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Society of & Table of Vol. 7 • Iss. 1 • 2018 Contents Message from the President 1-2

Editor’s File 3

Five Important Reviews in newsletter Perioperative Sleep Medicine Message from the President Published 2016/2017 4-5 Babak Mokhlesi, MD, MSc ERAS for Sleep Disordered University of Chicago Breathing – Pro! 5-6 Chicago, IL

CON: Enhanced Recovery After (ERAS) for with Obstructive These are exciting times for the Society of Anesthesia and Sleep Medicine (SASM). We are now in our (OSA)/ Sleep Disordered seventh year and it is my great honor to have been nominated by the Board and elected by the member- Breathing (SDB) 7-8 ship to serve as your fifth president. I am grateful to our past presidents (Drs. David Hillman, Frances Chung, Peter Gay and Girish Joshi) for setting a vision for our young, yet influential and vibrant Society. STOP-Bang Questionnaire: My goal is to serve SASM to the best of my ability to ensure advancing its vision. I will continue to rely A Screening Tool to Predict on our past leaders’ collective wisdom and counsel to chart our society through another year of success. Postoperative Complications 8-10 It is important to take a moment and reflect on our overarching mission. SASM was founded to pro- mote education and scientific inquiry in two areas of medicine that share significant common ground: Postoperative Delirium and and Sleep Medicine. Our mission is to advance standards of care for clinical problems Sleep Apnea 11-12 shared by Anesthesiology and Sleep Medicine and to promote interdisciplinary communication, educa- tion and research in matters common to both fields. As we continue to grow as a society, let us not forget Summary of SASM 2017 the pillars on which SASM was founded: Annual Meeting 13-14 • Promote the cross fertilization of ideas between anesthesiology and sleep medicine.

SASM 2017 Annual Meeting • Stimulate interest in research examining the relationships in respiratory, neurophysiological, neuro- Abstract Winners 14 psychological and neuropharmacological function between anesthesia and sleep.

SASM Officers & Board of • Promote studies of the mechanisms of anesthesia and sleep and the consequences of anesthesia and Directors 15 sleep on brain and other organ functions.

SASM Member Benefits 16 • Promote clinical and epidemiological studies determining the associations between sleep disordered breathing and perioperative risk.

• Examine methods of minimizing perioperative risk of upper airway obstruction or ventilatory insuf- ficiency in predisposed individuals.

• Explore the use of various (including, but not limited to non-invasive positive airway pres- sure therapies) to prevent and treat perioperative upper airway obstruction or hypoventilation.

I am proud to report that we have remained true to our mission of promoting education and scientific inquiry. SASM has successfully organized seven annual meetings for our membership. These meet- Society of Anesthesia & Sleep Medicine ings have provided a platform for exchange of ideas, introducing pathways to improve clinical care of 6737 W Washington Street, perioperative patients with sleep disorders, and planning of future research collaborations. Dr. Stavros Suite 4210 Memtsoudis and I were honored to chair the 2017 Annual Meeting. We were pleased that 32 abstracts Milwaukee, WI 53214 were submitted to the annual meeting. This task was successfully chaired by Drs. Malin Jonsson-Fa- www.sasmhq.org >> President’s Message continued on next page

1 >> President’s Message continued from previous page gerlund and Toby Weingarten and we look Chung. Drs. Dennis Auckley, Rahul Kakkar is our website that allows us to promote our forward to their future contributions. I look and their team are working on developing vision and to share with our members var- forward in working with Drs. Tom Clo- a guideline on perioperative management ious educational resources, our newsletters ward and Krish Ramachandran who are the of patients with . I am confident and literature updates. chairs of our 2018 Annual Meeting in San that these guidelines will become instru- Francisco. I am confident they will assem- mental for clinicians so that they can pro- In closing, our Society includes a large ble an outstanding scientific program and vide better care to patients with sleep disor- group of talented, dedicated and devot- workshops that will attract a large audience ders during the perioperative period. ed members. Many of our members are of clinicians and researchers interested in thought leaders in the field of Anesthesiol- perioperative medicine. Our Clinical Committee, co-chaired by ogy and/or Sleep Medicine. We are grate- Bhargavi Gali and Dennis Auckley, has ful to have them actively contributing to Under the leadership of Frances Chung, been extremely active. They have devel- our Society. It goes without saying that our SASM successfully assembled an interna- oped several valuable educational resources success is in great part due to the drive and tional team of experts in areas of anesthe- for clinicians and have made them avail- eagerness of our members. Your input as siology, sleep medicine, pulmonary and able on the SASM website to the public. Dr. a member is most valuable and I want to critical care medicine to develop a clinical Jean Wong has been chairing our News- encourage you to share your thoughts with practice guideline on preoperative screen- letter subcommittee that leads to three me. I would like to invite SASM members ing and assessment of adult patients with newsletters annually. These newsletters who want to volunteer and contribute to . This clinical prac- are important to keep our membership the Society to contact me directly. Only tice guideline was published in Anesthesia informed about new developments in our working together as a group we can con- and Analgesia in August 2016. I am proud Society and the field. Dr. Susana Vacas has tinue to promote our agenda as a Society. to inform our Society that it has been cit- also been working tirelessly on the Scien- I look forward to working with the Board, ed 40 times in 2017. This is a tremendous tific Updates. In her role as the chair of the Committee Chairs, and all members of milestone for our young society and I con- Scientific Update Subcommittee, her team SASM. Our collective expertise and enthu- gratulate all of my colleagues who were in- has developed literature updates that are siasm continues to be a catalyst for promot- volved in this monumental task. extremely useful for busy clinicians who ing safety and improved outcomes are interested in staying up to date in the in the context of perioperative care of pa- I am also excited to report that our Society field of sleep and perioperative medicine. I tients with sleep disorders. I wish all of you continues to work actively on several other am very grateful to Dr. Michael Pilla who a productive year that will culminate in our guidelines. A guideline on intraoperative over the years has been working diligently annual meeting in October 2018 in San management of patients with sleep apnea to improve the SASM website in his role as Francisco. is being developed under the leadership the Communication Subcommittee chair. It of Drs. Stavros Memtsoudis and Frances Save the Date

SASM 8th Annual Meeting October 12, 2018 San Francisco, California

2 Editor’s File Jean Wong, MD, FRCPC Associate Professor, Department of Anesthesia, University of Toronto Staff Anesthesiologist, Toronto Western Hospital University Health Network

