1/12/2016. WHAT s this STOP-BANG and why do I need to know about it? Preventing adverse events in patients with Sleep Apnea

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1 WHAT s this TOP-BANG and why do I need to know about it? Preventing adverse events in patients with leep Apnea Rose A. Franco, MD, FCCP Associate Professor of Pulmonary, leep and Critical Care Medicine Medical College of Wisconsin OBTRUCTIVE LEEP APNEA: The hidden epidemic OA is common (4-26%) in general population but 80-90% are undiagnosed. leep apnea is rarely recognized by the sufferer Most come to attention because of suffering observer or when physician specifically asks about sleep and breathing Cardiovascular dysfunction in OA Apnea Intermittent hypoxemia Pit Endothelial dysfunction ympathetic drive Marin JM, Carrizo J, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365: RV preload LV preload LV stroke V P LVTm LV diast relax and filling and endothelin ischemic events and PAP arrhythmia Prothrombotic tate: - PLT aggregat - fibrinogen - fibrinolysis ystemic BP Heart rate VR & afterload Cardiac myocyte hypertrophy and apoptosis 1066 men Cardiomyopathy 1

2 The perfect TORM: OA and analgesics OA is caused by upper airway collapse during sleep Perioperative status added risks: edatives, Anesthetics, Opioids, and Neuromuscular blocking agents. Decreased dilator muscle activity and inhibited protective airway reflexes, Decreased central respiratory drive, and blunted arousal INCREAED Upper airway obstruction.post intubation airway edema, nasal packing, nasal tubes, hematoma, prolonged head down/prone positioning during case upine positioning postop Periop pain, anxiety, agitation, nausea leading to lack of CPAP use Periop leep Deprivation When your patient has leep APNEA, does having an operation lead to increased complications? Postop Respiratory complications common in OA patients 2011 Memtsoudis, Anesth Analg database review of 6 million surgical cases General urgery Intubation/Mechanical Ventilation rates almost DOUBLE (10.8 vs 5.94%) Aspiration Pneumonia (2.79 vs 2.05%) Acute respiratory distress syndrome (3.79 vs 2.44%). Orthopedic urgery Increased risk for all above but at overall much lower rate meta-analysis (Kaw R et al. Br J Anaesth 2012) OR 2.4 for acute respiratory failure OR 2.3 for oxygen desaturation Cardiovascular Risk assessments Perioperative Larger BP fluctuations Perioperative INCREAED MI and Cardiac arrhythmias (esp Atrial fibrillation) 2012 meta-analysis (Kaw R, et al. Br J Anaesth 2012) 2013 database analysis (Mokhlesi B, et al. Obes urg 2013) 2013 database analysis (Mokhlesi B, et al. Chest 2013) More risk assessments measured Acute Renal Failure (OR 2.43) Wound hematomas/seromas (OR 1.36) Delirium postoperatively (OR 4.3) ICU transfer (OR 2.81) Longer hospital stay 6.8 vs 5.1 days for joint arthroplasty 2012 meta-analysis (Kaw R, et al. Br J Anaesth 2012) 2012 J. Arthroplasty. D Apuzzo et al Anesthesiology. Flink et al. MORTALITY RIK Variable reports ome with excess mortality, others with nonsignificant difference 2

3 WHAT WE NEED History of the TOP BANG Tool MAKE CREENING QUICK And catch most of the cases OA is associated with increased postoperative complication rates Anesthesiologists (Dr. Frances Chung et al) worked to develop a easy tool for screening that would be very sensitive. The TOP-BANG tool with a score of > 3 has a sensitivity of 93%-100% for moderate to severe sleep apnea. Applying the tool: Modified for OBEITY (BMI>35) Who should be screened? DIFFICULT AIRWAY assessment: MALLAMPATI scoring Preoperative screening is recommend by the American ociety of Anesthesiologists, the American Academy of leep Medicine, and other international health safety organizations Most critical are: OBEE (BMI >30) Those undergoing bariatric surgery Those with history of difficulty intubation or upper airway anatomy predicting difficulty intubation* Medical Comorbidities with high association with OA: Diabetes Hypertension Congestive Heart Failure troke Hypothyroidism 3

