A PACU order-based approach to facilitate postoperative decision making for patients with sleep apnea was introduced by the Vancouver Acute Department of Anesthesia in July 2012. The orders prompt anesthesiologists to consider the factors and events associated with higher risk of complications from OSA. Prompts are provided for diagnostic follow-up and for situations where a Respirology consult should be considered. The minimum requirement for extended PACU stay for patients with sleep apnea is also defined. Finally the anesthesiologist is prompted to consider a monitored bed for patients at higher risk. The reverse side of the order sheet has a STOP-Bang scoring table, and a previously published postoperative OSA management diagram.
A flow diagram summarizing the perioperative management of OSA at the Vancouver Acute Department of Anesthesia can be found under our Guidelines section.
to Download the Perioperative OSA Mx Flowchart
In an attempt to reduce the risk for adverse outcomes among surgical patients with sleep apnea, the current American Society of Anesthesiology practice advisory recommends the use of regional anesthesia. However, to date, no data are available to support this approach. Utilizing nationwide data collected from about 400 hospitals in the United States we identified 40,316 patients with a diagnosis of sleep apnea who underwent elective hip and knee arthroplasty between 2006 and 2010. Approximately 11% of cases were performed under neuraxial, 15% under combined neuraxial and general, and 74% under general anesthesia. The utilization of peripheral nerve blocks was 1%, 1.5% and 8% among these groups, respectively. Adjusted risk for major complications for those undergoing surgery under neuraxial or combined neuraxial-general anesthesia compared with general anesthesia was lower (OR, 0.83 [95% CI, 0.74;0.93; P =0.001] vs OR, 0.90 [95% CI, 0.82;0.99; P =0.03]). The use of neuraxial anesthesia with or without general was also associated with decreased odds for the need for mechanical ventilation, use of intensive care services, prolonged length of stay and cost above the 75th percentile.
The use of peripheral nerve blocks did not alter complication risk but was associated with decreased resource utilization in patients with sleep apnea.
We conclude that neuraxial anesthesia may convey benefits in the perioperative outcome of sleep apnea patients undergoing joint arthroplasty. Further research is needed however, to enhance an understanding of the mechanisms by which neuraxial anesthesia may exert comparatively beneficial effects.
This study shows that postoperative reduction of REM sleep occurs after surgery with general anesthesia as it does with regional anesthesia.
Twenty-one young adults had their blood drawn 1.5 hours before and 1.5 hours after the estimated time of dim light melatonin onset (DMLO). Participants were randomized to one week of either 1-hour morning blue light exposure or comparable dim light exposure; circadian genes were assessed. Analyses revealed significant changes in gene expression of 10 circadian genes in response to sleep-wake schedule advancement and morning blue-light stimulation.
Fifteen healthy residents in Internal Medicine were studied before and after one night on-call (i.e., acute sleep deprivation (ASD)) at rest and during gravitational stimulus. ASD was associated with modulation of sympathovagal balance toward sympathetic activation and increased levels of IFN-gamma compared to baseline. ASD was unrelated to changes in blood pressure variability and baroreflex sensitivity.
Sixteen healthy men underwent 3 experimental conditions in a cross-over design: SWS suppression, REM-sleep disturbance, and regular sleep; a glucose tolerance test was obtained the following morning. Morning plasma glucose and serum insulin responses were selectively increased and postprandial insulin sensitivity was reduced after SWS suppression. Disturbed REM had no effect on glucose homeostasis.
Seventy-seven non-obese (38 men and 39 women) with OSA were studied in the sleep laboratory over 4 nights and serial blood samples were taken. Apneic men were sleepier and had higher levels of hsCRP, IL-6, leptin and insulin resistance than controls; women did not show consistent elevations. Short term CPAP did not improve these markers.
This study used gaboxadol (agonist at extrasynaptic GABAA receptors that contain a δ subunit) to test show that extrasynaptic GABAA receptors within the pontine reticular formation modulate sleep and wakefulness.
Hypocretin/orexin (Hcrt)-producing neurons orchestrate global arousal state, wake-sleep architecture, energy homeostasis, stress adaptation, and reward behaviors. This study demonstrate that Hcrt neurons play an important role in the consolidation of social recognition memory, at least in part through enhancements of hippocampal synaptic plasticity and cAMP response element-binding protein phosphorylation.
It is likely that the modest efforts thus far realized in the context of biomarker discovery for the diagnosis and clinical monitoring of OSA in children will experience major acceleration in the upcoming years…