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Atef H, Gaber M. Would the Actigraph Always be Sufficient for Sleep Analysis in Exercise-Based Studies? A Case Report of Negative Response of Sleep to Exercise. Sleep Sci 2023; 16:265-270. [PMID: 37425977 PMCID: PMC10325867 DOI: 10.1055/s-0043-1770808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Introduction Sleep deprivation is common after coronary artery bypass grafting (CABG). It is mostly managed well by exercise. The number of reported post-CABG cases that respond negatively to exercise is scanty. The etiology is usually associated with the underlying sleep pathology, and how it responds to exercise. Cases with undiagnosed central sleep apnea post CABG have not been reported before. Case description A medically stable male patient, 63 years old, hypertensive, but not diabetic, had entered coronary artery bypass grafting (CABG) 8 weeks before attending the outpatient cardiac rehabilitation unit and was referred for a cardiac rehabilitation program at this time. He entered a study in the cardiac rehabilitation center utilizing either aerobic or combined aerobic and resistance training for 10 weeks to improve sleep architecture and functional capacity post-CABG. After randomization, he entered the group doing combined aerobic and resistance exercises. All of the patients in this group improved except him, his sleep quality worsened, but his functional capacity improved. After a complete analysis of sleep on polysomnography, it was revealed that the patient had central sleep apnea that was mostly worsened by resistance training. The patient was withdrawn from the study by the 8th week, and his sleep condition improved gradually. After then, he was asked to attend the cardiac rehabilitation center again to share in aerobic exercise, having evidence that central sleep apnea does not respond negatively to this form of training. After 12 months of follow-up, the patient still shows no signs of sleep deprivation. Conclusion Sleep deprivation is prevalent in post-CABG patients, but with different presentations and it can generally improve by exercise. Identification of the underlying cause of the sleeping difficulty is a cornerstone of targeted treatment.
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Affiliation(s)
- Hady Atef
- School of Allied Health Professions (SAHP), Keele University, Staffordshire, ST5 5BG, United Kingdom
- Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Marwa Gaber
- Medical Research Institute, Alexandria University, Alexandria, Egypt
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Chen J, Mei X. Sensitivity to remifentanil and its predictive factor in male patients with moderate to severe obstructive sleep apnea syndrome. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:347-355. [PMID: 37164918 PMCID: PMC10930082 DOI: 10.11817/j.issn.1672-7347.2023.220579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Obstructive sleep apnea syndrome (OSAS) is associated with increased risk of postoperative complications, which is possibly related to increased sensitivity to opioid. However, the effect of increased sensitivity to opioids in patients with OSAS remains controversial. This study aims to investigate whether male patients with moderate to severe OSAS have increased sensitivity to opioid remifentanil and its related predictive factors, so as to provide a reference for the rational use of opioids in patients with OSAS. METHODS This study was a prospective study. From December 28, 2021 to October 15, 2022, a total of 61 male patients aged 22 to 60 years old, American Society of Anesthesiologists (ASA) status I and II, who underwent nasopharyngeal surgery under general anesthesia, were selected. According to STOP-BANG questionnaire score and apnea-hypopnea index (AHI), the patients were divided into an OSAS group (n=39) and a control group (n=22). The pupil diameter (PD) of the patients was measured by hand-held monocular pupillometer, and the perception threshold (PT) and pain tolerance threshold (PTT) of the patients were measured by somatosensory evoked potential stimulator. The initial PD, PT, and PTT were measured in a quiet environment and recorded as PD0, PT0, and PTT0. Changes in PD, PT, PTT, respiration, and consciousness were recorded after remifentanil infusion. Age, body mass index (BMI), smoking, AHI, minimal oxygen saturation, and percentage of sleep time spent with oxygen saturation <90% (T90) were included as independent variables in multiple linear regression equations to analyze the possible predictors of increased opioid sensitivity in patients with moderate to severe OSAS. RESULTS There were no significant differences in PD0, PT0 and PTT0 between the OSAS group and the control group (all P>0.05). After remifentanil infusion, there was no significant difference in the rate of PT change between the 2 groups (P>0.05). The change rate of PTT and PD in the OSAS group was significantly higher than that in the control group (P<0.05 and P<0.001, respectively), PD in the OSAS group was significantly lower than that in the control group (P<0.001). During remifentanil infusion, there were no significant differences in the incidence of respiratory depression and the distribution of observer's assessment of alertness/sedation (OAA/S) scores between the 2 groups (both P>0.05), and there were no changes in mental status and airway support in the patients of the 2 groups. Multiple linear regression showed that T90 was positively correlated with miosis rate (β=0.597, 95% CI 0.269 to 0.924, P<0.05) and the rate of PTT change (β=0.458, 95% CI 0.116 to 0.800, P<0.05). However, minimal oxygen saturation, age, BMI, smoking, and AHI were not correlated with PD change rate and PTT change rate in the OSAS patients (all P>0.05). CONCLUSIONS Male patients with moderate to severe OSAS have increased sensitivity to remifentanil, the duration of nocturnal desaturation may be its predictive factor. Male patients with moderate to severe OSAS with a longer duration of nocturnal hypoxia are more sensitive to remifentanil, and the use of opioids in these patients should be more cautious in clinical.
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Affiliation(s)
- Jia Chen
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
| | - Xi Mei
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
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Chen YYK, Soens MA, Kovacheva VP. Less stress, better success: a scoping review on the effects of anxiety on anesthetic and analgesic consumption. J Anesth 2022; 36:532-553. [PMID: 35779126 DOI: 10.1007/s00540-022-03081-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
Preoperative anxiety has an incidence of 11-80% in patients undergoing surgical or interventional procedures. Understanding the role of preoperative anxiety on intraoperative anesthetic requirements and postoperative analgesic consumption would allow personalized anesthesia care. Over- or under-anesthetizing patients can lead to complications such as postoperative cognitive dysfunction in elderly patients, or procedural discomfort, respectively. Our scoping review focuses on the current evidence regarding the association between preoperative anxiety and intraoperative anesthetic and/or postoperative analgesic consumption in patients undergoing elective surgical or interventional procedures. Based on 44 studies that met the inclusion criteria, we found that preoperative anxiety has a significant positive correlation effect on intraoperative propofol and postoperative opioid consumption. The analysis of the literature is limited by the heterogeneity of preoperative anxiety tools used, study designs, data analyses, and outcomes. The use of shorter, validated preoperative anxiety assessment tools may help optimize the intraoperative anesthetic and postoperative analgesic regimen. Further research to determine the most feasible and clinically relevant preoperative anxiety tool and subsequent implementation has the potential to optimize perioperative care and improve patient outcomes.
