novel perioperative risk factors€¦ · objectives review postoperative outcomes in patients with...
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Novel Perioperative Risk Factors:
OSA/Pulmonary Hypertension/OHS:June 30th, 2017
Roop Kaw, MD
Associate Professor of Medicine.
Cleveland Clinic
Objectives
Review postoperative outcomes in patients with
OSA/OHS and PH compared to controls.
Identify patients with OSA who may be higher
risk for postoperative complications
Make the case for screening and perioperative
risk stratification in patients with OSA.
CASE
71 WF admitted to SICU s/p revision of VBG (initial 27 yrs ago) to open
RYGB
Medical morbidities :
Morbid obesity BMI 72. 38; DM; HTN; Ex smoker, COPD on 3 liters O2;
OSA on BiPAP 20/16; PAF on coumadin ; DVT 10 years & PE 2 years
before surgery; s/p IVC filter; Mild to moderate PULMONARY HTN
Positive exertional dyspnea; 4 pillow orthopnea, no PND
Short neck; potential difficult airway; never intubated for COPD
Nuclear perfusion stress test negative for ischemia 10 months ago
Echo 1 month before surgery: Normal sized atria; RV, LV, LVEF 55%
No documented PFTs
ABG one day before surgery: 7.38 / 54 / 95 / 31
Postoperative Course
6 liters O2 for 3 days; then BiPAP (16/6; day 4); SICU for another 2 days;
and discharged in 3 days
Readmitted with acute respiratory failure requiring re-intubation; acute
non-oliguric renal failure and hypotension requiring pressors
Failure to wean from ventilator over next 10 days at which time
tracheostomy was considered
Tracheostomy was done the following day and patient discharged to
LTAC
Dialysis initiated for oliguric acute renal failure
ReaRPostoperative Readmission # 2
Readmitted with hypoxic respiratory failure; unresponsiveness
and hypotension
Antibiotics initiated for presumed septic shock; presumed
source dialysis catheter; pressors started
PEA arrest treated with CPR/ epinephrine; pulse returned
V tach requiring DC shock x 2; epinephrine; pronounced dead
12Memstoudis et al . Anesthesia & Analgesia. 112(1):113-121, January 2011.
Published by International Anesthesia Research Society.2
Prevalence of OSA in General and Orthopedic Surgery patients
Memtsoudis et al…Anesthesia & Analgesia.
112(1):113-121, Jan 2011.
. 2
Respiratory complications in patients w/wo OSA
undergoing Orthopedic (A) or General surgery (B)
14
© The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Date of download: 8/10/2015 Copyright © 2015 American Society of Anesthesiologists. All rights reserved.
Risk of Specific Respiratory and Cardiovascular Complications in Obstructive Sleep Apnea Patients vs. Matched Controls
From: A Matched Cohort Study of Postoperative Outcomes in Obstructive Sleep Apnea:Could Preoperative Diagnosis and
Treatment Prevent Complications?
Anesthesiology. 2014;121(4):707-718. doi:10.1097/ALN.0000000000000407
Percentage of patients hospitalized at least once per year is shown.
Berg G et al. Chest 2001;120:377-383
©2001 by American College of Chest Physicians
Survival curves for patients with OHS (n = 47; mean BMI, 45 kg/m2) vs simple obesity (n = 103; mean BMI, 42 kg/m2).
Mokhlesi B , Tulaimat A Chest 2007;132:1322-1336
©2007 by American College of Chest Physicians
Prevalence of OHS amongst the general adult population in the US can, however
be estimated.
Assuming approximately 3% of the general US population has severe obesity
(BMI ≥ 40 kg/m2).
- half the patients with severe obesity have OSA: 1.5%
- 10-20% of the severely obese patients with OSA have OHS:
1.5-3 per 1000 patients in the general population have OHS.
Recent meta-analysis with the largest cohort of patients (n=4250) reported a 19%
prevalence of OHS among the OSA population, confirming an overall prevalence
of about 3 per 1000.*
Diagnostic criteria for
Obesity Hypoventilation Syndrome
BMI >30 kg/m2
Awake arterial hypercapnia (PaCO2 >45 mm Hg)
Polysomnography reveals OSA in 90% & Sleep hypoventilation in
10% patients.
Rule out other causes of hypoventilation.
Ann Thorac Med. 2009 Apr–Jun; 4(2): 41–49
20
Is it time to Risk Stratify patients
with known or suspected OSA
before surgery?
Which patients with OSA may be considered
high risk for elective surgery?
Patients with Obesity Hypoventilation Syndrome
Patients with severe OSA?
OSA patients with associated Pulmonary Hypertension.
