Patient Safety/Ethics

Perioperative Aspects of OSA

Post–Op Opioids

Post Covid Lab Operations

Peter Allen, BSRC, RRT-NPS-SDS, RPSGT

Philadelphia Sleep Conference 2020

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Conflicts of Interest

• Main Line Health System

• NBRC Sleep Exam Consultant

• Member: AAST, AASM, AARC, SASM

• Current Board Member PA Sleep

Society

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Questions for Attendees

• How many Night Sleep Technologists?

• How many RTs? How many Directors

• How many labs are back to Pre-Covid #s?

• How many are directly involved with a

Perioperative OSA and Opioid

Management Program?

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Goals

• Brief Overview of Perioperative Aspects

• Discuss Post-Op OSA & Opioids

• Discussion of Attendees Experiences

• Patient/Technologist Safety Post Covid

• Lab Start-up after Covid

• Solutions

• One or Two Ideas Back to Labs

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Learning Objectives

• Identification of the “At Risk” Patient

• Review of Adverse Outcomes

• Tools

• Why, Who, Where, What, How

• Supporting Perioperative OSA

Management

• Raising Questions for Discussion

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Why Perioperative Management?

• At Risk OSA Population is Growing

• More OSA Patient Post-Op Complications

• Respiratory Failure

• Re-Intubation

• Unexpected ICU Admissions

• Increased PACU Time

• Increased Suffering/Liability/Cost

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Raising Questions

• How often do you see respiratory

emergencies in the hospital?

• How many could OSA have been factor?

• Unexpected Deaths in the PACU

• Unexpected Deaths 24 hrs after Surgery

• Within one week of Surgery?

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Payment for Performance

• Value-Based Purchasing

• Rewards

• Disincentives

• Quality-Payment Alignment

http://www.ahrq.gov/qual/qpayment.htm

• Implementation Timelines

http://healthreform.kff.org/timeline.aspx

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American Society of Anesthesiologists

• 2006 Commissioned a Task Force that

Identified the Importance of Pre-Screening

surgery patients for the presence of

Obstructive Sleep Apnea (OSA).

• Purpose: Prevent Post-Surgical

Respiratory Events

• Anesthesiology 2006; 104:1081-93

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2008 National Patient Safety Goals

• Proposed Goal 17 from Task Force

• Reduce Risk of Post-Operative

Complications for Patients with

Obstructive Sleep Apnea

• Organization screens potential OSA

patients prior to surgical procedures

involving centrally acting anesthetic and/or

analgesic agents.

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Epidemiology of OSA

• It is estimated that 75% to 95% of patients

with OSA are not yet diagnosed.

• Many who are diagnosed are not being

treated effectively.

• Body Mass Index>30

• Estimates are that 26% of Adults are at

Risk

• 80%-Bariatric/60%-Diabetic/40%-CHF

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Pathophysiology of OSA

• Awake: Airway Patent/Neuromuscular Compensation

• Sleep Onset

• Neuromuscular compensation is lost

• Airway Collapses

• Apnea Occurs

• Hypoxia & Hypercapnia ensue

• Ventilatory effort increases

• Arousal from sleep

• Pharyngeal muscle tone increases

• Patent airway restored

• Hypoxia and Hypercapnia improved by hyperventilation

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OSA Increasing

• Obesity is increasing at epidemic

proportions which is only adding to the

problem of increasing numbers of “at risk”

patients presenting for surgery.

• Obesity Maps

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Associated OSA Conditions

• Obesity Hypertension

• Depression Coronary Artery Disease

• Accidents Arrhythmias

• Diabetes Left side heart enlargement

• GERD LV Dysfunction

• Stroke Congestive Heart Failure(CHF)

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Anesthesia Concerns with OSA

• OSA patients are more susceptible to airway collapse without anesthesia.

• OSA can affect all three phases of perioperative period.

• Anesthesiologists role in identification of the at risk OSA patient.

• Upper airway dilator muscles impaired.

