Sleep Labs Are Obsolete for Peri-operative Assessment of...
Transcript of Sleep Labs Are Obsolete for Peri-operative Assessment of...
SleepLabsAreObsoleteforPeri-operativeAssessmentof
SleepDisorderedBreathing- CONSocietyofAnesthesiaandSleepMedicine
2017AnnualMeetingOctober19th,2017
SusheelPatil,MD,PhDJohnsHopkinsSchoolofMedicine
ClinicalDirector,JohnsHopkinsSleepMedicine
SleepLabs CentersAreObsoleteforPeri-operativeAssessmentofSleep
DisorderedBreathing- CONSocietyofAnesthesiaandSleepMedicine
2017AnnualMeetingOctober19th,2017
SusheelPatil,MD,PhDJohnsHopkinsSchoolofMedicine
ClinicalDirector,JohnsHopkinsSleepMedicine
Currentguidelinesforsleeptesting
• PatientsathighriskformoderatetosevereOSAshouldbeconsideredforHSAT
• Patientswithsignificantcardiopulmonarycomorbidities,neuromusculardisorders,orothersleepdisordersshouldbeconsideredforin-labsleeptesting
• FailedornegativeHSATinapatientwithhighpre-testprobabilityshouldhavein-labsleeptestingtoruleoutOSA.
KapurV,etal.JCSM2017:13:479– 504.
ConsequencesofOSAonpost-operativeoutcomes
KawR,etal.BrJAnaesth;2012;109:897-906.
Dx ofOSAbasedonquestionnaire,oximetry,orPSG.ICD-9onlybaseddxexcluded.
PotentialeffectsofCPAPonpost-operativeoutcomes
LOS
Post-OpAdverseEvents
Nagappa etal.Anesth Analg 2015;120:1013–23.
Uniqueaspectsofperi-operativeassessmentofOSA
• Timesensitivity– donotwanttodelaysurgeriesunnecessarily
• Planningofresourceutilization• Isthepatientathighriskforanadverseoutcomeafterplannedsurgery?
• Canthisbesamedaysurgeryorisaninpatientadmissionneeded?
• Ifaninpatientadmissionneeded– isanICUbed,monitoredbed,orfloorbedneeded?
Emergentsurgeries
• ThereislittlethataSleepCentercanofferwhenemergentsurgeriesmustbedone
• Managingriskofpost-opcomplicationsinhighriskOSApatients:
• Inpatientpulmonary/anesthesiapre-opconsultations• AvailabilityofmonitoredbedwithoximetryandCO2monitoring
• ProtocolsformanagingpatientsrecognizedathighriskforOSA
EmergentsurgeriesSASM2016Guidelines:• WeakFor:ThereisinsufficientevidencetosupportcancelingordelayingsurgerytoperformmoreadvancedscreeningtechniquesorsleeptestingtodiagnoseOSAinthosepatientsidentifiedasbeingathighriskofOSApreoperatively,unless thereisevidenceofanassociatedsignificantoruncontrolledsystemicdiseaseoradditionalproblemswithventilationorgasexchange(LevelofEvidence:Low)
ASA2014Guidelines:• IfanycharacteristicsnotedduringthepreoperativeevaluationsuggestthatthepatienthasOSA,theanesthesiologistandsurgeonshouldjointlydecidewhetherto(1)managethepatientperioperatively basedonclinicalcriteriaalone or(2)obtainsleepstudies,conductamoreextensiveairwayexamination,andinitiateOSAtreatmentinadvanceofsurgery
• Ifthepreoperativeevaluationdoesnotoccuruntilthedayofsurgery,thesurgeonandanesthesiologisttogethermayelectforpresumptivemanagement basedonclinicalcriteriaoralast-minutedelayofsurgery.
ChungFetal.Anesth Analg 2016;123:452-473.ASAGuidelines.Anesthesiology2014;120:1-19.
Whyaresleepcentersevenneededforperi-operativeassessments?ItOnlyTakesOne...
P.Gay.JClin SleepMed2010;6:473-474
Acasetoconsider...
• 52yearoldmalewithHTNandT2DMandplansforelectiveAAArepair.
• BMI21kg/m2,neckcircumference14cm• Snoresperhiswife• Hassomefatigue• PCPhadsenthimforasleepstudy
Acasetoconsider...
• Sleepstudyreport• TST345minutes;TIB412minutes;SE84%• N1– 21%;N2– 53%,N3– 8%;R– 18%
• AHI– 8/h• RDI– 11/h
• Interpretation:Thepatient’ssleepisconsistentwithmildsleepapnea.