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Affiliation(s)
- Yun-Yun K Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, L1,, Boston, MA, 02115, United States of America
| | - Mieke A Soens
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, L1,, Boston, MA, 02115, United States of America
| | - Vesela P Kovacheva
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, L1,, Boston, MA, 02115, United States of America.
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The Association between Use of Benzodiazepine Receptor Agonists and the Risk of Obstructive Sleep Apnea: A Nationwide Population-Based Nested Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189720. [PMID: 34574645 PMCID: PMC8467455 DOI: 10.3390/ijerph18189720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022]
Abstract
Obstructive sleep apnea (OSA) is characterized by recurrent upper airway collapse. Benzodiazepine receptor agonists (BZRAs) are associated with pharyngeal muscle relaxation, increased apnea duration, and hypoxia, which might worsen OSA. This study aimed to examine the association between the use of BZRAs and the risk of OSA. The study was conducted using data from the National Health Insurance Database of Taiwan between 2002 and 2011. We only included new users who were never exposed to any BZRAs and identified 1848 participants with OSA, and 1848 matched controls. A logistic regression model was used to determine the association between the use of BZRAs and the development of OSA. BZRA exposure was divided into usage patterns, dosage, duration, and pharmacokinetic class. We found an increased risk of OSA in current users and recent past users compared with distant past users. Patients with a higher cumulative dose of BZRAs were more likely to develop OSA compared to those with a lower cumulative dose. We found an increased risk of OSA in patients treated with BZRAs, especially for current users and those with higher cumulative doses. A reduced risk of OSA was found in Z-drug users compared with benzodiazepine users.
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Pino RM, Dunn PF, Kacmarek RM, Bryan RJ, Bigatello LM. An algorithm for the sedation of patients with obstructive sleep apnea by non-anesthesiologists. Curr Med Res Opin 2021; 37:531-534. [PMID: 33565898 DOI: 10.1080/03007995.2021.1888706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Patients with obstructive sleep apnea (OSA) are at risk for adverse events when moderate sedation is administered by nurse protocols (NAMS) under the guidance of non-anesthesiologists. An algorithm was applied for the appropriate section of patients to receive NAMS and the application of continuous positive airway pressure (CPAP). METHODS An algorithm was developed for patients with OSA who were scheduled for gastroenterology, radiology, and cardiology procedures using NAMS. Those with normal airways and without contraindications for NAMS were classified as CPAP-independent (CPAP-I; not routinely used) or CPAP-dependent (CPAP-D; always used). CPAP machines were brought in by CPAP-D patients or supplied by the hospital and set at a patient's routine setting or 10 cm H2O if not known. CPAP-D patients for procedures for which CPAP could not be applied were done under anesthesia care. We retrospectively examined this program for the 2008-2018 period. RESULTS Since the inception of this protocol in 2008, 803 patients with OSA safely underwent procedures using either personal CPAP or CPAP provided by the hospital. CONCLUSIONS Patients with OSA can safely have NAMS for procedures when CPAP is applied based on a protocol that considers airway evaluation, the procedure, and whether there is dependence upon CPAP.
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Affiliation(s)
- Richard M Pino
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter F Dunn
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ruth J Bryan
- Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Luca M Bigatello
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
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6
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Affiliation(s)
- S Heikal
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - G Stuart
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Aleksandrovich YS, Rybianov VV, Pshenisnov KV, Razumov SA. Perioperative complications of pediatric otorhinolaryngological operations. Saudi J Anaesth 2020; 14:446-453. [PMID: 33447185 PMCID: PMC7796726 DOI: 10.4103/sja.sja_99_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The identification of risk factors for the development of perioperative complications is one of the most important problems of pediatric anesthesiology. PURPOSE To identify risk factors for the development of perioperative complications in children undergoing ambulatory surgical interventions on ENT organs. METHODS Total of 141 patients were examined at the age from 7 to 17 years. Depending on the presence of complications all patients were divided into three groups: «No complications» (n = 64), «One complication» (n = 55) and «Two or more complications» (n = 22). The study was carried out in the following areas: Preoperative clinical status, intraoperative and postoperative complications. The severity of nasal breathing disorders was determined rhinomanometrically. 31 children underwent somnography. In the study of heart rate variability was evaluated. Intraoperative complications included: Cardiac arrhythmias, arterial hypertension and desaturation less than 90%. Postoperative complications included: Cardiorespiratory complications, pain, delirium, postoperative nausea and vomiting. RESULTS The most significant complication in the intraoperative period is desaturation below 90%, in the postoperative period they are pain, nausea and vomiting. Risk factors for the development of complications in the perioperative period are a decrease in the thyromental distance, hyperplasia of the tonsils of the third degree, Malampati score ≥ to 2 points, parents' bad habits, combined neurological and respiratory pathologies in a child, an assessment of the class «allergology» of the ASPOND scale is not less than 180 points and the prevalence of vagal influences. CONCLUSIONS The obtained results indicate that the presence of risk factors for perioperative complications during operations on ENT organs in children are associated with the initial autonomic status and the predominance of the parasympathetic nervous system as well as with clinical markers.
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Affiliation(s)
- Yu. S. Aleksandrovich
- Department of Anesthesiology, Intensive Care and Emergency Pediatrics, Postgraduate Education, St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - V. V. Rybianov
- Department of Anesthesiology, Intensive Care and Emergency Pediatrics, Postgraduate Education, St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - K. V. Pshenisnov
- Department of Anesthesiology, Intensive Care and Emergency Pediatrics, Postgraduate Education, St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - S. A. Razumov
- Department of Anesthesiology, Intensive Care and Emergency Pediatrics, Postgraduate Education, St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
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The Role of Precedex in Post-Operative Pain Management Following Craniosynostosis Repair. J Craniofac Surg 2020; 31:e569-e572. [PMID: 32433135 DOI: 10.1097/scs.0000000000006547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The application of dexmedetomidine (precedex) in pediatric settings has increased due to its superior safety and efficacy profile and it has been specifically suggested as an adjunct to IV acetaminophen and a substitute for morphine in craniosynostosis repair. However, reports of its use in pediatrics, let alone in craniosynostosis repair, remain limited and to date there are no studies addressing its use after craniosynostosis repair in children. This study is an IRB-approved retrospective case review of the use of dexmedetomidine following pediatric craniosynostosis repair as a postoperative analgesic/sedative agent at one institution.
