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10/18/19
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RegionalanesthesiafortheOSApatient
–Isthereabenefitand
whenshoulditbeused?
CrispianaCozowicz,MD
Nothingtodisclose
10/18/19
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OSApatientsatincreasedriskforperioperativecomplicationsComplications OSAvsnon-OSARespiratoryfailure OR2.43p=0.003Cardiacevents OR2.07p=0.007ICUtransfer OR2.46p=0.006
Healthcarequestion
• AssociationbetweentypeofanesthesiaandperioperativeoutcomesinOSA
Populationbasedanalysis
• Premier,nationaladministrativedatabase
• Claimsdata>540UShospitals
• 30,024OSApatients(ICD-9code),2006– 2010
• GA74%,NA11%,GA/NA15%
Complications NAvsGA NA+GAvsGACombinedcomplications OR0.83p=0.03 OR0.89p=0.03Mechanicalventilation OR0.64p<0.0001 OR0.64p<0.0001ICU OR0.43p<0.0001 OR0.67p<0.0001Prolongedlengthofstay OR0.75p<0.0001 OR0.70p<0.0001Increasedcost OR0.88p=0.04 OR0.70p<0.0001Pulmonarycomplications OR0.77p=0.01
+PNBà additionalreductioninmechanicalventilation,ICUandLOS
ImpactofAnesthesiaTechniqueinOSA
RegAnesth PainMed|2013
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Healthcarequestion
• DoesanesthesiatechniqueinfluenceperioperativecomplicationsinOSA?
Retrospectiveobservationalanalysis
• Institutionaldata:ThomasJeffersonUniversity,PA
• 2005– 2016(ICD-9code)
• 1,246OSAmatchedto3,738non-OSApatients(1:3)
Complications GAvsNAinOSAPulmonarycomplications OR4.48p=0.004Gastrointestinalcomplications OR4.70p=0.02Acutehemorrhagicanemia OR2.14p=0.04Mortality OR14.0p=0.008
GAimpactoverallPulmonarycomplications OR5.04p<0.001Cardiaccomplications OR2.11p=0.02Gastrointestinalcomplications OR4.60p<0.001Acutehemorrhagicanemia OR3.58p<0.001Shock OR3.26p=0.003Woundcomplications OR13.01p=0.001Mortality OR15.88p<0.001
ImpactofAnesthesiaTechniqueinOSA
TheJournalofArthroplasty|2017
Healthcarequestion• Incidenceofperioperativecomplicationsbyanesthesiatechnique
Prospectiveobservationalstudy• Institutionaldata:NicolaeTestemitanu University,Romania• 2014– 2015,Berlinquestionnaire• 400patients;abdominalandorthopedicsurgeryResults
• HighestnumberofcomplicationsinOSA/abdominalsurgeryunderGA
• BestoutcomesinOSApatientswithorthopedicsurgeryunderRA
• Respiratorycomplicationsmostfrequent
• Riskforcomplicationsdependsontypeofsurgeryandanesthesia
Abdominalcavity OrthopedicComplications GAvsNA GAvsNARespiratorycomplications +17.3% +16.0%ICU(unplanned) +5.7% +4.3%Stroke +0.7% 0%Postoperativefever +1.4% -2.6%Postoperativeventilation +20.3% +20%Difficultintubation 3.5%inGAProlongedawakeningfromanesthesia
2.5%inGA 13%inGA
NA+PNBà additionalreductioninrespiratorycomplications
ImpactofAnesthesiaTechniqueinOSA
RomanianJournalofAnaesthesiaandIntensiveCare|2016
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Healthcarequestion
• IncidenceandriskfactorsforpostoperativehypoxemiainOSA
• Hypoxemia:SpO2<90%forover5min
Retrospectiveanalysis
• OSAsurgicalpatientrecordsattheHospitalforSpecialSurgery(2005– 2008)
• 527OSApatientsundergoingambulatoryorthopedicsurgery(ICD-9)(minimumone-nightPACUforcontinuousmonitoring)
Results
• GAidentifiedasariskfactorhypoxemiainOSA(+bloodloss,IVfluidsandsurgerytype)
• Hypoxemiaassociatedwithmajorrespiratorycomplications,increasedLOS,andwoundinfections
Anesthesia HypoxemiaGAonly 29%Spinal 4%Spinal+PNB 1%Epidural 5%PNB 4%IV-PCA 32%ContinuousPNB 4%
ImpactofAnesthesiaTechniqueinOSA
HSSJ|2011
AirwayManagementinOSA
Complications OSAvsnon-OSADifficultintubation OR3.46p<0.0001Difficultmaskventilation OR3.39p<0.0001Combined OR4.12p<0.0001Supraglotticairwayfailure OR1.34p=0.38
