Anesthesiology Vol.120, 268-286. 2014[go to full text of guideline]Population: Patients with a documented history, significant risk, or clinical suspicion of obstructive sleep apneaDefinition: "Obstructive sleep apnea (OSA) is a syndrome characterized by periodic, partial, or complete obstruction of the airway during sleep. This, in turn, causes repetitive arousal from sleep to restore airway patency which may result in daytime hypersomnolence. The airway obstruction may also cause episodic sleep-associated oxygen desaturation, episodic hypercarbia, and cardiovascular dysfunction."Preoperative Evaluation and ManagementRecommendations for Intraoperative ManagementRecommendations for Postoperative ManagementReview available recordsManagement is impacted by clinical findingsInterview patient and family about snoring and daytime sleepinessDetermine if surgery is best performed as inpatient or outpatient in conjunction with surgeonOutpatient surgery center should have clinical link with hospital in case admission is required Consider intraop CPAP for MAC or Sedation If the patient has had a sleep study, was moderate or severe OSA diagnosed?Patients with OSA have increased susceptibility to opioid-induced ventilatory depression.Non-supine, lateral or semi-upright positions may be superior if feasible.If the patient has not had a sleep study, are there clinical signs or symptoms suggestive of OSA?For superficial or peripheral surgical procedures, local or regional anesthesia is preferred.Opioid sparing techniques (e.g., regional anesthesia) or medications (e.g., COX inhibitors) should be used if feasible.Physical characteristics: Carefully examine airway, tongue, tonsils and neckBMI > 35 kg/m2Neck circumference > 17 inches (16 inches for women)Craniofacial abnormalities affecting the airwayAnatomical nasal obstructionTonsils nearly touching or touching in the midlineWhen moderate sedation is administered, the adequacy of ventilation must be monitored with capnography.Supplemental oxygen should be administered until the patient is able to maintain the baseline oxygen saturation value on room air.History of apparent airway obstruction during sleep Frequent snoringSnoring loud enough to be heard through a closed doorObserved pauses in breathing during sleepAwakens from sleep with choking sensationFrequent arousals from sleepIf general anesthesia is administered, consider extubating patient in lateral or semi upright position.Patients who used CPAP or NIPPV preoperatively should use these modalities postoperatively.Review for excessive somnolence Frequent somnolence or fatigue despite adequate "sleep"Falls asleep easily in non-stimulating environment despite adequate "sleep" (e.g., watching TV, reading, driving a car)Cautiously presume difficult airwayInpatients should have continuous pulse oximetry monitoring as long as they are at increased risk for episodes of apnea, hypopnea, or oxygen desaturation.Are there surgical or anesthetic factors that increase perioperative risk? Surgery under general anesthesia?Surgery on the airway?Major surgery?Requirement for postoperative high-dose oral opioids, parenteral opioids, or neuraxial opioids?Consider airway control in deep sedation cases Patients scheduled for outpatient surgery should not be discharged to an unmonitored environment or to home until they are no longer at risk for ventilatory depression.For patients with suspicion for moderate or severe OSA, without an established diagnosis: Decide whether to initiate OSA treatment in advance of surgery, especially with severe OSAConsider postponing surgery pending sleep study or CPAP therapy in cooperation with surgeonInform higher risk patients (and the surgeon) about postoperative consequences associated with OSAConfirm ... SN - PB - The McGraw-Hill Companies, Inc. CY - New York, NY Y2 - 2024/03/28 UR - accessanesthesiology.mhmedical.com/content.aspx?aid=1004250493 ER -