Ambulatory Surgery & Obstructive Sleep Apnea (OSA)

Did you know that approximately 20% of adults may suffer from Obstructive Sleep Apnea (OSA)? And 7% of those exhibit moderate-to-sever OSA. However, up to 80% of patients go undiagnosed and untreated. So why is this important when talking about ambulatory (outpatient) surgery you ask?

Well, OSA is the most common breathing disorder occurring during sleep. It is characterized by partial or complete obstruction of the upper airway during sleep despite continuing ventilatory efforts. Patients with OSA are at high risk of peri-procedure complications such as respiratory depression and decreased pharyngeal muscle tone, which may enhance airway obstruction and lead to hypoxia, hypercarbia, arrhythmias and ultimately cardiopulmonary arrest. 

When you combine OSA with ambulatory surgery, complications can arise. Most commonly, the use of sedative and anesthetics, muscle relaxants and opioids may worsen or trigger upper air way obstruction. These drugs also decrease the natural response to low oxygen and high carbon dioxide levels in the blood. Finally, the stress of the surgery itself can cause heightened symptoms of OSA, typically occuring several days after surgery.

Since anesthesia and sedation can have a negative impact on patients with OSA, let's discuss the proper way to determine if a patient is suitable for ambulatory surgery. 

Preoperative Considerations

  • Assess the existence/severity of OSA pre-procedure to ensure that patient selection is appropriate for the type of procedure and anesthesia planned
  • Follow the STOP-BANG outlined by the Society of Ambulatory Anesthesia (SAMBA). 
  • Take into consideration the level of invasiveness of the surgery and anesthesia, as well as the potential need for post-procedure opioids.
  • Pre-procedure education should encourage use of CPAP machine, sleeping in semi-upright position postoperatively and warning about the dangers or and/or the need to avoid opioids. 

Anesthesia

(Use non-opioid analgesic techniques, when possible)

  • Local or regional anesthesia should be used whenever possible
  • If moderate sedation is required, continuous capnography should be used during the procedure
  • If general anesthesia is planned, providers should preferably use a technique that allows early emergence
  • If opioids are required, use short-acting ones, when possible
  • Consider non-opioid multimodal analgesia approach (local/regional analgesia, non-steriodal anti-inflammatory drugs, and acetaminophen.)

Recovery

(Facilities should be prepared for respiratory care and have transfer agreements with inpatient facilities.)

  • Place patients in a semi-upright position
  • Observe patients for oxygen desaturation and/or apneic episodes.
  • If oxygen desaturation occurs while on supplemental oxygen therapy of on preoperative CPAP, use non-invasive ventilation.
  • Avoid systemic opioids, if possible. If necessary, titrate to the lowest dose that works for long acting opioids (morphine and hydromorphone)
  • Patients who are noted to easily obstruct their airway when drowsy should receive extra vigilance.

Postoperative Considerations

(Exercise caution in OSA patients who develop prolonged and frequent sever respiratory events (sedation analgesic mismatch with opioids, desaturation, and apneic episodes) in the postoperative period.

Significant Respiratory Depression

  • Appropriate resuscitation should be incited
  • Consider transfer to an inpatient facility for additional monitoring

Post Discharge

  • Patients who are suspected of having OSA based on clinical criteria should be encouraged to follow up with their primary care physicians to consider a sleep study
  • Post-discharge education should include a recommendation to continue use of CPAP while sleeping (day or night) and a warning about the dangers of and the need to avoid opioids. 

**{NOTE}**

It is important to state that patients that present for sedation type procedures (cataracts, GI cases) with sleep apnea need to be told that they will be receiving sedation not general anesthesia. They may hear and feel things during the procedure and due to their airway the amount of sedation they receive may be less to assure a safe anesthetic and procedure.  Airway assessment and communication between the patient and the anesthesia clinician is imperative to assure patient safety.

This article is an excerpt from the Institute for Quality Improvement's Patient Safety Tool Kit: Ambulatory Surgery and Obstructive Sleep Apnea. Download the brochure here.

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FDA Recall Alert: Hospira Announces Nationwide Voluntary Recall of Seven Lots of Propofol Injectable Emulsion, USP, Due to Visible Particulates

This morning, the Food and Drug Administration (FDA) alerted providers that Hospira, Inc. is conducting a nationwide recall of seven lots of Propofol Injectable Emulsion, USP, to the user level due to a glass defect located on the interior neck of the vial, which was identified during a retain sample inspection where the glass vial contained visible embedded metal particulate. Free-floating metal particulates were also identified in vials upon further analysis. To date, Hospira has not received reports of any adverse events associated with this issue for these lots.

The affected lots were distributed nationwide to distributors/wholesalers, hospitals and clinics from August 2013 through December 2013.

Propofol Injectable Emulsion, 1%, 200 mg/20 mL (10 mg/mL), NDC Number: 0409-4699-30.

The lot numbers affected by the recall are:

  • 29-614-DJ
  • 29-615 DJ
  • 29-616 DJ
  • 29-617 DJ
  • 29-628 DJ
  • 29-629 DJ
  • 29-630 DJ

All lots have the expiration date May 1, 2015.

On April 2, 2014, Hospira notified its customers via recall letter that the company had implemented corrective actions to the manufacturing process to prevent recurrence.

Customers have been advised to check inventory and immediately quarantine any affected product. In addition, customers should inform potential users of this product in their organizations of this notification. Affected product should be returned to Stericycle, which can be contacted at 1-877-272-2158 (M-F, 8 a.m. - 5 p.m. ET).

For medical inquiries, please contact Hospira Medical Communications at 1-800-615-0187. This phone number is available 24 hours a day, seven days a week.

