OSA and PONV Through the Eyes of An Ambulatory ... · •Health care disparities and anesthesia...
Transcript of 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
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
OSA and PONV and Ambulatory Anesthesia
• OSA and perioperative risks
• OSA identification
• Risk mitigation
• Risk factors for PONV
• Health care disparities and anesthesia practice
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OSA and PONV and Ambulatory Anesthesia
No financial disclosures
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Apnea Hypopnea Index
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• < 5 NORMAL
• 5-<15 MILD
• 15-<30 MODERATE
• >30 SEVERE
Screening Tools
• STOP-BANG QUESTIONAIRE
• ASA CHECKLIST
• P-SAP SCORE
• BERLIN QUESTIONAIRE
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Department of Anesthesiology
Anesth Analg,2016;123:452-473
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0-2 Mild
3-4 Moderate
5-8 Severe
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0-2 Mild
3-4 Moderate
5-8 Severe
STOP-BANG and Specificity
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Chest,2013;143:1284-1293
STOP-BANG and Specificity
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Contraindication for Ambulatory Status
• Obesity hypoventilation syndrome
• Pulmonary hypertension
• Resting hypoxemia
• Overlap syndrome COPD + OSA
• Uncontrolled Systemic Disease
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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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81% of patients with reported opioid doses received less than 10 mg morphine equivalent dose/day
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NO OPIOID
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) )
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Anesth Analg 2017;125:141-146
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Monitoring in the PACU
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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
OSA and Ambulatory Status
• EDUCATION
• Include STOP-BANG in Preop Evaluations
• Risk Mitigation Strategies
• No or Reduced Opioids
• PACU Monitoring Guidelines
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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
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BMC Anesthesiology 2018: 18, 128
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PONV Risk Score: Apfel
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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%
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PONV Risk Reduction
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Michigan Medicine PONV Prophylaxis
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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
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ASPIRE MONTHLY REPORT
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ASPIRE INDIVIDUAL PERFORMANCE
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Do Anesthesiologists Contribute to Health Care Disparities
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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
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Disparities in Anesthesia Care
National Anesthesia Clinical Outcomes Registry
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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
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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?
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Summary
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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
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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.