I would like to take this opportunity to many other fronts, including educational The STOP-Bang Questionnaire has been wish everyone a healthy and happy new resources, and developing guidelines that validated in the surgical population and year! Our past President, Girish Joshi, MB, will be valuable tools for clinicians caring other populations to screen patients for BS, MD, FFARCSI has provided outstand- for surgical patients with sleep disordered OSA, however, this meta-analysis shows ing leadership and vision over the past breathing. that the STOP-Bang questionnaire can year. Incoming President, Babak Mohkle- be used to risk stratify patients to predict si, MD, MSc, will ensure that our society I would like to thank Mandeep Singh, postoperative complications. continues to promote the goals of encour- MBBS, MD, MSc, FRCPC, for serving as aging collaboration amongst anesthesiolo- the previous Co-Chair of the newsletter. Sakura Kinjo, MD, examines recent evi- gists, sleep medicine specialists, surgeons, I welcome Mahesh Nagappa, MD as the dence suggesting that sleep apnea may be and other providers to pro- new Co-Chair of the Newsletter Commit- a risk factor for postoperative delirium. mote education and research to improve tee and look forward to working with Ma- She describes a recent systematic review perioperative management of patients hesh to bring readers 3 annual newsletters. published by Lam et al. explaining some with sleep-disordered breathing. of the evidence supporting possible mech- This issue of the newsletter features a sum- anisms for an association of sleep apnea Recently, one of the founding members mary from Susana Vacas, MD, PhD, of the with postoperative delirium. of our society, Frances Chung, MBBS, five most important reviews on periopera- FRCPC, was recognized for her publica- tive sleep medicine that were published in Finally, Mandeep Singh, MBBS, MD, MSc, tion: “High STOP-Bang score indicates 2016/2017. These reviews provide import- FRCPC, provides a summary of the 2017 a high probability of obstructive sleep ant summaries of the literature to date on Annual Meeting in Boston, Massachu- apnea” This paper was published in 2012 many areas of particular interest to mem- setts. This meeting was another success, in the British Journal of Anaesthesia. On bers of the society, and point to areas of with presentations and discussions of 2017 World Anesthesia Day, the British future research. challenging and controversial topics in Journal of Anaesthesia highlighted the top perioperative and sleep medicine. Enhanced Recovery After Surgery (ERAS) 25 key papers in the journal over the years protocols were introduced into clinical The articles in this issue highlight some of of major importance to the field of anes- practice to improve surgical outcomes in the exciting areas of previous and ongoing thesia. The papers were selected based general surgical patients about ten years research in perioperative management of on their novelty, significance, impact and ago. In this issue, the Pros and Cons of patients with sleep disordered breathing. contribution to the practice of anesthesia, ERAS protocols, and how they can be ap- We encourage and welcome submissions critical care and pain medicine. https://ac- plied for patients with OSA are debated for newsletter articles from all members ademic.oup.com/bja/pages/world_anaes- by Ellen M. Soffin, MD, PhD andMeltem of the society on all areas of periopera- thesia_day_2017. Yilmaz, MD. Some of the existing chal- tive management of patients with sleep Dr. Chung’s paper was chosen as one of lenges with implementation, and a lack of disordered breathing. Please contact me the top 25 articles indicating the impor- evidence for the use of ERAS protocols in ([email protected]) if you are interested tance of recognizing sleep apnea for sur- OSA patients are discussed. in contributing an article or joining the gical patients. Newsletter committee. This issue also features a summary of an In addition to this success, members of our important systematic review and me- society are currently actively working on ta-analysis by Mahesh Nagappa, MD, et al.

3 Five Important Reviews in Perioperative Sleep Medicine Published 2016/2017 Susana Vacas MD, PhD University of California, Los Angeles

Does Obstructive Sleep Apnea Influence Perioperative Complications in The aim of this systematic review and Perioperative Outcome? A Qualitative Obstructive Sleep Apnea Patients meta-analysis was to determine the as- Systematic Review for the Society of Undergoing Surgery: A Review of the sociation of postoperative complications Anesthesia and Sleep Medicine Task Legal Literature in patients screened as HR-OSA versus Force on Preoperative Preparation low-risk OSA (LR-OSA). From the ten 10 of Patients with Sleep-Disordered Nick Fouladpour, Rajinish Jesudoss, cohort studies included (23,609 patients, Breathing Norman Bolden, Ziad Shaman, Dennis HR-OSA, 7877; LR-OSA, 15,732) the au- Auckley thors suggest that HR-OSA is related with Mathias Opperer, Crispiana Cozowicz, higher risk of postoperative adverse events This study was undertaken to assess the Dario Bugada, Babak Mokhlesi, Roop and longer length of hospital stay when legal consequences associated with poor Kaw, Dennis Auckley, Frances Chung, compared with LR-OSA patients, support- outcomes related to OSA in the perioper- Stavros G. Memtsoudis ing the implementation of the STOP-Bang ative setting. screening tool for perioperative risk strat- The objective of this systematic review was ification. to evaluate whether the diagnosis of OSA Twenty-four cases met the inclusion crite- ria. The use of opioids and general anes- has an impact on postoperative outcomes. https://www.ncbi.nlm.nih.gov/ thetics was believed to play a role in 38% The authors identified 61 studies pertinent pubmed/28817421 to this review with 50 studies investigating and 58% of cases, respectively. Verdicts patients undergoing surgery with general favored the plaintiffs in 58% of cases. In CPAP in the Perioperative Setting. or neuraxial anesthesia and 11 studies re- cases favoring the plaintiff, the average fi- Evidence of Support porting on procedures under sedation. nancial penalty was $2.5 million. Frances Chung, Mahesh Nagappa, Overall, the included studies reported on In summary, perioperative complica- Mandeep Singh, Babak Mokhlesi 413,304 OSA and 8,556,279 control pa- tions related to OSA are increasingly be- tients. The majority reported worse out- ing reported as the central contention of This review examines the evidence regard- comes for a number of events, including malpractice suits. These cases can be as- ing the use of CPAP in the preoperative pulmonary and combined complications, sociated with severe financial penalties. and postoperative periods in surgical pa- among patients with OSA versus the refer- These data likely underestimate the actual tients with diagnosed and undiagnosed ence group. The association between OSA medicolegal burden, given that most such OSA. and in-hospital mortality varied among cases are settled out of court and are not In conclusion, diagnosing OSA and using studies; 9 studies showed no impact of accounted for in the legal literature. perioperative CPAP may be effec- OSA on mortality, 3 studies suggested a https://www.ncbi.nlm.nih.gov/ tive interventions to reduce the incidence decrease in mortality, and 1 study reported pubmed/26111263 of postoperative adverse outcomes in pa- increased mortality. In summary, the ma- tients with OSA undergoing surgery. jority of studies suggest that the presence Association of STOP-Bang of OSA is associated with an increased risk Questionnaire as a Screening Tool https://www.ncbi.nlm.nih.gov/ of postoperative complications. for Sleep Apnea and Postoperative pubmed/26469321 Complications: A Systematic Review and https://www.ncbi.nlm.nih.gov/ Bayesian Meta-analysis of Prospective pubmed/27101493 and Retrospective Cohort Studies

Mahesh Nagappa, Jayadeep Patra, Jean Wong, Yamini Subramani, Mandeep Singh, George Ho, David T. Wong, Frances Chung

>> Five Important Reviews continues on next page 4 >> Five Important Reviews continued from previous page

Understanding Phenotypes of dilator muscles such as the genioglossus, and adherence can be a problem. Pa- Obstructive Sleep Apnea: Applications arousal threshold of the individual, and tient-centered individualized approaches in Anesthesia, Surgery, and Perioperative inherent stability of the respiratory con- to OSA management will be the focus of Medicine trol system determine the pathogenesis future research into developing potential of OSA. Their recognition may have im- treatment options that will help decrease Subramani Y, Singh M, Wong J, Kushida plications for the perioperative health care the disease burden and improve treatment CA, Malhotra A, Chung F team. effectiveness.

