Perioperative Management

Patients undergoing any surgical procedure are susceptible to postoperative complications due to respiratory compromise. Patients with OSA are at obvious risk for a postoperative complication due to the perioperative use of narcotics and benzo-diazepines, which are known to blunt the respiratory response to hypercapnea and to hypoxia as well as exacerbate upper airway obstruction (126). Unfortunately, many patients undergoing surgical procedures are not appropriately screened for OSA and may be put at risk for postoperative complications, in particular patients having outpatient surgical procedures who are sent home to a completely unmonitored environment.

There are few studies looking directly at the risk of postoperative complications associated with OSA, however, the American Society of Anesthesiologists (ASA) have recognized the risk of postoperative complications associated with patients who have undiagnosed OSA and thereby published practice guidelines outlining recommendations of how to identify and treat patients at risk. The ASA practice parameters suggest that preoperatively, anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan. The recommendations go on to include preoperative preparation where preoperative initiation of CPAP should be considered, particularly if OSA is severe. As previously stated, because of their propensity for airway collapse and sleep deprivation, patients with OSA are especially susceptible to the respiratory depressant and airway effects of sedatives, narcotics, and inhaled anesthetics. Therefore, in selecting intraoperative medications, the ASA practice parameters suggest that the potential for postoperative respiratory compromise should be considered. Regional analgesic (pain relief) techniques should be considered to reduce or eliminate the requirement for systemic opioids (narcotics) in patients at increased perioperative risk from OSA. Finally, the practice parameters go on to recommend that before patients at increased perioperative risk from OSA are scheduled for surgery, a determination should be made regarding whether a given surgical procedure is most appropriately performed on an inpatient or outpatient basis. In addition, specific criteria should be met for discharging the patient after surgery to an unmonitored setting, such as the home (127).

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