Complex Sleep Apnea among patients on chronic opioid
therapy
Repetitive postoperative hypoxia
OSA severity (A) and PH severity and etiology (B) in
relation to Body Mass Index
For each BMI category in Figure B, bars on the left indicate all patients with PH and bars on
the right indicate patients with “severe” PH (mPAP ≥ 40 mmHg)
Minai OA, Ricaurte B, Kaw R et al. Am J Cardiol; 114: 1300-6
0< 30
20
40
60
80
100
30 -40
Body Mass Index
Re
lative
Fre
qu
en
cy o
f O
SA
(%
)
> 40
5 (16%)
Severe8 (28%)
3 (14%)
12 (37.5%)
Moderate9 (31%)
7 (32%)
15 (47%)Mild
12 (41%)12 (54.5%)
A.
0< 30
20
40
60
80
100
30 -40 > 40
13(41%)
PVH14
(48%)
7(22%)
PAH5
(17%)
13(60%)
6(27%)
7(34%)
mPAP5
(34.5%)6
(27%)Re
lative
Fre
qu
en
cy o
f P
H (
%)
B.Body Mass Index
International Anesthesia Research Society. Published by International Anesthesia Research Society. 2
Figure 2
Perioperative Mortality in Patients with Pulmonary Hypertension Undergoing Major Joint Replacement.Memtsoudis, Stavros; MD, PhD; Ma, Yan; Chiu, Ya; Walz, J; Voswinckel, Robert; Mazumdar, Madhu
Anesthesia & Analgesia. 111(5):1110-1116, November 2010.DOI: 10.1213/ANE.0b013e3181f43149
Figure 2 . The incidence of adverse events for full and matched samples. PHTN = pulmonary hypertension; THA = total hip arthroplasty; TKA = total knee arthroplasty.
IMPACT* Registry
n = 60,000
CCF RHC** Registry
n = 5445
Patients who underwent both
Non-Cardiac Surgery (NCS) and
Right Heart Catheterization (RHC)
n = 526
I/E Criteria (list)#
n = 173
Patients with PH
who underwent NCS
(n = 96)
Patients without PH
who underwent NCS
(n = 77)
Flow Diagram of Patient Selection for the Study
*IMPACT: Internal Medicine Preoperative Assessment, Consultation and Treatment. †RHC: Right Heart
Catheterization. ‡Age<18 yrs; Cardiac Surgery prior to NCS; minor procedures under local anesthesia and / sedation.
Perioperative Outcomes in Patients with & without
Pulmonary Hypertension After Non-cardiac Surgery
Perioperative Outcome PH No PH p-Value OR
(n = 96) (n = 77)
Morbidity/Mortality* 26.0 2.6 <.0001 13.1
Perioperative MI 1.0 0.0 .28
Perioperative CHF 13.5 1.3 .001 11.9
Hemodynamic Instability 8.3 0.0 .002 -
Sepsis 10.4 0.0 .0005 -
Respiratory Failure 7.3 0.0 .004 -
Prolonged Intubation 8.3 0.0 .002 -
ICU Length of Stay (Days) .66 ±2.7 .01 ± .11 .04 -
Hospital Length of Stay (Days) 7.0 ± 9.3 3.2 ± 3.1 .0008 -
30 day Hospital Readmission 16.7 7.8 .08 2.4
MI= Myocardial Infarction; CHF= Congestive Heart Failure; ICU: Intensive Care Unit.
* Numbers represent percentages within each group unless otherwise noted.
Date of download: 8/25/2014
Copyright © American College of Chest Physicians. All rights reserved.
From: Perioperative Risk and Management in Patients With Pulmonary HypertensionPulmonary Hypertension
and Surgery
Chest. 2013;144(1):329-340. doi:10.1378/chest.12-1752
Most Important things to avoid in the Perioperative setting
Spinal anesthesia is contraindicated among PH
patients due to its profound sympatholytic effects
and rapid onset.
Caution is advised with iv narcotics to prevent or
reverse sympathetically mediated increase in PVR.
Abrupt weaning from pulmonary vasodilators can
prevent dangerous rebound in PH.
Hyperinflation of lungs should be avoided because
PVR is lowest at lung volumes at or near FRC.
Among other things it reduces LV preload.
Identifying RV Failure
Life threatening rebound PH may occur in patients being weaned from
pulmonary vasodilators especially inhaled nitric oxide or mechanical
ventilation.
Elevations in RA pressure and reductions in CO are of much greater
concern than elevations in PA pressure as this indicates RV FAILURE.
Presence of significant RV dysfunction should prompt re-evaluation of
the need for surgery.
For patients with RV failure any surgeries beyond minor should be
avoided.
Society of Anesthesia and Sleep Medicine
Annual Meeting
Oct 20-21, 2016Chicago
http://www.sasmhq.org
Conclusions
OSA is a newly recognized perioperative risk factor and increases
the risk for postoperative complications.
OHS poses a much higher risk for postoperative complications
especially respiratory failure & must be screened for before NCS.
Patients with PH (known or unrecognized) are at risk of death
after NCS.
Right Ventricular failure & Respiratory failure are the most
common postoperative complications in patients with PH.