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10/18/19

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RegionalanesthesiafortheOSApatient

–Isthereabenefitand

whenshoulditbeused?

CrispianaCozowicz,MD

Nothingtodisclose

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OSApatientsatincreasedriskforperioperativecomplicationsComplications OSAvsnon-OSARespiratoryfailure OR2.43p=0.003Cardiacevents OR2.07p=0.007ICUtransfer OR2.46p=0.006

Healthcarequestion

• AssociationbetweentypeofanesthesiaandperioperativeoutcomesinOSA

Populationbasedanalysis

• Premier,nationaladministrativedatabase

• Claimsdata>540UShospitals

• 30,024OSApatients(ICD-9code),2006– 2010

• GA74%,NA11%,GA/NA15%

Complications NAvsGA NA+GAvsGACombinedcomplications OR0.83p=0.03 OR0.89p=0.03Mechanicalventilation OR0.64p<0.0001 OR0.64p<0.0001ICU OR0.43p<0.0001 OR0.67p<0.0001Prolongedlengthofstay OR0.75p<0.0001 OR0.70p<0.0001Increasedcost OR0.88p=0.04 OR0.70p<0.0001Pulmonarycomplications OR0.77p=0.01

+PNBà additionalreductioninmechanicalventilation,ICUandLOS

ImpactofAnesthesiaTechniqueinOSA

RegAnesth PainMed|2013

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Healthcarequestion

• DoesanesthesiatechniqueinfluenceperioperativecomplicationsinOSA?

Retrospectiveobservationalanalysis

• Institutionaldata:ThomasJeffersonUniversity,PA

• 2005– 2016(ICD-9code)

• 1,246OSAmatchedto3,738non-OSApatients(1:3)

Complications GAvsNAinOSAPulmonarycomplications OR4.48p=0.004Gastrointestinalcomplications OR4.70p=0.02Acutehemorrhagicanemia OR2.14p=0.04Mortality OR14.0p=0.008

GAimpactoverallPulmonarycomplications OR5.04p<0.001Cardiaccomplications OR2.11p=0.02Gastrointestinalcomplications OR4.60p<0.001Acutehemorrhagicanemia OR3.58p<0.001Shock OR3.26p=0.003Woundcomplications OR13.01p=0.001Mortality OR15.88p<0.001


TheJournalofArthroplasty|2017

Healthcarequestion• Incidenceofperioperativecomplicationsbyanesthesiatechnique

Prospectiveobservationalstudy• Institutionaldata:NicolaeTestemitanu University,Romania• 2014– 2015,Berlinquestionnaire• 400patients;abdominalandorthopedicsurgeryResults

• HighestnumberofcomplicationsinOSA/abdominalsurgeryunderGA

• BestoutcomesinOSApatientswithorthopedicsurgeryunderRA

• Respiratorycomplicationsmostfrequent

• Riskforcomplicationsdependsontypeofsurgeryandanesthesia

Abdominalcavity OrthopedicComplications GAvsNA GAvsNARespiratorycomplications +17.3% +16.0%ICU(unplanned) +5.7% +4.3%Stroke +0.7% 0%Postoperativefever +1.4% -2.6%Postoperativeventilation +20.3% +20%Difficultintubation 3.5%inGAProlongedawakeningfromanesthesia

2.5%inGA 13%inGA

NA+PNBà additionalreductioninrespiratorycomplications


RomanianJournalofAnaesthesiaandIntensiveCare|2016

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Healthcarequestion

• IncidenceandriskfactorsforpostoperativehypoxemiainOSA

• Hypoxemia:SpO2<90%forover5min

Retrospectiveanalysis

• OSAsurgicalpatientrecordsattheHospitalforSpecialSurgery(2005– 2008)

• 527OSApatientsundergoingambulatoryorthopedicsurgery(ICD-9)(minimumone-nightPACUforcontinuousmonitoring)

Results

• GAidentifiedasariskfactorhypoxemiainOSA(+bloodloss,IVfluidsandsurgerytype)

• Hypoxemiaassociatedwithmajorrespiratorycomplications,increasedLOS,andwoundinfections

Anesthesia HypoxemiaGAonly 29%Spinal 4%Spinal+PNB 1%Epidural 5%PNB 4%IV-PCA 32%ContinuousPNB 4%


