osa and ponv through the eyes of an ambulatory ... · •health care disparities and anesthesia...
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OSA and PONV Through the Eyes of An Ambulatory Anesthesiologist
Norah N. Naughton MD,MBAAssociate Professor
Senior Associate Chair, EducationDepartment of Anesthesiology
University of Michigan
Puerto Vallarta 2019
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Please consider the environment before printing this PowerPointDepartment of Anesthesiology
Why Choose Obstructive Sleep Apnea?
1. Prevalence of OSA in surgical population is high2. Associated co-morbidities can be significant3. Perioperative complications are associated with OSA4. Continued confusion regarding optimal perioperative
management5. Unique aspects of free standing ASC’s
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OSA and PONV and Ambulatory Anesthesia
• OSA and perioperative risks
• OSA identification
• Risk mitigation
• Risk factors for PONV
• Health care disparities and anesthesia practice
Department of Anesthesiology
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OSA and PONV and Ambulatory Anesthesia
No financial disclosures
Department of Anesthesiology
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Apnea Hypopnea Index
Department of Anesthesiology
• < 5 NORMAL
• 5-<15 MILD
• 15-<30 MODERATE
• >30 SEVERE
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Screening Tools
• STOP-BANG QUESTIONAIRE
• ASA CHECKLIST
• P-SAP SCORE
• BERLIN QUESTIONAIRE
Department of Anesthesiology
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Department of Anesthesiology
Anesth Analg,2016;123:452-473
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Department of Anesthesiology
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Department of Anesthesiology
0-2 Mild
3-4 Moderate
5-8 Severe
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Department of Anesthesiology
0-2 Mild
3-4 Moderate
5-8 Severe
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STOP-BANG and Specificity
Department of Anesthesiology
Chest,2013;143:1284-1293
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STOP-BANG and Specificity
Department of Anesthesiology
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Department of Anesthesiology
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Contraindication for Ambulatory Status
• Obesity hypoventilation syndrome
• Pulmonary hypertension
• Resting hypoxemia
• Overlap syndrome COPD + OSA
• Uncontrolled Systemic Disease
Department of Anesthesiology
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Mild OSA
Proceed with ambulatory surgery
D-Moderate or Severe OSA
S-Moderate or Severe OSA
Uncontrolled systemic diseaseOHS, pulmonary hypertension, resting hypoxemia
Further work-up and not appropriate for ambulatory surgery
Cpap compliant and Cpap postop
Cpap compliant and no Cpap postop
???
Education/Communication, Risk Mitigation, PACU stay
Proceed with ambulatory surgery
???
Communication/risk mitigation/pacu stay
D-Moderate or Severe OSA
Non-compliant with Cpap
PSG PSG
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CPAP WITHDRAWAL
Sleep, Vol 36, 2013, 405-412
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Department of Anesthesiology
81% of patients with reported opioid doses received less than 10 mg morphine equivalent dose/day
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NO OPIOID
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Multimodal Analgesia-Gabapentin
• Major Laparoscopic Surgery
• Propensity Score Matched Patients
• Gabapentin associated with increased likelihood of
respiratory depression ( OR 1.26 (95% CI,1.02-1.58) )
Department of Anesthesiology
Anesth Analg 2017;125:141-146
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Department of Anesthesiology
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Monitoring in the PACU
Department of Anesthesiology
Anesthesiology 2009; 110: 869-877
33% of patients screened positive for OSA AND had recurrent PACU respiratory events had desaturation and/or cardiopulmonary events post PACU discharge
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OSA and Ambulatory Status
• EDUCATION
• Include STOP-BANG in Preop Evaluations
• Risk Mitigation Strategies
• No or Reduced Opioids
• PACU Monitoring Guidelines
Department of Anesthesiology
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Patient Education, OSA, Shared Decision
Survey: OSA information and surgery risks
Survey administered prior to preoperative visit
473 surveys collected, 2 Canadian, 1 US site
44% would choose to delay surgery
40% would delay up to 2 months
Department of Anesthesiology
BMC Anesthesiology 2018: 18, 128
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Department of Anesthesiology
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PONV Risk Score: Apfel
Department of Anesthesiology
Anesthesiology 1999;91:693-700Anesth Analg 2014;118:85-113
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Antiemetic Intervention and Risk Reduction
• Ondansetron, Dexamethasone, Droperidol
26%
• Propofol 19%
• Nitrogen 12%
• TIVA 31%
Department of Anesthesiology
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PONV Risk Reduction
Department of Anesthesiology
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Michigan Medicine PONV Prophylaxis
Department of Anesthesiology
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Anesthesiology Performance Improvement and Reporting
Exchange = ASPIRE
• PONV-1 = Greater than 3 risk factors and at
least 2 anti-emetics of different classes
administered
Department of Anesthesiology
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ASPIRE MONTHLY REPORT
Department of Anesthesiology
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ASPIRE INDIVIDUAL PERFORMANCE
Department of Anesthesiology
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Do Anesthesiologists Contribute to Health Care Disparities
Department of Anesthesiology
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PONV Prophylaxis
• Relatively independent of patient co-
morbidities
• Specific measurable risk factors
• Standard of care with explicit guidelines
• Sole responsibility of anesthesia providers
• Not impacted by insurance constraints
• Patient centered outcome
Department of Anesthesiology
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Disparities in Anesthesia Care
National Anesthesia Clinical Outcomes Registry
Department of Anesthesiology
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Disparities in Anesthesia Care
• 440,000 anesthetic cases
• 6 large institutions: Northeast and South
• 2010-2013
• Socioeconomic status: insurance type, median
income by zip code
• Odds ratio of receiving either ondansetron,
dexamethasone, or both
Department of Anesthesiology
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Disparities in Anesthesia Care
• All four statistical models established lower
socioeconomic status was associated with
inferior treatment during anesthesia as
measured by the administration of antiemetic
medications
• Why
Individual provider bias?
Systems challenges in lower socioeconomic
neighborhoods?
Department of Anesthesiology
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Summary
Department of Anesthesiology
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Department of Anesthesiology
Why Choose Obstructive Sleep Apnea?
1. Prevalence of OSA in surgical population is high2. Associated co-morbidities can be significant3. Perioperative complications are associated with OSA4. Continued confusion regarding optimal perioperative
management5. Unique aspects of free standing ASC’s
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Other Mechanism of OSA
• Ineffective upper airway dilator muscle
• Low and high arousal thresholds
• Stability of respiratory control
• Rostral fluid shifts
• Supine position-related OSA
Department of Anesthesiology
Curr Opin Anesthesiol 2018, 31:89-95
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From: Response to CPAP Withdrawal in Patients with Mild Versus Severe Obstructive Sleep Apnea/Hypopnea
SyndromeSleep. 2013;36(3):405-412. doi:10.5665/sleep.2460
Sleep | © 2013 Associated Professional Sleep Societies, LLC.