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10
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Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, Doufas AG, Yilmaz M, Stein MH, Krajewski ML, Singh M, Pichler L, Ramachandran SK, Chung F. Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2019; 127:967-987. [PMID: 29944522 PMCID: PMC6135479 DOI: 10.1213/ane.0000000000003434] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Crispiana Cozowicz
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
| | - David T Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anthony G Doufas
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California
| | - Meltem Yilmaz
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - Mark H Stein
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Megan L Krajewski
- Department of Anesthesia, Critical Care, and Pain Management, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mandeep Singh
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Satya Krishna Ramachandran
- Department of Anesthesiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Obstructive sleep apnoea in adults: peri-operative considerations: A narrative review. Eur J Anaesthesiol 2019; 35:245-255. [PMID: 29300271 DOI: 10.1097/eja.0000000000000765] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
: Obstructive sleep apnoea (OSA) is a common breathing disorder of sleep with a prevalence increasing in parallel with the worldwide rise in obesity. Alterations in sleep duration and architecture, hypersomnolence, abnormal gas exchange and also associated comorbidities may all feature in affected patients.The peri-operative period poses a special challenge for surgical patients with OSA who are often undiagnosed, and are at an increased risk for complications including pulmonary and cardiovascular, during that time. In order to ensure the best peri-operative management, anaesthetists caring for these patients should have a thorough understanding of the disorder, and be aware of the individual's peri-operative risk constellation, which depends on the severity and phenotype of OSA, the invasiveness of the surgical procedure, anaesthesia and also the requirement for postoperative opioids.The objective of this review is to educate clinicians in the epidemiology, pathogenesis and diagnosis of OSA in adults and also to highlight specific tasks in the preoperative assessment, namely to select a suitable intra-operative anaesthesia regimen, and manage the extent and duration of postoperative care to facilitate the best peri-operative outcome.
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12
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Wang SH, Chen WS, Tang SE, Lin HC, Peng CK, Chu HT, Kao CH. Benzodiazepines Associated With Acute Respiratory Failure in Patients With Obstructive Sleep Apnea. Front Pharmacol 2019; 9:1513. [PMID: 30666205 PMCID: PMC6330300 DOI: 10.3389/fphar.2018.01513] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/10/2018] [Indexed: 01/05/2023] Open
Abstract
Aims: Obstructive sleep apnea (OSA) and insomnia commonly coexist; hypnotics are broadly prescribed for insomnia therapy. However, the safety of hypnotics use in OSA patients is unclear. We conducted a retrospective case-control study to investigate the risk of adverse respiratory events in hypnotics-using OSA patients. Methods: We obtained data from the Taiwan National Health Insurance Database from 1996 to 2013. The case group included 216 OSA patients with newly diagnosed adverse respiratory events, including pneumonia and acute respiratory failure. The control group included OSA patients without adverse respiratory events, which was randomly frequency-matched to the case group at a 1:1 ratio according to age, gender, and index year. Hypnotics exposure included benzodiazepines (BZD) and non-benzodiazepines (non-BZD). A recent user was defined as a patient who had taken hypnotics for 1–30 days, while a long-term user was one who had taken hypnotics for 31–365 days. Results: Multivariable adjusted analysis showed recent BZD use is an independent risk for adverse respiratory events (OR = 2.70; 95% CI = 1.15–6.33; P < 0.001). Subgroup analysis showed both recent and long-term BZD use increased the risk of acute respiratory failure compared to never BZD use (OR = 28.6; 95% CI = 5.24–156; P < 0.001, OR = 10.1; 95% CI = 1.51–67.7; P < 0.05, respectively). Neither BZD nor non-BZD use increased the risk of pneumonia in OSA patients. Conclusion: BZD use might increase the risk of acute respiratory failure in OSA patients.
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Affiliation(s)
- Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shan Chen
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Shih-En Tang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hung-Che Lin
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Te Chu
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan.,Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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13
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Cozowicz C, Poeran J, Zubizarreta N, Liu J, Weinstein S, Pichler L, Mazumdar M, Memtsoudis S. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty. Br J Anaesth 2019; 122:131-140. [DOI: 10.1016/j.bja.2018.08.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/02/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022] Open
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Obstructive Sleep Apnea Screening Among Surgical Patients: A Quality Improvement Project. J Perianesth Nurs 2018; 33:814-821. [DOI: 10.1016/j.jopan.2017.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 12/12/2022]
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15
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Hudson AJ, Walter RJ, Flynn J, Szpisjak DF, Olsen C, Rodgers M, Capaldi VF, McDuffie B, Lettieri CJ. Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial. J Clin Sleep Med 2018; 14:593-602. [PMID: 29609705 DOI: 10.5664/jcsm.7052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/03/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population. METHODS This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care. RESULTS Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpO2 nadir did not significantly change postoperatively from baseline. Cumulative percentage of time oxygen saturation < 90% significantly increased N1 as compared to baseline for all patients except for those with moderate to severe OSA. CONCLUSIONS Ambulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798.
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Affiliation(s)
- Arlene J Hudson
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Robert J Walter
- Department of Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John Flynn
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dale F Szpisjak
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Cara Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew Rodgers
- Department of Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Vincent F Capaldi
- Department of Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Brent McDuffie
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christopher J Lettieri
- Department of Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Fassbender P, Herbstreit F, Eikermann M, Teschler H, Peters J. Obstructive Sleep Apnea-a Perioperative Risk Factor. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:463-9. [PMID: 27476705 DOI: 10.3238/arztebl.2016.0463] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder of breathing but is probably underappreciated as a perioperative risk factor. METHODS This review is based on pertinent articles, published up to 15 August 2015, that were retrieved by a selective search in PubMed based on the terms "sleep apnea AND anesthesia" OR "sleep apnea AND pathophysiology." The guidelines of multiple specialty societies were considered as well. RESULTS OSA is characterized by phases of upper airway obstruction accompanied by apnea/hypoventilation, with hypoxemia, hypercapnia, and recurrent overactivation of the sympathetic nervous system. It has been reported that 22% to 82% of all adults who are about to undergo surgery have OSA. The causes of OSA are multifactorial and include, among others, an anatomical predisposition and /or a reduced inspiratory activation of the bronchodilator muscles, particularly when the patient is sleeping or has taken a sedative drug, anesthetic agent, or muscle relaxant. OSA is associated with arterial hypertension, coronary heart disease, and congestive heart failure. It can be assessed before the planned intervention with polysomnography and structured questionnaires (STOP/STOP-BANG), with sensitivities of 62% and 88%. The utility of miniaturized screening devices is debated. Patients with OSA are at risk for perioperative problems including difficult or ineffective mask ventilation and/or intubation, postoperative airway obstruction, and complications arising from other comorbid conditions. They should be appropriately monitored postoperatively depending on the type of intervention they have undergone, and depending on individually varying, patient-related factors; postoperative management in an intensive care unit may be indicated, although no validated data on this topic are yet available. CONCLUSION OSA patients need care by specialists from multiple disciplines, including anesthesiologists with experience in recognizing OSA, securing the airway of OSA patients, and managing them postoperatively. No randomized trials have yet compared the modalities of general anesthesia for OSA patients with respect to postoperative complications or phases of apnea or hypopnea.
