An Electronic Evidence-Based Checklist of Interventions for the Postoperative Management of Obstructive Sleep Apnea SyndromeBrian Gammon, RN, BSN1, Vandna Mittal, MPH2, Kandace Whiting, RN, MSN3,1Duke University School of Nursing, Durham, NC, 2Boston University School of Public Health, Boston, MA, 3University of California at Los Angeles, Los Angeles, CA

Abstract

Obstructive sleep apnea syndrome (OSAS) plac-es patients at increased risk for postoperative complications. A comprehensive literature re-view identified nine postoperative interven-tions known to reduce the risk of OSAS related apneic events and improve patient outcomes. Arden syntax was used to generate an electron-ic checklist CDS application that can be easily incorporated into clinician workflows to ensure OSAS evidence-based practices are consistently followed. This tool will increase the safe deliv-ery of postoperative care for OSAS patients.

Background

Obstructive sleep apnea syndrome (OSAS) is a dangerous and progressive disease of recur-rent impaired ventilation episodes that silently affects millions of Americans1. These frequent, intermittent airway obstructions result in snor-ing, fatigue, daytime sleepiness and can lead to life-threatening complications such as hyper-tension, coronary artery disease, atherosclero-sis, cerebral vascular events, congestive heart failure, cardiac dysrhythmias and myocardial in-farctions2.

In addition, OSAS presents unique challenges for patients undergoing surgical procedures as anesthesia and analgesics increase the risk for apnea events. Consider that an estimated 80–90% of patients with OSAS are undiagnosed preoperatively and the risks involved for caring for these postsurgical patients are magnified3.

Furthermore, postoperative OSAS patients have been found to experience more reintubations, unexpected ICU transfers, postoperative infec-tions and extended ICU stays without appropri-ate intercessions by clinicians4. The institution of a standard OSAS protocol, such as a checklist, is probably the most functional tool in the safe delivery of postoperative care2.

DCRI COMMUNICAtIONS • OCtOBER 2011

Problem

Failure to effectively disseminate and integrate research into clinical practice presents a fun-damental problem in healthcare. the resulting clinical variation places patients at increased risk for complications and in turn has a signifi-cant effect on healthcare expenditures. Given the substantial postoperative risks associated with OSAS, ensuring clinical practice parallels best-practice research guidelines is imperative. Creation of an evidence-based electronic clini-cal decision support (CDS) application presents a viable mechanism to facilitate the translation of OSAS research-based protocols into clinical practice.

Project Purpose

Despite the large body of research detailing OSAS best practices, standardized protocols de-signed to minimize postoperative complications have yet to be developed. this project aims to provide clinicians with an evidence based CDS checklist to ensure best-practice interventions are implemented consistently to reduce compli-cations and healthcare costs. An extensive re-view of the literature identified nine post-oper-ative interventions as integral to optimal patient outcomes. Identified interventions were then compiled into a rules based CDS checklist using Arden syntax. Integration of the generated CDS application into clinician workflows will serve to reinforce protocols and ensure interventions are consistently and correctly administered to OSAS patients throughout their recovery process.

References1. Baluch, A., Mahbubani, S., Al-Fadhli, F., Kaye, A., & Frost, E. (2009). Anesthetic care of the patient with obstructive sleep apnea. Middle East Journal of Anesthesiology, 20(2), 143-152.

2. Richard, R., Morgenthaler, t., Lickteig, C., & Carr, C. (2007). RtS’ role in the perioperative management of OSA. Rt: The Journal for Respiratory Care Practitioners, 20(6), 18.

3. Rudra, A., Chatterjee, S., Das, t., Sengupta, S., Maitra, G., & Kumar, P. (2008). Obstructive sleep apnea and anesthesia. Indian Journal of Critical Care Medicine, 12(3), 116-123.

4. Roop, K. (2008). What are the post-op risks in patients who have obstructive sleep apnea? to what extent are patients with obstructive sleep apnea syndrome (OSAS) at increased risk for postoperative complications? Are there any specific interventions that reduce the risks? Journal of Respiratory Diseases, 29(10), 389.

5. Mayo Clinic. (2010). Obstructive Sleep Apnea. Retrieved from http://www.Mayo Clinic.com/health/obstructive-sleep-apnea/DS00968/MEtHOD=print.

6. Gross, J., Bachenberg, K., Benumof, J., Caplan, R., Connis, R., & Coté, C., et al. (2006). 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 Obstructive Sleep Apnea. Anesthesiology, 104(5), 1081–93.

7. Blake, D., Yew, C., Donnan, G., & Williams, D. (2009). Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesthesia & Intensive Care, 37(5), 720-725.

8. Walsh, S., & Berry, K. (2010). Electroacupuncture and tENS: putting theory into practice. Journal of Chinese Medicine, (92), 46-58.

Table 1: OSAS Postoperative Assessment Risk Factors5

BMI > 28 kg/m2 the incidence of OSAS escalates with increasing BMI.

