"Perioperative Management of Patients with OSA" Jaime Hyman (02/02/2022)

February 13, 2022

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00:14Perfect so good afternoon everyone
00:16and welcome to sleep seminar and
00:19so just a couple of announcements.
00:21Remember this leap seminar lectures
00:22are available for CME credit and
00:24to get credit just text the ID
00:26for the lecture to Yale Cloud.
00:28See any that needs to be done within
00:3015 minutes after the lecture.
00:31Friends and information will show up
00:33in the chat recordings of the lecture
00:35are available within two weeks at
00:37the site noted in the chat and if
00:39you have questions during the talk,
00:41use the chat feature.
00:43Feel free to use it throughout.
00:44I'll moderate the questions at the end
00:46and if you and also at the end I will
00:48give you permission to unmute yourself,
00:49so feel free to ask your own questions.
00:52So now it's my pleasure to introduce
00:54today's sleep seminar speaker
00:56Doctor Jamie ***** Dr ***** is an
00:58associate professor in the Department
00:59of Anesthesia and also Division
01:01Chief of ambulatory anesthesia.
01:03Here at Yale,
01:04she received her MD from Albert
01:05Einstein College of Medicine and
01:07her internship at Memorial Sloan,
01:09Kettering and her residency at Mount Sinai.
01:12She stayed on the faculty at Mount
01:14Sinai and there she served as clinical
01:16coordinator of the Perioperative
01:17and Pain Management Service.
01:19The chair of the difficult Area Response
01:21Team and the Fellowship director of
01:23the head and Neck Anesthesiology and
01:25Advanced Airway Management program,
01:27she moved to Yale in 2020,
01:28so still a relative newcomer.
01:29As we were saying,
01:31and she's now division chief of ambulatory.
01:33Anesthesiology so she is an active member
01:35of the Society for Ambulatory Anesthesia.
01:38She Co chairs,
01:39the Anesthesia Education committee.
01:41She is also a member of the New York
01:42State Society of Anesthesiologist and the
01:45American Society of Anesthesiologists.
01:46She has received numerous awards
01:48really throughout her career,
01:49including intranet,
01:50the year resident of the Year,
01:51Outstanding Mentor of the year,
01:53several Faculty research awards,
01:54and even during her time here at Yale,
01:57she received a faculty Award for
01:59Excellence in Education and Leadership.
02:01Her work has been published
02:03in diverse journals including
02:05anesthesiologist laryngoscope,
02:06anesthesiology and analgesia.
02:07Journal of Emergency Medicine,
02:09Journal of Quality Health.
02:11So really diverse group.
02:12She's currently a member of a combined
02:14writing group including members from
02:16the Society for Ambulatory Anesthesia,
02:18Society of Anesthesia and Sleep Medicine,
02:20and Society of Critical Care.
02:21Anesthesiologists who have been developing
02:23guidelines for the perioperative
02:25management of patients with sleep apnea,
02:27so this is a really timely
02:28and important topic,
02:29and I'm so pleased that Doctor
02:30***** can join us today.
02:32So welcome.
02:33Thank you so much Doctor Hilbert
02:35for that really kind introduction.
02:37I'm really thrilled with the
02:38opportunity to speak today,
02:39and I'm also humbled to be speaking to
02:42an audience that is so expert in OSA.
02:45But hoping that I can provide some
02:47insight into our sort of everyday
02:50experience of as anesthesiologists
02:51in caring for and providing the best
02:54possible care for this challenging,
02:56patient and population which
02:57you all know very well.
02:59I have no disclosures related
03:01to the talk today and the CME.
03:04Voters here. So this will be well
03:08known to this audience today.
03:10But you know,
03:11OSA has a tremendous prevalence worldwide,
03:14with an estimated overall
03:16prevalence of 1 billion,
03:17with 425 million patients in the
03:20moderate to severe category based
03:22on American Academy of Sleep
03:24Medicine to the 2012 guidelines.
03:27And if you overlay that with
03:29the global volume of surgery,
03:31which is just tremendous,
03:32you know several 100,000,000.
03:34It just really speaks to.
03:37The volume of this problem of
03:39caring for these patients,
03:41who are as I'll discuss,
03:43at elevated risk of perioperative
03:46complications.
03:48And because of the volume of the problem,
03:51there is quite a volume of
03:52literature on the topic,
03:53and it was a challenge to figure
03:55out exactly what to focus in on in
03:57preparing for the talk for all of you today.
03:59So before I get into the bulk of it,
04:01I just want to give this disclaimer and
04:02it's a quote from a recent review article
04:05published in anesthesia and Analgesia.
04:06One of our main journals on the
04:08topic of perioperative management
04:10of patients with OSA,
04:11and that is that despite a plethora
04:14of clinical evidence delineating the
04:16perioperative risk associated with OSA,
04:18much of which I'll go over today.
04:20Scientific data on the efficacy
04:21of perioperative safety measures
04:23are largely lacking,
04:24so a lot of those recommendations
04:26are really still based on expert
04:28opinion for maybe lower levels of
04:30evidence at this point and then also
04:32of interest to the audience today.
04:34Moreover,
04:34OSA is increasingly acknowledged as
04:36a complex condition with significant
04:38heterogeneity in terms of disease severity,
04:40comorbidity,
04:40burden and complication risks.
04:42So, as you all know,
04:44far in far more detail than I do.
04:45There are many phenotypes of OSA
04:46and so that makes the study of
04:48this problem in the perioperative.
04:50Period,
04:50you know ever more complex and
04:52and something that's gonna,
04:53you know,
04:54take a lot more you know body
04:56of literature in the future.
04:59So with that sort of disclaimer in mind,
05:01the learning objectives for the next
05:0340 minutes or so of this talk for
05:05you are to lift the perioperative
05:07adverse events associated with OSA.
05:09Review recommendations for the
05:11perative management of OSA patients,
05:13identify gaps in evidence for the rabbit.
05:15If management OSA patients that warrant
05:17research and then possibly inspire one
05:19or more of you who are here at Yale to see.
05:22How we can work within our institution
05:25to possibly improve the pathways for
05:27perative care for our patients here?
05:30So as I said,
05:31there's a plethora of literature
05:32on this topic,
05:33and there are a plethora of
05:34guidelines on this topic,
05:35probably because of the just
05:37magnitude of the problem.
05:39So these are the available guidelines
05:41right now for the perioperative
05:42management of patients with OSA,
05:45and they all really do still have a place,
05:47despite some of them being a
05:48little bit on the older side.
05:49So the Society of ambulatory
05:51anesthesia guidelines or Samba
05:53guidelines are now a decade old,
05:54but are still really do inform my
05:57clinical decision making on a daily basis.
05:59And I will be touching upon those.