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Affiliation(s)
- Philipp Fassbender
- Clinic for Anesthesiology and Intensive Care & Essen University Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA, und Universität Duisburg-Essen, Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen
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Singh PM, Panwar R, Borle A, Mulier JP, Sinha A, Goudra B. Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis. Surg Obes Relat Dis 2017; 13:1434-1446. [DOI: 10.1016/j.soard.2017.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/05/2017] [Accepted: 02/25/2017] [Indexed: 11/16/2022]
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Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, Patrawala S, Lam D, Kumar A, Joshi GP, Fleetham J, Ayas N, Collop N, Doufas AG, Eikermann M, Englesakis M, Gali B, Gay P, Hernandez AV, Kaw R, Kezirian EJ, Malhotra A, Mokhlesi B, Parthasarathy S, Stierer T, Wappler F, Hillman DR, Auckley D. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2017; 123:452-73. [PMID: 27442772 PMCID: PMC4956681 DOI: 10.1213/ane.0000000000001416] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Frances Chung
- From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; ‡Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; §Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph's Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph's Health care, Western University, London, Ontario, Canada; ‖Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; ¶Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; #Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; **Department of Medicine, University of California San Diego, San Diego, California; ††Sparrow Hospital, Lansing, Michigan; ‡‡Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; §§Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; ‖‖University of British Columbia, Vancouver, BC, Canada; ¶¶Department of Medicine, Emory University, Atlanta, Georgia; ##Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; ***Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; †††Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‡‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §§§Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; ‖‖‖School of Medicine, Universidad Peruana de Ciencias Apl
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Butterfield KJ. Outpatient Anesthetic Safety Considerations for Obstructive Sleep Apnea. Oral Maxillofac Surg Clin North Am 2017; 29:189-196. [PMID: 28417891 DOI: 10.1016/j.coms.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most patients with obstructive sleep apnea (OSA) are not diagnosed preoperatively. The STOP-Bang questionnaire may identify patients at risk of OSA, especially those with severe OSA. Patients with mild to moderate OSA, with optimized comorbidities, can usually safely undergo outpatient surgery. Patients with severe OSA, who are not optimized medically, should avoid outpatient surgery.
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Affiliation(s)
- Kevin J Butterfield
- Division of Dentistry/Oral and Maxillofacial Surgery, Department of Otolaryngology, Ottawa Hospital, University of Ottawa School of Medicine, Ottawa, Ontario, Canada.
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Jullian-Desayes I, Revol B, Chareyre E, Camus P, Villier C, Borel JC, Pepin JL, Joyeux-Faure M. Impact of concomitant medications on obstructive sleep apnoea. Br J Clin Pharmacol 2016; 83:688-708. [PMID: 27735059 DOI: 10.1111/bcp.13153] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 01/11/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is characterized by repeated episodes of apnoea and hypopnoea during sleep. Little is known about the potential impact of therapy drugs on the underlying respiratory disorder. Any influence should be taken into account and appropriate action taken, including drug withdrawal if necessary. Here, we review drugs in terms of their possible impact on OSA; drugs which (1) may worsen OSA; (2) are unlikely to have an impact on OSA; (3) those for which data are scarce or contradictory; and (4) drugs with a potentially improving effect. The level of evidence is ranked according to three grades: A - randomized controlled trials (RCTs) with high statistical power; B - RCTs with lower power, non-randomized comparative studies and observational studies; C - retrospective studies and case reports. Our review enabled us to propose clinical recommendations. Briefly, agents worsening OSA or inducing weight gain, that must be avoided, are clearly identified. Drugs such as 'Z drugs' and sodium oxybate should be used with caution as the literature contains conflicting results. Finally, larger trials are needed to clarify the potential positive impact of certain drugs on OSA. In the meantime, some, such as diuretics or other antihypertensive medications, are helpful in reducing OSA-associated cardiovascular morbidity.
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Affiliation(s)
- Ingrid Jullian-Desayes
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Bruno Revol
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France.,Pharmacovigilance Department, Grenoble Alps University Hospital, Grenoble, France
| | - Elisa Chareyre
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Philippe Camus
- Pneumology Department, Dijon Bourgogne University Hospital, Dijon, France
| | - Céline Villier
- Pharmacovigilance Department, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Christian Borel
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Louis Pepin
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Marie Joyeux-Faure
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
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Weatherspoon D, Sullivan D, Weatherspoon CA. Obstructive Sleep Apnea and Modifications in Sedation: An Update. Crit Care Nurs Clin North Am 2016; 28:217-26. [PMID: 27215359 DOI: 10.1016/j.cnc.2016.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
One factor that may contribute to an increased risk for airway compromise is obstructive sleep apnea (OSA). Sedation in this population carries an increased risk for hypopnea. Critical care nurses must decide on the amount and type of sedation to administer at the point of care. It is important for them to understand OSA and the routinely prescribed sedatives that may affect this disorder. This article discusses the pathophysiology of OSA and traits that may help identify patients with undiagnosed OSA. The most commonly prescribed sedative pharmacologic agents and adjunctive airway support mechanisms are reviewed for use in this population.
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Affiliation(s)
- Deborah Weatherspoon
- School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA.
| | - Debra Sullivan
- School of Nursing MSN Program, School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
| | - Christopher A Weatherspoon
- School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA; Veteran Affairs, Tennessee Valley Health System, Fort Campbell, KY, USA
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Spence DL, Han T, McGuire J, Couture D. Obstructive Sleep Apnea and the Adult Perioperative Patient. J Perianesth Nurs 2015; 30:528-545. [DOI: 10.1016/j.jopan.2014.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/09/2014] [Accepted: 07/19/2014] [Indexed: 10/23/2022]
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Seet E, Chua M, Liaw CM. High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events. Singapore Med J 2015; 56:212-6. [PMID: 25917473 DOI: 10.11622/smedj.2015034] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification. METHODS In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events. RESULTS Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1-6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8-6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7-15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1-15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a 'one in four' chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028). CONCLUSION STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.
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Affiliation(s)
| | | | - Chen Mei Liaw
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828.
