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.