The pathophysiology of OSA varies be- This review describes the clinically rele- https://www.ncbi.nlm.nih.gov/ tween individuals and is composed of vant endotypes and phenotypes of OSA. pubmed/27861433 different underlying mechanisms. Several Continuous components including the upper airway (CPAP) therapy is the treatment of choice anatomy, effectiveness of the upper airway for most patients with OSA but tolerance

ERAS for Sleep Disordered Breathing – Pro! Ellen M. Soffin, MD, PhD Assistant Attending Anesthesiologist, Associate Director of Clinical Research, Department of Anesthesiology, Hospital for Special Surgery

Enhanced Recovery After Surgery (ERAS) The first argument is a mechanistic one. Nationally, the mean probability of receiv- represents a leading example of path- A fundamental goal of ERAS is to ensure ing 2 or more analgesic agents after sur- way-based perioperative care. ERAS is patients receive care based on the highest gery is just 54%.6 Likewise, only 20% of consistently associated with improved level(s) of evidence for benefit. Indeed, elective total knee arthroplasty (TKA) is outcomes, fewer complications, and high- the ERAS community advocates that “… performed under neuraxial anesthesia and er patient satisfaction in a range of surgi- the immediate challenge to improving the just 25% feature peripheral nerve block cal .1 ERAS is predominately quality of care is not discovering new knowl- for postoperative analgesia.7 This is par- organized along surgical service lines and edge, but rather how to integrate what we ticularly striking considering TKA is com- components of care are directed toward already know into practice.” 2 By auditing monly performed in a population with a mediating major surgical and anesthet- and linking pathway compliance with out- high estimated prevalence of SDB. Fortu- ic-related complications. A by-product comes, ERAS provides a framework to im- nately, reports are starting to demonstrate of this organization is that individual plement and deliver care. that ERAS increases adherence with best patient co-morbidities are not necessar- practice recommendations. In a study of ily addressed within the structure of the For patients with SDB, ERAS may facili- open hepatectomy, an ERAS protocol fea- pathways. Given the success of ERAS for tate the implementation of society and turing MMA was associated with signifi- improving overall care and outcomes, it evidence-based recommendations. For cantly lower opioid consumption up to follows that similar gains may be achieved example, multimodal analgesia (MMA) 72 hours post-surgery. Pain scores were by applying ERAS principles to individ- is endorsed by several pain and anesthet- lower up to 24 hours, and 72% of patients ual disease states. Specifically, outcomes ic societies to optimize pain control and received epidural analgesia under the new for surgical patients with sleep disordered minimize opioid use and -related side ef- protocol.8 3-4 breathing (SDB) may be positively influ- fects. This is a parallel goal in care of the enced by ERAS pathways, irrespective of surgical patient with SDB, and the SASM The second argument in favor of ERAS for the surgical indication. To date, there is Practice Guidelines for the Perioperative patients with SDB is a biochemical one. no evidence in the literature addressing Management of Patients with Obstructive The basis for ERAS efficacy is modulation this question. However, there are three Sleep Apnea make a similar recommen- of the surgical stress response: Surgery is 5 main arguments which can be advanced dation. However, large population-based associated with predictable changes in that ERAS should benefit surgical patients studies indicate low rates of uptake, and physiology, including release of inflam- with SDB. wide variation in the use of MMA and re- matory mediators, sympathetic surge, gional anesthesia / analgesia techniques. and insulin resistance.9 Obstructive sleep >> ERAS for Sleep continues on next page 5 >> ERAS for Sleep continued from previous page apnea (OSA) may be viewed as a similar to surgical patients with SDB, including 7. Cozowicz C, Poeran J & Memtsoudis SG. Epide- state, and high levels of circulating cyto- ERAS as a framework to ensure delivery miology, trends and disparities in regional ana- ethesia for . BJA 115(S2):ii57- kines, adipokines, CRP and homocysteine of best practice; ERAS as a plausible bio- ii67. often accompany OSA. Likewise, OSA is logical substrate to improve physiology; associated with obesity, insulin resistance, and data from surgical cohorts with a high 8. Grant MC, Sommer PM, He C, Li S, Page A, metabolic syndrome and cardiovascular probability of SDB showing benefits of Stone A et al. Preserved analgesia with reduc- tion in opioids through the use of an acute pain disease. By modulating the inflammato- ERAS. Common goals link ERAS with the protocol in enhanced recovery after surgery ry response to surgery, ERAS may be par- care of patients with SDB. Rather than a for open hepatectomy. Reg Anesth Pain Med ticularly beneficial for patients with OSA. one-size-fits-all approach to surgical care, 2017;42(4):451-7. Although there is not yet evidence to ERAS should also begin to incorporate in- 9. Kehlet H. Multimodal approach to control post- support the latter hypothesis, ERAS itself terventions targeted to superior outcomes operative pathophysiology and rehabilitation. is associated with improved insulin resis- for individual disease states. BJA 1997;78:606-17. tance 10 and more favorable inflammatory 11 References 10. Ljungqvist O. Jonathan E. Rhoads lecture 2011: profiles after surgery. Insulin resistance and enhanced recovery after 1. Melnyk M, Casey RG, Black P & Koupparis J. surgery. JPEN J Parenter Enteral Nutr;36(4):389- Given that reports of ERAS targeted to Enhanced recovery after surgery (ERAS) pro- 98. patients with SDB are not yet in evidence, tocols: time to change practice? Can Urol Assoc the final argument considers whether 2011;5:342-8. 11. Warr DG, McSorley ST, Horgan PG & McMil- lan DC. Enhanced recovery after surgery: Which ERAS benefits surgical populations with 2. Urbach DR & Baxter NN. Reducing variation in components, if any, impact on the systemic in- a high prevalence of OSA. One series es- surgical care. BMJ 2005; 330(7505):1401-2. flammatory response following colorectal sur- timates the overall prevalence of OSA in gery? Medicine 94(36):e1286. patients presenting for bariatric surgery at 3. American Society of Anesthesiologists Task 12. Lopez PP, Stefan B, Schulman CI & Byers PM. over 70%, rising to 95% with BMI >60.12 Force on Acute : Practice guidelines for acute pain management in the Prevalence of sleep apnea in morbidly obese In this population, there are 2 meta-anal- perioperative setting: an updated report by the patients who presented for weight loss surgery yses associating ERAS with shorter length American Society of Anesthesiologists Task evaluation: more evidence for routine screening of hospital stay and no increase in read- Force on Acute Pain Management. Anesthesiol- for obstructive sleep apnea before weight loss surgery. Am Surg 2008;74(9):834-8. mission rates or overall complications.13-14 ogy 2012; 116:248-273. Retrospective studies also support early 4. Chou, R., Gordon, D.B., de Leon-Casasola, 13. Malczak P, Pisarska M, Piotr M, Wysocki M, discharge after bariatric surgery (post-op- O.A. et al. Management of postoperative pain: Budzynski A & Pedziwiatr M. Enhanced recov- erative day 1) without increased compli- A clinical practice guideline from the American ery after bariatric surgery: Systematic review and meta-analysis. Obes Sug 2017; 27(2):226-235. cations, readmission, or post-discharge Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the Ameri- resource use, although BMI >50 predicts can Society of Anesthesiologists’ Committee on 14. Singh PM, Panwar R, Borle A, Goudra B et al. Ef- a longer length of stay.15 Interestingly, full Regional Anesthesia, Executive Committee, and ficiency and safety effects of applying ERAS pro- consensus guidelines for ERAS-Bariat- Administrative Council. Jl Pain 2016; 17(2):131- tocols to bariatric surgery: A systematic review 157. with meta-analysis and trial sequential analysis ric-Surgery have been published, and in- of evidence. Obes Surg 2017; 27(2):489-501. clude recommendations for patients with- 5. Chung F, Memtsoudis SG, Ramachandran SK, and-without OSA.16 Nagappa M, Opperer M, Cozowicz C. et al. So- 15. Khorgami Z, Petrosky JA, Andalib A, Amin- ciety of Anesthesia and Sleep Medicine Guide- ian A et al. Fast track bariatric surgery: Safety lines on Preoperative Screening and Assessment of discharge on the first postoperative day after The benefits of ERAS on peri-operative bariatric surgery. Surg Obesity Related Dis 2017; care and outcomes are now firmly estab- of Adult Patients with Obstructive Sleep Apnea. Anesth Analg 2016;123(2):452-73. 13(2):273-80. lished. In contrast, there is little, if any data, linking individual disease states to 6. 6. Ladha KS, Patorno E, Huybrechts KF, Liu J, 16. Thorell A, MacCormick AD, Awad S, Reynolds N et al. Guidelines for perioperative care in bar- outcomes within ERAS pathways. There Rathmell JP & Bateman BT. Variations in the use of perioperative multimodal analgesic therapy. iatric surgery: Enhanced recovery after surgery are several lines of evidence suggesting Anesthesiology 2016;124:837-45. (ERAS) Society Recommendations. World J Surg that ERAS may be particularly beneficial 2016; 40:2065-83.