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Mason M, Cates CJ, Smith I. Effects of opioid, hypnotic and sedating medications on sleep-disordered breathing in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2015:CD011090. [PMID: 26171909 DOI: 10.1002/14651858.cd011090.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is a common sleep disorder characterised by partial or complete upper airway occlusion during sleep, leading to intermittent cessation (apnoea) or reduction (hypopnoea) of airflow and dips in arterial oxygen saturation during sleep. Many patients with recognised and unrecognised OSA receive hypnotics, sedatives and opiates/opioids to treat conditions including pain, anxiety and difficulty sleeping. Concerns have been expressed that administration of these drugs to people with co-existing OSA may worsen OSA. OBJECTIVES To investigate whether administration of sedative and hypnotic drugs exacerbates the severity of OSA (as measured by the apnoea-hypopnoea index (AHI) or the 4% oxygen desaturation index (ODI)) in people with known OSA. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register (CAGR) of trials. The search was current as of March 2015. SELECTION CRITERIA Randomised, placebo-controlled trials including adult participants with confirmed OSA, where participants were randomly assigned to use opiates or opioids, sedatives, hypnotics or placebo. We included participants already using continuous positive airway pressure (CPAP) or a mandibular advancement device. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by The Cochrane Collaboration. MAIN RESULTS Fourteen studies examining the effects of 10 drugs and including a total of 293 participants contributed to this review. Trials were small, with only two trials, which used sodium oxybate, recruiting more than 40 participants, and all but three trials were of only one to three nights in duration. Most participants had mild to moderate OSA with a mean AHI of 11 to 25 events/h, and only two trials recruited patients with severe OSA. Two trials investigating the effects of ramelteon, a treatment option for insomnia, recruited adults over 60 years of age with OSA and concomitant insomnia.The drugs studied in this review included remifentanil (infusion) 0.75 mcg/kg/h, eszopiclone 3 mg, zolpidem 10 and 20 mg, brotizolam 0.25 mg, flurazepam 30 mg, nitrazepam 10 mg to 15 mg, temazepam 10 mg, triazolam 0.25 mg, ramelteon 8 mg and 16 mg and sodium oxybate 4.5 g and 9 g. We were unable to pool most of the data, with the exception of data for eszopiclone and ramelteon.None of the drugs in this review produced a significant increase in AHI or ODI. Two trials have shown a beneficial effect on OSA. One study showed that a single administration of eszopiclone 3 mg significantly decreased AHI compared with placebo (24 ± 4 vs 31 ± 5; P value < 0.05), and a second study of sodium oxybate 4.5 g showed a significant decrease in AHI compared with placebo (mean difference (MD) -7.41, 95% confidence interval (CI) -14.17 to -0.65; N = 48).Only four trials reported outcome data on ODI. No significant increase, in comparison with placebo, was shown with eszopiclone (21 (22 to 37) vs 28.0 (15 to 36); P value = NS), zolpidem (0.81 ± 0.29 vs 1.46 ± 0.53; P value = NS), flurazepam (18.6 ± 19 vs 19.6 ± 15.9; P value = NS) and temazepam (6.53 ± 9.4 vs 6.56 ± 8.3; P value = 0.98).A significant decrease in minimum nocturnal peripheral capillary oxygen saturation (SpO2) was observed with zolpidem 20 mg (76.8 vs 85.2; P value = 0.002), flurazepam 30 mg (81.7 vs 85.2; P value = 0.002), remifentanil infusion (MD -7.00, 95% CI -11.95 to -2.05) and triazolam 0.25 mg in both rapid eye movement (REM) and non-REM (NREM) sleep (MD -14.00, 95% CI -21.84 to -6.16; MD -10.20, 95% CI -16.08 to -4.32, respectively.One study investigated the effect of an opiate (remifentanil) on patients with moderate OSA. Remifentanil infusion did not significantly change AHI (MD 10.00, 95% CI -9.83 to 29.83); however it did significantly decrease the number of obstructive apnoeas (MD -9.00, 95% CI -17.40 to -0.60) and significantly increased the number of central apnoeas (MD 16.00, 95% CI -2.21 to 34.21). Similarly, although without significant effect on obstructive apnoeas, central apnoeas were increased in the sodium oxybate 9 g treatment group (MD 7.3 (18); P value = 0.005) in a cross-over trial.Drugs studied in this review were generally well tolerated, apart from adverse events reported in 19 study participants prescribed remifentanil (n = 1), eszopiclone (n = 6), sodium oxybate (n = 9) or ramelteon (n = 3). AUTHORS' CONCLUSIONS The findings of this review show that currently no evidence suggests that the pharmacological compounds assessed have a deleterious effect on the severity of OSA as measured by change in AHI or ODI. Significant clinical and statistical decreases in minimum overnight SpO2 were observed with remifentanil, zolpidem 20 mg and triazolam 0.25 mg. Eszopiclone 3 mg and sodium oxybate 4.5 g showed a beneficial effect on the severity of OSA with a reduction in AHI and may merit further assessment as a potential therapeutic option for a subgroup of patients with OSA. Only one trial assessed the effect of an opioid (remifentanil); some studies included CPAP treatment, whilst in a significant number of participants, previous treatment with CPAP was not stated and thus a residual treatment effect of CPAP could not be excluded. Most studies were small and of short duration, with indiscernible methodological quality.Caution is therefore required when such agents are prescribed for patients with OSA, especially outside the severity of the OSA cohorts and the corresponding dose of compounds given in the particular studies. Larger, longer trials involving patients across a broader spectrum of OSA severity are needed to clarify these results.
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Affiliation(s)
- Martina Mason
- Respiratory Support and Sleep Centre, Papworth Hospital, Cambridge, UK
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27
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Gaddam S, Gunukula SK, Mador MJ. Post-gastrointestinal endoscopy complications in patients with obstructive sleep apnea or at high risk for sleep apnea: a systematic review and meta-analysis. Sleep Breath 2015; 20:155-66. [PMID: 26066700 DOI: 10.1007/s11325-015-1199-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 05/13/2015] [Accepted: 05/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is becoming increasingly more prevalent with the rise in obesity. Complications from gastrointestinal (GI) endoscopy in this patient population have been reported in several studies, but the modest complication rates from these procedures make it difficult to come to definitive conclusions based on single studies. The objective of our study was to systematically review these studies reporting the incidence of post-procedure complications in patients with OSA undergoing endoscopy to determine whether the presence of OSA increases post-procedure complications. METHODS We conducted a systematic review using the Cochrane Collaboration Methodology. We searched Medline via Ovid, PubMed, Embase, and Evidence Based Medicine Reviews databases from 1950 to August 2013. We rated the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Meta-analysis was done using Review Manager Version 5.0.20. RESULTS Our search resulted in seven eligible studies. There was no significant association between diagnosis of OSA and post-GI endoscopy complications including hypoxemia, respiratory distress, variations in blood pressure or heart rate, bradypnea, or need for significant interventions. Subgroup analysis based on the type of GI endoscopy or the type of anesthesia used did not show any significant associations either. CONCLUSIONS Obstructive sleep apnea patients and/or patients at high risk for obstructive sleep apnea do not appear to be at increased risk of adverse outcomes from GI endoscopy.