06:00Abet as an inventory anesthesiologist
06:03our main professional society,
06:05the American Society of Anesthesiologists
06:07guidelines were last updated in 2013
06:09and are probably the most well known
06:11among clinical anesthesiologist sasom,
06:13the Society of Anesthesia and Sleep
06:16Medicine has preoperative guidelines
06:17from 2016 as well as intra operative
06:19guidelines for 2018 and the work
06:21in progress that I'm part of.
06:23The writing group is for the
06:25post operative guidelines,
06:26which will hopefully be published
06:27in the next year or
06:29so. There are guidelines
06:30specific to patients with OSA.
06:32Having bariatric surgery since it's
06:33obviously going to be prevalent
06:35problem in that patient population
06:37and then also of interest.
06:38The most recent guidelines to
06:40be published back in 2019 are
06:42specific to patients with OSA.
06:43Have been having upper airway
06:44surgery and I'm going to highlight
06:46these a little bit because of my
06:47interest in head and neck anesthesia.
06:49So I care for these patients pretty
06:51frequently and also because I
06:52thought it would be of interest to
06:53you as Sleep Medicine specialists
06:55today because your patients,
06:56you know obviously present for
06:59these surgeries.
07:00So the for the first portion
07:01of the talk I'll focus in on an
07:04adverse events and the evidence
07:05for our patients with OSA being at
07:08elevated risk for adverse events
07:09in the perioperative period.
07:11So the literature and this is heterogeneous.
07:13We do have a meta analysis that
07:16I'd like to highlight here that's
07:18has a series of cohort studies
07:20and case control studies.
07:2217 studies in all,
07:23and when these studies were pooled together,
07:26there was an increased risk of
07:28respiratory failure found for patients
07:30with OSA relative to those without.
07:33That includes reactivation,
07:34prolonged mechanical ventilation,
07:36etc,
07:37as well as cardiac events including
07:40acute myocardial infarction.
07:41Arrhythmia is cardiac arrests
07:43as well as icing transfer,
07:46so the overall risk is elevated,
07:47but when you look at the individual studies,
07:49the results are really quite heterogeneous
07:51and it probably speaks to the fact
07:53that the method of diagnosis of OSA,
07:55whether the gold standard price
07:56*********** versus screening,
07:58is variable between studies as well as.
08:02The adherence to prescribed
08:04treatment is variable across studies.
08:08So just to really drive home this point,
08:10I wanted to share this table from
08:12Sassins preoperative guidelines,
08:14which summarizes the literature on the
08:16elevated risk of complications from
08:18patients having OSA in aperitive period.
08:20And if you look in at pulmonary
08:23complications in particular,
08:24really all the studies looked
08:25at that as a possible outcome,
08:26which makes sense given the
08:28pathophysiology of OSA.
08:29Of those 17 studies,
08:3111 found that OSA was predictive of
08:34increased risk of pulmonary complications,
08:36but six phones.
08:38No impact of OSA on increased
08:40risk of pulmonary complications.
08:42When it comes to a cardiac complications,
08:452 of the 11 studies did show
08:47that there was a doctor.
08:48Mental impact of OSA on the
08:50risk of cardiac complications,
08:51but nine found no significant difference
08:55and then really, interestingly,
08:57when it comes to mortality,
08:59there have been 13 studies that have
09:01reported on whether OSA increases the
09:03risk for mortality perioperatively
09:05and one found that it did.
09:07Nine found that there was no
09:08significant impact,
09:09and three studies actually found a
09:11beneficial impact of obstructive sleep apnea.
09:13On patients mortality after surgery,
09:15which probably speaks to the fact
09:17that maybe these patients underwent
09:18greater levels of monitoring,
09:20there was heightened vigilance
09:22surrounding their care or possibly
09:24positive area pressure treatment.
09:26But this doesn't mean that
09:28as anesthesiologist,
09:29as para poder physicians,
09:31we don't worry about mortality
09:32for our OSA patients.
09:34Of course, we do think it's just
09:36luckily a rare complication due to,
09:38you know, heightened vigilance.
09:40But that being said,
09:41there are definitely reports of
09:43mismanagement of OSA patients in
09:45the perioperative period leading to
09:47what this editorial author writes.
09:49So bluntly, those patients
09:51being found dead in bed.
09:52And I think this is the kind of
09:53scenario that really keeps you
09:55up at night anesthesiologists.
09:56If we miss the diagnosis if.
09:59Don't don't plan for an elevated level
10:02of monitoring postoperatively in a
10:03patient that would have benefited from it.
10:05Could one of our patients
10:06be found dead in bed?
10:07And in this editorial
10:10the author highlighted 12
10:12closed claims analysis
10:14closed claim study is closed,
10:16claims cases rather of the patients with
10:19OSA were just that exactly that happened.
10:23So because death is so rare,
10:25the best way to study it really
10:26is going to be through case
10:28series and medical legal reports.
10:30And this study of 60 patients total
10:34looked at those who died related to
10:38OSA in the postoperative period or
10:40had a noxic brain injury as well
10:42as those who had very critical
10:44respiratory events are near death
10:46patients who had cardiac arrest.
10:47But where we citated in patients with
10:50heart block also related to OSA and.
10:52Interestingly importantly,
10:53the vast majority of events were
10:56in the 1st 24 hours after surgery,
10:59so that seems to be the really
11:01critical time period and the majority
11:02happened on the floor as opposed to
11:04in operating room or in the pacu,
11:05where there's higher levels of monitoring.
11:09There can also be lessons learned from
11:13comparing those patients who had death
11:16or anoxic brain injury to those who
11:20who had respiratory adverse events,
11:23to see which ones end to
11:27see which factors may have.
11:30Increase their risk for actual death
11:32and a future study. I'll show next.
11:34Will will elaborate on that a little bit,
11:35but I also just briefly wanted to point out
11:38that of those 60 patients in this study,
11:4135 of them had diagnosed OSA preoperatively.
11:4411 of those 35 were on preoperative C Pap.
11:48The remaining were not,
11:49and then only four of those eleven were
11:51on who are on preoperative have actually
11:53used their seat post operatively,
11:54so not using CPAP or you know,
11:58not using it in the postoperative period.
11:59When I was prescribed Preoperatively
12:01could have been risk factors.
12:02For those patients,
12:03and then also of note,
12:04the majority of patients and with these
12:06really critical adverse events and
12:08deaths we're receiving less than 10
12:09milligram of morphine equivalents per day,
12:11which suggests that it's a very modest
12:13dose of suggests that you know opioid
12:16induced respiratory depression,
12:17while contributory was probably
12:18not the whole picture,
12:19and what led to death and oxyc brain injury
12:21or other critical events in these patients.
12:24So lessons can also be learned from the
12:25Society of anesthesia and Sleep Medicine,
12:27death and near Miss Miss Registry.
12:29This registry study included 60.
12:32Six patients who died had an accident,
12:34brain injury or a handful that
12:36had other critical events.
