Recently, we have seen more referrals of adults for evaluations preoperatively. This is an important article from the Texas Medical Liability Trust ways to reduce risk when treating patients risk of sleep apnea. JR
Sleep apnea and surgical complications
by Laura Hale Brockway, ELS
Sleep disorders, including obstructive sleep apnea (OSA), have become a significant health issue in the United States. When left untreated, OSA can lead to high blood pressure, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular problems. OSA is associated with type 2 diabetes and depression, and it is a factor in many traffic accidents.
OSA has also been associated with increased perioperative risk and postoperative complications. (1)
This article will provide a brief overview of sleep apnea, describe two closed claim studies that feature sleep apnea, and discuss ways to reduce liability when treating patients with sleep apnea.
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Risk management considerations
Physicians can consider the following guidelines to help reduce liability when treating patients with sleep apnea.
Screening for sleep apnea
Patients with OSA may present significant problems in the perioperative and postoperative period. Because a significant proportion of OSA patients remain undiagnosed when they present for surgery, proposed guidelines from the American Academy of Sleep Medicine suggest that questions regarding OSA should be included in routine health screenings. If OSA is suspected, the patient should undergo a comprehensive sleep evaluation. 1
Patients with OSA may present significant problems in the perioperative and postoperative period. Because a significant proportion of OSA patients remain undiagnosed when they present for surgery, proposed guidelines from the American Academy of Sleep Medicine suggest that questions regarding OSA should be included in routine health screenings. If OSA is suspected, the patient should undergo a comprehensive sleep evaluation. 1
If a patient is found to have OSA, ensure that everyone involved in the patient’s treatment is aware of the diagnosis of OSA.
Preoperative
According to the American Society of Anesthesiologists, “Patients with known or suspected OSA may have difficult airways and therefore should be managed according to the ‘Practice Guidelines for Management of the Difficult Airway.’ In patients at risk for perioperative complications from OSA, a preoperative determination must be made regarding whether surgery should be performed on an inpatient or outpatient basis.” 5
According to the American Society of Anesthesiologists, “Patients with known or suspected OSA may have difficult airways and therefore should be managed according to the ‘Practice Guidelines for Management of the Difficult Airway.’ In patients at risk for perioperative complications from OSA, a preoperative determination must be made regarding whether surgery should be performed on an inpatient or outpatient basis.” 5
Postoperative
Because episodes of critical obstruction may occur unpredictably — only minutes after a normal respiratory rate has been observed — the Anesthesia Patient Safety Foundation urges health care professionals to “give consideration to the potential safety value of continuous monitoring of oxygenation (pulse oximetry) and ventilation in patients receiving PCA or neuraxial opioids in the postoperative periods.” (5)
Because episodes of critical obstruction may occur unpredictably — only minutes after a normal respiratory rate has been observed — the Anesthesia Patient Safety Foundation urges health care professionals to “give consideration to the potential safety value of continuous monitoring of oxygenation (pulse oximetry) and ventilation in patients receiving PCA or neuraxial opioids in the postoperative periods.” (5)
Patients who use CPAP devices at home should be advised to bring the mask to the hospital and to use it while in the hospital. Postoperative instructions should clearly indicate whether or not the patient should continue use of CPAP once discharged from the hospital.
Narcotics
Narcotics may profoundly impair respiration in the postoperative period in patients with OSA.1 Therefore, the administration of narcotic pain medication in patients with OSA should be closely monitored, according to recommendations from the American Society of Anesthesiologists. (5)
Narcotics may profoundly impair respiration in the postoperative period in patients with OSA.1 Therefore, the administration of narcotic pain medication in patients with OSA should be closely monitored, according to recommendations from the American Society of Anesthesiologists. (5)
One issue is that multiple physicians may write pain medication orders for a single patient and they may not be aware of the diagnosis of OSA. One suggestion is to flag the records of these patients to warn of the risks of narcotics usage.
Conclusion
“While there may not be a consensus regarding the best and most cost effective methods to ensuring fewer perioperative complications from OSA, there continues to be a need for informed clinicians, as patients are typically presenting with undiagnosed or misdiagnosed cases.” 1 Awareness of the risk factors and complications associated with OSA, along with adherence to applicable guidelines, can help enhance patient safety when treating patients with OSA.
“While there may not be a consensus regarding the best and most cost effective methods to ensuring fewer perioperative complications from OSA, there continues to be a need for informed clinicians, as patients are typically presenting with undiagnosed or misdiagnosed cases.” 1 Awareness of the risk factors and complications associated with OSA, along with adherence to applicable guidelines, can help enhance patient safety when treating patients with OSA.
Sources
- UC San Diego School of Medicine, University of Toronto. Perioperative management of OSA Patients. April 2011. Available at http://cme.ucsd.edu/OSAonline. Accessed January 18, 2013.
- Kingman PS. Overview of obstructive sleep apnea in adults. UptoDate. July 3, 2012. Available at http://www.uptodate.com/contents/overview-of-obstructive-sleep-apnea-in-adults?source=search_result&search=sleep+apnea&selectedTitle=1~150. Accessed January 18, 2013.
- American Sleep Apnea Association. A very short course on sleep apnea. Available at http://sleepapnea.org/i-am-a-health-care-professional.html. Accessed January 18, 2013.
- Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine. 2009; 5(3): 263-276.
- American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104: 1081-93.
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