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Affiliation(s)
- Swarna Gaddam
- Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sameer K Gunukula
- Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - M Jeffery Mador
- Division of Pulmonary, Sleep and Critical Care Medicine, University at Buffalo and Western New York Veteran Affairs Healthcare System, 3495 Bailey Ave, Buffalo, NY, 14215, USA.
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Safe Use of Opioids in Individuals with Obstructive Sleep Apnea. Pain Manag Nurs 2015; 16:411-7. [DOI: 10.1016/j.pmn.2014.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/25/2014] [Accepted: 05/27/2014] [Indexed: 11/18/2022]
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Wang HL, Tang SH, Wang XQ, Gong WH, Liu XM, Lei WF. Doxapram hastens the recovery following total intravenous anesthesia with dexmedetomidine, propofol and remifentanil. Exp Ther Med 2015; 9:1518-1522. [PMID: 25780462 PMCID: PMC4353763 DOI: 10.3892/etm.2015.2249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 01/23/2015] [Indexed: 01/08/2023] Open
Abstract
Dexmedetomidine is a suitable sedative for awake fiberoptic intubation in patients with obstructive sleep apnea (OSA). However, previous studies have shown that dexmedetomidine delays recovery from propofol-remifentanil anesthesia. This study aimed to determine whether doxapram may hasten the recovery following dexmedotomidine-propofol-remifentanil anesthesia. Sixty patients scheduled for uvulopalatopharyngoplasty with total intravenous anesthesia were randomized to two groups according to the medicine given at the end of surgery. These were the doxapram (1 mg/kg) and control (normal saline) groups (n=30 per group). The primary outcome was the time to eye opening on verbal command. The time to return to spontaneous breathing, to hand squeezing in response to verbal command, to extubation of the trachea, and the heart rate (HR), bispectral index (BIS) values, respiratory rate (RR) and pulse oximetry values were also recorded and compared. The time to return to spontaneous breathing (5.2±2.9 vs. 11.7±3.4 min, P<0.001), eye opening (9.3±4.7 vs. 15.9±6.3 min, P<0.001), hand squeeze to command (11.8±6.5 vs. 17.6±7.7 min, P=0.0026) and extubation (14.2±7.8 vs. 19.2±9.6 min, P=0.0308) were significantly shorter in the doxapram group compared with the control group. BIS scores (at 3–14 min), RR (at 4–10 min) and HR (at 2–13 min) were significantly higher in the doxapram group compared with those in the control group (P<0.05). Doxapram hastens the recovery from dexmedetomidine-propofol-remifentanil anesthesia in patients undergoing uvulopalatopharyngoplasty, and may benefit patients with OSA.
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Affiliation(s)
- Huan-Liang Wang
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Shu-Hai Tang
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xue-Qin Wang
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Wen-Hua Gong
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiao-Mei Liu
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Wei-Fu Lei
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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Stundner O, Opperer M, Memtsoudis SG. Obstructive sleep apnea in adult patients: considerations for anesthesia and acute pain management. Pain Manag 2015; 5:37-46. [DOI: 10.2217/pmt.14.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Obstructive sleep apnea (OSA) represents a challenge in the perioperative period for both physicians and the health care system alike. A number of studies have associated OSA with increased risk for postoperative complications. This is of particular concern in the face of this disease remaining vastly underdiagnosed. In this context, current guidelines and established concepts such as the use of continuous positive airway pressure or the level of postoperative monitoring, lack strong scientific evidence. Other interventions such as the use neuraxial/regional anesthesia may however offer added benefit. This review aims to address considerations for physicians in charge of OSA patients in the perioperative setting and to give an outlook for current and future research on this topic.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Mathias Opperer
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Perioperative Medicine & Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
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Sedation in non-invasive ventilation: do we know what to do (and why)? Multidiscip Respir Med 2014; 9:56. [PMID: 25699177 PMCID: PMC4333891 DOI: 10.1186/2049-6958-9-56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/06/2014] [Indexed: 01/01/2023] Open
Abstract
This review examines some of the issues encountered in the use of sedation in patients receiving respiratory support from non-invasive ventilation (NIV). This is an area of critical and intensive care medicine where there are limited (if any) robust data to guide the development of best practice and where local custom appears to exert a strong influence on patterns of care. We examine aspects of sedation for NIV where the current lack of structure may be contributing to missed opportunities to improve standards of care and examine the existing sedative armamentarium. No single sedative agent is currently available that fulfils the criteria for an ideal agent but we offer some observations on the relative merits of different agents as they relate to considerations such as effects on respiratory drive and timing, and airways patency. The significance of agitation and delirium and the affective aspect(s) of dyspnoea are also considered. We outline an agenda for placing the use of sedation in NIV on a more systematic footing, including clearly expressed criteria and conditions for terminating NIV and structural and organizational conditions for prospective multicentre trials.
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Abstract
PURPOSE OF REVIEW Sleep apnea syndrome (SAS) in the elderly presents varied clinical symptoms and also has many complications. Moreover, there are many hospital departments related to these symptoms. This article uses literature to provide an outline on SAS observed in the elderly. RECENT FINDINGS SAS sufferers often have complications with so-called lifestyle-related diseases, such as hypertension, hyperlipidemia, diabetes mellitus and metabolic syndrome. These symptoms, along with SAS, recede as a result of continuous positive airway pressure treatment. Some have also reported recession of depression symptoms and delay in deterioration of cognitive functions. SUMMARY The elderly tends to develop SAS through coexistence of chronic respiratory organ disorders, increase in upper airway collapse, strokes, cardiovascular diseases, hypertension, diabetes mellitus and other physiological anatomical changes that accompany aging. However, judgment on the severity and effects regarding prognosis by each remedy used in the diagnosis and treatment of SAS in the elderly is still being developed, and it is considered necessary to accumulate more evidence and establish new standards.