• Effect may last for hours

• Eikermann, et. Al., AmJRespirCritCareMed 2007 175:9-15

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Anesthesia

• Impairs airway patency

• Increases difficulty of intubation

• Brain response less effective

• Narcotics decrease sensitivity to CO2

• Respiratory drive/rate depressed

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Anesthesia

• Upper airway muscle tone reduced with

opiates, sedatives and volatile agents.

• Perpheral control of O2 inhibited

• Recovery rooms

• Local and regional nerve block options

• Malampatti Scores 1-4

• Patients now encouraged to bring PAP

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Anesthesia

• Unexpected Risks during

Administration of Conscious Sedation:

Previously Undiagnosed Obstructive

Sleep Apnea

• Annals of Internal Medicine, 2003;139:

707-708

• Pressman, et. Al.

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Case Reports 1of 6

• Male 65 years of age-Radical prostatectomy

• History showed Positive OSA Profile

• Not diagnosed/treated

• Morphine 5 mg, epidural

• 8 hours later found unresponsive

• Apneic with Cyanosis

• Patient recovered

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Case Report 2 of 6

• Male 38 years of age-Emergent mastoidectomy

• History of loud snoring

• Diagnosed with OSA, but never treated

• Upon extubation patient airway collapses

• Reintubated

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Case Report 3 of 6

• Male 41 years of age-Orthopedic surgery

• Diagnosed, but not treated

• Epidural opiods

• Post-op day 2 found unresponsive

• Irregular respiratory pattern

• Cardiac arrest lead to death

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Case Report 4 of 6

• Female 42 years of age-Laproscopic surgery

• Diagnosed with OSA, but not treated

• Post-op prolonged heart block during sleep

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Case Report 5 of 6

• Obese male, 42 years of age-Surgery

• Diagnosed with OSA, not treated

• Morphine

• Cardiac arrest

• Severe hypoxia followed by cerebral silence

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Case Report 6 of 6

• 101 OSA patients and 101 matched controls

• Hip & knee surgery

• OSA patient diagnosis prior to or after surgery

• Controls did not get PSG-????

• Post-op complications greater in OSA patients

• Hospital reported longer stays for OSA group

• Hospital reported more ICU transfers/OSA pts.

Parker Stewart’s Bill

• Uintah Basin Medical Center

• 3 unexplained deaths post-op

• Parkers death ruled Pneumonia/Ethics

• Post-Op Opioids, common factor

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At Home Monitoring

• Being studied at this time

• Respiratory Rate

• Pulse Oximetry

• Capnography

• Hospital Revenue???

• Masimo

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Peer Review Article

• HOME MONITORING OF POST-OPERATIVE EAR, NOSE & THROAT

(ENT) PATIENTS FOR OPIOID INDUCED RESPIRATORY DEPRESSION-

--MORE THAN OSA

• PRESENTING AUTHOR: Kim Bennion MsHS, RRT, CHC, Intermountain

Healthcare

• CO-AUTHOR: Shaylynn Uresk BSRT, RRT, SDS, Uintah Basin Medical

Center

• BACKGROUND: Opioid related deaths have been rapidly increasing1. A

recent study suggested oxygen saturation (SpO2) & other overnight

oximetry measurements may provide additional Opioid Induced Respiratory

Depression (OIRD) risk stratification insight2.

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Parker References

• CDC’s report on opioid related deaths• https//www.cdc.gov/drugoverdose/epidemic/index.html

• Suen C, Ryan et al

• Sleep study and oximetry parameters for predicting

postoperative complications in patients with OSA.

• Chest ; 155(4):855-867 2019

• https://youtu.be/R-4JwdUC4hO Parker’s Story

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OSA – Diagnosis

• Clinical examination(history and physical

examination) carries a diagnostic sensitivity and

specificity of only 50 to 60% even when

performed by experienced sleep physicians

• Clinics of Chest Med 1998; 19:1-19

• If it walks like, talks like, looks like a ….

• Its OSA

• If it walks like, talks like, looks like a ….