6 CON: Enhanced Recovery After Surgery (ERAS) for Patients with Obstructive Sleep Apnea (OSA)/ Sleep Disordered Breathing (SDB) Meltem Yilmaz, MD Department of Anesthesiology, Northwestern University

The argument against Enhanced Recovery 5. Educators for patients and their family primary outcome measure for majority of After Surgery (ERAS) for patients with ob- members and for all perioperative staff ERPs.9 structive sleep apnea can be summed up members involved in the care of these with the following six points. patients. Pearsall and colleagues from University of Toronto, listed the barriers to compliance First argument is the title: “Enhanced re- 6. Team leaders in charge of creating pro- as: lack of education for patients and fam- covery after surgery” does not describe tocols and following adherence to their ily members as well as medical staff; lack the intended purpose. It implies that en- specific areas of available resources such as not having hancement is happening after surgery. enough nurses to help with postoperative It also implies only surgeons and nurses The enormity and complexity of coordi- ambulation; not enough financial support. are involved and that the perioperative nating these groups is daunting! It is ex- Most importantly, inadequate buy-in from events are not included. More important- tremely difficult to achieve without ade- members of the perioperative team. The ly, it implies a surgeon driven process as quate resources, the buy-in from all of the reasons stated were resistance to change opposed to a multidisciplinary approach. parties involved and most importantly ad- due to rigid guidelines which were not all “Enhanced recovery program ‘(ERP) is ministrative and financial support. In an evidence based, poor communication and more fitting and for the remainder of this era of cost cutting, this may be the major lack of collaboration between team mem- discussion will refer to it as such. factor in rejecting the implementation of bers.7 such a protocol. Second point, is that the complexity of im- The fifth argument, is the financial burden plementing an ERP is colossal. It involves; The complexity in instituting an ERP for on the system in implementing such a pro- the OSA patient becomes even more chal- gram. In 2016, Stone and colleagues from 1. Multiple medical specialties such as lenging in that these patients may be hav- Johns Hopkins used a model that was de- anesthesiologists, sleep medicine (pul- ing a multitude of different for signed to analyze the net impact of a hos- monologists, neurologists, anesthesiol- various parts of their body making it diffi- pital implementing an ERP for colorectal ogists), surgeons, hospitalists. cult to have one specific protocol. Compli- surgery. Per their calculations, the cost for cating this further, is that patients may not a hospital that performs 100 cases a year 2. Multiple level of providers such as phy- have been identified as having OSA when starts at US $117,875 in the first year. The sicians including attendings, residents, they present for their surgery. cost for each consecutive year remains at and medical students; such as US $108,000.10 Despite the savings, which preoperative, operative room, postop- Third argument, is the fact that despite are based on early discharge of patients, erative care unit, intensive care unit, all the reported benefits of ERPs, reports there needs to be a large sum that needs perioperative floor nurses and nurse of challenges and failures abound. These to be dedicated to this process yearly. In anesthetists, nurse practitioners; phy- publications are by institutions that have another study from the same institution sician assistants, respiratory therapists, implemented ERPs which have not yield- assessing 30-day readmissions in patients pharmacists and physical therapists, ed the expected results, despite robust sys- in an ERP compared to patients in non- and nutritionists. tems in place.1-8 ERP, found that hospital length of stay 3. Administrative staff including hospital This may be due to my fourth argument, (LOS) was in fact shorter for patients in administrators, champions which is compliance and adherence to the ERP group. However, when they com- representing the different specialties, ERPs. Studies have identified a direct cor- pared the total number of hospital days resource coordinators, and represen- relation between compliance to ERPs and including the 30-day readmissions, the tatives from quality improvement and outcomes. For an ERP to succeed, a com- composite LOS did not differ between the 11 risk management, throughput coordi- pliance of greater than 70% is needed.1,8 two groups. nators, and patient representatives. Most studies however, document compli- Lastly, the sixth argument is that there is ance to be less than 65%.9 Even when the absolutely no evidence in the literature 4. Information technology teams for desired adherence rates are achieved, pa- that supports the benefit of having an en- electronic medical records, order set tients still fail early discharge which is the creation, protocol checklist to follow hanced recovery program for OSA/SDB. adherence, pop-up reminders to follow the protocol etc. >> CON: Enhanced Recovery continued on next page 7 >> CON: Enhanced Recovery continued from previous page

In summary, ERP for OSA is not feasible 4. Hoffman H et al. Fast-track surgery- Condi- 9. Hendry PO et al. Determinants of outcome after due to the six points made above. tions and challenges in postsurgical treatment: colorectal resection within an enhanced recov- A review of elements of translational research in ery programme. BJS 2009; 96: 197-206 ERAS. Eur Surg Res, 2012; 49:24–34 References: 10. Stone AB et al. Implementation Costs of an En- 5. Pedziwiatr M et al. Early implementation of hanced Recovery After Surgery Program in the 1. Keller DS, et al. Predicting who will fail early dis- ERAS protocol: Compliance improves outcomes: United States: A Financial Model and Sensitivity charge after laparoscopic with A prospective cohort study. Inter J of Surg, 2015; Analysis Based on Experiences at a Quaternary an established enhanced recovery pathway. Surg 21: 75-81 Academic Medical Center. J Am Col Surg, 2016; Endosc 2014; 28:74–79 222: 219-225 6. Bakker N et al. Eight years of experience with 2. Smart NJ et al. Deviation and failure of enhanced ERAS in patients with colon cancer: Impact of 11. Fabrizio AC et al. Is enhanced recovery enough recovery after surgery following laparoscopic measures to improve adherence. Surgery, 2015: for reducing 30-d readmissions after surgery? J colorectal surgery: early prediction model. Col- 157:1130-36 Surg Research 2017; 217:45-53 orectal Dis, 2012:1463-1318. 7. Pearsall EA et al. A Qualitative Study to Under- 3. Oh HK et al. Factors associated with failure of stand the Barriers and Enablers in implementing enhanced recovery protocol in patients undergo- an ERAS program. Ann Surg, 2015; 261: 91-96 ing major hepatobiliary and pancreatic surgery: a retrospective cohort study. Surg Endosc 2016; 8. Gustafsson UO Adherence to ERAS protocol 30:1086-93 and outcomes after colorectal cancer surgery. Arch Surg. 2011;146:571-577

