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Society of Anesthesia and Sleep Medicine Guideline On E SPECIAL ARTICLE Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea Stavros G. Memtsoudis, MD, PhD, Crispiana Cozowicz, MD, Mahesh Nagappa, MD, Jean Wong, MD, FRCPC, Girish P. Joshi, MBBS, MD, FFARCSI,║ David T. Wong, MD, FRCPC, Anthony G. Doufas, MD, PhD, Meltem*† Yilmaz, MD, Mark H. *Stein,† MD, ‡ Megan L. Krajewski, MD,§ Mandeep Singh, MBBS, MD, MSc, FRCPC, Lukas Pichler,§ MD, Satya Krishna Ramachandran,¶ MD, and Frances #Chung, MBBS, FRCPC** †† ‡‡§§¶¶## *† The purpose of the Society*** of Anesthesia and Sleep Medicine Guideline§ on Intraoperative 07/07/2018 on BhDMf5ePHKbH4TTImqenVLeEdd5NVDXpsv/wMCbE4bP6HQREYnIxByUL3Ye/wWTshIKnEwtQwdU= by http://journals.lww.com/anesthesia-analgesia from Downloaded Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommenda- tions based on current scientific evidence. This guideline seeks to address questions regarding Downloaded the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies from with regard to study design and execution in this perioperative field, recommendations were http://journals.lww.com/anesthesia-analgesia to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the by groundwork of a comprehensive systematic literature review, these recommendations reflect the BhDMf5ePHKbH4TTImqenVLeEdd5NVDXpsv/wMCbE4bP6HQREYnIxByUL3Ye/wWTshIKnEwtQwdU= current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence. (Anesth Analg XXX;XXX:00–00) he purpose of the Society of Anesthesia and Sleep patient populations, specifically those with obesity, was Medicine (SASM) Guideline on Intraoperative considered if appropriate. When this was the case, it is TManagement of Adult Patients With Obstructive explicitly stated in various parts of this document. Sleep Apnea (OSA) is to present recommendations based The guideline presented may not be suitable for all clini- on the available scientific evidence. In light of a paucity cal settings and patients. Thus, its consideration requires an of well-designed, high-quality studies in this periopera- assessment of appropriateness by clinicians on an individ- tive field, a large part of the present recommendations was ualized basis. Among many factors, the existence of insti- developed by experts in the field taking into account pub- tutional protocols, individual patient-related conditions, lished evidence in the literature and utilizing consensus the invasiveness of an intervention, and the availability processes, including the grading of the level of evidence. At of resources need to be considered. The present practice times, when specific information on patients with OSA was guideline is not intended to define standards or represent on not available in the literature, evidence in highly correlated absolute requirements for patient care. Adherence to this 07/07/2018 From the Department of Anesthesiology, Critical Care & Pain Management, Department of Anesthesia, Critical Care, and Pain Management, Beth Weill Cornell Medical College and Hospital for Special Surgery, New York, Israel Deaconess Medical Center, Boston, Massachusetts; Department of New York;* Department of Anesthesiology, Perioperative Medicine and Anesthesia,†† University of Toronto, Toronto, Ontario, Canada; Toronto Sleep Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; and Pulmonary Centre, Toronto, Canada; Department of‡‡ Anesthesia and Department† of Anesthesia and Perioperative Medicine, London Health Pain Management, Women's College Hospital, Toronto, Canada;§§ Toronto Sciences Centre and St Joseph’s Health Care, Western University, London, Western Hospital, University Health Network,¶¶ Toronto, Ontario, Canada; Ontario,‡ Canada; Department of Anesthesia and Pain Medicine, Toronto and Department of Anesthesiology, Harvard Medical School, Beth## Israel Western Hospital, University Health Network, University of Toronto, Toronto, Deaconess Medical Center, Boston, Massachusetts. § *** Ontario, Canada; ║Department of Anesthesiology and Pain Management, Accepted for publication March 27, 2018. University of Texas Southwestern Medical School, Dallas, Texas; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Funding: None. Medical Center, Palo Alto, California; Department of Anesthesiology,¶ Conflicts of Interest: See Disclosures at the end of the article. Northwestern University, Chicago, Illinois; Department of Anesthesiology, Supplemental digital content is available for this article. Direct URL citations Rutgers-Robert Wood Johnson Medical School,# New Brunswick, New Jersey; appear in the printed text and are provided in the HTML and PDF versions of ** Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. this article on the journal’s website (www.anesthesia-analgesia.org). on behalf of the International Anesthesia Research Society. This is an open- LMA Unique is a registered trademark of Teleflex Incorporated or its affiliates. access article distributed under the terms of the Creative Commons Attribu- tion-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it Reprints will not be available from the authors. is permissible to download and share the work provided it is properly cited. Address correspondence to Stavros G. Memtsoudis, MD, PhD, Departments The work cannot be changed in any way or used commercially without per- of Anesthesiology, Critical Care & Pain Management and Public Health, mission from the journal. Weill Cornell Medical College and Hospital for Special Surgery, 535 E 70th St, DOI: 10.1213/ANE.0000000000003434 New York, NY 10021. Address e-mail to [email protected]. XXX 2018 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 E SPECIAL Article guideline cannot guarantee successful outcomes but rather patients with OSA. Therefore, a careful examination of the should aid health care professionals and institutions to for- current literature using a systematic review approach with mulate plans for improved management of patients with a focus on airway management, commonly used anesthe- OSA. The present recommendations reflect the current state sia-related drugs and agents, and anesthetic techniques in of knowledge and its interpretation by a group of experts in this patient population was conducted. The task force rec- the field at the time of publication. Periodic reevaluations ognizes that there has been recent progress in attempts to of the literature will be needed, and novel scientific evi- subcategorize patients with OSA according to anatomic dence should be considered between updates. Deviations predisposition, arousal thresholds, muscle responsiveness, from this guideline in the practical setting may be justifi- and ventilatory control characteristics.15 However, given the able, and such deviations should not be interpreted as a lack of evidence in this context, statements were made refer- basis for negligence claims. ring to patients with OSA as a general group. Nevertheless, OSA is a common and frequently undiagnosed disor- phenotypic subcategorization may allow the development der defined by the repeated collapse of the upper airway of individual risk profiling in the future. with resultant blood oxygen desaturation events dur- ing sleep.1,2 OSA has been associated with adverse long- Aims term health outcomes and has been linked to increased The aim of this guideline was to present recommendations perioperative complication risk.3–5 Indeed, a comprehen- based on the best current evidence. Clinical research as it sive review of the literature performed by a task force relates to best perioperative practices in OSA is burdened by appointed by SASM revealed substantial risk for adverse numerous difficulties. The intraoperative setting involves a events, especially pulmonary complications, to be associ- multitude of concurrent interventions and use of anesthetic ated with OSA in the perioperative period.6 Based on the medications, making it difficult to single out specific factors elevated risk for perioperative complications, the recently that potentially drive the adverse outcome. Lack of preoper- published SASM Guideline on Preoperative Screening ative polysomnography data within publications represents and Assessment of Adults With Obstructive Sleep Apnea a further challenge, making it difficult to include informa- recommends that attempts should be made to appropri-
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