12:37And again,
12:38most of the events were on the
12:40hospital floor as opposed to
12:43higher monitored locations,
12:44although some did occur in the
12:45ICU or step down,
12:46so that's important to note.
12:48And for me,
12:49as someone who does a lot of
12:50ambulatory anesthesiology,
12:51I'm of course you know concerned
12:53about the 14 patients who died
12:55or had a noxic brain injury at
12:57home after ambulatory anesthesia.
12:59So that's particularly concerning.
13:00And when you look at the patients
13:02who had death or brain damage versus
13:04those who had other critical events
13:06but were rescued for that from them.
13:08Death and brain damage were less common
13:10when the event was witnessed less
13:12common when supplemental oxygen was utilized.
13:14Less common when respiratory
13:16monitoring was utilized.
13:17More common when opioids and sedatives
13:20were given compared to just opioids alone.
13:23And in this small registry study,
13:26there was no evidence for an association
13:28with OSA severity or cumulative opioid dose,
13:31and the risk of death or bearing
13:32damage being the outcome,
13:33with the caveat that it's obviously
13:35a very small sample size,
13:37so I don't know what conclusions
13:38we can really draw from that.
13:42So now that I've touched upon the risks
13:44of adverse events in terms of cardio,
13:47pulmonary complications,
13:47and the rare but really feared
13:50risk of death or not sticker,
13:52brain and brain damage and our
13:54patients with OSA perioperatively,
13:56how can we approach preoperative risk
14:00assessment and then planning to reduce risk?
14:04We have robust guidelines from the
14:05Society of Anesthesia and Sleep Medicine.
14:07As I mentioned at the outset.
14:09And of course the gold standard
14:12for diagnosis is polysomnography.
14:13But a lot of our patients present
14:15to us for surgery and have not had
14:19polysomnography to diagnose their OSA.
14:21And of course, many,
14:22many patients present to us with undiagnosed.
14:24So, in the absence of formal testing,
14:28we're left with screening questionnaires.
14:29My name, which have been validated
14:32and the most popular one.
14:33Is certainly the Stop Bang score
14:36and there's currently insufficient
14:37evidence to suggest that for
14:39the vast majority of patients,
14:41presenting for the vast majority of
14:43types of surgery that you know delaying
14:46surgery that isn't urgent in order to
14:49get formal testing with polysomnography is,
14:52you know is not the best way to
14:54utilize resources for for our
14:56perioperative patients at this point,
14:57which leaves us with these
15:01screening questionnaires.
15:02So on a daily basis,
15:04we are then confronted with
15:06diagnosed patients with OSA,
15:07who are treated which is our favorite type.
15:09Those with OSA that's diagnosed
15:11but are either partially treated
15:13or untreated or maybe not adherent
15:15to their prescribed treatment and
15:17then those with suspected OSA based
15:19on preoperative screening tools
15:21such as stopping.
15:25And here at Yale in our
15:27preanesthesia evaluation note,
15:29which is standard throughout the
15:31health system, we do document
15:32unknown diagnosis of OSA and then
15:34whether or not the patient is on C.
15:36Pap and then in the absence of
15:38that we can document using a pre op
15:41screening tool section of our pre op.
15:43Note whether we used,
15:45we did a stop bang score and then if the
15:48patient has three or more risk factors,
15:50whether they are at risk for OSA.
15:55So that begs the question,
15:56if we're frequently taking care of
15:58patients who screen positive for
16:00OSA and aren't formally diagnosed,
16:02and therefore of course don't have
16:04any treatment, they're not going
16:06to be in positive area pressure.
16:07And what is the impact of positive air
16:11pressure on adverse outcomes after surgery?
16:14Well, there's a bit of literature on it.
16:15It's hard to study and really
16:17tease out what the benefit is,
16:20but here there is a meta
16:23analysis of six studies.
16:25Two of them are randomized controlled trials.
16:27The remaining were observation,
16:29ULL that included almost 1000 patients and
16:32in terms of the impact on adverse outcomes,
16:35I'll give go over that in just a moment.
16:37But I first wanted to point out that
16:40of the patients who were in the see
16:42PAP group in these pooled studies,
16:45the vast majority of them
16:46around preoperative C PAP.
16:47However,
16:47fewer than half actually used
16:49their C PAP in the postoperative
16:51period and that could be,
16:52for various reasons,
16:54noncompliance clinicians.
16:55Didn't prescribe it and no protocols
16:58in the hospitals that they were at
17:00in order to make sure the patients
17:02got their CPAP postoperatively.
17:04So with that caveat that the postoperative
17:07adherence was only about 50%.
17:09This meta analysis found that there was
17:11no significant difference in adverse
17:13events postoperatively in patients
17:15who were on positive air pressure
17:17therapy versus those that were not.
17:22Another kind of creative study designed
17:24to try to answer this question comes
17:27from this match cohort study where where
17:31patients were divided up into three groups,
17:33those that had diagnosed OSA
17:35prior to presenting to surgery.
17:37Those that had OSA diagnosed and.
17:42After their surgery within
17:44the next five years,
17:45with the presumption that they probably
17:47had OSA at the time of their surgery,
17:50it just wasn't diagnosed yet and so
17:53therefore they weren't on any treatment yet.
17:55And then those matched controls that
17:57did not have an elevated risk for OSA.
18:00And when you pulled together the
18:02patients with diagnosed and treated OSA,
18:05undiagnosed OSA at the time of surgery
18:07and compared them to the match controls,
18:09OSA, whether diagnosed or undiagnosed,
18:11did lead to an increased risk
18:13of respiratory complications.
18:14For all patients with OSA.
18:17Interestingly,
18:17the cardiac comma cardiovascular
18:20complications including cardiac
18:21arrest and shock.
18:23The patients who had undiagnosed OSA,
18:26meaning that they ended up getting diagnosed
18:27in the five years after their surgery,
18:29had nearly had over twice increased
18:32risk of having cardiac arrests
18:35and or shock in the postoperative
18:38period compared to those that were
18:40diagnosed with OSA and prescribed
18:42CPAP in the preoperative period,
18:45suggesting that it may be
18:47cardiovascular complications.
18:47That CPAP use and adherence could
18:51be particularly beneficial for.
18:53And then one final study that I
18:55wanted to share trying to delve into
18:56this question of whether kpap is
18:58protective in the perioperative period
19:00comes from the Michigan Surgical
19:01Quality Collaborative 2646 patients
19:05were extracted from this database
19:08that had diagnosed or suspected OSA
19:11based on clinician documentation
19:13of preoperative screening and of
19:17those 26155.4% were untreated.
19:19So either because they just screen
19:21positive or they had diagnosed
19:22but were untreated.
19:23And when you compare the two groups,
19:25the untreated patients with OSA
19:27or suspected OSA had an increased
19:29risk of pooled cardio,
19:31pulmonary complications,
19:32unplanned reintubation's,
19:33and postoperative MI's.
