Anesthesiology and obstructive sleep apnea: A patient safety challenge

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american society of anesthesiologistsA guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

Obstructive sleep apnea (OSA) has been diagnosed in more than 18 million American adults, but there are likely millions of others who suffer with OSA, but are undiagnosed. While OSA is frustrating to the patient and the patient’s family, it is crucial to remember OSA is a significant disease that can affect the patient’s safety during and after medical and surgical procedures. The involvement of a physician anesthesiologist is critical to a successful outcome before, during and after a procedure. While the care of these patients may seem as conventional as healthy patients without OSA, it is only because the physician anesthesiologist has addressed the unique risks of this patient group and prepared appropriately.

Since the care of patients with OSA is not only unusual, but potentially devastating if not done correctly, the American Society of Anesthesiologists (ASA) adopted Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea in October 2005. This document is being updated with the latest research and is scheduled for release in October 2013.

The first step when caring for a patient with OSA is identifying them. OSA patients often have a high body mass index, large neck circumference, daytime sleepiness and snoring, but many don’t have any or all of these features. To discover these details, the physician anesthesiologist completes a preoperative evaluation by reviewing medical records, interviewing the patient and his or her family members, and conducting a physical exam. The importance of pre-procedure identification is critical because being recognized as a person with OSA will drastically change the care a physician anesthesiologist will provide during and after the operation or procedure. In fact, it is not unusual that a patient with severe sleep apnea has his or her procedure in a hospital as opposed to an outpatient center or office.  If a patient has been diagnosed with OSA and uses a CPAP machine (continuous positive airway pressure) to help breathe during sleep at home, it is ideal for the patient to bring the machine the day of the procedure for use in the recovery room and during sleep in their hospital room.

Next, the physician anesthesiologist decides which type of anesthesia is ideal for the patient and the procedure. The prescription of the anesthetic plan will affect the patient’s postoperative care. Each plan must be individualized to the patient and the procedure. The plan may include an intentional avoidance of general anesthesia, to avoid exaggerated sleepiness and airway obstruction postoperatively. If general anesthesia is required, non-standard approaches to securing the airway may be needed, which means alternate equipment like fiberoptic bronchoscopy or videolaryngoscopy may be necessary. This kind of equipment may not available at all locations. Medications used during the procedure may be different for OSA patients because they are more sensitive to the effects of sedatives and opioids (morphine-like drugs).  Further, regional anesthesia (including nerve blocks) may be used to either provide the sole anesthetic or minimize postoperative pain (which will allow lower doses of opioids).  The anesthetic will not just affect the care of the patient in the recovery room, but also beyond that time, stressing the importance of a physician anesthesiologist who understands the intricacies of OSA.

After the procedure or operation, the patient’s pain relief and recovery from anesthesia should be constantly monitored. In fact, it is recommended that patients with OSA remain in a monitored setting with pulse oximetry (which measures the amount of oxygen in the patient’s blood) until they are able to sleep and maintain an oxygen saturation of at least 90 percent while breathing room air. This almost always requires a longer recovery room stay as compared with patients who do not have OSA. If a patient fails this trial, hospital admission may be required. Pain control should ideally avoid the use of opioids whenever possible because OSA patients are hypersensitive to these medications, which could result in respiratory depression and even cessation of breathing. Options may include non-steroidal medications (like ketorolac) and nerve blocks (local anesthesia anesthetizing a specific body part). If intravenous opioids are needed, continuous infusions should be avoided and supplemental oxygen along with continuous oxygen monitoring is recommended. The complications of oversedation and apnea can be catastrophic (possible brain injury or death), but with appropriate planning, can be avoided.

Patients with diagnosed and undiagnosed OSA are physiologically “different” than healthy patients, and they need to be treated with great care. This treatment begins before the procedure and lasts well into the postoperative phase. Because of the variety of possible strategies and the unfortunate possibility of devastating complications, the anesthetic plan is best orchestrated by a physician anesthesiologist who has been trained in all facets of OSA care.

Jeffrey S. Jacobs is an anesthesiologist. 

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