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Shin S, Lee SK, Min KT, Kim HJ, Park CH, Yoo YC. Sedation for interventional gastrointestinal endoscopic procedures: are we overlooking the “pain”? Surg Endosc 2014; 28:100-7. [PMID: 23959522 DOI: 10.1007/s00464-013-3133-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/19/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although interventional gastrointestinal (GI) endoscopic procedures are known to cause greater pain and discomfort than diagnostic procedures, the efficacy of adequate pain control or the difference in pain and amount of analgesic required according to type of intervention is not well known. This study was done to investigate the safety and efficacy of combining fentanyl with propofol for interventional GI endoscopic procedures and determine whether this method is superior to propofol monosedation. METHODS The data of 810 patients that underwent interventional GI endoscopic procedures under sedation with either propofol alone (Group P, n = 499) or propofol/fentanyl (Group PF, n = 311) at a single tertiary-care hospital between May 2012 and December 2012 were retrospectively reviewed. Rates of respiratory and cardiovascular events, propofol and fentanyl requirements, and risk factors of respiratory events of the two groups were analyzed. RESULTS The incidence of respiratory events (P = 0.001), number of cases in which the procedure had to be interrupted for assisted mask bagging (P = 0.044), and propofol infusion rates were significantly lower in Group PF compared to Group P (P < 0.0001). The amount of fentanyl required for diagnostic procedures was significantly lower than that for interventional procedures (P < 0.001). Patients of Group PF showed a lower risk of developing respiratory events compared to Group P (OR 0.224, 95 % CI 0.069–0.724). CONCLUSIONS Combining fentanyl with propofol seems to reduce the risk of respiratory events compared with propofol monosedation during GI endoscopic procedures by providing effective analgesia.
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Sim EY, Tan TK. Awake Craniotomy with Intraoperative MRI: Description of a Sedation Technique Using Remifentanil and Dexmedetomidine. PROCEEDINGS OF SINGAPORE HEALTHCARE 2014. [DOI: 10.1177/201010581402300312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We describe the anaesthetic management of a patient requiring intra-operative MRI and awake neurological testing during neurosurgical resection of a frontal tumour. This tumour involved her motor and speech areas. The anaesthetic drugs administered during awake craniotomy should be safe and allow appropriate changes in the level of sedation, so that the patient is adequately sedated during periods of intense surgical stimulus, yet awake, comfortable and cooperative during functional testing and tumour resection. We report the novel and successful use of a sedative — dexmedetomidine in combination with a narcotic, remifentanil. There has not been much experience with this combination locally. Dexmedetomidine, a selective alpha-2 agonist with sedative, analgesic and anaesthetic-sparing effect does not suppress ventilation. Patients are sedated, but can be easily roused verbally. Remifentanil is a useful choice in this surgery as it can be rapidly titrated according to level of surgical intensity and has a reliable context sensitive half life. Potential problems associated with awake craniotomy such as impaired ventilation during sedation, nausea, vomiting and seizures are discussed. These anaesthetic challenges are compounded by the challenges posed by the iMRI environment. Emphasis is placed on patient selection and preparation peri-operatively. This is crucial to the success of the operation.
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Affiliation(s)
- Eileen Yilin Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Filbey WA, Sanford DT, Baghdoyan HA, Koch LG, Britton SL, Lydic R. Eszopiclone and dexmedetomidine depress ventilation in obese rats with features of metabolic syndrome. Sleep 2014; 37:871-80. [PMID: 24790265 PMCID: PMC3985114 DOI: 10.5665/sleep.3650] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
STUDY OBJECTIVES Obesity alters the therapeutic window of sedative/hypnotic drugs and increases the probability of respiratory complications. The current experiments used an established rodent model of obesity to test the hypothesis that the sedative/hypnotic drugs eszopiclone and dexmedetomidine alter ventilation differentially in obese rats compared with lean/fit rats. DESIGN This study used a within-groups/between-groups experimental design. SETTING University of Michigan. PARTICIPANTS Experiments were conducted using lean/fit rats (n = 21) and obese rats (n = 21) that have features of metabolic syndrome. INTERVENTIONS Breathing was measured with whole-body plethysmography after systemic administration of vehicle (control), the nonbenzodiazepine, benzodiazepine site agonist eszopiclone, or the alpha-2 adrenergic receptor agonist dexmedetomidine. MEASUREMENTS AND RESULTS Data were analyzed using two-way analysis of variance and appropriate post hoc comparisons. At baseline, the obese/metabolic syndrome rats had increased respiratory rates (21.6%), lower tidal volumes/body weight (-24.1%), and no differences in minute ventilation compared to lean/fit rats. In the obese rats, respiratory rate was decreased by dexmedetomidine (-29%), but not eszopiclone. In the lean and the obese rats, eszopiclone decreased tidal volume (-12%). Both sedative/hypnotic drugs caused a greater decrease in minute ventilation in the obese (-26.3%) than lean (-18%) rats. Inspiratory flow rate (VT / TI) of the obese rats was decreased by dexmedetomidine (-10.6%) and eszopiclone (-18%). Duty cycle (TI / TTOT) in both rat lines was decreased by dexmedetomidine (-16.5%) but not by eszopiclone. CONCLUSIONS Dexmedetomidine, in contrast to eszopiclone, decreased minute ventilation in the obese/metabolic syndrome rats by depressing both duty cycle and inspiratory flow rate. The results show for the first time that the obese phenotype differentially modulates the respiratory effects of eszopiclone and dexmedetomidine. These differences in breathing are consistent with previously documented differences in sleep between lean/fit and obese rats. These findings also encourage future studies of obese/metabolic syndrome rats that quantify the effect of sedative/hypnotic drugs on respiratory mechanics as well as hypoxic and hypercapnic ventilatory responses. Continued findings of favorable homology between obese humans and rodents will support the interpretation that these obese rats offer a unique animal model for mechanistic studies.
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Affiliation(s)
| | - David T. Sanford
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | - Lauren G. Koch
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | - Ralph Lydic
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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Doufas AG. Obstructive Sleep Apnea, Pain, and Opioid Analgesia in the Postoperative Patient. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0047-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Fleck RJ, Mahmoud M, McConnell K, Shott SR, Gutmark E, Amin RS. An adverse effect of positive airway pressure on the upper airway documented with magnetic resonance imaging. JAMA Otolaryngol Head Neck Surg 2013; 139:636-8. [PMID: 23787424 DOI: 10.1001/jamaoto.2013.3279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Positive pressure air is used during basic life support to provide respirations and applied as continuous positive airway pressure to maintain a patent airway during sleep or anesthesia. These functions are more critical in children with obstructive sleep apnea, who often have smaller airway dimensions and increased airway collapsibility. OBSERVATIONS We report 2 cases of boys with Down syndrome and a history of obstructive sleep apnea in whom adverse narrowing of the retroglossal airway is caused by continuous positive airway pressure applied via face mask as documented with magnetic resonance imaging. CONCLUSIONS AND RELEVANCE Administration of continuous positive airway pressure by means of face mask to patients can result in adverse effects on the airway patency by pushing the tongue posteriorly. Awareness of this effect on patients with open mouths and large tongues, as present in Down syndrome, is important for sleep apnea treatment, anesthesia, and emergency respiratory support. Generalization of our observation is not possible at this time. Additional prospective studies of the effects of continuous positive airway pressure on airway patency in sedated and/or anesthetized children are required to confirm our anecdotal observations.
