OSA and PONV Through the Eyes of An Ambulatory ... · •Health care disparities and anesthesia practice Department of Anesthesiology. OSA and PONV and Ambulatory Anesthesia No financial

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OSA and PONV Through the Eyes of An Ambulatory Anesthesiologist

Norah N. Naughton MD,MBAAssociate Professor

Senior Associate Chair, EducationDepartment of Anesthesiology

University of Michigan

Puerto Vallarta 2019

Please consider the environment before printing this PowerPointDepartment of Anesthesiology

Why Choose Obstructive Sleep Apnea?

1. Prevalence of OSA in surgical population is high2. Associated co-morbidities can be significant3. Perioperative complications are associated with OSA4. Continued confusion regarding optimal perioperative

management5. Unique aspects of free standing ASC’s

OSA and PONV and Ambulatory Anesthesia

• OSA and perioperative risks

• OSA identification

• Risk mitigation

• Risk factors for PONV

• Health care disparities and anesthesia practice

Department of Anesthesiology

OSA and PONV and Ambulatory Anesthesia

No financial disclosures




Apnea Hypopnea Index


• < 5 NORMAL

• 5-<15 MILD

• 15-<30 MODERATE

• >30 SEVERE

Screening Tools

• STOP-BANG QUESTIONAIRE

• ASA CHECKLIST

• P-SAP SCORE

• BERLIN QUESTIONAIRE



Anesth Analg,2016;123:452-473



0-2 Mild

3-4 Moderate

5-8 Severe


0-2 Mild

3-4 Moderate

5-8 Severe

STOP-BANG and Specificity


Chest,2013;143:1284-1293

STOP-BANG and Specificity



Contraindication for Ambulatory Status

• Obesity hypoventilation syndrome

• Pulmonary hypertension

• Resting hypoxemia

• Overlap syndrome COPD + OSA

• Uncontrolled Systemic Disease



Mild OSA

Proceed with ambulatory surgery

D-Moderate or Severe OSA

S-Moderate or Severe OSA

Uncontrolled systemic diseaseOHS, pulmonary hypertension, resting hypoxemia

Further work-up and not appropriate for ambulatory surgery

Cpap compliant and Cpap postop

Cpap compliant and no Cpap postop

???

Education/Communication, Risk Mitigation, PACU stay

Proceed with ambulatory surgery

???

Communication/risk mitigation/pacu stay

D-Moderate or Severe OSA

Non-compliant with Cpap

PSG PSG


CPAP WITHDRAWAL

Sleep, Vol 36, 2013, 405-412



81% of patients with reported opioid doses received less than 10 mg morphine equivalent dose/day


NO OPIOID

Multimodal Analgesia-Gabapentin

• Major Laparoscopic Surgery

• Propensity Score Matched Patients

• Gabapentin associated with increased likelihood of

respiratory depression ( OR 1.26 (95% CI,1.02-1.58) )


Anesth Analg 2017;125:141-146





Monitoring in the PACU


Anesthesiology 2009; 110: 869-877

33% of patients screened positive for OSA AND had recurrent PACU respiratory events had desaturation and/or cardiopulmonary events post PACU discharge

OSA and Ambulatory Status

• EDUCATION

• Include STOP-BANG in Preop Evaluations

• Risk Mitigation Strategies

• No or Reduced Opioids

• PACU Monitoring Guidelines


Patient Education, OSA, Shared Decision

Survey: OSA information and surgery risks

Survey administered prior to preoperative visit

473 surveys collected, 2 Canadian, 1 US site

44% would choose to delay surgery

40% would delay up to 2 months


BMC Anesthesiology 2018: 18, 128


PONV Risk Score: Apfel


Anesthesiology 1999;91:693-700Anesth Analg 2014;118:85-113


Antiemetic Intervention and Risk Reduction

• Ondansetron, Dexamethasone, Droperidol

26%

• Propofol 19%

• Nitrogen 12%

• TIVA 31%


PONV Risk Reduction


Michigan Medicine PONV Prophylaxis


Anesthesiology Performance Improvement and Reporting

Exchange = ASPIRE

• PONV-1 = Greater than 3 risk factors and at

least 2 anti-emetics of different classes

administered


ASPIRE MONTHLY REPORT


ASPIRE INDIVIDUAL PERFORMANCE


Do Anesthesiologists Contribute to Health Care Disparities



PONV Prophylaxis

• Relatively independent of patient co-

morbidities

• Specific measurable risk factors

• Standard of care with explicit guidelines

• Sole responsibility of anesthesia providers

• Not impacted by insurance constraints

• Patient centered outcome


Disparities in Anesthesia Care

National Anesthesia Clinical Outcomes Registry



• 440,000 anesthetic cases

• 6 large institutions: Northeast and South

• 2010-2013

• Socioeconomic status: insurance type, median

income by zip code

• Odds ratio of receiving either ondansetron,

dexamethasone, or both



• All four statistical models established lower

socioeconomic status was associated with

inferior treatment during anesthesia as

measured by the administration of antiemetic

medications

• Why

Individual provider bias?

Systems challenges in lower socioeconomic

neighborhoods?


Summary





Why Choose Obstructive Sleep Apnea?

1. Prevalence of OSA in surgical population is high2. Associated co-morbidities can be significant3. Perioperative complications are associated with OSA4. Continued confusion regarding optimal perioperative

management5. Unique aspects of free standing ASC’s


Other Mechanism of OSA

• Ineffective upper airway dilator muscle

• Low and high arousal thresholds

• Stability of respiratory control

• Rostral fluid shifts

• Supine position-related OSA


Curr Opin Anesthesiol 2018, 31:89-95




From: Response to CPAP Withdrawal in Patients with Mild Versus Severe Obstructive Sleep Apnea/Hypopnea

SyndromeSleep. 2013;36(3):405-412. doi:10.5665/sleep.2460

Sleep | © 2013 Associated Professional Sleep Societies, LLC.

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OSA and PONV Through the Eyes of An Ambulatory ... · •Health care disparities and anesthesia practice Department of Anesthesiology. OSA and PONV and Ambulatory Anesthesia No financial