A Rude Awakening - The Perioperative Sleep Apnea Epidemic

Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, USA.
New England Journal of Medicine (Impact Factor: 54.42). 06/2013; 368(25):2352-3. DOI: 10.1056/NEJMp1302941
Source: PubMed
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    ABSTRACT: Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification. In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events. Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1-6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8-6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7-15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1-15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a 'one in four' chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028). STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.
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    ABSTRACT: Obstructive sleep apnea (OSA) is a chronic prevalent condition which may be under-recognized in surgical populations. Patients with OSA may be at increased perioperative risk, in part due to the effects sedatives and anesthetics have on upper airway tone and respiratory drive. A growing amount of data suggests that OSA patients have increased odds for adverse postoperative outcomes including intensive care unit transfer, respiratory failure, arrhythmias, and cardiac ischemia. Several screening tools have been developed to identify patients at risk for OSA preoperatively, but it remains to be seen whether routine implementation of these tools improves outcomes. In this review, we discuss the perioperative complications of OSA, the tools with which physicians can screen surgical patients, and the perioperative management of these patients.
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    ABSTRACT: Opioids remain the most common analgesic tool for the surgeon, owing to their cost-effectiveness in both the inpatient and outpatient setting. Aside from these attributes, opioids have significant side effects that are associated with morbidity and mortality. Specifically, obese patients, patients with sleep apnea, and the elderly may be at an increased risk of experiencing sedation and respiratory depression in response to opioids. Opioid reduction strategies prove useful for decreasing total opioid dose and, in turn, their associated adverse effects. Such strategies may include adjuvant nonopioid analgesics such as α-2 agonists, gabapentinoids, and N-methyl-D-aspartate receptor agonists as well as local, regional, or neuraxial anesthesia and modification of surgical technique where possible for operative patients. Patients may also present to surgeons while taking chronic opioids, including high-dose opioids and opioid agonist/antagonists. These clinical scenarios are associated with extreme challenges in postoperative analgesic management. With all opioid prescribing, other sedative medications should be limited or avoided as the risk for additive sedation is significant. This review aims to describe systematic methods to reduce opioid side effects and identify specific risk-reduction strategies within each risk group.
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