Patients with obstructive sleep apnea (OSA) who underwent total joint arthroplasty and received higher levels of opioids had an increased risk for gastrointestinal complications, according to researchers.
Those patients also experienced longer hospital lengths of stay, but they were less likely to develop pulmonary complications.
This study, a retrospective analysis of a nationwide database, indicates that prescribers should heed guidelines and minimize the use of respiratory depressant drugs, such as opioids, as much as possible for patients with OSA.
As Dr. Mörwald reported at the annual Spring meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 3596), patients with OSA are a growing cohort in the surgical population, and previous studies have shown they have an increased risk for perioperative complications (Anesth Analg 2016;122:1321-1334). In particular, according to Dr. Mörwald, pulmonary complications occur more frequently in patients with sleep apnea (Anesth Analg 2011;112:113-121).
Large Database Study
“Most practice guidelines recommend reducing the use of opioids and other respiratory depressant drugs among individuals with OSA because it is assumed that opioids and OSA affect similar pathophysiologic mechanisms and the combination could potentially increase complications,” Dr. Mörwald said. “However, the evidence relating different levels of opioid prescription to perioperative complications is limited. We hypothesized that higher opioid prescriptions would be associated with higher rates of complications.”
Dr. Mörwald and her colleagues used the Premier Perspective Database to identify 107,610 OSA patients receiving elective primary total hip or knee arthroplasty from 2006 to 2013. Patients were divided into quartiles according to the amount of opioids prescribed. The investigators then compared the quartiles on odds of perioperative complications, using multilevel multivariable logistic regression models.
As Dr. Mörwald reported, OSA patients who received a higher level of opioids had an increased risk for gastrointestinal complications (odds ratio [OR], 1.90; 95% CI, 1.47-2.46), prolonged hospital length of stay (OR, 1.64; 95% CI, 1.57-1.72) and increased cost of care (OR, 1.48; 95% CI, 1.40-1.57).
Despite previous literature showing a greater incidence of pulmonary complications in OSA patients, the investigators found lower odds for the high-prescription quartile (OR, 0.85; 95% CI, 0.74-0.96).
Although this finding is unlikely to be causal, Dr. Mörwald said, it may indicate the growing awareness among practitioners of potential respiratory complications of OSA in the perioperative setting and how these complications may be aggravated by opioid side effects.
“It’s possible that practitioners increased their efforts to prevent those complications or that interventions were started earlier to avoid those complications,” Dr. Mörwald said. “Nevertheless, this finding should not encourage the administration of high doses of opioids in an unmonitored setting, and attempts to further reduce opioid prescription in patients with OSA should be continued.”
According to the study authors, additional research regarding risks and possible complications in OSA patients is needed to improve quality and safety because implementation of practice guidelines, institutional policies and utilization of resources for this cohort remain suboptimal (Sleep Breath 2015;19:315-325).
John F. Butterworth IV, MD, professor and chair of anesthesiology at Virginia Commonwealth University School of Medicine, in Richmond, theorized that tolerance to opioids in the high-prescription quartile could account for the decreased incidence of complications. “Is it possible that patients who were on more than 400 mg per day had an advantage in that they were already tolerant and were thus less likely to get complications from opioids?” he asked.
“It’s possible,” Dr. Mörwald responded, “but we didn’t analyze chronic opioid use or chronic pain conditions. We were also unable to see with this database whether patients had received treatment for their OSA, so that’s certainly a limitation.”
“We tend to think of OSA as one population, whereas there is a population of OSA patients that appears to be exquisitely sensitive to opioids,” Dr. Butterworth said. “Those are the patients who are more likely to suffer severe complications and we’d really like to know how to target them. By focusing on the diagnosis rather than that specific population, however, we may be missing the problem.”