HSSJ|2011

AirwayManagementinOSA

Complications OSAvsnon-OSADifficultintubation OR3.46p<0.0001Difficultmaskventilation OR3.39p<0.0001Combined OR4.12p<0.0001Supraglotticairwayfailure OR1.34p=0.38

PLOSONE|Oct2018

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IncreasinglitigationcasesinOSA

Deathoranoxicbraininjuryduetodifficultairwaymanagement• Difficultintubation• Postoperativefailuretoreintubateafterprematureextubation

A&A|Jan2016


KnownorsuspectedOSAshouldbeconsideredanindependentriskfactorfordifficultintubation,difficultmaskventilation,orboth

PatientswithknownorsuspectedOSAshouldbemanagedaccordingtothe

Anesthesiology|2014

A&A|2018

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HealthcareQuestion

• EarlypostoperativerespiratorycomplicationsinhighriskOSAafterGA

Observationalprospectivedoublecohortstudy

• Institutional,CentroHospitalarSãoJoãoinPorto,Portugal

• PACUafternon-cardiac,non-neurologicalsurgery,2011

• 340patients(STOP-BANG)

Results

• ResidualneuromuscularblockademorefrequentinOSA

• InabilitytobreathedeeplymorefrequentinOSA

• IncreasedrespiratorycomplicationsinOSAafterGA

• Residualneuromuscularblockadeindependentriskfactorforadverserespiratorycomplications

Complications OSA non-OSA P-valueHypoxia 9% 3% 0.012Respiratorycomplications 39% 10% <0.001Inabilitytobreathedeeply 34% 9% 0.001ResidualNeuromuscularblockade 20% 16% 0.035PACULOS 120min 99min 0.04

NeuromuscularBlockadeinOSA

RevPortPneumol |2013

NeuromuscularBlockadeinOSA

OSAcomparedtonon-OSApatientsreceivingneuromuscularblockingagentsmaybeatincreasedriskofeffectsof

• Postoperativeresidualneuromuscularblockade

• Hypoxemia

• Respiratoryfailure

FullreversalofNMBshouldalwaysbeverifiedbeforeextubation

• Effectsmaypersistevenaftertheuseofreversalagents

• Ingeneralpopulation,sugammadex vsneostigminemoreefficientindecreasingresidualparalysis

• InOSApopulation,insufficientevidencetodemonstratesuperiorityofsugammadex

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Prospectiveobservationalstudy

• Institutional:TorontoWesternandMt.Sinai,Canada

• 58patients,PSGpreop.+postop.night1,3,5,7

Postoperativeworseningof

• SDB:AHIincreased,exacerbationofnocturnalhypoxiaandhypercapniaOSA>non-OSApeakpostoperativenight3,sustained7days

• Sleeparchitecture:REMsleep,slowwavesleeppeakonpostoperativenight1

ImpactofAnesthesiainOSA

Anesthesiology|2014

Driversofpostoperativesleep-disorderedbreathing

Prospectiveobservationalstudy

• Institutional:TorontoWesternandMt.Sinai,Canada

• 376patients,orthopedic,spinal,orgeneralsurgery

• PSGpreop.,postop.nights1and3

Result

• GAassociatedwithincreasedpostoperativeCentralApneaIndex

• 72hopioiddosepositivelycorrelatedwithAHIseverity

DriversofpostoperativeApneaHypopneaIndex(AHI)• PreoperativeAHI• Age• 72hoursopioiddoseDriversofpostoperativeCentralApneaIndex• Preoperativecentralapneaindex• Malesex• GA

ImpactofAnesthesiainOSA

Anesthesiology|2014

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PostoperativeDeathandCriticalEventsinOSA

PostoperativeDeathandCriticalEventsinOSA

Commonlysharedpostoperativecourse• Patientsawake,alert,andstable(favorablesedationscores)• Precedinghighpainscoresanduseofpainmedicatione.g.PCA• Typicalorlessthantypicaldosesofnarcoticsandsedatives• Aftergoingtosleepfounddeadorincriticalcondition• Cardiorespiratoryarrest

Retrospectivelyoftendeemedapreventable• Lapsesinmonitoringoftenimplicated

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Upperairwayanatomy

• Narrower,higherpharyngealcollapsibility,obesity(parapharyngealfatdeposition),craniofacialabnormalities