Adverse reactions or quality problems experienced with the use of this product may be reported to the FDA’s MedWatch Adverse Event Reporting Program either online, by mail or by fax.

If you need additional information, please contact Ashley McGlone, manager of regulatory affairs, at amcglone@ascrs.org or 703-591-2220.

Read Entire Recall Alert

Anesthesia Sedation: The After Affect

As we all know anesthesia comes in varying degrees. It can be conscious sedation, to monitored anesthesia care where the patient gets very little sedation to deep sedation. It can also be general anesthesia or combination of all of those mentioned with a regional technique.

Regardless of the type of anesthesia what we need to remember is this….anesthesia affects everyone differently. The onset of Propofol has made the outpatient anesthesia experience very pleasant for patients. If used as the sole source of anesthesia the patients wake quickly with little to no side-effects and are alert and oriented when they leave.However, when sedation is given by using a combination of benzodiazepines and narcotics; with or without Propofol, patients may respond differently post-procedure. 

Before patients can leave a facility they must meet the discharge criteria determined by that facility. Their vitals are stable, they can drink, go to the bathroom and ambulate without problems. They may feel a little groggy but they know what is going on and appear “normal.” The problem is there is really know way of knowing how the patient really feels. They will tell the nurses they feel fine and they probably do but ask them an hour later and they will not remember talking to the nurses.

The medications given in a combination anesthesia will cause amnesia and a lack of inhibition, like an intoxicated type state. The degrees of the state of inhibition may vary but this behavior is something that we as anesthesia clinicians need to be more conscious of. We tell people that they should not drive following sedation or general anesthesia; we tell them they should not make important, life changing decisions. But, do we tell them they should not get on the internet?

In a recent article I found the following incident that occurred:

“Recently, a patient’s husband was upset when his wife returned for a diagnostic test.  On further discussion, it was revealed that his concern wasn’t the quality of care, the size of the bill, the amount of the deductible, or the length of the wait, but the fact that his wife had spent a large amount on the Home Shopping Network (“HSN”) during the afternoon following her last procedures and sedation.”

After reading this I realized that we owe it to our patients to ensure that they truly understand the affects that anesthesia may have on them and advise them accordingly. In our high tech world we should stop and consider that people may get on line and shop

or even text people and say things they may not normally say. This could cause devastating consequences that ultimately we as clinicians could be responsible for.

Source: PhySynergy

Why Has the Number of Colonoscopies Tripled in the Last Decade?

By: Dr. Kim Riviello DNP, MBA, CRNA   |  President   |  Anesthesia Services Group 

On March 17, 2014, headlines released by USA TODAY and the WALL STREET JOURNAL praised the fact that the screening rate for colon cancer has nearly tripled in the last decade. It has gone from 19% in 2000 to 55% in 2010 according to a recent study by the American Cancer Society.

As a healthcare provider, this is great news (for once) about something positive occurring in the healthcare industry. However, as an anesthetist who provides anesthesia services to GI facilities, I ask, “Why?” “Why has the screening rate tripled in the last decade?” There was no mention in either article explaining why this trend has occurred. Both articles addressed the positive effect of the increased screening related to a decrease in colon cancer. But what has driven more people to get colonoscopies? Is it because patients know they can get an anesthetic with their colonoscopy that is administered by an anesthesia clinician who will provide Propofol; the drug that causes you to sleep through this gut wrenching procedure and then allows you to awake quickly with no side effects or hangover? Propofol was introduced into the endoscopy suites in the late 1990s and early 2000s. Its use has progressively increased in the last 15 years to the point it is becoming the standard of care. A recent study looking at over 3000 patients presenting for EGDs and Colonoscopies, showed that patients presenting to the endoscopy suites have more high risk co-morbidities of diabetes, obesity, coronary artery disease, COPD than ever before, increasing the risk of colonoscopies. 

Anesthesia clinicians (CRNA and/or MD) within the endoscopy suite increase the safety and quality of the procedure by providing proper pre-op screening of these high risk patients and ensuring a safe and quality anesthetic during the colonoscopy. Now that patients are aware of the benefits of having anesthesia at their side for their colonoscopy they are more willing to have their screening performed. Anesthesia cannot be denied some credit for why colon screenings have tripled over the last decade. So let anesthesia continue to do what they do best and we will see an even further increase in colon screening. 

Sources: A Study of the co-morbidity risk of patients in freestanding surgery facilities; a retrospective study of a gastroenterology facility: Are the patients sicker?

Is There Such A Thing As ADHD?

Dr. Richard Saul, a Behavioral Neurologist based in Chicago, claims that there is no such thing as ADHD and that the drugs prescribed for the disorder do more harm than good. Are there really other underlying problems associated with these types of behaviors? Could doctor's just be lumping all of the symptoms together in some type of knee-jerk reaction and calling ADHD? Dr. Saul explains his theories behind the disorder below.

Distracted, fidgeting and squirming in his seat, the 13-year-old boy in my consulting room was exhibiting all the classic signs of an attention disorder.

His desperate mother hoped that I could do something for her son, who had become sluggish and unfocused at school, did not seem to care that his academic performance was declining, and claimed to feel ‘too tired’ for sport, which he used to enjoy.

He had been diagnosed with ADHD – Attention Deficit Hyperactivity Disorder – and been taking medication for a year but, to the despair of his teachers and mother, his behavior had not improved at all.

I was not at all surprised. Why? Because, after 50 years of practising medicine and seeing thousands of patients demonstrating symptoms of ADHD, I have reached the conclusion there is no such thing as ADHD.

Read more about this doctor's philosophy here.

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