PLOSONE|Oct2018
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AirwayManagementinOSA
IncreasinglitigationcasesinOSA
Deathoranoxicbraininjuryduetodifficultairwaymanagement• Difficultintubation• Postoperativefailuretoreintubateafterprematureextubation
A&A|Jan2016
AirwayManagementinOSA
KnownorsuspectedOSAshouldbeconsideredanindependentriskfactorfordifficultintubation,difficultmaskventilation,orboth
PatientswithknownorsuspectedOSAshouldbemanagedaccordingtothe
Anesthesiology|2014
A&A|2018
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HealthcareQuestion
• EarlypostoperativerespiratorycomplicationsinhighriskOSAafterGA
Observationalprospectivedoublecohortstudy
• Institutional,CentroHospitalarSãoJoãoinPorto,Portugal
• PACUafternon-cardiac,non-neurologicalsurgery,2011
• 340patients(STOP-BANG)
Results
• ResidualneuromuscularblockademorefrequentinOSA
• InabilitytobreathedeeplymorefrequentinOSA
• IncreasedrespiratorycomplicationsinOSAafterGA
• Residualneuromuscularblockadeindependentriskfactorforadverserespiratorycomplications
Complications OSA non-OSA P-valueHypoxia 9% 3% 0.012Respiratorycomplications 39% 10% <0.001Inabilitytobreathedeeply 34% 9% 0.001ResidualNeuromuscularblockade 20% 16% 0.035PACULOS 120min 99min 0.04
NeuromuscularBlockadeinOSA
RevPortPneumol |2013
NeuromuscularBlockadeinOSA
OSAcomparedtonon-OSApatientsreceivingneuromuscularblockingagentsmaybeatincreasedriskofeffectsof
• Postoperativeresidualneuromuscularblockade
• Hypoxemia
• Respiratoryfailure
FullreversalofNMBshouldalwaysbeverifiedbeforeextubation
• Effectsmaypersistevenaftertheuseofreversalagents
• Ingeneralpopulation,sugammadex vsneostigminemoreefficientindecreasingresidualparalysis
• InOSApopulation,insufficientevidencetodemonstratesuperiorityofsugammadex
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Prospectiveobservationalstudy
• Institutional:TorontoWesternandMt.Sinai,Canada
• 58patients,PSGpreop.+postop.night1,3,5,7
Postoperativeworseningof
• SDB:AHIincreased,exacerbationofnocturnalhypoxiaandhypercapniaOSA>non-OSApeakpostoperativenight3,sustained7days
• Sleeparchitecture:REMsleep,slowwavesleeppeakonpostoperativenight1
ImpactofAnesthesiainOSA
Anesthesiology|2014
Driversofpostoperativesleep-disorderedbreathing
Prospectiveobservationalstudy
• Institutional:TorontoWesternandMt.Sinai,Canada
• 376patients,orthopedic,spinal,orgeneralsurgery
• PSGpreop.,postop.nights1and3
Result
• GAassociatedwithincreasedpostoperativeCentralApneaIndex
• 72hopioiddosepositivelycorrelatedwithAHIseverity
DriversofpostoperativeApneaHypopneaIndex(AHI)• PreoperativeAHI• Age• 72hoursopioiddoseDriversofpostoperativeCentralApneaIndex• Preoperativecentralapneaindex• Malesex• GA
ImpactofAnesthesiainOSA
Anesthesiology|2014
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PostoperativeDeathandCriticalEventsinOSA
PostoperativeDeathandCriticalEventsinOSA
Commonlysharedpostoperativecourse• Patientsawake,alert,andstable(favorablesedationscores)• Precedinghighpainscoresanduseofpainmedicatione.g.PCA• Typicalorlessthantypicaldosesofnarcoticsandsedatives• Aftergoingtosleepfounddeadorincriticalcondition• Cardiorespiratoryarrest
Retrospectivelyoftendeemedapreventable• Lapsesinmonitoringoftenimplicated
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Upperairwayanatomy
• Narrower,higherpharyngealcollapsibility,obesity(parapharyngealfatdeposition),craniofacialabnormalities
Abilityofupperairwaydilatormusclestorespondpharyngealcollapseduringsleep