Abilityofupperairwaydilatormusclestorespondpharyngealcollapseduringsleep

• Decreasedtoneofupperairwaydilatatormuscles– obstructiveevents

Arousalthreshold- propensitytowakeupfromrespiratorystimulusduringsleep

• Hypercapnicrespiratorydriveanddiaphragmaticallygeneratednegativepressureduringairwayobstructionpredisposerepeatedarousal

• Lowarousalthreshold,disruptivesleep,wakeupbeforereachingverylowoxygensaturation

• Higharousalthreshold- preoperativeidentificationnotfeasible

Inherentinstabilityofventilatorycontrol

CriticalComponentsofOSAPathogenesis

A&A|Jan2017

TypeIIIPatternofventilationandSPO2 cyclingduringsleep

Instabilityofventilationand/orupperairwaycontrolfollowedbyprecipitousandfataloxygendesaturationifarousalfailureisinducedbynarcoticsand/orsedation

Deathandlife-threateningeventsinOSA

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OSArelatedcyclingscoresofapneasduetoinstabilityofupperairwaycontrol

• Perpetualarousaldependentsurvivalduringsleep- reopeningofupperairway

Sentinelinstabilitycomponent:arousalfailureinthepresenceofsleepapnea

• Precipitoushypoxemia- steepfataloxygendesaturation

• Severearousalfailure- profoundcerebralhypoxemia“LightsOutSaturation”sufficienttoinducecentralarousalarrest

• Patientsdeadinbedwithoutwarningfromprolongedapneas

Delayedarousal

• SubgroupsofOSApatientsexhibitseverelydelayedarousals• Occultarousalfailure

• OSAacquiredarousalfailure• Centralarousalsystemfailureinresponsetodailyrepetitivehypoxemiaand• Sleepfragmentation

• CPAPinitiation– sleeprebound

• Anesthetic,sedativeandnarcoticagentsadditionalfactorsthatdelayrespiratoryarousal

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Generalanesthesiaanddosedependentdepressionofupperairwayactivity

Anesthetic,sedative,andnarcoticdrugeffects

WorsenedupperairwaycollapsibilityDepressionofcentralrespiratoryactivity• Diminishedventilatoryresponsetohypercarbiaandhypoxia• Delayedrespiratoryarousalresponsetoairwayocclusion• Depressionofcentralrespiratoryoutputtoupperairwaydilatormusclesand

upperairwayreflexes(e.g.genioglossusmuscle)DepressionofperipheralreflexpathwaysofupperairwaymuscleactivityExacerbatedSDB

à Mayprecipitatecompletearousalarrestinpatientswithhigharousalthreshold

à Sudden,unexpecteddeath

OSAcomplicatingopioidanalgesia

EnhancedpainsensitivityconferredbyOSAfeatures

Chronicintermittenthypoxia• NocturnalarterialdesaturationmaybeassociatedwithincreasedpaininpatientswithSDB

Sleepfragmentation• Hyperalgesiaininsomnia• CPAPwithimprovedsleepcontinuityreducedpainsensitivityinOSA

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OSAcomplicatingopioidanalgesia

Chroniccyclinghypoxiapotentiatingopioidanalgesiceffects• DecreasedpostoperativeopioidconsumptioninOSAwithrecurrentnocturnalhypoxia

• NocturnalhypoxiaOSAassociatedwithincreasedpotencyofopioids

AlteredpainsensitivityandopioidpotencyshouldbeconsideredinOSA• Preoperativenocturnalhypoxiadeterminantofpostoperativeopioidpharmacology

• Opioidandanalgesicrequirementspotentiallylower

Healthcarequestion

• Impactofmultimodalanalgesiaonopioiduseandcomplicationrisk

Populationbasedretrospectivecohortstudy

• Premiernationalhealthcaredatabase

• 2006-2016;Claims-baseddata>540UShospitals(25%)

• 181,182OSApatientsundergoingtotalhip/kneearthroplasty(ICD-9)

Intervention

• Multimodalanalgesiavsopioids-only

• Systemicopioids+1,2,or>2non-opioidanalgesicmodalities• NSAIDs,Cox-2inhibitors,Acetaminophen/paracetamol,Peripheralnerveblocks,Steroids,Gabapentin/pregabalin,

Ketamine

MultimodalpainmanagementinOSA

BritishJournalofAnesthesia|2019

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Results

• Stepwisebeneficialeffectswithincreasingnumberofnon-opioidanalgesicmodesaddedtoopioids

