OSA: Perioperative Management

Now that we understand the importance and relevance of OSA in surgical patients, let’s review the perioperative management of these patients. Your approach has three phases: preoperative, intraoperative, and postoperative. Each of these moments is an opportunity to reduce the perioperative complications associated with OSA. This can reduce overall health care cost, reduce prolonged hospital stays, reduce ICU upgrades, and make for a better operative experience for the patient.

Preoperatively:

1. Identify OSA: using the “STOP-BANG” criteria, identify which patients are low, intermediate, or high risk for OSA.

2. Determine severity of OSA: if they have undergone a sleep study, investigate the polysomnography to see if they have an Apnea-Hypopnea Index (AHI) indicating if their OSA is mild, moderate, or severe.

3. Evaluate type of treatment and their compliance with treatment: examples include CPAP, how often they use it, and what their settings are.

4. Consider optimization of comorbidities prior to surgery such as

   1. Obesity-hypoventilation syndrome (Serum Bicarb > 27 mmol/L)

   2. Severe pulmonary hypertension

   3. Resting hypoxemia

   4. Associated significant or uncontrolled systemic disease (cardiac disease, insulin resistance, stroke)

Intraoperatively:

1. Opioid sparing techniques: local anesthetics to incisional site, regional blocks, multimodal analgesia.

2. Light sedation for MAC cases: reduces lingering effect of sedation in PACU

3. Low threshold for respirator monitoring such as end-tidal CO2

4. Consider use of CPAP for MAC cases

5. If deep sedation is required, consider securing the airway with LMA/ETT

6. Elevate the head, rotate neck to relieve obstruction

7. Airway adjuncts like an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA)

8. Lean towards short-acting agents to avoid dose stacking and delayed respiratory depression

9. Lung recruitment and addition of PEEP when ventilating: helps reduce development of atelectasis

10. Complete reversal of neuromuscular blockade: Sugammadex has helped tremendously with this problem.

Postoperatively:

1. Again, use opioids sparingly and cautiously to avoid dose stacking and delayed respiratory depression

2. Extended observation in the PACU to ensure no recurrent oxygen desaturations

3. Have respiratory therapy available for use of CPAP in the PACU if concern for hypoventilation: employing this early can avoid severe hypercarbia and need for intubation.