19:40So, given that we don't yet have
19:42enough evidence to refer to all of
19:45our patients for Sleep Medicine,
19:47consultation and treatment,
19:48and we are going to be taking
19:51care of patients you know with
19:53just a presumed diagnosis of OSA,
19:55which patient should we not go
19:57ahead with that plan and actually
19:59pause in the case of you know,
20:01non urgent surgery and send our
20:04patients for Sleep Medicine,
20:05consultation and possible
20:07treatment preoperatively?
20:08Well, pretty much.
20:09All of the guidelines I share at the
20:11outset have similar recommendations,
20:12which is those patients with
20:14particular comorbidities,
20:15including hypoventilation syndromes,
20:17pulmonary hypertension,
20:18and resting hypoxemia diagnosed
20:21preoperatively most certainly will
20:24benefit from preoperative Sleep
20:25Medicine consultation and possibly
20:27initiating positive air pressure
20:29therapy prior to going ahead with surgery,
20:32and so that's that's a pretty consistent
20:35recommendation across guidelines.
20:39Another clinical decision that we're
20:41faced with when we do ambulatory surgery
20:43on a daily basis is which patients
20:45are safe to send home and this is,
20:48you know, the the low clinical location.
20:50I work in most commonly the
20:52East pavilion here at the York
20:54Street Street campus of Yale,
20:55New Haven Hospital.
20:56There really isn't a day that goes
20:58by where I don't have a patient
21:00scheduled for inventory surgery.
21:01Who has a diagnosis of OSA and I
21:02have to decide whether or not it's safe.
21:04So as I mentioned,
21:05the 2012 Samba Guidelines Society
21:08of Ambulatory Anesthesia.
21:09Really do still guide our decision
21:11making and despite the age of
21:13the guidelines at this point,
21:15and like other guidelines,
21:16it divides patients into known OSA
21:18versus presumed OSA and those with
21:20known OSA who are compliant with C PAP
21:23at home have their C PAP machine at
21:25home and are going to be able to use
21:27it and here to it post operatively.
21:29It's safe to proceed with ambulatory surgery.
21:33Patients who either don't use CPAP or
21:36haven't been prescribed but but are
21:38going to be able to have their pain
21:41mostly controlled by non opioid techniques,
21:44probably also safe to proceed
21:45with ambulatory surgery,
21:46but it's those patients without paper,
21:48certainly with non optimized
21:50comorbid conditions,
21:50and in particular if they're going
21:52to be using opioids postoperatively
21:53that are not suitable for ambulatory
21:55surgery and should be done in a
21:57place where inpatient admission
21:58afterwards is is possible.
22:04So both the Samba guidelines and also the
22:07saw some guidelines recommend that CPAP
22:10should be available in the perioperative
22:12period and for ambulatory surgery centers,
22:15which unlike a hospital setting like here
22:17at Yale, are not going to have respiratory
22:19therapists and CPAP machines available.
22:21The recommendation is for patients
22:23to bring their own CPAP machines on
22:25the day of surgery so that they can
22:27use it in the postoperative period.
22:29A recent survey of ambulatory Surgery center
22:33medical directors found that only 60.
22:35Present facilities did have a policy that
22:37required their patients to bring their CPAP
22:39devices in the day of surgery and only a
22:41quarter of facility facility is reported.
22:43Patients actually using their C PAP
22:45machines at some point in their AFC.
22:47Within the past two years.
22:49So in all, this means that 40% of ASD
22:52in the United States are likely not
22:54compliant with Samba and saw some
22:57recommendations to have CPAP available.
22:59Despite that,
23:00none of the medical directors did
23:01report any adverse outcomes or adverse
23:03events that to their knowledge,
23:05in patients with OSA at their ASC.
23:07Which may reflect pay,
23:08careful patient selection as opposed
23:10to the fact that you know the idea
23:12that our OSA patients don't need
23:14CPAP in the perioperative period.
23:19As promised, I'm going to
23:21briefly highlight some specific
23:23recommendations from the upper airway
23:25surgery guidelines and namely,
23:27I wanted to point out here.
23:28These are more statements than
23:30recommendations, but when you look at every
23:32type of upper airway surgery that is,
23:35you know common in current practice,
23:37bleeding is, you know,
23:39the main risk factor for complications
23:41post-op really for all of them.
23:42And as you can imagine,
23:44bleeding Airways in patients
23:46with OSA is definitely something
23:48that presents a challenge from a
23:51clinical management standpoint.
23:52And then when it comes to a
23:54couple of recommendations for the
23:56preoperative phase of care for
23:57patients having upper airway surgery,
23:59you know there's some soft
24:00recommendations for if patients
24:01are in positive air pressure.
24:02It should be.
24:04It should be continued in the
24:06perioperative period.
24:06But of course patients are presenting
24:08for upper airway surgery.
24:09Often we're not able to tolerate or
24:11adhere to their positive air pressure,
24:12hence the plan for surgery.
24:14So maybe potentially not as relevant
24:17in this patient population.
24:19So moving on to intra operative management,
24:22I'm I'm gonna go through this section,
24:24you know,
24:24not the greatest of detail because
24:26it's more relevant to an anesthesiology
24:28audience than a Sleep Medicine audience.
24:30But I did want to highlight
24:31the literature on OSA and its
24:33association with difficult airway
24:34management because I know there are
24:36of course a lot of pulmonologists,
24:38intensivists,
24:38and respiratory therapists in the audience.
24:41And today there are six studies that
24:44evaluate the association between
24:46OSA and difficult mask ventilation,
24:48five of which so that.
24:50OSA does have a significant impact on OSA,
24:52one which did not when it comes
24:55to tracheal intubation,
24:5612 studies have examined this,
24:57and seven of them found a significant
25:00impact of OSA, whereas 5 did not.
25:02The dreaded combined difficult
25:04ventilation and intubation has
25:05been examined in two studies,
25:07and both did find that OSA was
25:09a significant predictor of this
25:11airway management difficulty.
25:13So far,
25:13there's been two studies on
25:15supraglottic airway insertion,
25:16and neither of them found that
25:17OSA predicted increased risk with
25:19Super Matic airway.
25:20Management and to my knowledge no
25:21one has done a study of whether
25:23surgical airway is more difficult
25:25in patients with OSA.
25:29I wanted to briefly bring up the
25:30idea of the rostral fluid shift which
25:32has not received very much attention
25:34in the anesthesiology literature.
25:36But my understanding is that it has been
25:39covered in the Sleep Medicine literature,
25:41and you know with the idea being
25:43that when patients lie down at night,
25:45the fluid shifts from the lower
25:47extremities up to the neck and and
25:49upper airway can increase upper airway
25:51collapsibility as well as neck fluid volume,
25:53leading to you know one of the
25:56pathophysiologic mechanisms of OSA and.