STOP-Bang Questionnaire: A Screening Tool to Predict Postoperative Complications Mahesh Nagappa, MD Assistant Professor, Western University, Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care

Obstructive Sleep Apnea (OSA) OSA has have used the STOP-Bang tool to classify ± 2.8 days; pooled mean difference 2.01; a variable prevalence in the surgical popu- patients as HR-OSA and low-risk OSA 95% CI, 0.77–3.24; P = 0.005; Figure B). lation, with as high as 70% in the bariatric (LR-OSA) and shown a linear association Metaregression and sensitivity analysis surgical population.1 The presence of OSA between increasing postoperative compli- on various confounding factors and sub- is associated with higher postoperative ad- cations with higher scores.7 groups did not impact the final inference verse outcomes2 which poses an economic or results of postoperative complications burden by increasing the duration of hos- We published a systematic review and for HR-OSA versus LR-OSA groups. pital stay and health care expenditures.3 A meta-analysis of 10 studies with a total majority of OSA patients are undiagnosed of 23,609 patients (7877 HR-OSA versus Despite advancements in anesthetic and and untreated during the perioperative 15,732 LR-OSA) undergoing a variety of perioperative care, postoperative compli- period.4 The STOP-Bang is a validated surgical procedures: head and neck, tho- cations are still a significant problem in 2 screening tool to identify high-risk OSA racic, abdominal, vascular, genitourinary, OSA surgical patients. Two respective me- (HR-OSA) patients (STOP-Bang ≥3) in and orthopedic surgeries. Of these, 8 stud- ta-analyses on 13 and 17 studies found that 8–15 the perioperative period.5,6 The 8 dichot- ies were prospective and 2 were retro- adverse cardiopulmonary events were in- 7,16 omous items are , tiredness, ob- spective in nature. creased by 2- to 3-fold in OSA versus non- served apnea, high blood pressure, body OSA patients after noncardiac surgical Overall, postoperative complications were 2 mass index (BMI>35 kg/m2), age (>50 procedures. The American Society of An- almost 4-fold higher in HR-OSA versus years), neck circumference (male >43 cm; esthesia’s (ASA) Guidelines recommend- LR-OSA patients [pooled OR, 3.93; 95% female >41 cm), and male sex. Screening ed preoperative identification of patients confidence interval (CI), 1.85–7.77, P = 17 for OSA allows preoperative risk stratifi- with OSA. The recent Guidelines on the 0.003; Figure A]. The duration of the hos- cation and optimum perioperative man- Preoperative Screening and Assessment of pital stay was 2 days longer in HR-OSA agement with risk minimization, and OSA patients by the Society of Anesthesia versus LR-OSA patients (5.0 ± 4.2 vs 3.4 appropriate perioperative anesthetic man- agement. Several studies in the literature >> STOP-Bang Questionnaire continued on next page 8 >> STOP-Bang Questionnaire continued from previous page and Sleep Medicine also recommended the LR-OSA group resulting in the inher- reduced by 25 events/h and the duration screening for HR-OSA patients in the pre- ent differences between the groups. Fif- of hospital stay was 0.4 days less in treated operative period.18 Our meta-analysis pro- ty-two percent of the HR-OSA patients in versus untreated OSA patients.20 vides evidence to support the implemen- our analysis were ASA physical status III tation of the STOP-Bang tool to identify or greater. HR-OSA patients had a higher Our meta-analysis has some limitations: the HR-OSA patients in the perioperative prevalence of cardiovascular risk factors it included clinically and methodological- period to ensure risk stratification for HR- than LR-OSA patients. Hence identifying ly diverse studies, some of the important OSA patients. Patients with OSA may ex- and treating HR-OSA is an important step comorbidities like coronary artery disease, perience perioperative complications due to improve perioperative outcomes. IHD, and CHF were not reported by many to sedatives and opioids2, which inhibit of the studies. These unreported comor- the protective arousal reflex and reduce The STOP-Bang score 3 or greater has the bidities and other unknown confounding pharyngeal muscle tone, increasing upper best balance between sensitivity and spec- factors may have introduced some bias 6 airway collapsibility, and worsening the ificity. Depending on the prevalence of into our mean estimate. Despite these lim- existing OSA. Age, sex, BMI, and hyper- OSA in the surgical population, the cut- itations, our meta-analysis offers a com- tension are components of the STOP-Bang off of STOP-Bang score can be increased prehensive analysis of the available evi- scores, while diabetes mellitus, ischemic to detect moderate to severe OSA with a dence on the association of perioperative heart disease, and cerebrovascular disease higher accuracy. complications in HR-OSA patients under- are some of the accepted comorbidities of going surgical procedures. In conclusion, Limited data are available on the periop- OSA. These components along with the our meta-regression analysis suggests that erative management of HR-OSA patients. other associated comorbidities like smok- patients with HR-OSA had almost a 4-fold There is evidence that CPAP can be ben- ing and chronic obstructive pulmonary higher risk of postoperative complications. eficial in the perioperative setting.19 A re- disease contributes to higher prevalence of The duration of hospital stay was longer in cent meta-analysis found that the AHI was these diseases in HR-OSA compared with HR-OSA versus LR-OSA patients. This Figure >> STOP-Bang Questionnaire continued on next page

