On the Cutting Edge

Ideas on Surgery and OSA from Anesthesiologists

We've come a long way since the days--not that long ago--when a person undergoing surgery had to rely on a whiff (generally of nitrous oxide) and a prayer, Anesthesia today encompasses a sophisticated array of general and local techniques that are equal to the challenge of providing pain relief during even the most invasive and complex surgical procedures.

But when someone has obstructive sleep apnea, anesthesia poses special challenges, for both medical personnel and patients. How should an anesthesiologist, using agents that suppress or depress breathing, best handle a patient whose breathing is already disturbed? How should a patient, groggy after an operation, deal with an overworked nursing staff that may never have seen a PAP machine.

"For a long time, we weren't that attuned to the problem," says anesthesiologist Jeffrey Gross, of the University of Connecticut School of Medicine in Farmington. "But we're seeing a lot more sleep apnea than we used to, and we've become a lot more aware of it. It's now a hot topic." In 2003, Gross became the chair of an American Society of Anesthesiologists task force charged with developing guidelines for the management of patients with OSA. The resulting "Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea" were approved by the society in 2005, and were published in the May 2006 issue of the journal Anesthesiology.

Starting with the premise that "both pediatric and adult patients with OSA ... present special challenges that must be systematically addressed ... to improve [their] care and reduce the risk of adverse outcomes," the task force, which included an otolaryngologist and bariatric surgeon in addition to anesthesiologists and methodologists, made recommendations for preoperative preparation, intraoperative management, and postoperative management of people with OSA. (These three together constitute the "perioperative" of the paper's title.

Preoperative

According to the guidelines, a surgical candidate's OSA status needs to be established early on, by means of medical histories, family interviews about snoring and arousals, and physical examinations that take into account such risk factors as large neck circumference, and airway and palate anomalies. For someone who has not already been formally diagnosed with OSA, but manifests the clinical signs, surgery may need to be delayed to allow for sleep studies and, possibly, the initiation of PAP therapy. (A delay in an elective procedure also gives an obese patient a chance to iimprove his or her OSA status by losing weight.) In the period leading up to the operation, anesthesiologists should work with surgeons to develop a management plan, which would include a determination as to whether the procedure can be safely done on an outpatient basis, or will require inpatient monitoring.

Intraoperative

Given that patients with OSA have airways that are especially susceptible to the effects of inhaled anesthetics, sedatives and opioids, the task force recommends that general anesthesia be avoided in peripheral (that is, arms and legs) procedures and that sedation be minimized. Instead, where possible, local anesthesia or what is called general conduction anesthesia (spinals or epidurals) should be employed. If sedation is required, ventilation should be continuously monitored, and PAP should be used by patients who have been previously treated with this modality. If possible, recovery should be carried out in a semi-upright or lateral position.

Postoperative

Regional analgesic techniques, such as nonsteroidal anti-inflammatory eliminate the need for systemic opioids. Supplemental oxygen should be administered until patients can maintain their baseline oxygen saturation while breathing room air, and continuous pulse oximetry monitoring should be employed. Patients should remain in a semi-upright position if possible, and PAP should be continued. Those patients on PAP should be able to bring their own equipment to the hospital. OSA patients should not be sent to an unmonitored setting until they are no longer at risk for postoperative respiratory depression. This may require a longer than usual stay. These represent the best practices.

But until they become the standard of care, OSA patients facing surgery can anticipate some hurdles to getting the care they require. One of the American Sleep Apnea Association's patient board members, Vicki Thon, recently discovered how high those hurdles can be. An educated and proactive apneic, Thon thought she had covered all the bases before her foot surgery. But a respiratory therapist's insistence that she use a leaky hospitalprovided mask, rather than the one she'd brought from home, led to an unnecessarily prolonged and difficult hospital stay. Sleep-deprived and suffering, Thon was unable to figure out where to turn for help. Upon her discharge, she wrote a strongly worded letter to the hospital, and received an apology and the promise that the hospital had changed its policy to allow patients to use their own equipment.

But it's obviously better not to be in a situation where an apology is later required. How to accomplish that? Find out everything you can about hospital procedure, and who is going to be in charge of the different aspects of your care, and make as many people as possible aware of your condition and needs. In these days of (mis)managed care, you may not be able to talk with your anesthesiologist ahead of time, but you can probably arrange a consult with a nurse on the anesthesiology team. Still, no matter how much you communicate before your procedure, problems may arise afterward. Be aware that having done time on the operating table, you may not be your own best advocate. Have a friend or family member--someone familiar with your medical situation--standing by to intervene on your behalf. Many hospitals these days have someone on staff who is designated as the "patient representative" or "patient advocate." Get that person's name and phone number, and don't hesitate to call if you need an intermediary.

Link to Monograph on Perioperative Management of OSA Patients, courtesy of Society of  Anesthesia and Sleep Medicine

Two Patient Education Bulletins for OSA Patients in the hospital or undergoing surgery

Hospital Checklist for Obstructive Sleep Apnea Patients

PAP Use in a Hospital or Surgical Setting