powerpoint presentation•increase referrals to sleep center for at risk patients to improve...
TRANSCRIPT
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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
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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
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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
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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 1996-2012
using the keywords obstructive sleep apnea
and perioperative risk or post-operative
complications.
SYNTHESIS OF LITERATURE
Reference: 1st 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 +
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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.
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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 2012.
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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)
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PREDICTIVE VALUE OF STOP-BANG
Negative predictive value = 100%
Sensitivity = 83-100%
Specificity = 60-100%
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, 459-465B.
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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
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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
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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
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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