• Decreasedtoneofupperairwaydilatatormuscles– obstructiveevents
Arousalthreshold- propensitytowakeupfromrespiratorystimulusduringsleep
• Hypercapnicrespiratorydriveanddiaphragmaticallygeneratednegativepressureduringairwayobstructionpredisposerepeatedarousal
• Lowarousalthreshold,disruptivesleep,wakeupbeforereachingverylowoxygensaturation
• Higharousalthreshold- preoperativeidentificationnotfeasible
Inherentinstabilityofventilatorycontrol
CriticalComponentsofOSAPathogenesis
A&A|Jan2017
TypeIIIPatternofventilationandSPO2 cyclingduringsleep
Instabilityofventilationand/orupperairwaycontrolfollowedbyprecipitousandfataloxygendesaturationifarousalfailureisinducedbynarcoticsand/orsedation
Deathandlife-threateningeventsinOSA
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OSArelatedcyclingscoresofapneasduetoinstabilityofupperairwaycontrol
• Perpetualarousaldependentsurvivalduringsleep- reopeningofupperairway
Sentinelinstabilitycomponent:arousalfailureinthepresenceofsleepapnea
• Precipitoushypoxemia- steepfataloxygendesaturation
• Severearousalfailure- profoundcerebralhypoxemia“LightsOutSaturation”sufficienttoinducecentralarousalarrest
• Patientsdeadinbedwithoutwarningfromprolongedapneas
Delayedarousal
• SubgroupsofOSApatientsexhibitseverelydelayedarousals• Occultarousalfailure
• OSAacquiredarousalfailure• Centralarousalsystemfailureinresponsetodailyrepetitivehypoxemiaand• Sleepfragmentation
• CPAPinitiation– sleeprebound
• Anesthetic,sedativeandnarcoticagentsadditionalfactorsthatdelayrespiratoryarousal
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Generalanesthesiaanddosedependentdepressionofupperairwayactivity
Anesthetic,sedative,andnarcoticdrugeffects
WorsenedupperairwaycollapsibilityDepressionofcentralrespiratoryactivity• Diminishedventilatoryresponsetohypercarbiaandhypoxia• Delayedrespiratoryarousalresponsetoairwayocclusion• Depressionofcentralrespiratoryoutputtoupperairwaydilatormusclesand
upperairwayreflexes(e.g.genioglossusmuscle)DepressionofperipheralreflexpathwaysofupperairwaymuscleactivityExacerbatedSDB
à Mayprecipitatecompletearousalarrestinpatientswithhigharousalthreshold
à Sudden,unexpecteddeath
OSAcomplicatingopioidanalgesia
EnhancedpainsensitivityconferredbyOSAfeatures
Chronicintermittenthypoxia• NocturnalarterialdesaturationmaybeassociatedwithincreasedpaininpatientswithSDB
Sleepfragmentation• Hyperalgesiaininsomnia• CPAPwithimprovedsleepcontinuityreducedpainsensitivityinOSA
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OSAcomplicatingopioidanalgesia
Chroniccyclinghypoxiapotentiatingopioidanalgesiceffects• DecreasedpostoperativeopioidconsumptioninOSAwithrecurrentnocturnalhypoxia
• NocturnalhypoxiaOSAassociatedwithincreasedpotencyofopioids
AlteredpainsensitivityandopioidpotencyshouldbeconsideredinOSA• Preoperativenocturnalhypoxiadeterminantofpostoperativeopioidpharmacology
• Opioidandanalgesicrequirementspotentiallylower
Healthcarequestion
• Impactofmultimodalanalgesiaonopioiduseandcomplicationrisk
Populationbasedretrospectivecohortstudy
• Premiernationalhealthcaredatabase
• 2006-2016;Claims-baseddata>540UShospitals(25%)
• 181,182OSApatientsundergoingtotalhip/kneearthroplasty(ICD-9)
Intervention
• Multimodalanalgesiavsopioids-only
• Systemicopioids+1,2,or>2non-opioidanalgesicmodalities• NSAIDs,Cox-2inhibitors,Acetaminophen/paracetamol,Peripheralnerveblocks,Steroids,Gabapentin/pregabalin,
Ketamine
MultimodalpainmanagementinOSA
BritishJournalofAnesthesia|2019
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Results
