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Society of Anesthesia & Sleep Medicine Newsletter Society of Anesthesia & Sleep Medicine Newsletter Volume 3 u Issue 2 u 2014 Message from the President tabase, Memtsoudis and colleagues extracted data on 530,089 patients who underwent total hip or total knee arthroplasty between 2006 and 2010 in nearly 400 hospitals in the United States. 12 OSA was present in Frances Chung, MBBS, FRCPC 8.4% of the cohort based on the In- President, SASM ternational Classification of Diseases 9th Revision-Clinical Modification Professor, Department of Anesthesiol- (ICD-9-CM) diagnostic codes. With ogy, Toronto Western Hospital, University continued on page 3 Health Network, University of Toronto President’s Message ��������1, 3-4, 6 bstructive sleep apnea (OSA) bate upper airway collapsibility and is a prevalent disorder char- blunt the arousal response. Editor’s File ��������������������������������2 acterized by recurrent epi- Several single-institution stud- Holding Your Breath…� Osodes of complete or partial collapse Too Long� ������������������������������ 5-6 ies have reported an association of the upper airway during sleep between OSA and a myriad of Apnea And Prematurity: A Need leading to intermittent hypoxemia adverse postoperative outcomes. For Better Understanding To and hypercapnia as well as sleep 8-11 In the absence of large-scale Improve Perioperative Neonatal fragmentation. A recent community- well-controlled prospective studies, Care ����������������������������������7-8, 13 based study reported an increasing analysis of administrative databases Strategies To Understand And prevalence of OSA in parallel with can shed some light on the associa- 1 Modify Postoperative Cognitive the obesity epidemic. Concur- tion between OSA and postoperative rently, the number of surgical cases Dysfunction: A Sleep outcomes and provide data that is Perspective ���������������������9-10, 13 performed globally is increasing. In more generalizable than single- fact, Weiser and colleagues estimated center smaller studies. This is of Sleep Apnea: An Update Of that 234 million major surgeries importance because implementation Pharmacologic Therapies �� 11-13 were performed in 2004 worldwide. of systematic screening for OSA and STOP-BANG ���������������������������14 2 Although the reported prevalence initiating treatment in the periop- SASM Department Membership of OSA in presurgical cohorts has erative period for those patients at Information ����������������������������15 varied, undoubtedly the vast major- risk would impose a significant cost SASM 2014 Annual Meeting ity of anesthesiologists are bound burden, particularly in the setting of Schedule of Events ��������������16-17 to encounter patients with OSA in large surgical volumes. their daily clinical practice. 3-7 This is SASM Officers & Board of In an observational study performed of clinical relevance since sedatives, Directors ���������������������������������18 narcotics and anesthetics can exacer- using the Premier Perspective da- SASM Member Benefits ����������18 Editor’s File Satya Krishna Ramachandran, MD, FRCA Editor Assistant Professor in Anesthesiology and Director of Perioperative Quality Improvement University of Michigan, Ann Arbor, MI USA The Trouble with Teams he trouble with teams is that considerations in determining the therapy are more likely to use it in the every team member has to available time between preoperative early postoperative period. Thus, key share the same mental model clinic visit and surgical date. Two, metrics of success of the preoperative Tnecessary to achieve a goal. The the need for pre-authorization of surgical home should include PAP advent of a few key team concepts key steps in polysomnography and rates in patients screened to be high in perioperative medicine, notably positive airway pressure (PAP) fitting risk for OSA, and PAP adherence the perioperative surgical home and introduces a minimum delay of days rates in patients with known OSA. We enhanced recovery protocols, are between steps, with additional steps look to expert bodies like the SASM to set to change the culture of patient needed postoperatively to maintain provide more detailed process guides care in the coming years. These therapy. At the risk of preaching to to help develop OSA protocols for processes have a direct impact on our the converted, the evidence that PAP local implementation. ability to efficiently screen and treat treatment of OSA has a large impact conditions such as sleep disorders on surgical outcomes is accumulating Introducing a perioperative OSA before elective surgery, employ robust rapidly. Dr. Babak Mokhlesi’s recent protocol in the framework of a busy risk reduction strategies and enable studies highlight better outcomes perioperative surgical home would effective