NEW YORK (Reuters Health) – Patients identified on preoperative screening as having a moderate-to-high risk for obstructive sleep apnea (OSA) have worse postoperative outcomes than patients previously diagnosed with OSA, according to a retrospective study.
“We were surprised that patients we identified immediately before surgery as ‘at risk for OSA’ or ’suspected OSA’ had the same or worse respiratory complications or 30-day mortality after surgery than those with the diagnosis of OSA,” said Dr. Ana Fernandez-Bustamante of the University of Colorado Denver.
“The thousands of patients we studied make this finding quite reliable. We cannot deny the evidence that undiagnosed (and untreated) OSA is a significant health problem,” she told Reuters Health by email.
OSA predisposes surgical patients to cardiopulmonary complications and intensive care unit admissions, so anesthesiologists routinely screen for it. Previous reports suggest that as many as 90% of patients with OSA present for surgery undiagnosed.
Dr. Fernandez-Bustamante and colleagues used the Epic Clarity Electronic Medical Record database at the University of Colorado Health to compare perioperative adverse respiratory events (ARE) and other outcomes between patients with a day-of-surgery screened OSA diagnosis (S-OSA) and those arriving for surgery already diagnosed with OSA (D-OSA).
The frequency of any perioperative ARE (hypoxemia events, difficult airway management, or both) was similar in S-OSA patients (68%) and D-OSA patients (71%), but much lower in patients without any OSA diagnosis (52%).
Compared with D-OSA patients, S-OSA patients had similar frequency and duration of oxygen therapy and significantly lower rates of postoperative positive airway pressure (PAP) therapy. But they had higher rates of mechanical ventilation and reintubation, the researchers report in the August issue of Anesthesia and Analgesia.
S-OSA patients were also more often directly transferred to the ICU and had significantly greater hospital length of stay and postoperative mortality within 30 days, compared with D-OSA patients.
Among patients with D-OSA, the frequency of ARE did not differ significantly between patients adherent and those nonadherent to any PAP therapy.
“In general, I would suggest that if a patient has been identified as ‘suspected’ or ‘at risk for’ OSA you should probably care for that patient like you would for someone with a confirmed OSA diagnosis,” Dr. Fernandez-Bustamante said.
“Not doing so puts them at risk for postoperative respiratory depression, even if this means temporary hypoxemia events,” she added. “These can activate sympathetic, cardiovascular, and stress responses and impair healing, and they will also be harder to treat if extreme (the airway management will likely be more difficult than the average patient).”
“The screening tool that we used (the STOP-BANG screening score) and others are a simple and inexpensive way to identify patients at risk,” she said. “They are not perfect, but anesthesiologists have the advantage of directly observing the patient’s breathing pattern and oxygenation during sedation states. We can help identify those patients that are at high risk for respiratory depression or that are more sensitive to its consequences, from OSA or other reasons.”
Dr. Fernandez-Bustamante added, “I would like to see more collaborations (among) anesthesiologists, surgeons, and internal medicine physicians to improve the care and outcomes of surgical patients with suspected OSA.”
Dr. Uma Devaraj from St. John’s Medical College and Hospital in Bangalore, India, who recently investigated undiagnosed OSA and postoperative outcomes there, told Reuters Health by email, “A large percentage of the preoperative patients (38.5%) were previously undiagnosed. Though this is not surprising, it reveals the fact that OSA is still largely unsuspected and unrecognized in the population – more so in India, where snoring and daytime sleep (siesta) are culturally acceptable.”
She said patients “should be screened for OSA in the preoperative period. More than one screening method, such as a level III polysomnography/STOP-BANG questionnaire, should be used in patients considered to be at high risk for OSA.”
Dr. Devaraj added, “There should be more awareness about sleep problems, (especially) OSA, not only among patients but also in treating physicians and surgeons, so that appropriate treatment is instituted and complications are reduced.”
SOURCE: http://bit.ly/2uZYdjG
Anesth Analg 2017.
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