• Its OSA

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OSA Obvious as a Duck

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Preoperative screening for OSA

• Stop Bang Questionnaire with H&P

• Preoperative diagnosis

• Referral to sleep disorder center

• Preoperative treatment if possible

• PAP Treatment prior to surgery

• PAP Treatment documented prior to surgery

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Identifying the Problem

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Stop-Bang Stop-Bang Stop-Bang

• 1. Do you Snore loudly?

• 2. Do you often feel Tired during the daytime?

• 3. Has anyone Observed you stop breathing during your sleep?

• 4. Do you have or are you being treated for high blood Pressure? Stop

• 5. BMI more than 35 kg/m ?

• 6. Age over 50?

• 7. Neck circumference greater than 40cm?

• 8. Gender male? Bang

• High Risk of OSA=Yes to 3 or more items

• Low Risk of OSA= Yes to less than 3 items

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American Society of Anesthesiology

Recommendations

• Anesthesiologists are working with Surgeons

• Develop Protocols

• Get suspected OSA patients diagnosed and

treated prior to surgery whenever possible

• If diagnosis of OSA is made on the day of the

surgery, then patient and family needs to be

informed of the potential implications of OSA on

the perioperative course.

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ASA Recommendations Continued

• Be prepared for difficult intubation

• Choice of anesthetic technique

• Oximetry and end-tidal CO2 monitoring

• Full reversal of neuromuscular blocking agents

• Consider non-supine extubation.

• General anesthesia preferable to deep sedation

• Spinal epidural considerations vs IV

• Use of opioids vs regional anesthesia

• Discharge delay a consideration

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Perioperative Program Awareness

• Contact these areas all at the same time

• Bio-Ethics Department

• All medical staff members

• Grand Rounds Presentations

• Lunch and Learn AMA CEUs

• Community Outreach Programs

• Allied Healthcare Staff

• Home Care Companies

• Manufacturers

• Implement Outcome Tracking Protocols

Home Monitoring

• Check w Masimo

• DME/Hospital Revenue

• Physician/Patient Education is Key

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Perioperative Management of OSA,

Budget

• Questions to Ask:

• Cost Center vs Revenue Center

• What is it going to cost to implement or

to increase awareness?

• What will it cost if we do not

implement or promote?

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Hospital Implications

• At risk patients not served-Ethical aspects

• Patient Safety/Patient experience

• Hospital revenue

• Hospital reputation

• Hospital recognition

• Physician revenues/Sleep Lab Revenues

• Surgical Risk Liability and SurgSchedules

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HME Considerations

• Perioperative program will:

• Drive PAP business higher

• Drive O2 business higher

• Increase your referral base

• Improved relations with area medical and

surgi-centers

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Sleep Disorder Centers

• Additional Revenue

• Navigators???

• Increase Referral Base

• Reinforces the fact that to survive sleep

disorder centers need to diversify/change

their sales and marketing focus on more

complex patients and new opportunities.

• Periop, Stroke, CHF, Diabetes-In House

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Working Together

• Primary Care Physicians

• Surgeons

• Anesthesiologists

• Allied Health, Nursing, Respiratory Care

• Sleep Disorder Centers

• Home Care Companies

• Hospital Administration

Post Covid Sleep Lab Thoughts

• Performing HSTs, Performing PSGs/PAP?Note: Market/Referral Sources Lost can stay lost

• Keys to Bringing Back Your Numbers

• Disposable Everything (Even HSTs)

• PPE for Technologists

• Patient Screening at every stage of process

• Room Cleaning Machines

• Negative Air Rooms

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Helpful Organizations

• American Society of Anesthesiology

• ASA

• Society of Anesthesia & Sleep Medicine

• SASM

American College of Chest Physicians

ACCP

American Academy of Sleep Medicine

AASM and AARC

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Summary

• Patients with OSA

• Make up a significant portion of the surgical population and will only

increase as obesity trends move upward.

• Most are not identified before surgery

• Have an increased risk for perioperative complications

• Can be screened diagnosed and treated to manage perioperatively

to reduce risks.

• Programs can be implemented to identify and treat these patients

without substantial increases in costs, resulting in risk reduction,

improved patient safety and better outcomes.(Needs Champion)

• Implement a Post Covid Lab Program – AASM very helpful.

