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A quick, spontaneous Saturday #tweetorial #Medthread about periop OSA inspired by @cacace_frank's journal catch up (w my first response below). Going to make this interactive (& tag #periop hospitalists & anesthesiologists along the way)... 1/x
@cacace_frank rightfully so, #periop OSA is getting more and more attention. It, and the company it keeps (OHS, PHTN, R heart failure) are driving periop risk factors, for respiratory events (resp failure, esp with opioids on board) AND cardiac events 2/x
@cacace_frank society guidelines recommend screening for OSA pre-op (ex. STOP-BANG), but what do you do with a positive screen? recall, it only takes 3/8 points on STOP-BANG to get to "high risk". It's a patient risk/benefit AND systems-based Q re utilization of/access to sleep studies...3/x
@cacace_frank We talk about guidelines for screening for CAD preop, screening for LV dysfunction and severe valve disease...are we really talking about sending 1000s of pts for sleep studies? great read from a few years ago...4/x
@cacace_frank taking a step back, this is how I think about the complex pathophysiology...(screen grab from a lecture I give our residents) 5/x
@cacace_frank thanks to work from @FrancesChung6 and others, STOP-BANG points stratify w risk, and even individuals without OSA had bump in AHI index post-op 6/x
@cacace_frank @FrancesChung6 From the 2010 CHEST guidelines, including recs for post-op management 7/x
@cacace_frank @FrancesChung6 now this is where it starts to get interesting. The rec for "continuous O2 monitoring" or "supplemental O2" could cause more harm, by masking hypercarbia! back to the alveolar gas equation...
(this may be a subject worthy of a @tony_breu pathophys tweetorial...) 8/x
@cacace_frank @FrancesChung6 @tony_breu for me in pre-op clinic, it comes down to performing STOP-BANG, counseling risk, & providing anticipatory guidance (ex. minimize narcotics before sleep, sleep with HOB elevated)
and risk applies to unknown AND known OSA but unable to tolerate CPAP
now some theoretical cases: 9/x
@cacace_frank @FrancesChung6 @tony_breu 55yo man scheduled for elective TKA, HTN on 5mg amlodipine, BMI 23, neck slender, no snoring or witnessed apnea (bed partner is a light sleeper). STOP-BANG is already 3! (10/x)
70yo man scheduled for THA, BMI 40, HTN on 3 meds, obese neck, tired during day. STOP-BANG definitely higher! (11/x)
What if that last case was modified to be total shoulder arthroplasy, home pump anticipated, and the patient had COPD?? (12/x)
What about 65yo woman w pancreatic cancer scheduled for whipple. BMI 36, tired (but w chemo...), snores loudly, off HTN meds w chemo related WT loss, neck 17cm (13/x)
Last one! 75yo man w KNOWN OSA but could not tolerate any CPAP (ptsd and claustrophobia due to service in Vietnam), scheduled for lap cholecystectomy (14/dx)
I hope you can see now how nuanced and complex management of known or potential OSA can be #periop. I’m excited to see where new CPAP devices, HOME studies, and more advances in non-narcotic analgesia bring us in the next few years (15/x)
Ack! Forgot another pearl! In addition to patient factors limiting CPAP use, there may be surgery specific factors limiting CPAP immediately—ex sinus surgery, Nissan fundoplications...so that also needs to be factored into post planning and counseling
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