Perioperative Care in OSA Surgery Disclosures Apnicure Minor stock holder – sleep apnea device Siesta Medical Minor stock holder – sleep apnea device Patent Pending 61/624,105 Sinus diagnostics and therapeutics Andrew N. Goldberg, MD, MSCE Professor Department of Otolaryngology-Head and Neck Surgery University of California-San Francisco Anesthesia and Non-Airway Surgery Overview in OSA Patients • Anesthetic Risk in Non-OSA patients • 80% of patients with OSA undiagnosed • Prevalence of Complications in OSA Surgery (Young 2002) • Risk Factors • 22% of general surgical patients have OSA • Peri-Operative Planning (Finkel 2009) • Avoidance of Complications •70% of these undiagnosed 1
Perioperative Outcomes in OSA Patients Effects of Anesthesia on OSA Patients • OSA patients experience higher periop • Exacerbates pharyngeal collapse complication rates • Blunts arousal from sleep – Higher reintubation rates • Reduce muscle tone – Hypercapnia • Depress ventilation – Oxygen desaturation • Apneic episodes increase by 50% with – Cardiac arrhythmias and cardiac injury modest doses of fentanyl – Unplanned ICU transfer Waters 2002, Bachar 2008, Strauss 1999 – Delirium Airway Changes with Induction Screening Tools for OSA in Anesthesia • Loss of Genioglossus activity (Leiter 1984) • The Berlin Questionnaire • Loss of hypoglossal nerve activity (Hwang 1983, • American Society of Anesthesiologist checklist Nishino 1984) • STOP-Bang – Snoring, Tiredness, Observed apnea, elevated BP, BMI (35), Age(50), Neck circumfrence(40), male Gender Because of these and other changes, the larynx opens, – Predicted post op complications, esp respiratory (Chung 2008) but moves anteriorly, while the tongue slips backwards An easy awake DL does not necessarily mean and easy asleep DL (Sivarajan 1990) 2
Intraoperative Management Post - Operative Care • Regional Anesthesia with minimal sedation • Pts are at risk for hypoxia and hypercapnia • Minimize perioperative opioids • HOB a 30 degrees • Pre-oxygenate with 100% O2 for 3-5 mintues • CPAP can improve airway postoperatively if used • Ancillary intubation techniques PRE-operatively (reduces airway edema) (Gupta 2001) – Awake fiberoptic intubation • Have patients bring CPAP and use it postoperaively – Glide Scope – Laryngeal Mask Airway • Carefully titrate opioids – Tracheotomy Peri-Op Complications in Surgery for OSA Estimate of Peri-Op Complications • Survey of Surgeons who performed UP3 • Review at U of W • 72 respondents over 9 years • All patients from 1982 - 1987 – Determine incidence • 46 nasopharyngeal stenosis • 16 fatalities, 7 “ near fatalities ” – Identify risk factors • 42 palatal incompetence – Recommendations for peri-op management – 3/23 hemorrhage – 3/23 undetermined deaths – 17/23 airway loss Fairbanks 1990 Esclamado 1989 3
Incidence of Complications Medical Risk Factors • Overall - 13% (18/135) No Comp Comp • Airway 77% (14/18) N 117 18 Esclamado 1989 Age (years) 50.7 42.7 Sex (F:M) 1:16 1:18 – Failed Intubation 7 % IBW 145 155 – Airway post-extubation 7 Min O2 Sat 79 66 p< .001 – Post-op hemorrhage 4 AI 57 75 p< .02 Arrhythmias 13 6 Co-Morbidity also not significant Esclamado 1989 Surgical Risk Factors Anesthetic • For UP3 +/- tonsillectomy, Septoplasty, Tracheotomy No Comp Comp • No difference based on procedure or concomitant Narcotic µg/min 2.7 9.5 p< .005 nasal procedure Narcotic µg/kg 1.7 2.9 p< .008 IBW comparison 145 178 p< .06 Intubation comp. Esclamado 1989 Use of narcotics not influenced by IBW Narcotics only a factor in extubation complications Muscle relaxants not a factor Esclamado 1989 4