Acasetoconsider...
• Wouldhestillbeconsideredlowerrisk?• Wouldprecautionsmightbetakenknowingthisinformation?
• Presumepost-ophehastolaysupine?• MightbeatriskforREM-sleepreboundafterreceivinggeneralanesthesiaandpossibleopiatesforpaincontrol?
• Ifnotontherapyathome,shouldPAPbestartedinhouse?
Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.
• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.
• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)
• Toensureappropriatepost-surgeryevaluationandcare
Questionnairesareimperfect
• Falsepositiveratescanrangefrom44– 68%• Falsenegativeratecanrangefrom7– 32%• Willvarybasedonsensitivity/specificitythresholdschosenforaparticularOSA
threshold• Implications
• Moreresourceuseandcostsdependingonthresholdchosen• Costsassociatedwithpotentialmisseddiagnosisandsubsequentcomplications
ChungF,etal.Anesth Analg 2016;123:452-473..
Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.
• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.
• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)
• Toensureappropriatepost-surgeryevaluationandcare
SamedayassessmentofOSAmayhaveworseoutcomesthandiagnosedOSA
• Setting:AcademicCenterand2communitypractices• Retrospective,dataextractionfromEMR• PreviouslydiagnosedOSA(D-OSA)– pre-existinginmedicalrecordorselfreportbypatientondateofsurgery
• Pre-operativesuspectedOSA(S-OSA)- ifclassifiedbyanesthesiaprovidersandhadSTOP-Bang>3.
• STOP-Bangmissingdataon“STO”– considerednegative:• Snoring(44%)• Tiredness(83%)• Observedapneas(82%)
• 57%ofthosewithreportedOSAself-identifiedasbeingcompliantwithCPAP.
Fernandez-Bustamente.Anesth Analg 2017;125:593-602.
SamedayassessmentofOSAmayhaveworseoutcomesthandiagnosedOSA
Fernandez-Bustamente.Anesth Analg 2017;125:593-602.
SamedayassessmentofOSAmayhaveworseoutcomesthandiagnosedOSA
Fernandez-Bustamente.Anesth Analg 2017;125:593-602.
Post-opdesaturationeventsarecommoninthefirst48h
Sun,etal.Anesth Analg 2015;121:709-715.
• 66%receivedsupplementaloxygen• 4-5%receivedPAPtherapy• Only5%hadasingledesaturation<90%
documented
37%
11%3%
CouldhomeinstitutionofCPAPreduceadverseoutcomes?
GuptaR,etal.MayoClin Proceed2001;76:897.
• Lessthan½ofpatientswithhomeCPAPreceivedroutineCPAPtherapyinthehospital- ?carryoverprotectionforthe1st post-opday
Reducedpost-opcomplications:PAPusecomparedtountreatedOSA
• 10%of26,842pre-oppatientswithdiagnosedorsuspectedOSA
• 55%Untreated
N=2646
Abdelsattar etal,SLEEP2015;38(8):1205–1210.
aOR=1.8
aOR=2.5
aOR=2.6
InitiatingPAPinhospitalisnotalwayseasy...
• HighriskgroupidentifiedwithSACS>=15• Randomizedtostandardcare(n=43)vs.standardcare+APAP(n=43)
• MedianAPAPusewas184.5min(IQR:64– 451min)
• 64%usedAPAP100%ofpost-opnights• 36%reportedAPAPtobetoouncomfortable• 14/38withanAHI<10/hperAPAPcard• NoreductioninLOSinAPAPvsnoAPAPgroups
GormanS,etal.Chest2013;144:72-78.
PotentialreasonswhypriorCPAPusemayimproveoutcomes
• Possiblecarryovereffectresultingin:• Decreasedupperairwayinflmamtion• Decreasedupperairwayedema• Increasedupperairwaystability
• ThosewhousePAPathomemaybemorelikelytouseinthehospital
Abdelsattar etal,SLEEP2015;38(8):1205–1210.
Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.
• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.
• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)
• Toensureappropriatepost-surgeryevaluationandcare
Complexpatients
SASM2016Guidelines(similarstatementsforthoseathighriskforOSAorpoorlyadherentorrefusetherapyforOSA):• WeakFor:Wesuggestthatadditionalevaluationforpre-operativecardiopulmonaryoptimizationbeconsideredinpatientswhohaveaknowndiagnosisofOSAandnon-adherentorpoorlyadherenttoPAPtherapyandwherethereisindicationofuncontrolledsystemicconditionsoradditionalproblemswithventilationorgasexchange.Theseconditionsincludebutarenotlimitedto:i)hypoventilationsyndromes,ii)severepulmonaryhypertension,iii)restinghypoxemianotattributabletoothercardiopulmonarydisease(LevelofEvidence:Low)
• WeakFor:WesuggestthatuntreatedOSApatientswithoptimizedcomorbidconditionsmay proceedtosurgeryprovidedstrategiesformitigationofpostoperativecomplicationsareimplemented.Therisksandbenefitsofthedecisionshouldincludeconsultationanddiscussionwiththesurgeonandpatient(LevelofEvidence:Low)
ChungFetal.Anesth Analg 2016;123:452-473.
Considerations
• Suchpatientsaremorelikelytodeveloppost-opcomplications
• Thesecomorbiditiesoftenco-existwithformsofsleepdisorderedbreathing
Considerations
• Sleepcentersaffiliatedwithhospitalscansupporttheperi-operativeteamthroughurgentinpatientrespiratorypolygraphytesting
• Sleepcenterproviderscanprovideneededconsultationsupporttooptimizecardiopulmonarystatuspriortoaftertesting
• Caninvestigatereasonsfortreatmentrefusalornon-compliance
PamidiS,etal.Chest2012;141:51-57.
Sleepmedicinetrainedprovidershadhigheradherencewithpatientsthannon-sleepmedicineproviders
Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.
• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.
• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)
• Toensureappropriatepost-surgeryevaluationandcare
CPAPasasurrogateforcompliancewithothertherapies
• 330veteransonlipidloweringmedicationsandnewlyprescribedCPAP.
• Thoseadherenttoanti-hyperlipidemic medicationsaremoreadherenttoCPAP
• 40.1%probabilityofCPAPadherenceinthosewith<80%adherencetomedicationscomparedto55.2%CPAPadherenceinthosewith≥80%medicationadherence
PlattABetal.Chest2010;137:102-108
CPAPadherencepredictedweightlosstrajectory
• Studyof24subjectthatunderwentgastricbanding
• Age:48.5± 9.4years;73%werefemale;
• Pre:• BMI:51.1± 10.9kg/m2• MeanAHI:48.2/h± 32.8/h
• Post:• Weightloss:121.1± 50.2lb;BMI:-18.6kg/m2.
• MeanAHI:24.5± 18.8events/h
• n=8wereusingCPAP
Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.
• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.
• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)
• Toensureappropriatepost-surgeryevaluationandcare
• WeakFor:SASM2016Guideline:PatientsshouldbeadvisedtonotifytheirprimarymedicalproviderthattheywerefoundtohaveahighprobabilityofhavingOSA,thusallowingforappropriatereferralforfurtherevaluation(LevelofEvidence:Low)
• 80%ofpatientswithOSAareundiagnosedanduntreated
• Pre-operativeevaluationcanbeatimetoincreasepatientawarenessofpotentialimportanceofaddressingsleepissues
ValueaddedofSleepCenters?
• SleepCentersprovideexpertisetocomplementpre-operativeevaluations
• Sleeptesting• Implicationsofsleeptestingresults• Consultationstounderstandcomplexbreathingissue• Optimizationoftreatmentpriortooperativecare
Missing Periods of Hypoxemia
• 8 patients – every one had at least on event not detected by routine monitoring
• T90 was 165 +/- 49 minutes
• Mean total number of events with SpO2<90% for > 30s: 62 +/- 16 events
• No patient experienced cardiopulmonary arrest/instability.
Gallagher et al JOURNAL OF SURGICAL RESEARCH: VOL. 159, NO. 2, APRIL 2010
• In this study post op gastric bypass patients were monitored with pulse oximetry.• Even the use of CPAP therapy did not completely resolve desaturation events• However, timing of PAP use was not known
Why would PAP therapy fail?Why would PAP therapy fail?
OSA and post-operative complications in orthopaedic procedures
• 101 OSA and 101 controls matched on age, sex, operation type, side, surgeon, year, anesthesia.
• Group 1A: surgery 3 years prior to diagnosis of OSA• Group 1B: confirmed OSA at time of surgery• Complication or intervention
• Complication - Reintubation, acute hypercapnia, episodic desaturations, acute cardiac ischemia or arrhythmia, delirium
• Serious complication – ICU transfer, acute cardiac ischemia or arrhythmia, or urgent need for respiratory support.
• Intervention - performed in response to the historically reported complication was defined as administration of a new treatment (such as supplemental oxygen) or implementation of additional monitoring (such as pulse oximetry).
GuptaR,etal.MayoClin Proceed2001;76:897.