25:58Certainly there could be, you know,
26:00a component of this relevant to the
26:02interop and postoperative period.
26:04Our patients do tend to be supine
26:06and you tend to get fluid and salt
26:08loads in response to hypotension.
26:10After induction you know blood loss in
26:13the operating room medication administration,
26:15so the implication being that
26:18potentially management could include
26:21judicious fluid administration,
26:22giving fluids with less salt content and
26:25putting our patients in the head up position.
26:27After surgery when possible,
26:29wanted to briefly touch upon regional
26:32anesthesia.
26:32You know there are some types of
26:34surgery as anesthesiologists where
26:35we have the option to do either
26:37complete regional or primary regional
26:39technique as opposed to general
26:40anesthesia and it make you know.
26:42Seems like common sense that
26:43avoiding airway instrumentation and
26:45sedative medications and potentially
26:47sparing opioids would improve
26:49outcomes for patients overall.
26:50But particularly with OSA and this large
26:53database study in the total joint population,
26:55including over 400 hospitals.
26:57Did show that the adjusted risk of
27:00major complications for patients
27:01having total joint with OSA was
27:03lower when neuraxial anesthesia
27:05meaning spinal's or epidurals,
27:07or a combination of the two were used
27:09as compared to general anesthesia.
27:10So there was a modest reduction
27:12in adverse events.
27:16And finally circling back again
27:18to our upper airway surgery
27:20intra operative guidelines.
27:21Now there's some, you know,
27:25strong recommendations,
27:25but based on pretty low levels of
27:28evidence that premedication that
27:30is sedative should be avoided,
27:32that opioids should be minimized when
27:35possible and multimodal energies
27:36that should be used when possible.
27:38And these guidelines do do mention
27:40that OSA is a risk factor for
27:43difficult airway management.
27:47So moving on to postoperative management,
27:51which is where you know a lot of
27:54our complications or most of the
27:56complications of of OSA happen
27:58in the perioperative period.
28:00So obviously, opioids have to
28:02factor into the discussion and it
28:04really is a complicated discussion.
28:05Opioids have gotten kind of a bad
28:07rap over the last several years
28:09due to the opioid epidemic and of
28:11course opioid induced respiratory
28:13depression is a major problem in
28:15hospital patients as well as.
28:18Post operative patients and
28:19OSA patients in particular,
28:21but it's complicated because they're
28:23also very effective pain medications.
28:25And there's of course acute
28:26pain after surgery,
28:27and they're titratable and they're effective.
28:29So so we're kind of stuck with them.
28:32For, you know,
28:33multiple types of surgeries and it is
28:35a complicated picture of observational
28:37studies of patients with OSA.
28:39Do suggest an association between opioids
28:41and opioid dose and adverse events,
28:43but not consistently.
28:45And it's possible that mitigating measures.
28:47Such as increased monitoring
28:49or positive air pressure,
28:50do overcome some of those those risks,
28:53and for what it's worth,
28:54you know there's not much that's
28:57prospective but one randomized
28:58controlled trial that randomized
29:00patients either morphine PCA
29:02versus a multimodal opioid sparing
29:04technique didn't find a significant
29:06difference with the opioid sparing
29:08technique in terms of apneas,
29:10hypopneas or overall respiratory events.
29:15But what we are kind of more
29:18confident in is that patients who
29:21do have respiratory events apneas
29:23high pop me as desaturations early
29:25on in their postoperative course,
29:27are likely to have them later on in
29:29their postoperative course as well.
29:30So this observation,
29:32ULL study of patients who screened
29:34as being highly likely to be at risk
29:36for OSA in the preoperative period
29:38were observed in the pacu and the
29:41patients who were observed who were
29:42thought to be high risk and then had.
29:44Pack you index events such as
29:47hypoxemia or witnessed apnea.
29:49Went on later on in their hospital
29:50course to have a you know,
29:51tremendously increased odds of
29:54having further respiratory events,
29:56which suggests that this is
29:58where really you know we could.
29:59We could focus our expensive resources
30:02in terms of specialized pathways
30:05in terms of increased monitoring
30:08and in terms of possibly initiating
30:10positive airway pressure when
30:12someone hasn't been on it before.
30:18And a quick plug too. That's awesome.
30:20Soca and Samba postoperative
30:22guidelines that are a work in progress
30:24that doctor Hilbert mentioned.
30:26It's been, you know,
30:27a real honor to be part of
30:29the writing group so far.
30:30We're currently in the data extraction
30:33phase and the methodology for this
30:35guideline is really state of the art.
30:37All this awesome guidelines were but
30:38this one we're trying to even approve,
30:40improve upon further with having patient
30:44representatives as well as you know,
30:46other other aspects of.
30:48Really state of the art guideline formation,
30:51and so we're hoping to be able to
30:53make recommendations on as many
30:55of these topics that are really
30:57important for the postoperative
30:59care of OSA patients as possible.
31:01So hopefully stay tuned within the next year.
31:03So we published in anesthesia and analgesia.
31:08Going back to our upper
31:10airway surgery guidelines,
31:12there's you know multiple recommendations
31:14for the postoperative period which
31:17speaks to the tenuous time period.
31:19This is for our patients with OSA,
31:21a couple of kind of weak recommendations,
31:24but not too hard to to follow to avoid
31:27the supine position in the postoperative
31:29setting and elevating the head of the bed,
31:31which makes good sense.
31:34And then there's a recommendation for
31:36in addition to standard monitoring in
31:38the pack you that patients with OSA
31:40having upper airway surgery should
31:42have breathing monitoring as well be
31:44entitled CL two or impedance monitoring.
31:47There's a recommendation specifically
31:49about which patients are candidates
31:51for positive air pressure afterwards,
31:52and it's recommended versus those
31:54where you may want to avoid it
31:56due to possibly disrupting tissue
31:58planes right after surgery.
32:00And a recommendation that OSA severity
32:02should be one factor in the decision
32:04making regarding whether a patient can
32:05go home on the same day as their surgery.
32:08There's some specific recommendations
32:10I wanted to highlight about nasal
32:12surgery in particular and minimally
32:15invasive surgery in the pallet,
32:17and whether those patients need
32:19prolonged monitoring versus are
32:21able to have ambulatory surgery,
32:24and specifically the patients
32:26having invasive palatal surgery do
32:28not need to receive prolonged.
32:30Postoperative monitoring and
32:32potentially could be appropriate
32:34for a floor bed if if the surgeon
32:36in the anesthesiologist degree,
32:38however patients with invasive lower
32:40pharyngeal airway surgery should have
32:42prolonged postoperative monitoring.
32:47So given the plethora of guidelines
32:50for this complicated problem of the
32:52perioperative management of OSA,
32:54how are we doing at following the guidelines?
