Ambulatory anesthesia for patients with sleep apnea

Figures & data

Table 1 STOP-Bang questionnaire

Yes	No	Snoring?
○	○	Do you snore loudly (loud enough to be heard through closed doors or your bed partner elbows you for snoring at night)?
Yes	No	Tired?
○	○	Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving)?
Yes	No	Observed?
○	○	Has anyone observed you stop breathing or choking/ gasping during your sleep?
Yes	No	Pressure?
○	○	Do you have or are being treated for high blood pressure?
Yes	No
○	○	Body mass index more than 35 kg/m^2?
Yes	No
○	○	Age older than 50 years? Neck size large? (measured around Adam’s apple)
Yes	No	For male, is your shirt collar 17 inches or larger?
○	○	For female, is your shirt collar 16 inches or larger?
Yes	No
○	○	Sex = male?

Notes: Scoring criteria (for general population): low risk of OSA, yes to 0–2 questions; intermediate risk of OSA, yes to 3–4 questions; high risk of OSA: yes to 5–8 questions, yes to 2 of 4 STOP questions + individual’s sex is male, yes to 2 of 4 STOP questions + BMI >35 kg/m², yes to 2 of 4 STOP questions + neck circumference (male) 17″(female) 16″. Property of University Health Network.

Abbreviations: OSA, obstructive sleep apnea; BMI, body mass index.

Figure 1 Decision making in preoperative selection of a patient with obstructive sleep apnea (OSA) for ambulatory surgery.

Notes: Adapted from Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115:1060–1068.¹¹ Promotional and commercial use of the material in print, digital or mobile device format is prohibited without the permission from the publisher Wolters Kluwer Health. Please contact [email protected] for further information.¹¹
Abbreviation: CPAP, continuous positive airway pressure.

Table 2 Perioperative precautions and risk mitigation for OSA patients

Anesthetic concern	Principles of management
Premedication	Avoid sedating premedication Consider α2-adrenergic agonists (clonidine, dexmedetomidine)
Potential difficult airway (difficult mask ventilation and tracheal intubation)	Optimal positioning (head-elevated laryngoscopy position) if patient obese Adequate preoxygenation Consider CPAP preoxygenation Two-handed triple airway maneuvers Anticipate difficult airway; personnel familiar with a specific difficult airway algorithm
Gastroesophageal reflux disease	Consider proton-pump inhibitors, antacids, rapid-sequence induction with cricoid pressure
Opioid-related respiratory depression	Minimize opioid use Use of short-acting agents (remifentanil) Multimodal approach to analgesia (NSAIDs, acetaminophen, tramadol, ketamine, gabapentin, pregabalin, dexmedetomidine, clonidine, dexamethasone, melatonin) Consider local and regional anesthesia where appropriate
Carryover sedation effects from longer-acting intravenous and volatile anesthetic agents	Use of propofol/remifentanil for maintenance of anesthesia Use of insoluble potent anesthetic agents (desflurane) Use of regional blocks as a sole anesthetic technique
Excessive sedation in monitored anesthetic care Postextubation airway obstruction	Use of intraoperative capnography for monitoring of ventilation verify full reversal of neuromuscular blockade Extubate only when fully conscious and cooperative Nonsupine posture for extubation and recovery Resume use of positive airway-pressure device after surgery

Note: Adapted from: Seet E, Chung F. Management of sleep apnea in adults – functional algorithms for the perioperative period: Continuing Professional Development. Can J Anaesth. 2010; 57:849.³²

Abbreviations: OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure; NSAIDs, nonsteroidal anti-inflammatory drugs.

Figure 2 Postoperative management of the diagnosed or suspected OSA patient after general anesthesia.

Notes: Postoperative PACU discharge timing and location for the patient with known or suspected OSA after general anesthesia. Such patients should be monitored for >60 minutes after usual PACU criteria are met. *Positive airway pressure (PAP) therapy, including continuous PAP, bilevel PAP, or automatically adjusting PAP; ^Δsignificant comorbidities (eg, heart failure, arrhythmias, uncontrolled hypertension, cerebrovascular disease, metabolic syndrome, BMI >35 kg/m²); ^◊recurrent postanesthesia care unit (PACU) respiratory event: repeated occurrence of oxygen saturation <90 percent, or bradypnea <8 breaths/min, or apnea ≥10 seconds, or pain sedation mismatch (high pain and sedation scores concurrently);^{75 §}equianalgesic doses of oral opioids: codeine 120 mg every 4 hours, oxycodone 10 mg every 4 hours, hydromorphone 4 mg every 4 hours; ^¥monitored bed: environment with continuous oximetry and the possibility of early medical intervention (eg, intensive care unit, step-down unit, or remote pulse oximetry with telemetry in surgical ward). Adapted from: Seet E, Chung F. Management of sleep apnea in adults – functional algorithms for the perioperative period: Continuing Professional Development. Can J Anaesth. 2010; 57:849.³²
Abbreviations: PACU, postanesthesia care unit; OSA, obstructive sleep apnea; AHI, apnea-hypopnea index; PAP, positive airway pressure.

Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115:1060–1068.

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Seet E, Chung F. Management of sleep apnea in adults – functional algorithms for the perioperative period: Continuing Professional development. Can J Anaesth. 2010;57:849–864.

 PubMed Web of Science ®Google Scholar

Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology. 2009;110:869–877.

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