postoperative care. I would in patients with sleep disordered address many of the challenges we like to talk about one such function breathing, largely driven by the face. But, for these fairly complex that has direct implications to our temporary and early presentation of processes to take root, it is imperative interest in sleep disorders. As several postoperative respiratory failure. The for us to participate in the planning of us have already experienced, a studies also describe a greater usage and implementation of these surgical tremendous amount of effort and of postoperative PAP in patients with homes. I’m sure we all will have investment is required to coordinate SDB. Squadrone previously showed a slightly different experiences of implementation of a preoperative several-fold reduction of respiratory the surgical home team, but our fast-track sleep study protocol. Our failure when PAP was used to treat common goal should remain the efforts are typically challenged by early postoperative hypoxia. This is allocation of appropriate resources two major constraints: one, surgical relevant to the perioperative surgical to this population of patients who scheduling preferences and urgency home because patients who are are at greater risk of postoperative of surgery are still the most important adherent with preoperative PAP complications. Go team! v 2 Society of Anesthesia & Sleep Medicine w Volume 3 w Issue 2 w 2014 Message from the President continued from page 1 robust statistical methodology fibrillation� 14,15 A recent meta- complications do not lead to an and after adjusting for important analysis of 13 single-center stud- increase in in-hospital mortality. confounders, they found that OSA ies also demonstrated a higher A few possibilities include obesity was independently associated incidence of respiratory failure, paradox or ischemia precondition- with increased odds ratio for cardiac events and ICU transfers ing playing a protective role.17-20 It the composite outcome of ma- in patients with OSA� 8 is also possible that OSA patients jor postoperative adverse events In the study by Memt- with impending respiratory failure (OR 1�47; 95% CI 1�39-1�55)� The soudis et al, despite the increased were recognized earlier and defini- association was stronger with pul- rates of complications, there was tive treatment (i.e. endotracheal monary complications (OR 1�86; no significant increase in the risk intubation or NIV) was imple- 95% CI 1�65-2�09) than cardiac of in-hospital mortality in patients mented in a more timely fashion. complications (OR 1�59; 95% CI with OSA. 12 In patients undergo- Indeed, Mokhlesi et al reported 1�48-1�71) with the risk of cardiac ing elective surgeries and bariatric that in the subgroup of postopera- complications mainly due to atrial surgeries OSA was also found not tive patients who were emergently fibrillation� The risk of emergent to be associated with increased in- reintubated, reintubation occurred reintubation was significantly in- hospital mortality. 14,15 D’Apuzzo et significantly earlier in OSA pa- 14,15 creased in patients with OSA (OR al examined a cohort of 258,488 pa- tients. Another speculation 10.26; 95% CI 9.01-11.69). OSA tients undergoing revision total hip is that some of the patients with- patients without hypertension and arthroplasty or total knee arthro- out a diagnosis of OSA may have COPD were 14 times more likely plasty surgeries between 2006-2008. had unrecognized OSA leading to to receive mechanical ventilation Contrary to these studies, OSA was an under-estimation of mortality 5-7 and 46 times more likely to under- associated with increase in-hospital rates. Indeed, studies utilizing go non-invasive ventilation. OSA mortality (odds ratio 1.9; 95% CI cohorts from databases to identify was also independently associated 1.3-2.8) with a mortality of 0.2% in OSA patients are bound to include with escalation of care, increased patients without OSA and 0.4% in only those patients with diagnosed health care resource utilization patients with OSA.16 However, this OSA, leaving us to wonder, if 12 and length of stay� study only included patients under- outcomes in undiagnosed patients The types of complications associ- going revision arthroplasty which may be worse. Irrespective of the ated with OSA reported by Memt- may suggest a higher comorbidity reasons for these findings, however, soudis and colleagues are similar to burden. one should not lose sight of the fact the findings from a recent analysis that mortality is a rare outcome in So what do these results tell total hip and knee arthroplasties of the Nationwide Inpatient Sam- us? First and foremost, it appears 14,15 and that other more frequently en- ple. Mokhlesi et al examined a that OSA is consistently and inde- cohort of 1,058,710
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