32:57As you know, perioperative physicians
32:59and physicians involved in the care of
33:02patients with OSA either Sleep Medicine,
33:04specialist surgeons,
33:05or family practitioners,
33:07or primary care provider as well.
33:09This is a large survey study of
33:11USA physicians involved in the
33:13perioperative care of OSA patients,
33:15and unfortunately, only 27% reported that
33:17their hospital had a specific policy.
33:20For the pre operative care of OSA patients,
33:21there's definitely still work to be done.
33:24And then the survey respondents
33:26were asked with a hypothetical
33:27patient who presents to them,
33:29and they suspect the patient
33:31probably has moderate to severe OSA.
33:34What would their recommendation be
33:36in terms of proceeding with surgery
33:38versus doing further work up and?
33:40Anesthesiologist the majority said that
33:41they would go ahead and proceed with surgery,
33:44but manage the patients as if they
33:47had suspected OSA Sleep Medicine
33:49specialists said either the same or
33:51that they would delay surgery to
33:53get a sleep study prior to surgery.
33:56Surgeons were kind of split in
33:57terms of their response.
33:58A good number of them said that
33:59they would just proceed to surgery
34:01with no special measures measures.
34:02Some said that they would proceed
34:04and assume the patient had OSA
34:05and others said they would refer.
34:07But primary care physicians for
34:09the most part, you know.
34:12Which said that they would,
34:14you know,
34:14proceed to surgery without any
34:16particular recommendations.
34:21How are we doing here at Yale?
34:23Well, we have some.
34:26I wouldn't say protocols in place,
34:27but some in addition to, you know,
34:31recognizing in our pre operative note
34:32whether a patient has OSA or suspected OSA.
34:34We do have a modification to our
34:37pack you order set that is relevant
34:39to this patient population.
34:41So just for comparison,
34:42this is what our regular pacu
34:44discharge orders that looks like,
34:46or as a component of it.
34:48It's not the whole thing, but in while
34:50in the packet the patients vital signs are.
34:52Monitored rich in every 15 minutes and then
34:54patients can be discharged from the pack.
34:56You either to the floor or it's
34:58a home for ambulatory patients.
34:59Once they've met certain packet
35:01criteria known as the aldready criteria,
35:04but it's really a nurse,
35:05a nursing driven decision.
35:07There's a special section of the
35:09discharge order set for OSA patients.
35:12Which one clicked will provide an
35:15order specifically for ambulatory
35:17patients with known or suspected OSA
35:19to be observed prior to discharge.
35:22Home in a quiet, you know,
35:23setting on room air to make sure
35:26that they don't have signs of of
35:29desaturation or hypoventilation.
35:30And then after that could be considered
35:34OK to discharge a special order for
35:37patients own CPAP if they have it.
35:38And then importantly that the
35:40patient should be discharged from
35:42the pack you either to home or to
35:44an unmonitored floor bed only after
35:46evaluation by an anesthesia attending.
35:48I think the use of this is
35:50pretty variable among different
35:51anesthesiologists as well as.
35:52Got different delivery networks
35:54within the Yale New Haven Health
35:57system and aside from this I only know
35:59of one other OSA related specific
36:01perioperative pathway which is
36:03used at the Saint Rayfield campus
36:06specifically for patients having spine
36:08surgery or total joint replacement,
36:10but definitely room for improvement
36:12in perioperative pathways of patients
36:14with OSA within the health system.
36:16So if anyone is interested in partnering
36:18on that note, please do reach out.
36:21And then finally,
36:22before I give a summary and open
36:24it up for questions I wanted to
36:26talk about the public health impact
36:28of screening patients for OSA in
36:31the perioperative period,
36:32getting them safely through surgery and
36:34then referring them to Sleep Medicine
36:36for Poly sonography and potential
36:37treatment of their OSA postoperatively.
36:39So this is a study that followed
36:41patients who screen positive for
36:42OSA in a preoperative clinic and of
36:44the couple thousand patients over a
36:46few year period of screen positive.
36:49They were able to follow up with
36:51211 of them who went on to have Poly
36:53sonography and a official diagnosis of OSA.
36:54And of those 211,
36:56eighty 8 received a prescription
36:57for CPAP and answered a survey,
37:00and of those 8855% were non compliant
37:03and 45% were compliant with their
37:06C PAP treatment.
37:07For those 40 patients they did
37:10report improved snoring,
37:11sleep quality and daytime sleep
37:13sleepiness relative to those
37:15who are not compliant with C PAP
37:17or not treated with
37:18C PAP and they also really importantly.
37:20Reported a decrease need for medications
37:22for comorbidities that they had originally
37:24been on at the time of their surgery.
37:26Hypertension, diabetes, asthma,
37:27GERD need for medication for
37:30all of these comorbidities had
37:32decreased with the use of CPAP,
37:34which this audience knows well
37:35of all the benefits of treating
37:37sleep apnea for overall health,
37:39so these patients were discovered in
37:41the perioperative period and those
37:43that did go on to get a prescription
37:45for CPAP after a diagnosis of OSA
37:47and then actually adhere to that
37:49treatment had an improvement in
37:50their overall quality of life.
37:51So a big impact that we can
37:53make in perioperative medicine.
37:55So in summary OSA is associated with
37:58increased risk of cardio pulmonary
38:00complications in the perioperative period.
38:02Mortality, while rare,
38:03has definitely been reported in case reports,
38:05registries and closed claims,
38:07and as you know,
38:08a fear that we deal with everyday as as
38:11practicing perioperative physicians,
38:13there is currently insufficient
38:14evidence to recommend delaying surgery
38:16for polysomnography for all comers.
38:18But for the highest risk,
38:19patients with comorbidities,
38:21that is a recommendation.
38:23There's indirect evidence that suggests CPAP
38:25may reduce risk in the perioperative period.
38:27Many hospitals lack protocols
38:29for period of management of OSA
38:31despite a plethora of guidelines.
38:32Suggesting protocols for perioperative
38:34management of OSA and then further
38:36study is needed to determine the
38:38optimal balance between the risk
38:40reduction and resource utilization.
38:41Because it's such a prevalent
38:43problem and you know we want to
38:45reduce the risk to our patients.
38:46But without you know unnecessary
38:48resource utilizations that has to
38:51be a factor in all decision making.
38:53Of course,
38:54as physicians and then finally
38:56the PARRIOTT appeared,
38:57represents an opportunity to initiate
39:00referral for high risk patients
39:02to potentially have a bigger.
39:04Public health impact
39:08So thank you again so much.
39:09Doctor Hibbert for the opportunity.
39:11My email address is there for anyone
39:12who's interested in following up
39:14and I'm happy to take questions no.
39:16Thank you so much. That was wonderful.
39:18Wonderful doctor *****.
39:19Really great overview.
39:20I love how organized it was.
39:23Let me ask you.
39:24Well, people are starting to think about
39:26their questions and putting them in the chat.
39:28What do you think? Why?