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References

• Stop Bang Questionnaire, Anesthesiology, V 108, No 5 May Chung, et al.

• Anesthesiology News Guide to Airway management-Obstructive Sleep Apnea Anesthesia, and Ambulatory Surgery, Bishop, et. al

• Perioperative Screening for and Management of Patients with Obstructive sleep Apnea-Beth Israel Deaconess Medical Center, Boston, MA, Sundar, et. al

• Avoiding adverse outcomes in patients with obstructive sleep apnea(OSA); development and implementation of a perioperative OSA protocol, Bolde, et. al.

• Postoperative Complications in Patients With Obstructive Sleep Apnea, CHEST 2012; 141;436-44, Kaw, et. Al.

• Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature, Journal of Clinical Medicine, Vol. 8, NO. 2 2012, Vasu, et. Al

• Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study 2001 Mayo Foundation, Mayo Clin Proc. 2001;76:897-905 Gupta, et.al.

Home Monitoring of High-Risk

Opioid Patients

• Cheatle MD, Klocek JW and McLessan AT (2012). Managing pain in high-risk patients within a

patient-centered medical home. Translational Behavioral Med. 2012;2(1): 47–56.

• Shoemaker WC, Wo CJ, Bishop MH, Asensio J, Demetriades D, Appel PL, Thangathurai D and

Patil RS (1996). Noninvasive Physiologic Monitoring of High-Risk Surgical Patients. Arch

Surg.1996;131(7):732-737.

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• Gwira-Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ and Jones TF (2014).

High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths. JAMA

Intern Med. 2014;174(5):796-801.

• Straus MM, Ghitza UE and Tai B (2013). Preventing deaths from rising opioid overdose in the US

– the promise of naloxone antidote in community-based naloxone take-home programs. Subst

Abuse Rehab. 2013; 4: 65–72.

•

• Janssens JP, Borel JC, Pepin JL (2011). Nocturnal monitoring of home non-invasive ventilation:

the contribution of simple tools such as pulse oximetry, capnography, built-in ventilator software

and autonomic markers of sleep fragmentation. Thorax 2011; 66 (5): 438-445.

•

• Sliwinski P, Lagosz M, Gorecka D and Zielinski J (1994). The adequacy of oxygenation in COPD

patients undergoing long-term oxygen therapy assessed by pulse oximetry at home. Euopean

Resp Journal 1994; 7: 274-278.

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• Bohnhorst B, Corina CS and Poets CF (2000). Pulse oximeters’ reliability in detecting hypoxemia

and bradycardia: Comparison between a conventional and two new generation oximeters.

Critical Care Medicine 2000; 28(5):1565–1568.

• Jensen LA, Onyskiw J and Prasad GN (1998). Meta-analysis of arterial oxygen saturation

monitoring by pulse oximetry in adults. Heart & Lung 1998; 27 (6): 387-40.

•

• Chan ED, Chan MM, Chan MM (2013). Pulse oximetry: Understanding its basic principles

facilitates appreciation of its limitations. Resp. Med. 2013; 107 (6): 789-799.

•

• Lam T, Nagappa M, WONG J, Singh M, Wong D and Chung F (2017). Continuous Pulse Oximetry

and Capnography Monitoring-Postoperative Respiratory Depression and Adverse Events.

Anesthesia & Analgesia 2017: 125 (6): 2019-2029.

•

• San Diego Patient Safety Council (2014). Monitoring Patient Outside the ICU Took Kit. Located at

https://www.hqinstitute.org/sites/main/files/file-

attachments/2013_resp_monitoring_patients_tool_kit_june2014_final-appendices_0.pdf.

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Home Monitoring of High-Risk

Opioid Patients

• Kodali BS (2013). Capnography Outside the Operating Rooms. Anesthesiology 2013;118: 192-

201.

•

• Huttman SE, Windisch W and Storre JH (2014). Techniques for the Measurement and Monitoring

of Carbon Dioxide in the Blood. Annals Am Thoracic Soc 2014; 11 (4): 645-652.

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Home Monitoring of High-Risk

Opioid Patients

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petersleep@comcast.net