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Affiliation(s)
- Robert J Fleck
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati,OH 45229, USA.
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Cha JM, Jeun JW, Pack KM, Lee JI, Joo KR, Shin HP, Shin WC. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol 2013; 19:4745-51. [PMID: 23922472 PMCID: PMC3732847 DOI: 10.3748/wjg.v19.i29.4745] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/10/2013] [Accepted: 06/18/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether patients with obstructive sleep apnea (OSA) are at risk of sedation-related complications during diagnostic esophagogastroduodenoscopy (EGD). METHODS A prospective study was performed in consecutive patients with OSA, who were confirmed with full-night polysomnography between July 2010 and April 2011. The occurrence of cardiopulmonary complications related to sedation during diagnostic EGD was compared between OSA and control groups. RESULTS During the study period, 31 patients with OSA and 65 controls were enrolled. Compared with the control group, a higher dosage of midazolam was administered (P = 0.000) and a higher proportion of deep sedation was performed (P = 0.024) in the OSA group. However, all adverse events, including sedation failure, paradoxical responses, snoring or apnea, hypoxia, hypotension, oxygen or flumazenil administration, and other adverse events were not different between the two groups (all P > 0.1). Patients with OSA were not predisposed to hypoxia with multivariate logistic regression analysis (P = 0.068). CONCLUSION In patients with OSA, this limited sized study did not disclose an increased risk of cardiopulmonary complications during diagnostic EGD under sedation.
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The effects of a single mild dose of morphine on chemoreflexes and breathing in obstructive sleep apnea. Respir Physiol Neurobiol 2013. [DOI: 10.1016/j.resp.2012.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Doufas AG, Tian L, Padrez KA, Suwanprathes P, Cardell JA, Maecker HT, Panousis P. Experimental pain and opioid analgesia in volunteers at high risk for obstructive sleep apnea. PLoS One 2013; 8:e54807. [PMID: 23382975 PMCID: PMC3558510 DOI: 10.1371/journal.pone.0054807] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 12/17/2012] [Indexed: 01/20/2023] Open
Abstract
Background Obstructive sleep apnea (OSA) is characterized by recurrent nocturnal hypoxia and sleep disruption. Sleep fragmentation caused hyperalgesia in volunteers, while nocturnal hypoxemia enhanced morphine analgesic potency in children with OSA. This evidence directly relates to surgical OSA patients who are at risk for airway compromise due to postoperative use of opioids. Using accepted experimental pain models, we characterized pain processing and opioid analgesia in male volunteers recruited based on their risk for OSA. Methods After approval from the Intitutional Review Board and informed consent, we assessed heat and cold pain thresholds and tolerances in volunteers after overnight polysomnography (PSG). Three pro-inflammatory and 3 hypoxia markers were determined in the serum. Pain tests were performed at baseline, placebo, and two effect site concentrations of remifentanil (1 and 2 µg/ml), an μ-opioid agonist. Linear mixed effects regression models were employed to evaluate the association of 3 PSG descriptors [wake after sleep onset, number of sleep stage shifts, and lowest oxyhemoglobin saturation (SaO2) during sleep] and all serum markers with pain thresholds and tolerances at baseline, as well as their changes under remifentanil. Results Forty-three volunteers (12 normal and 31 with a PSG-based diagnosis of OSA) were included in the analysis. The lower nadir SaO2 and higher insulin growth factor binding protein-1 (IGFBP-1) were associated with higher analgesic sensitivity to remifentanil (SaO2, P = 0.0440; IGFBP-1, P = 0.0013). Other pro-inflammatory mediators like interleukin-1β and tumor necrosis factor-α (TNF-α) were associated with an enhanced sensitivity to the opioid analgesic effect (IL-1β, P = 0.0218; TNF-α, P = 0.0276). Conclusions Nocturnal hypoxemia in subjects at high risk for OSA was associated with an increased potency of opioid analgesia. A serum hypoxia marker (IGFBP-1) was associated with hypoalgesia and increased potency to opioid analgesia; other pro-inflammatory mediators also predicted an enhanced opioid potency. Trial Registration: ClinicalTrials.gov NCT00672737.
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Affiliation(s)
- Anthony G Doufas
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA.
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Ankichetty SP, Khunein S, Venkatraghavan L. Presentation of occult Chiari I malformation following spinal anesthesia. Indian J Anaesth 2013; 56:579-81. [PMID: 23325947 PMCID: PMC3546249 DOI: 10.4103/0019-5049.104583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chiari I malformation (CM-I) manifests with tonsillar herniation below foramen magnum. These patients are at high risk of respiratory depression and bulbar dysfunction in the perioperative period with underlying obstructive sleep apnea. However, the safe use of both general and regional anaesthesia has been documented in a known CM-I parturients. We describe the successful management of a patient who had hypercapnic respiratory failure in the post-anaesthetic care unit following an uneventful subarachnoid block for left knee replacement surgery. This patient was retrospectively diagnosed with occult CM-I and moderate to severe obstructive sleep apnea in the postoperative period.
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Affiliation(s)
- Saravanan P Ankichetty
- Department of Anesthesia, Toronto Western Hospital, 399 Bathurst Street, MCL 2-405, Toronto, Ontario, M5T 2S8, Canada
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Drabek T, Němec J. Anesthetic management of electrophysiological procedures for heart failure. Int Anesthesiol Clin 2012; 50:22-42. [PMID: 22735718 DOI: 10.1097/aia.0b013e3182603e95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent advances in EP enabled significant improvement in the care for cardiac patient. Implantation of PMs or ICDs, CRT, and RFA of tachyarrhythmias represent EP procedures that significantly improve quality of life and outcome in selected patient populations. The complexity of the procedure and the off-site EP laboratory environment create a new, challenging scenario for the anesthesiologist. A complex medical history and a current physical status of a patient presenting for a procedure must be carefully weighed in when discussing the options of anesthesia care. The roles of individual anesthetics and anesthesia techniques need to be further evaluated to facilitate the procedure and optimize patient care.
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Affiliation(s)
- Tomas Drabek
- Department of Anesthesiology, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania 15213, USA.
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