39:30Why is it that you know with all
39:32these guidelines you mention all
39:34these beautiful guidelines out there?
39:35Why is it that of these
39:37ambulatory anesthesia centers,
39:39only 60% are following the guidelines?
39:41And why is it that hospitals only 27%
39:44have perioperative management, is it?
39:46Is it that there's not?
39:48People aren't reading the guidelines
39:49or we have to do more outreach?
39:51Is it people don't buy into them?
39:53Is it just lack of time?
39:55And how can we help that?
39:57What can we do?
39:58I think
39:58this is a really great question
40:00and you know really the problem is
40:02implementation and you know implementation.
40:04Science is now becoming a
40:05field in and of itself,
40:07and you know there's there's an
40:10amazing body of evidence for this
40:12and other major problems.
40:14We have perioperatively.
40:15And then there's really well thought
40:16out guidelines using state of the
40:18art methodology and it's all there,
40:19and it's in our journals and
40:21it's presented at meetings,
40:21but then actually getting people to do
40:23it as where the book kind of stops.
40:26So I think that you know future research.
40:28For OSA management and other
40:30perioperative problems really
40:32needs to be in how you know the
40:35implementation science of it.
40:36So you know, I,
40:37I don't have a great answer right now as
40:39to how we get people to actually do it.
40:42You know,
40:42I think that our ASC is tend to be
40:45very strict in their patient selection
40:48criteria and aren't taking on the
40:50patients at the most elevated risk
40:52for perioperative adverse events.
40:54And that's how they kind of get
40:56away with not having people
40:57bring their CPAP but in.
40:58In you know,
40:59hospital based ambulatory
41:01anesthesia or hospital based
41:03surgery with inpatient emission?
41:04You know we can't.
41:05We can't get away with that.
41:06We take care of the absolute
41:08sickest patients so we really
41:09do need to have protocols
41:12and we need to have a
41:13you know a more robust way to have all of
41:16our you know major health systems like Yale.
41:19Create these protocols and then actually get
41:21the on the ground clinicians to follow them.
41:24So I'd like I said I'd be happy to
41:26partner with anyone from Sleep Medicine
41:28who's particularly interested in this.
41:29Topic at Yale. You know,
41:31one way that we we did actually
41:32do this at Mount Sinai.
41:33During my time there,
41:34which is where I spent the first decade
41:37of my career is that our malpractice
41:39insurance company required it.
41:40So maybe about four or five years
41:42into my being in attending,
41:44they they required that we had a
41:47specialized pathway for patients
41:49with BMI over 40 and with diagnosed
41:52or suspected OSA that included
41:54observation in the Pacquiao and then
41:57prior to discharge from the pacu,
41:58whether it was home or two.
42:00An unmonitored bed and anesthesiology
42:02attending had to write an order set
42:04about that patient disposition,
42:06including whether it was safe
42:07for them to go home.
42:08Weather was safe for them to
42:09go to an unmonitored bed,
42:10or they needed prolonged respiratory
42:12monitoring or oxygen saturation monitoring,
42:13and whether they needed a referral
42:15for respiratory therapy for positive
42:17airway pressure so it it can be done.
42:19That was outside pressure that
42:21was applied in us to do it.
42:23And so, you know, that's one route to go,
42:26right,
42:26right? Yeah, I can definitely see that
42:28when there's when there's external
42:29pressure, things have a way of.
42:30We get done a little bit more.
42:32Doctor Krieger has a question. Go ahead
42:34yeah, so I became very
42:36interested in in this topic,
42:38about 15 maybe even more years ago
42:41when there was a major hospital
42:43whose name I will not mention
42:46was sued because a patient died.
42:49Immediately post-op who was
42:51known to have severe sleep apnea,
42:54and the hospital ended up settling for
42:58$40 million, and that hospital said
43:01this is never going to happen again.
43:03Every patient is going to be
43:06screened pre-op pre every op.
43:09And that's what it takes and sometimes.
43:14Absolutely, and we we.
43:16We'd rather be proactive and
43:18find our our you know, our.
43:21Danger Points prior to having
43:23a horrible outcome like that,
43:25but it's I guess you know it's hard
43:26to to find the motivation and the
43:28organization until it actually happens.
43:43Janet, I think you're muted.
43:46I was just going to say, Christine,
43:47you could unmute yourself, thanks.
43:50I was reading your lips.
43:52Hi Doctor ***** I'm Christine one.
43:54I'm actually very active and sassaman.
43:56I think you and I are probably on the
43:58same committee. It's or I.
44:00I definitely know you from the meetings.
44:01Christine, thanks so much.
44:03Yeah, no. I'm I'm so grateful that
44:05your this is your area of interest
44:08and and you're working on this.
44:10I think prior you might have heard
44:12prior to coming here there was a series
44:16of adverse events perioperatively.
44:18Related to what was thought to be untreated,
44:21unrecognized sleep disorder.
44:22Breathing in these patients
44:23who were not being monitored,
44:25and I believe there was,
44:28like you said it was.
44:29It was these adverse,
44:30even though they weren't frequent.
44:32They were unfortunate and it was
44:34these adverse events that kind
44:35of drove the hospital.
44:36Actually, the system was system
44:37wide to to really mobilize and and
44:40and form this huge committee there.
44:43I think there are like over
44:4520 nurses involved in this.
44:46To get a perioperative.
44:50Protocol,
44:50but unfortunately it never took off,
44:54so it would be really great,
44:56and it sounds like you would be just
44:58the right person to jumpstart jumpstart
45:00this 'cause again very important,
45:02and again that frequent,
45:04but very tragic cases that
45:05that could have been avoided.
45:07I think I think there was a a
45:09protocol with they'd still the stop
45:12bang and the and the epic right.
45:14Epic custom.
45:15The nurse nurses that were protocol
45:17protocol eisd to to try to.
45:19Do that in the pack you,
45:20I think,
45:21and then they were piloting something
45:23up in in the ortho unit at SRC.
45:26That was the first sort of pilot,
45:29but it kind of lost momentum.
45:31So I mean eager to see it launch again,
45:34viewed
45:35the pathway from SRC and it's
45:38excellent and clearly incredibly
45:40well thought out and I think has
45:42the potential to be used systemwide.
45:45It would be a big lift like everything
45:46is that we want to do system wide.
45:48My guess is that it lost steam.
45:50After having tremendous thought
45:51being put into it because of
45:53the timing and the pandemic,
45:54but I think it's definitely time to
45:56to revisit it as a health system.
45:59Terrific, thank you.
46:00Well there is a question in
46:01the chat about the risk for if
46:03you could comment on the risk
46:05for OSA in patients who receive
46:07neuromuscular blockade but are in
46:09completely reversed by excavation
46:11train of four can be 4 out of four,
46:12but fade not recognized.
46:13You want to comment on that?
46:16Yeah, absolutely.
