Authors: Crispiana Cozowicz, M.D.; Stavros G. Memtsoudis, M.D., Ph.D.
ASA Monitor 07 2017, Vol.81, 14-15.
Crispiana Cozowicz, M.D., is Research Fellow, Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Private Medical University, Muellner Hauptstrasse, Salzburg, Austria.
Stavros G. Memtsoudis, M.D., Ph.D., is Clinical Professor of Anesthesiology and Public Health; Attending Anesthesiologist and Senior Scientist, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Private Medical University, Muellner Hauptstrasse, Salzburg, Austria.
More than a decade after the first publication of ASA’s Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea,1 the approach to patients with suspected or diagnosed obstructive sleep apnea (OSA) remains a topic of intense debate. To date, significant energy and focus has gone into the recognition of OSA as a perioperative risk factor for complications and adverse events.2 Also, a number of expert groups have attempted to guide clinicians in the perioperative care of patients with OSA, with considerable focus on preoperative screening and post-operative management. However, evidence-based approaches to the anesthetic care of this patient population remain unclear. Thus, guidance in respect to intraoperative management specific to patients with OSA with the goal to optimize outcomes has received less attention. It is therefore not surprising that real-world practice variability in our approach to patients with sleep apnea remains vast3 and attitudes among perioperative physicians representing different specialties non-uniform.4 Moreover, it appears that, to date, the majority of hospitals do not have written protocols on institutional pathways for the perioperative management of OSA patients.4 Therefore, with increasing prevalence of OSA,5 there is an urgent need for an evidence-based practice consensus that proves feasible in a highly dynamic health care environment.
In fact, recent population-based data in elective lower-limb joint arthroplasties indicate that perioperative anesthesia practice may not substantially differ by OSA diagnosis.3 In contrast to recommendations, the practice of general rather than regional anesthesia remains the predominant pathway regardless of OSA status.6 Similarly, postoperative continuous pulse oximetry monitoring does not seem to be routinely followed in this patient population. Most notably, trend analyses in joint replacement surgery indicate a proportional decrease in the practice of guideline-suggested precautions for OSA.3 With lack of evidence to support augmented perioperative care, and lack of clarity regarding clinical practicability of measures such as increased monitoring, it is not surprising that clinicians find it difficult to follow guidelines, rendering general acceptance and implementation of these suggestions a challenge.
Given that sleep apnea-associated perioperative complications reach levels as far as unexpected death and malpractice lawsuits,7 –9 due to the interaction between OSA and analgesic and sedative medications,7,10 members of the multidisciplinary Society for Anesthesia and Sleep Medicine (SASM) have embarked on the task of rigorously and systematically dissecting available scientific evidence that may inform best practices of intraoperative management.
A task force for the development of best practices for the intraoperative management of patients with sleep-disordered breathing has been assembled. Although one may question the value of yet another guideline, we believe this aspect of perioperative care has received limited attention thus far. While current guideline recommendations clearly aim to increase perioperative safety among OSA patients, they lack a firm scientific evidence base and are rather broadly positioned, rarely taking factors such as OSA severity into account. Moreover, the implementation of suggested interventions is linked to the allocation of clinical and economic resources with increased cost. The paucity of data on the efficacy of measures of precaution prohibits robust risk-benefit assessment and therefore poses an obstacle to the broad adoption of guidelines into clinical practice, despite the common acceptance of OSA as a perioperative risk factor.
A meticulous literature search with subsequent quantitative and qualitative analysis, if possible, is being conducted. As in the previous guidelines on preoperative management of OSA,11 the group is relying on quantitative analysis and the GRADE approach12 (Grading Recommendations, Assessment, Development and Evaluation) for qualitative analysis to establish the confidence that can be placed on evidence provided. This is identified by analysis of potential risk of bias, heterogeneity, indirectness, imprecision and publications bias for each outcome. The overall goal is to reach evidence-guided consensus and recommendations using GRADE.13
The task force assembled during the past SASM annual meeting in October 2016 and outlined the path of action revolving around a clinical question-driven approach. After comprehensive discussions among its 15 members, it was determined that the topics requiring attention concern: 1) airway management, 2) pharmacologic considerations involving anesthetics and analgesics and 3) the choice of anesthetic techniques. It is our hope to complete the project by the end of this year with subsequent publication of our findings and recommendations to provide a stronger evidence base for best practices in OSA patients. This task force will also discuss areas of missing evidence in order to give specific guidance for future research.
Gross JB, Bachenberg KL, Benumof JL, et al; ASA Task Force on Periopertive Mgmt. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: A report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081–1093.
Opperer M, Cozowicz C, Bugada D, et al. Does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of patients with sleep-disorder breathing. Anesth Analg. 2016;122(5):1321–1334.
Cozowicz C, Poeran J, Olson A, Mazumdar M, Mörwald EE, Memtsoudis SG. Trends in perioperative practice and resource utilization in patients with obstructive sleep apnea undergoing joint arthroplasty [published online May 11, 2017]. Anesth Analg. oi:10.1213/ANE.0000000000002041
Auckley D, Cox R, Bolden N, Thornton JD . Attitudes regarding perioperative care of patients with OSA: a survey study of four specialties in the United States. Sleep Breath. 2015;19(1):315–325.
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM . Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006–1014.
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N . Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;141(2):436–441.
Benumof JL . Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Can J Anaesth. 2016;63(1):3–7.
Obstructive Sleep Apnea Death and Near Miss Registry. Society of Anesthesia and Sleep Medicine website. http://depts.washington.edu/asaccp/projects/obstructive-sleep-apnea-osa-death-near-miss-registry. Last accessed May 1, 2017.
Cottam D, Lord J, Dallal RM, et al. Medicolegal analysis of 100 malpractice claims against bariatric surgeons. Surg Obes Relat Dis. 2007;3(1):60–66.
S, Zilberman P, Chung F . Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anesth. 2009;56(11):819–828.
Chung F, Memtsoudis S, Krishna Ramachandran S, et al. Society of Anesthesia and Sleep Medicine Guideline on Preoperative Screening and Assessment of Patients with Obstructive Sleep Apnea [published online June 1, 2016]. Anesth Analg. doi: 10.1213/ANE.0000000000001416
Brozek JL, Akl EA, Alonso-Coello P, et al; for GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669–677.
Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–725.