9 >> STOP-Bang Questionnaire continued from previous page analysis supports the implementation of 8. Vasu TS, Doghramji K, Cavallazzi R, Grewal R, Obstructive Sleep Apnoea Syndrome question- the STOP-Bang questionnaire as a periop- Hirani A, Leiby B, Markov D, Reiter D, Kraft naires for determining respiratory complica- WK, Witkowski T. Obstructive sleep apnea syn- tions during the perioperative period? J Clin erative risk stratification tool to identify drome and postoperative complications: Clini- Nurs 2016;25:1238–52. the HR-OSA patients. cal use of the STOP-Bang questionnaire. Arch Otolaryngol Head Neck Surg 2010;136:1020–4. 16. Proczko MA, Stepaniak PS, Quelerij M de, Lely References: FH van der, Smulders JF, Kaska L, Soliman Ha- 9. Lockhart EM, Willingham MD, Abdallah A mad MA. STOP-Bang and the effect on patient 1. Hallowell PT, Stellato T a, Petrozzi MC, Schus- Ben, Helsten DL, Bedair BA, Thomas J, Duntley outcome and length of hospital stay when pa- ter M, Graf K, Robinson A, Jasper JJ. Eliminat- S, Avidan MS. Obstructive sleep apnea screen- tients are not using continuous positive airway ing respiratory intensive care unit stay after gas- ing and postoperative mortality in a large surgi- pressure. J Anesth 2014;28:891–7. tric bypass surgery. Surgery 2007;142:608–12. cal cohort. Sleep Med 2013;14:407–15. 17. Gross JB, Bachenberg KL, Benumof JL, Caplan 2. Opperer M, Cozowicz C, Bugada D, Mokhlesi 10. Chudeau N, Raveau T, Carlier L, Leblanc D, RA, Connis RT, Coté CJ, Nickinovich DG, B, Kaw R, Auckley D, Chung F, Memtsoud- Bouhours G, Gagnadoux F, Rineau E, Lasoc- Prachand V, Ward DS, Weaver EM, Ydens L, is SG. Does obstructive sleep apnea influence ki S. The STOP-BANG questionnaire and the Yu S. Practice guidelines for the perioperative perioperative outcome? A qualitative systemat- risk of perioperative respiratory complications management of patients with obstructive sleep ic review for the society of anesthesia and sleep in urgent surgery patients: A prospective, ob- apnea: A report by the American Society of medicine task force on preoperative prepara- servational study. Anaesth Crit Care Pain Med Anesthesiologists task force on perioperative tion of patients with sleep-disordered breath- 2016;35:347–53. management of patients with obstructive sleep ing. Anesth Analg 2016;122:1321–34. apnea. Anesthesiology 2006;104:1081-93-8. 11. Acar H V, Yarkan Uysal H, Kaya A, Ceyhan A, 3. Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Dikmen B. Does the STOP-Bang, an obstruc- 18. Chung F, Memtsoudis S, Krishna Ramachan- Chung F, Meltzer DO. Sleep-disordered breath- tive sleep apnea screening tool, predict diffi- dran S, Nagappa M, Opperer M, Cozowicz C, ing and postoperative outcomes after elective cult intubation? Eur Rev Med Pharmacol Sci Patrawala S, Lam D, Kumar A, Joshi GP, Fleeth- surgery: Analysis of the nationwide inpatient 2014;18:1869–74. am J, Ayas N, Collop N, Doufas A, Eikermann sample. Chest 2013;144:903–14. M, Englesakis M, Gali B, Gay P, Hernandes A, 12. Corso RM, Petrini F, Buccioli M, Nanni O, Car- Kaw R, Kezirian E, Malhotra A, Mokhlesi B, 4. Singh M, Liao P, Kobah S, Wijeysundera DN, retta E, Trolio A, Nuzzo D De, Pigna A, Giacin- Parthasarathy S, Stierer T, Wappler F, Hillman Shapiro C, Chung F. Proportion of surgical pa- to I Di, Agnoletti V, Gambale G. Clinical util- DR, Auckley D. Society of Anesthesia and Sleep tients with undiagnosed obstructive sleep ap- ity of preoperative screening with STOP-Bang Medicine Guideline on Preoperative Screening noea. Br J Anaesth 2013;110:629–36. questionnaire in elective surgery. Minerva and Assessment of Patients With Obstructive Anestesiol 2014;80:877–84. Available at: http:// Sleep Apnea. Anesth Analg 2016;XXX:1–22. 5. Nagappa M, Liao P, Wong J, Auckley D, Ra- www.ncbi.nlm.nih.gov/pubmed/24280812. Ac- machandran SK, Memtsoudis S, Mokhlesi B, cessed October 6, 2017. 19. Liao P, Luo Q, Elsaid H, Kang W, Shapiro CM, Chung F. Validation of the STOP-Bang Ques- Chung F. Perioperative auto-titrated continu- tionnaire as a Screening Tool for Obstructive 13. Pereira H, Xará D, Mendonça J, Santos A, ous positive airway pressure treatment in sur- Sleep Apnea among Different Populations: A Abelha FJ. Patients with a high risk for ob- gical patients with obstructive sleep apnea: A Systematic Review and Meta-Analysis. PLoS structive sleep apnea syndrome: postoperative randomized controlled trial. Anesthesiology One 2015;10. respiratory complications. Rev Port Pneumol 2013;119:837–47. 2013;19:144–51. 6. Chung F, Yegneswaran B, Liao P, Chung S a., 20. Nagappa M, Mokhlesi B, Wong J, Wong DT, Vairavanathan S, Islam S, Khajehdehi A, Shap- 14. Xará D, Mendonça J, Pereira H, Santos A, Abel- Kaw R, Chung F. The effects of continuous posi- iro CM. STOP Questionnaire. Anesthesiology ha FJ. [Adverse respiratory events after general tive airway pressure on postoperative outcomes 2008;108:812–21. anesthesia in patients at high risk of obstructive in obstructive sleep apnea patients undergoing sleep apnea syndrome]. Rev Bras Anestesiol surgery: A systematic review and meta-analy- 7. Seet E, Chua M, Liaw CM. High STOP-Bang 65:359–66. sis. Anesth Analg 2015;120:1013–23. questionnaire scores predict intraoperative and early postoperative adverse events. Singapore 15. Gokay P, Tastan S, Orhan ME. Is there a differ- Med J 2015;56:212–6. ence between the STOP-Bang and the Berlin COMMITTEE SIGN-UP

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10 Postoperative Delirium and Sleep Apnea Sakura Kinjo, MD Clinical Professor, Anesthesia Medical Director, UCSF Orthopaedic Institute Anesthesia and Perioperative Care, University of California, San Francisco

Post-operative delirium (POD) POD, including sleep fragmentation co-morbidities (diabetes, obesity, met- and hypoxia. In patients with sleep abolic syndrome) which may increase Delirium is defined as a sudden change apnea, the risk of POD may be higher the risk of developing a hyper-inflam- in mental function. Symptoms of deliri- due to the patient having pre-existing matory state. The combination of sur- um may fluctuate during the course of a sleep-disordered breathing. gery induced neuro-inflammation and day and include attention deficit, disorga- a baseline pro/hyper-inflammatory nized thinking or an altered level of con- 2. Pre-existing cognitive impairment/low state may therefore possibly increase sciousness. It is one of the most common cognitive reserve the risk of delirium. post-operative complications in older Patients with OSA are at risk of neu- adults undergoing major surgery. POD has ropsychological problems including The Effect of Continuous Positive Airway significant health and economic impacts; memory deficits, cognitive decline, Pressure (CPAP) on Cognition it is associated with increased morbidity and mood disorders. Animal studies The review article Lam et al 3 also identi- and mortality, prolongs hospital stay and indicate that chronic continuous and/ increases costs of care. 1, 2 fied several studies on the effect of CPAP or intermittent hypoxia causes hippo- on cognition. Long term use of CPAP campal impairment;6 the region im- Is sleep apnea a risk factor for POD? helps to improve cognition. These stud- portant for learning and memory. In ies are typically conducted with at least 3 Sleep apnea is attracting attention as one fact, recent imaging studies indicate months of CPAP treatment. Therefore, of the causes of POD. The recent review that sleep apnea causes structural brain 7, 8 the effect on POD of shorter CPAP treat- article by Lam et al 3identified two relevant changes in multiple brain regions. ment has not been well investigated. In prospective observational studies.4, 5 A recent meta-analysis of population addition, CPAP therapy seems to have the studies suggests that individuals with 4 favorable effect of reducing night time cor- A clinical study by Flink et al, investigated sleep disordered breathing are 26% tisol levels.10 patients who are ≥ 65 years old, who un- more likely to develop cognitive im- derwent elective total knee arthroplasty. pairment. 9 Untreated sleep apnea may Does CPAP Prevent or Mitigate POD? Among 106 patients, 27 Patients (25%) de- make these patients vulnerable to de- veloped POD. Incidence of delirium was veloping POD, or increasing the sever- If sleep apnea increases the risk of devel- higher in OSA group than the non-OSA ity of POD. oping POD, then whether or not periop- group (53% vs 20%). Roggenbach et al5 erative use of a CPAP preventing deliri- investigated the incidence of POD in pa- 3. Hormonal changes um or mitigating the severity of delirium tients who underwent . In Hypoxic stress and a fragmentation of is an important question. Nadler and 13 their study, overall incidence of delirium sleep cause altered cortisol levels by af- colleagues studied 114 patients who was 48%. They concluded that patients fecting the hypothalamic-pituitary-ad- underwent joint replacement surgery. with a higher preoperative Apnea Hypo- renal axis.10 Cortisol is an important Patients at risk for sleep apnea (preoper- pnea Index (AHI) of 19 or higher showed hormone for cognitive function by ative STOP-Bang Score ≥ 3) were enrolled an almost 6-fold increased risk of POD binding to various brain receptors. in the study. Patients were randomized (odds ratio 6.4; confidence interval, 2.6 to High cortisol levels are associated with (CPAP therapy vs. routine perioperative 15.4; p< 0.001). cognitive impairment.11 care). In the CPAP group, CPAP was used before, and at least one night after surgery. POD in Sleep Apnea Patients 4. Neuro-inflammation Higher preoperative AHI was associated A recent study12 suggests that neu- with POD. However, perioperative use of There are some possible mechanisms of CPAP did not change the incidence or se- POD in sleep apnea patients. ro-inflammation induced by surgery is associated with cognitive chang- verity of POD. The effect of perioperative 1. Perioperative sleep fragmentation, es. Sleep apnea patients may be in a use (short course) of CPAP on POD needs deprivation/hypoxia pro/hyper-inflammatory state due to further research. Although the mechanism of POD has sleep-disordered breathing. In addi- not been well established, there are tion, sleep apnea patients often have multiple risk factors associated with >> Postoperative Delirium continued on next page 11 >> Postoperative Delirium continued from previous page