46:16And in the intra operative guidelines
46:19from SAS and they do talk about
46:21neuromuscular blockade and it is
46:23strongly recommended that dose you know,
46:25be dosed judiciously that train train of four
46:27monitoring be utilized to determine dose.
46:30And also to determine reversal dosing and
46:33adequate return of neuromuscular function.
46:37So it's always important in every patient,
46:39but particularly important
46:40in patients with OSA.
46:41There's so far insufficient
46:44evidence that using sugammadex,
46:46which is a cyclodextrin to reverse
46:50nondepolarizing neuromuscular blockade,
46:51is not yet shown to be superior
46:54to the classic neostigmine.
46:56However, in our guidelines for.
47:00Reversal were encouraged to use
47:02sugammadex in the in place of neostigmine.
47:05For patients with OSA as well
47:08as another uncommon list of of
47:10problems that could put them at
47:12increased risk postoperatively.
47:13So yeah,
47:14we you know the gold standard would
47:15be to use quantitative monitoring
47:17and make sure that our patients are
47:19fully reversed for all patients in
47:21particularly patients with OSA.
47:23Thank you. There is also a question
47:25if you have any comments about
47:27relatively asymptomatic opioid
47:29induced central sleep apnea.
47:31How does that impact anesthesia
47:33management say it? One more time?
47:34Sorry, relatively asymptomatic
47:36opioid induced central sleep apnea,
47:39so we commonly see this in
47:40patients on high dose methadone.
47:42I don't know.
47:43The question refers to patients with
47:44method with that kind of scenario who
47:46then gets surgery versus somebody
47:48who has substantial apneas on?
47:50Yes yeah. So I think this speaks to
47:51the fact that there is, you know,
47:53multiple phenotypes of sleep apnea,
47:55obstructive and central and so
47:58teasing out which of our patients are.
48:01More sensitive to opioids than others,
48:03or perhaps have have pain.
48:05Sedation mismatches is where it
48:07becomes really really tricky and so
48:10you know that's the type of patient
48:12who probably would benefit from
48:14a period of prolonged increased
48:16monitoring in the setting of
48:19receiving opioids postoperatively.
48:22What are your thoughts?
48:23You know I was interested in that at the
48:25very end you you brought up, you know.
48:27Oftentimes patients are identified,
48:29you know, in that sort of
48:31perioperative setting, right?
48:32Even if it's just something they have
48:33an endoscopy and they get anesthesia or
48:35they in hospital and have anesthesia.
48:37And then a lot of stuff happens
48:39and the conversion of that to
48:41getting to Sleep Medicine?
48:42Sometimes it shows up in the discharge
48:43summary and somebody down the road.
48:45How do you think we can do better there,
48:47you know, in the immediate setting,
48:48it seems like that would be the time
48:50and place to to put in that referral.
48:52Thoughts on that?
48:53That's
48:53a really good idea.
48:54I mean, I think engaging our surgical
48:55colleagues is certainly part of it,
48:57because they're the ones who
48:59write the discharge instructions
49:00and the discharge summary is,
49:02and the patients follow up with.
49:03But as anesthesia providers were
49:05often the ones who are doing
49:08the preoperative screening or
49:09who notice intra op or post op,
49:12you know signs of obstruction,
49:13so it would be nice if there
49:14was a way for us to communicate
49:16directly with our Sleep Medicine
49:18colleagues to initiate the referral.
49:19I do speak to patients.
49:22Come in the preoperative period and
49:23their family members when they've
49:25screened positive based on stopping
49:26score that this is something you obviously.
49:28Right now we're going to focus on
49:30getting safely through surgery,
49:31but you should, you know,
49:32speak to your primary care provider.
49:34Once you've recovered to get a
49:36referral to evaluate to see if
49:37you do have sleep apnea because
49:39of all of the downstream health
49:40consequences of having undiagnosed
49:42and untreated sleep apnea.
49:43Just like all do something similar
49:45for smoking cessation and try to
49:46use it as my kind of moment to
49:48impact the patient's overall health
49:50because patients are much more.
49:52Hyper aware of their health
49:53in the perioperative period,
49:55they're thinking about their health,
49:56so I think you know the patient.
49:59But also,
49:59if a family member is there with them,
50:00they may be able to better
50:02absorb that message.
50:03So I I do communicate with patients,
50:05but it might be nice when patients
50:06and families are overwhelmed
50:07in the perioperative periods.
50:09Be able to communicate directly
50:10amongst each other for referral,
50:12right?
50:13Right? Yeah, we it's not uncommon.
50:14We get all my GI doctor or the
50:16nurse who was there told me,
50:18you know, but we see them.
50:19You know it's like 8 months later
50:20that this happened or you you know?
50:21Oh yeah. By the way,
50:22they did say that and it somehow falls away.
50:25So yeah, there's another question
50:26in the chat about suggestions
50:28for procedural sedation.
50:29I presumably this is for
50:31things like bronchoscopy.
50:33It's like procedural
50:34sedation and OSA patients.
50:35What about DXM tomatine?
50:36Is it better than standard meds?
50:38What are your thoughts?
50:40So he's
50:41not a great level.
50:43There's not a great literature
50:45to guide us here, but there are
50:48recommendations based on expert opinion,
50:51and we do know that propofol sedation
50:53in the you know absence of a controlled
50:55airway is tricky in this patient population,
50:58and the dex medata mean may be easier.
51:01Probably the the most.
51:04Concerning is when you're starting
51:06to combine sedative agents,
51:07so benzodiazepine's opioids, propofol,
51:09even Dexmedetomidine Academy and
51:11all these things in isolation.
51:14RR Titratable and inexperienced
51:18hands you know are probably possible
51:20to use in patients with OSA,
51:21but propofol,
51:22probably with the most caution and
51:24anytime you're mixing sedative agents
51:26they'll they'll work synergistically.
51:28And then you can get into trouble.
51:29And you know,
51:30I do drug induced sleep endoscopy
51:32all the time with my E NT colleagues.
51:35Where we use these medications
51:37specifically to induce obstruction
51:38to figure out the best surgical
51:41plan for for management.
51:42So I'm watching it happen.
51:44You know,
51:45with their flexible scopes,
51:47so you know it's it obviously
51:49happens with all of these agents.
51:52Thank you. Excellent. Alright,
51:53so I'm not seeing much in the chat.
51:55I'm going to give people if anyone
51:57in the audience would like to
51:58either type anything or now is your
52:00opportunity to unmute yourself,
52:02ask a question. See.
52:08Alright, well really pretty much at the end.
52:09Anyway, listen, thank you.
52:11Doctor ***** that was really wonderful.
52:12Really engaging presentation and
52:14I think we all learned a lot.
52:15Thank you so much.
52:16Thank you so much again for
52:17having me. It was a pleasure.
52:19Bye bye thanks everyone for joining.