Neck Circumference > 43 cm (Male) | > 40.5 cm (Female)

Large neck circumference is associated with an increased risk of OSAS.

General Anesthesia Anesthetics, analgesics and sedatives increase the risk of airway collapse.3

Hypertension 50% of OSAS patients are diagnosed with hypertension.

Diabetes OSAS is 3x more prevalent in diabetics.

Male Men are 2x more likely to have OSAS.

Age >65 OSAS occurs 2–3x more often in adults over 65.

Alcohol, Sedative or tranquilizer Usage these substances relax the muscles in the throat.

Smoking Smokers are 3x more likely to have OSAS.

Figure 1: OSAS Form Figure 3: OSAS Postoperative Protocol

Table 3: Evidenced–Based Checklist of Interventions for Postoperative OSAS Patients

Immediate Postoperative Period

P Admit patient to a continuous respiratory and cardiac monitoring environment for the first 24 hours or until baseline oxygen saturation is maintained on room air.

P OSAS Extubation Criteria: Ensure patient is fully awake by following commands, demonstrating a sustained head lift > 5 seconds, a vital capacity > 15 cc/kg, a negative inspiratory force < -25 cm H2O, and a respiratory rate > 12 breaths/min. Position patient in 30° reverse trendelenberg immediately after extubation.

P titrate supplemental oxygen until patient achieves oxygen saturation of 95% and can maintain oxygen saturation above 90% on room air.

P Use caution when administering opioid analgesics or sedatives; If possible, manage pain with Regional Nerve Blocks, NSAIDs, Ketamine, tramadol, or trancutaneous Electrical Nerve Stimulation and other non-pharmacological modalities.

Sleep Period

P For patients with prior CPAP therapy, administer CPAP using patient’s own equipment, if possible; provide an oral appliance for patients without previous CPAP treatment.

P Maintain patient in a Semi-Fowler position with HOB >30° to minimize the risk of soft palate collapse.

P Use capnography to identify hypoventilation and intervene before hypoxemia or an apnea event occurs.

Table 2: Alternatives to Opioid Pain Management

Intervention Rationale

Regional Nerve Blocks Lower risk for adverse outcomes in OSAS patients compared to systemic opioids6

NSAIDs Can reduce opioid requirements for effective pain relief3

Ketamine Blocks N-Methyl D-Aspartate (NMDA) pain receptors7

tramadol Increases brainstem catecholamines for analgesia7

transcutaneous Electrical Nerve Stimulation

Blocks somatic and visceral pain mechanisms without inhibiting sensation8

Ice Packs Reduces local discomfort and pain3

POSTOPERATIVE CARE FORM DUKE HOSPITAL

MRN RX1049 Admit Date 08/10/2011 Admit Time 13:35

Patient Gammon, Brian T. DOB 10/19/1981 Sex Male

Height 179 cm Weight 136 kg BMI 42.4

Physician Vandna Mittal, MD Diagnosis Morbid Obesity (278.01)

Procedure Bariatric surgery status gastric

bypass and gastric banding status

for obesity (V45.86)

Medical History Influenza with Pneumonia (478.0),

Achalasia (530.0), Morbid Obesity

(278.01), Diabetes Mellitus (250)

Type II Adult Onset (V58.672),

Hypertension (997.91)

OSAS Post Operative Assessment YES NO

BMI > 28 kg/m2?

Neck circumference >43cm (Male) | >40.5cm (Female)?

Anesthetic drugs administered during surgery?

Opioid analgesia administered during surgery?

Male gender?

History of hypertension?

History of diabetes?

History of alcohol, sedative or tranquilizer usage?

History of smoking? Age >65?

OSAS Care Plan Diagnosis Interventions Expected Outcome Evaluation Date Time

Risk for Airway Collapse Continually monitor

respiratory and cardiac

functions

Titrate oxygen > 95%

SPO2

Maintain patient in

Semi-Fowler position

Administer CPAP/Oral

appliance during sleep

Apply capnography

device during sleep

Patient will demonstrate

no signs of respiratory

depression/distress or

cardiovascular instability

Vital signs stable

SPO2 > 90% room air

CO2 >25, < 50

Absence of respiratory

distress

08/10/2011

KW

17:09

KW

Acute Pain related to

Surgery

Manage pain with

NSAIDs, Ketamine or

Tramadol

Apply TENS, Ice

Reposition for comfort

Patient with report

satisfaction with pain

management regimen

States satisfaction with

pain level

08/10/2011

KW

17:09

KW

Extubation Ensure patient meets

OSAS specific criteria

before extubation

30° reverse

Trendelenberg position

immediately after

extubation

Patient will maintain

ventilation without

assistance

Follows commands

Head lift >5 seconds

Vital capacity > 15cc/kg

Negative Inspiratory

Force > -25 cm H2O

RR > 12/min

08/10/2011

KW

14:51

KW

RN Signature Kandace Whiting, RN

Figure 2: OSAS Arden Syntax