• Opioidprescriptiondose• LOS• Gastrointestinalcomplications• Mechanicalventilation• PostoperativeICU

• StrongestopioidsparingwithCox-2inhibitorsandNSAIDs

• LowerPCAuse

Conclusion

• Multimodalanalgesiaassociatedwithopioidsparingandreducedcomplications

• doseresponsegradient

MultimodalpainmanagementinOSA

Opioidanalgesia+

1additionalmode

2additionalmodes

≥3additionalmodes

OpioiddosePOD-1 -5.0% -10.4% -14.9%OpioiddosePOD-1+ -5.7% -9.0% -12.5%LOS -4.6% -7.8% -11.8%Cost -1.4% -2.5% -3.2%

GIcomplications OR0.75 OR0.69 OR0.65Mechanicalventilation OR0.60 OR0.33 OR0.23ICUadmission OR0.81 OR0.73 OR0.60

PCAuse 19.2% 13.7% 7.7%alloutcomesp<0.0001

BritishJournalofAnesthesia|2019

Comparativeeffectiveness:GAvsRAYear Author RCTs OutcomesdecreasedwithNeuraxialanesthesia

2019 Memtsoudis 94 Mortality,pulmonary,renal,DVT,infections,bloodtransfusion

2014 Guay9Cochranereviews

117 30-mortality,pneumonia

2016 Meng 8 LOS,intraoperativehypertensionandtachycardia,analgesicrequirementinthePACU,PONV

2016 Johnson 29 LOS

2016 Guay Hypertension

2013 Barbosa Pneumonia

2009 McFarlane 18 Postoperativepain,morphineconsumption,opioidrelatedadverseeffects

2010 Luger 34 Mortality,reducedpostoperativeconfusion,DVT,postoperativehypoxia,pneumonia

2006 Mauerman DVT,PE,bloodtransfusions

2000 Parker 17 Mortality30day,DVT

2000 Rodgers 141 Mortality30%,DVT40%,pneumonia50%,respiratorydepression60%,myocardialinfarction,bloodtransfusion,woundinfectionsrenalfailure

Complications NAvs.GAMortality OR0.67CI0.57-0.80Pulmonary OR0.65CI0.52-0.80CNS OR0.39CI0.23-0.65Thromboembolism OR0.61CI0.53-0.71

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QualityoftheBodyofEvidenceStudydesign• LackofRCTs,mostlyobservational,nocausality,residual

confoundingRiskofbias• AccuracyofOSAidentification:STOP-BANG,Berlin

Questionnaire,PSGrarely

• OSAseverity,whichsubpopulationsareathigherperioperativerisk?

• Surgicalinvasiveness• OSAtreatmentandcompliancee.g.CPAP• Anesthesiaandanalgesia/consumptionofanesthetics

andnarcotics• IndicationbiasselectionbiasImprecision• MoststudiesdonotreachOIS

Directness• Sparsenessofdirectcomparativeeffectivenessresearch

inOSA• Judgementsregardingthestrengthoftheassociation

requiredConsistency

• ResultslargelyconsistentindemonstratingdetrimentaleffectsofGAvsRA

• ConsistencyinsizeofeffectPublicationbias• Lowrisk

Lackofevidenceontheimpactofinterventionsofprecaution• e.g.CPAP,feasibilityofrandomization

Rationalesupportingregionalanesthesia

ImprovedoutcomeswithregionalanesthesiaReducedcomplicationsandresourceutilization

AvoidanceofairwaymanipulationDifficultairway

Avoidanceofneuromuscularblockade

EfficientpainreliefAlteredpainandopioidsensitivity

ReducedconsumptionofopioidsandanestheticmedicationMultimodalpainmanagementHighvulnerabilityinpatientswithdelayedarousalSuppressionofsurgicalcatabolicstressresponseBlockofsystemicendocrinecatabolicresponse

Expeditedmobilization/recovery

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WhatisthepreferredanesthesiatechniqueinpatientswithOSA?• Whenapplicable,RApreferableoverGAinpatientswithOSA

• Potentialforpostoperativecompromiseshouldbeconsideredinselectingintraoperativeanestheticmedications

• Superficialprocedures:useoflocalanesthesiaandPNB(with/withoutmoderatesedation)

• GAwithsecureairwaypreferabletodeepsedationwithoutsecureairway

• Majorconductionanesthesia(spinal/epidural)forperipheralprocedures

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