• Stepwisebeneficialeffectswithincreasingnumberofnon-opioidanalgesicmodesaddedtoopioids
• Opioidprescriptiondose• LOS• Gastrointestinalcomplications• Mechanicalventilation• PostoperativeICU
• StrongestopioidsparingwithCox-2inhibitorsandNSAIDs
• LowerPCAuse
Conclusion
• Multimodalanalgesiaassociatedwithopioidsparingandreducedcomplications
• doseresponsegradient
MultimodalpainmanagementinOSA
Opioidanalgesia+
1additionalmode
2additionalmodes
≥3additionalmodes
OpioiddosePOD-1 -5.0% -10.4% -14.9%OpioiddosePOD-1+ -5.7% -9.0% -12.5%LOS -4.6% -7.8% -11.8%Cost -1.4% -2.5% -3.2%
GIcomplications OR0.75 OR0.69 OR0.65Mechanicalventilation OR0.60 OR0.33 OR0.23ICUadmission OR0.81 OR0.73 OR0.60
PCAuse 19.2% 13.7% 7.7%alloutcomesp<0.0001
BritishJournalofAnesthesia|2019
Comparativeeffectiveness:GAvsRAYear Author RCTs OutcomesdecreasedwithNeuraxialanesthesia
2019 Memtsoudis 94 Mortality,pulmonary,renal,DVT,infections,bloodtransfusion
2014 Guay9Cochranereviews
117 30-mortality,pneumonia
2016 Meng 8 LOS,intraoperativehypertensionandtachycardia,analgesicrequirementinthePACU,PONV
2016 Johnson 29 LOS
2016 Guay Hypertension
2013 Barbosa Pneumonia
2009 McFarlane 18 Postoperativepain,morphineconsumption,opioidrelatedadverseeffects
2010 Luger 34 Mortality,reducedpostoperativeconfusion,DVT,postoperativehypoxia,pneumonia
2006 Mauerman DVT,PE,bloodtransfusions
2000 Parker 17 Mortality30day,DVT
2000 Rodgers 141 Mortality30%,DVT40%,pneumonia50%,respiratorydepression60%,myocardialinfarction,bloodtransfusion,woundinfectionsrenalfailure
Complications NAvs.GAMortality OR0.67CI0.57-0.80Pulmonary OR0.65CI0.52-0.80CNS OR0.39CI0.23-0.65Thromboembolism OR0.61CI0.53-0.71
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QualityoftheBodyofEvidenceStudydesign• LackofRCTs,mostlyobservational,nocausality,residual
confoundingRiskofbias• AccuracyofOSAidentification:STOP-BANG,Berlin
Questionnaire,PSGrarely
• OSAseverity,whichsubpopulationsareathigherperioperativerisk?
• Surgicalinvasiveness• OSAtreatmentandcompliancee.g.CPAP• Anesthesiaandanalgesia/consumptionofanesthetics
andnarcotics• IndicationbiasselectionbiasImprecision• MoststudiesdonotreachOIS
Directness• Sparsenessofdirectcomparativeeffectivenessresearch
inOSA• Judgementsregardingthestrengthoftheassociation
requiredConsistency
• ResultslargelyconsistentindemonstratingdetrimentaleffectsofGAvsRA
• ConsistencyinsizeofeffectPublicationbias• Lowrisk
Lackofevidenceontheimpactofinterventionsofprecaution• e.g.CPAP,feasibilityofrandomization
Rationalesupportingregionalanesthesia
ImprovedoutcomeswithregionalanesthesiaReducedcomplicationsandresourceutilization
AvoidanceofairwaymanipulationDifficultairway
Avoidanceofneuromuscularblockade
EfficientpainreliefAlteredpainandopioidsensitivity
ReducedconsumptionofopioidsandanestheticmedicationMultimodalpainmanagementHighvulnerabilityinpatientswithdelayedarousalSuppressionofsurgicalcatabolicstressresponseBlockofsystemicendocrinecatabolicresponse
Expeditedmobilization/recovery
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WhatisthepreferredanesthesiatechniqueinpatientswithOSA?• Whenapplicable,RApreferableoverGAinpatientswithOSA
• Potentialforpostoperativecompromiseshouldbeconsideredinselectingintraoperativeanestheticmedications
• Superficialprocedures:useoflocalanesthesiaandPNB(with/withoutmoderatesedation)
• GAwithsecureairwaypreferabletodeepsedationwithoutsecureairway
• Majorconductionanesthesia(spinal/epidural)forperipheralprocedures
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