4 o your patient s TOP-BANG is abnormal, Now what. What we are doing at Froedtert Health.. PREOPERATIVELY assessing risk improves our ability to anticipate and PROTECT the patient from adverse outcomes If the procedure is elective, get sleep apnea testing completed before setting up the patient for the surgery consult/surgery date. If the procedure is urgent/emergent, management with presumptive OA is the best strategy. Implementation of the Respiratory afety PROTOCOL at Froedtert Health started with inpatients in 2014 and will move to cover all outpatients by Order for Consult to Respiratory Care (TOPBang screen positive. Assess for PAP) Review TOPBang Tool & Perform Assessment Assessed Risk Monitoring Category Monitoring systems. High Risk Monitoring Moderate Risk Monitoring Diagnosis of OA/tandar d of Care (Not taking Opioids) Recommend Monitoring, BiPAP/CPAP Auto Mode Check Q4 Diagnosed OA? Home Bipap/CPAP with Known ettings? Recommend Monitoring, BiPAP with Home ettings Check Q4 Does patient have any of the following: C-spine/thoracic, or abdominal surgery Opioid and/or sedative Comorbidities Recommend Monitoring Check EtCO2 Q4 if ordered Order BiPAP/CPAP with Auto Mode Home Bipap/CPAP with Known ettings Continue/orde r Home ettings Assessment must be completed within two hours of order aved Work must be used when ordering therapies (notify physician) Reassess Every 48 hours. Change Orders if needed. (tart at top of Algorithm) Discontinue 12 hours after Opioids are stopped 4

5 MEAURING UCCE. How can you appreciate a safer environment as the result of your program? How can you convince those with the most to gain that these efforts are necessary and helpful? Outcome after 5 months of implementation Inpatient Process Up tick in use of reversal agents The rate of RRT events dropped overall AA sleep meetings October 2015 results: In the first 4 months of implementation, 96% (5998/6223) of patients admitted to our academic medical center were assessed. 72% of patients admitted had a /N ordered. 69.9% of patients with TOPBang of 3 or > and /N had enhanced respiratory monitoring. (Table 1) Retrospective chart review determined that 85% of at the defined at risk patients could have been detected by the protocol, and 26% of those patients had severe outcome or death. After the implementation of the protocol, the number of evere outcome or death decreased to 7% in those who were monitored with the protocol. K. Lauer et al Anesthesia leep ociety Meeting, an Diego My patient has OA already diagnosed What is my obligation? Documentation of the EVERITY of the OA AHI (5-15 mild, moderate, >30 severe) Nadir of Oxygen saturation Date of the sleep study Documentation of adequacy of therapy Current state of symptoms, Adherence to therapy (PAP device or other) ADVIE at least 2 weeks of regular nightly use (at least 4 hours/night) is enough to reduce risks Documentation of the current therapy settings The actual ettings of the PAP device are critical. Bringing the PAP device to the hospital is also very very helpful Consideration of co-existing Obesity hypoventilation Look at the Bicarbonate level, if >27 then get an Arterial Blood Gas to look for hypercapnia (pco2> 46) Consideration of co-existing Cardiovascular disease Does your patient also need a preop cardiac work up 5

6 Next steps Move to screening all outpatients prior to planned procedures Adjust site of procedure, type of anesthesia based on risk For elective procedures, optimize prior to scheduling Recognize the post procedure risk and adjust the post op pain management accordingly Known OA evere coring ystem for the Management of Outpatients with OA Moderate Mild Patient Factors OR uspected OA (TOPBang core) 1 if compliant with CPAP +1 if BMI is over for AHI of >60 or ao2 <75% TOPBang >5 +BMI >40 or* Comorbidities uncontrolled TOPBang >5 and BMI <40, or comorbidities controlled TOPBang <5 and BMI >40 Major surgery or airway surgery without protocol Peripheral/uperficial surgery under GA Peripheral/uperficial surgery, mod sedation, under local/regional anesthesia uperficial surgery, no sedation, under local/regional anesthesia Procedure Factors Parenteral narcotics (Exceed low dose) Parenteral narcotics low dose Oral narcotic No opioids Baseline Risk core Postoperative Risk Minimum Observation Level 5 6 Increased risk Overnight observation = admission 4 May be at increased risk Prolonged monitoring 2 3 Probably no increased risk Home HOME CARE leep with HOB elevated Use PAP machine Limit narcotics/sedatives Counsel on risk of taking meds with OA (untreated and treated). A safe and successful procedure is our goal. afety factors include not only what happens during the procedure but also what happens after your procedure and when you go home. You have been identified as at risk for obstructive sleep apnea. leep apnea can increase the chances of breathing issues during sleep after a procedure. This is especially true when pain medications are also needed. To help guard your safety the physician and staff who care for you during and after your procedure will provide additional monitoring to be sure that you are ready to go home safely. This may include a longer period in the recovery area, an overnight stay in the observation unit or in rare cases a change in the location of the procedure to allow for access to hospitalization if needed. Once you are discharged home, you may still need additional precautions to help reduce breathing issues when you are sleeping during the first several nights home. Adjusting the sleeping position can help. Your doctor may request that you sleep in a recliner or if you have an adjustable bed with the head of the bed increased several inches to help reduce your risk in the first few nights after your procedure. Breathing issues with sleep are more common for those who are taking narcotic pain medication or other sedative medications. Adjusting the medication dosing can help reduce breathing problems. If you have already been diagnosed with sleep apnea and have a cpap machine please use it every time you sleep including naps. Thank you 6