1/27/2017 RECOGNITION AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA: STRATEGIES TO PREVENT POST-OPERATIVE RESPIRATORY FAILURE DEFINITION PATHOPHYSIOLOGY

Transcription

1 RECOGNITION AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA: STRATEGIES TO PREVENT POST-OPERATIVE RESPIRATORY FAILURE Peggy Hollis MSN, RN, ACNS-BC March 9, 2017 DEFINITION Obstructive sleep apnea is a disorder characterized by repetitive episodes of apnea or reduced inspiratory airflow due to upper airway obstruction during sleep. PATHOPHYSIOLOGY 1

2 BACKGROUND AND SIGNIFICANCE 80% of patients with OSA have never been diagnosed 22% of adult surgical patients have OSA 7 % of patients have moderate to severe OSA Patients with OSA are 8 times more likely to have postop hypoxemia PERIOPERATIVE RISK 44% of patients with OSA have postop complications (attributable to adverse respiratory events) General anesthesia exacerbates OSA by causing: Upper airway collapse Blunted arousal from sleep Depressed ventilation PERIOPERATIVE RISK Respiratory failure Cardiac arrhythmias Delirium Death 2

3 PERIOPERATIVE RISK Vulnerability to airway obstruction can last for days ISSUE PROBLEM In CY 2010 the postoperative respiratory failure rate at SMMC was 17.96/1000 pt. elective surgery days and in CY 2011 the rate was 18.17/1000 patient elective surgery days Post-operative Respiratory Failure PSI-11 Mechanical Ventilation for 96 consecutive hours or more - zero or more days after the major operating room procedure code Mechanical Ventilation for less than 96 consecutive hours or undetermined - two or more days after the major operating room procedure code Re-intubation - one or more days after the major operating room procedure code 3

4 PICO In adult surgery patients does OSA risk identification and stratification combined with use of a management protocol reduce the occurrence of post-operative respiratory failure? LITERATURE SEARCH OVID Medline was searched from using the keywords obstructive sleep apnea and perioperative risk or post-operative complications. SYNTHESIS OF LITERATURE Reference: 1 st Author, year, level of evidence Supports risk screen and prevention bundle Does not support risk screen and prevention bundle Chung, S. (2008) Level of evidence V + Olson, E. (2012) Level of evidence V + Farney, R. (2011) Level of evidence VI + Gali, B. (2009) Level of evidence IV + Joshi, G. (2012) Level of evidence VII (or weak I) + Kaw, R. (2012) Level of evidence V + Meoli, A. (2003) Level of evidence VI + O Gorman, S. (2013) Level of evidence II (weak) + Vasu, T. (2012) Level of evidence V + Gross, J. (2006) Level of evidence VII + 4

5 CLINICAL PRACTICE GUIDELINES AASM-American Academy of Sleep Medicine (2003) ASA- American Society of Anesthesiologists (2006) ACCP-American College of Chest Physicians (2010) Time to Get With the Guidelines CURRENT CONDITION (2010) Patients admitted for elective surgical procedures without OSA screening, risk stratification or risk mitigation strategies. 5

6 ROOT CAUSES No systematic method for screening and identifying patients at risk for OSA No bundled protocol for management of patients to mitigate risk No clear definition of respiratory precursor event Triggers for ventilatory support. No plan for longer observation of day surgery patients. RECOMMENDATION All patients will be screened for risk of OSA prior to admission. Those determined to be at risk will be identified with a unique wrist band and management protocol orders will be initiated. Identification of at risk patients combined with risk mitigation strategies will reduce the rate of postoperative respiratory failure. SMART GOAL We will appreciate a 25% reduction in postoperative respiratory failure by the end of calendar year

7 Plan/ Integration PREOPERATIVE EVALUATION Based on history and physical exam Screening questionnaire that asks about snoring, daytime sleepiness, BMI and neck circumference. Screening is done prior to surgery RISK SCREEN Chung, F. (2008) 7

8 PREDICTIVE VALUE OF STOP-BANG Negative predictive value = 100% Sensitivity = % Specificity = % DEFINITIONS Apnea- cessation of airflow for >10 secs Hypopnea- Reduction in airflow <50%, with desaturation ± arousal Apnea Hypopnea Index (AHI)- number of apneas and hypopneas per hour of sleep PREDICTIVE VALUE Farney, RJ. et al. (2011). The STOP-Bang equivalence model and prediction of severity of obstructive sleep apnea: Relation to polysomnographic measurements of the apnea/hypopnea index. The Journal of Sleep Medicine, B. 8

9 9

10 INTRAOPERATIVE MANAGEMENT Premeds with sedatives or analgesics discouraged Consider regional anesthesia Monitor oximetry and capnography Maintain positive airway pressure Follow ASA guidelines for difficult airway Pre-oxygenate with mask 3 minutes PACU MANAGEMENT Order RT to eval. and treat HOB at 30 deg. (unless prohibited) Keep patient lateral rather than supine Keep SaO2 >89% Use CPAP/BiPAP Referral to Sleep Center PACU MANAGEMENT Respiratory event RR < 8 min. Apnea > 9 secs. SaO2 < 88% on 3 l/min. via NC Interventions for respiratory event RT to initiate APAP therapy Anesthesia to determine disposition 10

11 SDS MANAGEMENT Keep patient 3 hours longer than a normal stay. FLOOR MANAGEMENT Sign on HOB ZZZzzz Notify Pharmacy Caution inputs Transition from IV to oral analgesics ASAP PCA should be only on demand Utilize CPAP/BiPAP Continuous pulse oximetry Place near nurses station Hourly assessment 11

12 FLOOR MANAGEMENT CPAP/BiPAP should be used: When asleep When level of sedation is >/= 2 Sedation scale 1=wide awake 2=Drowsy 3=Dozing intermittently 4=Mostly sleeping 5=Only awakens at when aroused ADVISING PATIENTS OF RISK Outcomes/ Check 12

13 PSI-11 TREND POSTOPERATIVE RESPIRATORY FAILURE ACT Expand screen to all inpatients to be done with admission history Optimization of EMR to include screening, orders and interventions Increase referrals to Sleep Center for at risk patients to improve population health SUMMARY Obstructive sleep apnea is a high-risk condition with serious morbidity Identification of at risk patients combined with use of an evidence-based prevention bundle will improve patient outcomes 13