Risk Factors for Complications - Epidemiology Incidence of Complications • Analyzed 3130 patients from previous study • Review of 3130 patients s/p UP3 at VA hospitals – Comorbidity 2x risk for each ASA grade increase • Data gathered 1991 – 2001 – 5x risk for UP3 + non-nasal OSA procedure (BOT, etc) Kezirian Archives of OTO-HNS 2006 • Serious complication rate 1.5% • Subset analysis of 43 with case controls • Fatality rate 0.2% Observe association of complications – AHI, BMI and co-morbidity also associated with complications Kezirian Laryngoscope 2004 • May not be independent – Tongue procedures independently associated with complications – LSAT not associated with complications Kezirian Archives of OTO-HNS 2006 Pre-Operative Assessment Pre-Operative Planning • Previous Anesthetics • Optimize medical condition • Routine Systems Review – Internist/Pulmonologist/Cardiologist – Hypertension, CAD, CHF, Arrhythmias – Chest Pain – Chronic hypoxemia and high catecholamines – Palpitations Imaizumi 1980 – Shortness of Breath • Secure monitored bed – GERD – Pulse ox; Telemetry for selected patients • Aspirin, NSAIDS, ginko biloba, vitamin E • Arrange post-op CPAP – May have patient bring in home unit 5
Operative Securing the airway • Oral if appropriate (Fujita I or II (a)) • Plan method of securing airway with – Establish ventilation prior to paralysis if possible anesthesiologist • Awake, fiberoptic nasal • Have contingency plan ready – Adequate topical anesthesia is critical • Careful titration of sedative agents during the case • Glide Scope • Recheck oral cavity edema prior to extubation • Laryngeal Mask Airway – especially if multilevel surgery is done – Special configuration for intubation through LMA • Have a doctor at intubation and extubation who is • Tracheotomy prepared to secure a surgical airway if needed – Awake or post intubation • Other methods Awakening Post-operative • Full reversal of muscle relaxants • ICU monitoring? restored - avoid “ deep extubation ” • Extubate when patient is awake and reflexes are • Pulse ox monitoring? • Cardiac monitoring? – May delay extubation 24 - 48 hours • Intensive BP monitoring? – Steroids may be given to decrease edema – Faux conscious state (Rafferty 1980) • Have nasal trumpet and oral airway available • Tracheotomy tray should be immediately available 6
Acute Effects of UP3 Post-operative • 125 surgical procedures • AHI remains relatively stable at POD 2 – 71 with multilevel surgery – AI generally decreased, HI increased – mean RDI 38, BMI 29 • Significant increase in a-a gradient during wakefullness • No need for monitoring • Recommend – most common issue was BP control – Monitoring of O2 post-op – 1 patient with airway obstruction immediately post op – No prophylactic tracheotomy – no bleeding during hopsitalization – CPAP if AHI persistently high • Cannot determine high risk patients pre-op Sanders 1988 Terris 1998 Post-Operative Post-Operative Resources Used • 42 patients s/p UP3 • 117 patients s/p UP3 w/ or w/o other procedures • AHI 47; Desat nadir 76% • No major complications • Respiratory events in up to 11% • Hemorrhage in up to 14% • Hospital resource utilization examined – Immediately post op or after ~3 days – PO intake 305 cc in first 12 hours • Virtually all complications occurred w/in 3 hours – Average nursing care needed level 3 (1-4 scale) • Suggest that same day surgery can be considered – Average IV narcotic doses 8.9 Spiegel Oto-HNS 2005 – Hospitalization justified for comfort/pain control Rodriguez-Bruno 2005 7
Conclusions Avoidance of Complications • Awake or fiberoptic intubation if significant airway risk • Surgery for OSA poses special risks to the patient • Minimize intraoperative narcotics related to the disease state and anatomy Esclamado 1989 • Extubate when fully awake and reversed • These risks can generally be managed successfully – May keep intubated and extubate within 24 hours through recognition of the issues and through taking appropriate precautions • For airway compromise from edema with wakefulness, • Post operative monitoring should be tailored to the tracheotomy or intubation is needed Sheppard 1985 individual patient and disease severity • EKG monitor w/ dysrhythmias or O2 sat<60% • Hospitalization may be warranted for IV fluids, pain control, nausea control • CPAP post-op in patients w/ exacerbation Powell 1988 • Pulse oxymetry in all patients 8
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