Clinical Implication 3. Lam EWK, Chung F, Wong J. Sleep-disordered 9. Leng Y, McEvoy CT, Allen IE, Yaffe K. Associ- breathing, postoperative delirium, and cogni- ation of sleep-disordered breathing with cogni- Sleep apnea is prevalent in older people, tive impairment. Anesth Analg. 2017;124:1626- tive function and risk of cognitive impairment: 1635 A systematic review and meta-analysis. JAMA and many with this condition are not diag- Neurol. 2017;74:1237-1245 nosed. Given an increasing geriatric pop- 4. Flink BJ, Rivelli SK, Cox EA, White WD, Fal- ulation, as well as the increasing number cone G, Vail TP, et al. Obstructive sleep apnea 10. Schmoller A, Eberhardt F, Jauch-Chara K, Sch- of patients with sleep apnea, the number of and incidence of postoperative delirium after weiger U, Zabel P, Peters A, et al. Continuous elective knee replacement in the nondemented positive airway pressure therapy decreases eve- patients with POD is expected to increase. elderly. Anesthesiology. 2012;116:788-796 ning cortisol concentrations in patients with There is growing evidence that sleep apnea severe obstructive sleep apnea. Metabolism. is an independent risk factor for POD. If 5. Roggenbach J, Klamann M, von Haken R, 2009;58:848-853 confirmed in larger controlled trials, sleep Bruckner T, Karck M, Hofer S. Sleep-disor- dered breathing is a risk factor for delirium af- 11. Lara VP, Caramelli P, Teixeira AL, Barbosa MT, apnea may represent a modifiable risk ter cardiac surgery: A prospective cohort study. Carmona KC, Carvalho MG, et al. High corti- factor for reducing the incidence of POD. Crit Care. 2014;18:477 sol levels are associated with cognitive impair- Screening for both cognitive decline and ment no-dementia (cind) and dementia. Clin 6. Feng J, Wu Q, Zhang D, Chen BY. Hippocampal Chim Acta. 2013;423:18-22 sleep apnea prior to surgery may improve impairments are associated with intermittent the care of this vulnerable population. hypoxia of obstructive sleep apnea. Chin Med 12. Feng X, Valdearcos M, Uchida Y, Lutrin D, Maze J (Engl).125:696-701 M, Koliwad SK. Microglia mediate postopera- References tive hippocampal inflammation and cognitive 7. Macey PM, Kumar R, Woo MA, Valladares decline in mice. JCI Insight. 2017;2:e91229 1. Marcantonio ER, Goldman L, Mangione CM, EM, Yan-Go FL, Harper RM. Brain structur- Ludwig LE, Muraca B, Haslauer CM, et al. A al changes in obstructive sleep apnea. Sleep. 13. Nadler JW, Evans JL, Fang E, Preud’Homme clinical prediction rule for delirium after elec- 2008;31:967-977 XA, Daughtry RL, Chapman JB, et al. A ran- tive noncardiac surgery. JAMA. 1994;271:134- domised trial of peri-operative positive airway 139 8. Canessa N, Castronovo V, Cappa SF, Aloia MS, pressure for postoperative delirium in patients Marelli S, Falini A, et al. Obstructive sleep ap- at risk for obstructive sleep apnoea after re- 2. Edlund A, Lundstrom M, Brannstrom B, Bucht nea: Brain structural changes and neurocogni- gional anaesthesia with sedation or general G, Gustafson Y. Delirium before and after op- tive function before and after treatment.Am J anaesthesia for joint arthroplasty. Anaesthesia. eration for femoral neck fracture. J Am Geriatr Respir Crit Care Med. 2011;183:1419-1426 2017;72:729-736 Soc. 2001;49:1335-1340

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12 Summary of SASM 2017 Annual Meeting Mandeep Singh, MD, FRCPC Assistant Professor, University of Toronto, Department of Anesthesia, Toronto Western Hospital, University Health Network

The Society of Anesthesia and Sleep Med- Following from the dis- icine’s 7th Annual Meeting was held in cussion on challenges Boston, MA on October 19-20, 2017. The in conducting research, theme of this year’s meeting was “Periop- the next session dealt erative and Sleep Medicine: Controversies with “Challenges in the and Challenges”. From the conception of Practice of Sleep Medi- the theme, to design of the program to its cine:”, and was moder- implementation, the scientific meeting ated by Peter Gay, MD. was a great success. Following on from A Pro-Con session on previous meetings, the program targeted “Sleep Labs are Obsolete audience from multiple disciplines such as for Perioperative As- sleep medicine, anesthesiology, ENT sur- sessment of Sleep-Dis- gery, nursing and respiratory therapy. ordered Breathing” was well received by the au- The program began on October 19, 2017 dience, where Dr. Lau- with informative presentations on ‘’Re- rence Epstien (Pro), and search in Perioperative Sleep Medicine’’ Dr. Susheel Patil (Con) met MD, who presented “The Opioid which was moderated by Babak Mokhlesi, presented their cases with presentation of Epidemic, Chronic Pain Syndromes and MD, MSc. The first presentation was by published literature, and some light hu- the Patient with Sleep-Disordered Breath- Susana Vacas, MD, PhD, on “Most Influ- mor. Satya Krishna Ramachandran MD, ing”, followed by the next Keynote Speak- ential Publications in Perioperative Sleep MBBS, later talked about “Postoperative er, Dean Hess PhD, RRT, who talked about Medicine”, followed by an excellent pre- Monitoring for Patients with Sleep Apnea: “Traditional and Novel Ways to Moni- sentation on “Designing Clinical Trials in The Good, The Bad and the Useless”, -in tor Patients in the Post- Operative Peri- Perioperative Sleep Medicine: A Ratio- cluding his own published and un-pub- o d ”. Several important topics related to nale and Pragmatic Approach”, by Daniel lished work. sleep-disordered breathing were present- Gottlieb, MD, MPH. It was emphasized ed by world experts, including interaction that more research is needed to evaluate The Welcome Reception and Dinner on of opioids and pain perception; postop- the impact of diagnosing sleep-disordered the opening night of the meeting was erative delirium; hypercapnic respiratory breathing in the perioperative period and hosted by the SASM President, Girish failure; influence on postoperative recov- the challenges in conducting research Joshi MBBS, MD, FFARCSI. The evening ery; legal implications in the perioperative were highlighted. was graced by a very thoughtful talk by period. Koby Sheffy on “Nov- el Ways of Diagnos- The SASM Guidelines Committee present- ing Sleep-Disordered ed the work conducted over the last year, Breathing”, where the and this session was chaired by Frances history of development Chung, MBBS, FRCPC. Dennis Auckley, of sleep diagnostic de- MD talked about “Perioperative Manage- vices was discussed ment of the Patient with Narcolepsy”. This and the current tech- was followed by presentation of findings nological advances and of the “Intraoperative Management of Pa- newest devices were tient with Sleep Apnea” by Mahesh Nagap- highlighted. pa MD (Airway Management), Jean Wong MD (Drug Responses), and Crispiana Co- The second day of the zowicz, MD (Anesthesia Techniques). meeting was highlight- ed by the first Keynote In addition to the outstanding scientif- speaker, Chad Brum- ic program, many interesting research >> SASM 2017 Annual Meeting continued on next page 13 >> SASM 2017 Annual Meeting continued from previous page abstracts were presented. Vidya Raman MD, presented her 2016 SASM Research Grant winning abstract titled, “Using Questionnaire Tools to Predict Pediatric OSA Outcomes.” The Abstract Awards were presented and the first place award for the best Abstract went to Talha Mubashir, MD for his abstract “Continuous Positive Pressure Therapy Improves Symptoms of in Elderly Patients with Ob- structive Sleep Apnea: A Systematic Re- view and Meta-analysis of 11 RCTs”. The second place award went to Lukas Pichler MD, for the abstract, “The Perioperative Impact of Sleep Apnea in a High-Volume Practice with Focus on Regional Anesthesia”, and third place award went to Crispiana Cozowicz MD, for “Multimodal Analgesia and Opioid Prescription Levels in Sleep Apnea Patients Undergoing Total Hip and Knee Arthroplasties - A Population Based Study”.

