The management of patients with known or suspected OSA is an evolving field. Practice guidelines have been published though most are consensus-based and limited by issues such as failing to objectively establish OSA as a perioperative risk factor, not addressing how to identify OSA patients preoperatively, and making recommendations that may be difficult to implement and cost prohibitive for clinical practice. As such, SASM formed a task force to develop a more evidence-based and cost effective approach to preoperative work up of patient with known or suspected OSA. The task force was comprised of 28 members of SASM, including 12 anesthesiologists, 9 sleep medicine specialists, 2 hospitalists, 1 otolaryngologist, 2 research assistants, a research librarian and a clinical epidemiologist. Members represented both academic and non-academic settings in various parts of the United States, Canada, Europe, Australia and South America. The task force performed a literature review from 1946 through June of 2014, analyzed the relevant literature, and developed recommendations with the goal of finding a practical balance between minimizing postoperative complications and the efficient use of healthcare resources.
A summary of the recommendations is as follows:
- OSA patients undergoing procedures under anesthesia are at increased risk for perioperative complications compared to patients without the disease diagnosis. Identifying patients at high risk for OSA prior to surgery for targeted perioperative precautions and interventions may help to reduce perioperative patient complications.
- Screening tools may help to risk stratify patients with suspected OSA with reasonable accuracy. Practice groups should consider making OSA screening part of standard pre-anesthetic evaluation.
- There is insufficient evidence in the current literature to support canceling or delaying surgery for a formal diagnosis (laboratory or home polysomnography) in patients with suspected OSA, unless there is evidence of uncontrolled systemic disease.
- The patient and the health care team should be aware that known, treated, partially treated and untreated OSA as well as suspected OSA may be associated with increased postoperative morbidity.
- Consideration should be given to obtaining the results of the sleep study and the recommended Positive Airway Pressure (PAP) setting before surgery.
- If resources allow, facilities should consider having PAP equipment for perioperative use, or have patients bring their own PAP equipment with them to the surgical facility.
- Additional evaluation for preoperative cardiopulmonary optimization should be considered in patients with known, partially treated/untreated and suspected OSA who have uncontrolled systemic conditions e.g. i) hypoventilation syndromes, ii) severe pulmonary hypertension, and iii) resting hypoxemia in the absence of other cardiopulmonary disease.
- Patients with known OSA, partially treated/untreated and suspected OSA with optimized co-morbid conditions may proceed to surgery provided strategies for mitigation of postoperative complications are implemented.
- The risks and benefits of the decision should include consultation and discussion with the surgeon and the patient.
- The use of PAP therapy in previously undiagnosed but suspected OSA patients should be considered case by case. Due to the lack of evidence from randomized controlled trials, we cannot recommend its routine use.
- Continued use of PAP therapy at previously prescribed settings is recommended during periods of sleep while hospitalized, both preoperatively and postoperatively. Adjustments may need to be made to the settings to account for perioperative changes such as facial swelling, fluid shifts, recent pharmacotherapy, and pulmonary function.
The primary goal of this SASM guideline is to ensure optimal pre-operative evaluation of patients with known or suspected OSA in order to improve patient safety. It is hoped that the recommendations from this guideline will influence clinical practice as well as stimulate additional research to address the questions for which there is currently insufficient evidence to support recommendations.