The next SASM Annual Meeting will be held in San Francisco, CA on October 12, 2018.

2017 Annual Meeting Abstract Winners

1st Place – Jayadeep Patra, PhD 2nd Place – Lukas Pichler, MD 3rd Place – Crispiana Cozowicz, MD Abstract: Continuous Positive Pressure Abstract: The Perioperative Impact of Abstract: Multimodal Analgesia and Opi- Therapy Improves Symptoms of Depres- Sleep Apnea in a High-Volume Specialty oid Prescription Levels in Sleep Apnea sion in Elderly Patients with Obstructive Practice with Focus on Regional Anesthe- Patients Undergoing Total Hip and Knee Sleep Apnea: A Systematic Review and sia Arthroplasties - A Population Based Study Meta-analysis of 11 RCTs

14 2018 SASM Board of Directors President Treasurer Director Babak Mokhlesi, MD Anthony Doufas, MD, PhD Najib Ayas, MD University of Chicago Stanford University University of British Columbia

President-Elect Secretary Director Stavros Memtsoudis, MD, PhD Dennis Auckley, MD Nancy Collop, MD Weill Cornell Medical College MetroHealth Medical Center/Case Emory Sleep Center (HSS) Western Reserve University Director Past President Director Christine Won, MD Girish Joshi, MB, BS, MD, David Hillman, MBBS, FANZCA, Yale University School of Medicine FFARCSI FRCP, FRACP University of Texas Southwestern Sir Charles Gairdner Hospital Director Medical Center Satya Krishna Ramachandran, MD, MBBS Beth Israel Deaconess Medical Center Committee & Subcommittee Chairs & Co-Chairs Bylaws Committee Conference Committee Membership Committee David Hillman, MBBS, FARACS, Stavros Memtsoudis, MD, PhD Stavros Memtsoudis, MD, PhD FANZCA (Chair) (Chair) (Chair) Babak Mokhlesi, MD (Co-Chair) Melted Yilmaz, MD (Co-Chair) Clinical Committee Ellen Soffin, MD, PhD (Vice- Bhargavi Gali, MD Education Committee Chair) (Co-Chair) Stavros Memtsoudis, MD, PhD Dennis Auckley, MD Babak Mokhlesi, MD Communications Committee (Co-Chair) Girish Joshi, MB, BS, MD, Michael Pilla, MD (Chair) FFARCSI Obstetric Subcommittee Research Committee Jennifer Domingues, MD, MHS Newsletter Subcommittee Anthony Doufas, MD, PhD (Chair) Jean Wong, MD (Chair) (Chair) Mandeep Singh, MBBS, MD, MSc, Roop Kaw, MD (Co-Chair) Pediatric Subcommittee FRCPC (Vice-Chair) Kimmo Murto, MD, FRCPC Abstract Subcommittee (Chair) Scientific Updates Subcommittee Malin Fagerlund, MD, PhD (Co- Rajeev Subramanyam, MD, MS Susana Vacas, MD, PhD (Chair) Chair) (Co-Chair) Toby Weingarten, MD IARS/ASA/ATS/AASM Liaison (Co-Chair) Sleep Medicine Clinical Practice Subcommittee Subcommittee David Hillman, MBBS, FARADS, Dale Capener, MD (Chair) FANZCA (Co-Chair) Frances Chung, MBBS, FRCPC Peter Gay, MD (Co-Chair) (Co-Chair)

15 SASM Membership Benefits at a Glance…

The mission of SASM is to advance standards of care for clinical challenges shared by Anesthesiology and Sleep Medicine, including perioperative management of sleep disordered breathing, as well as to promote interdisciplinary communication, education and research in matters common to anesthesia and sleep. Benefits of SASM Membership include: • Significantly Reduced Registration Fees at SASM Sponsored Scientific Meetings • SASM Newsletter • *Full Voting Rights in Electing SASM Board of Directors and SASM Officers (*Dependent on membership category) • Regular Receipt of “Literature Updates” and “Featured Articles,” Allowing All Members to Stay Current on New Developments in the Area • Enhances Your Network of Regional, National and International Colleagues • Learn of Collaborative Research Projects • Educational Material Posted on SASM Website for Members • Access to a “Discussion Forum” to Evaluate and Discuss the Latest Research, Education and Clinical Practices Pertaining to OSA and Patients with Other Sleep-Disordered Breathing • Get Advice and Counsel from Other Members Regarding Various Practice Paradigms

SASM Classes of Membership: ▶▶ Gold Patron Member - $250 ▶▶ Associate Member - $65 • Showing special support for SASM. This donation is inclusive • Non- and non- of annual membership and available for all classes of scientists, without voting rights. membership. ▶▶ Active Member - $115 ▶▶ Educational Member - $65 • Physician and scientist members with the ability to vote, hold • Fellows, residents, medical office and serve as Directors on the Board. students and other ▶▶ International Active Members - $40 undergraduates, without voting • Physician and scientist members, who practice outside of the rights. United States or Canada, with the ability to vote, hold office and serve as Directors on the Board.

To become a member of SASM, please visit our website and click on the Membership tab: www.SASMhq.org You can also mail a check to our office: SASM 6737 W Washington Street, Suite 4210 Milwaukee, Wisconsin 53214

SASM is a 501(C)(3) non-profit organization. Membership dues may be deductible as a business expense. SASM Tax ID number is 27–4613034

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