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Operative risk in patients with Obstructive Sleep Apnea Syndrome (OSAS). Why give preference to RA? Luc Sermeus Luc Sermeus Antwerp University Hospital.

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Presentation on theme: "Operative risk in patients with Obstructive Sleep Apnea Syndrome (OSAS). Why give preference to RA? Luc Sermeus Luc Sermeus Antwerp University Hospital."— Presentation transcript:

1 Operative risk in patients with Obstructive Sleep Apnea Syndrome (OSAS). Why give preference to RA? Luc Sermeus Luc Sermeus Antwerp University Hospital Antwerp University Hospital Belgium Belgium ESRA winterweek 2012

2 OSA: characteristics SnoringSnoring Apnea caused by airway obstructionApnea caused by airway obstruction ArousalArousal

3 Anesthesia Anesthesia = a state of unrousable unconsciousness a state of unrousable unconsciousness

4 OSA: Preop assessment OSA already diagnosedOSA already diagnosed OSA not (yet) diagnosed (80-95%)OSA not (yet) diagnosed (80-95%) 82% men, 93% women82% men, 93% women Polysomnography / nocturnal oxymetry / HolterPolysomnography / nocturnal oxymetry / Holter Cancel surgery?Cancel surgery?

5 C.L. Wang et al. Sleep Breath 2011, 16 (ahead of print) “Half of Chinese anesthesiologists lacked sufficient knowledge and had low confidence levels in dealing with OSA patients” OSAKA- questionary

6 Preop OSA: symptoms SnoringSnoring Men 44% > women 28%Men 44% > women 28% 30-60y, peak 50-60y30-60y, peak 50-60y Obesity (60-90%) BMI > 30kg/m²Obesity (60-90%) BMI > 30kg/m² BMI: Western > Asian, prevalence OSA similarBMI: Western > Asian, prevalence OSA similar 5% in men, 2% in women (Young, J Resp Crit Care Med 2002)

7 Preop OSA: symptoms SnoringSnoring PredispositionPredisposition Alcohol, Upper airway infectionAlcohol, Upper airway infection Hypertrophic tonsils, nasal obstructionHypertrophic tonsils, nasal obstruction Craniofacial anatomy (Kushida Laryngoscopy 2000)Craniofacial anatomy (Kushida Laryngoscopy 2000) Lower facial height, more backward position jaw in Asian populationLower facial height, more backward position jaw in Asian population

8 Airway obstruction with apnea ObesityObesity Correlation: fatty tissue lateral of pharynx & OSA Neck Ø > 42-44 cm  fast collapse of airway Micro- / retrognathiaMicro- / retrognathia Hypertrophic tonsils, big tongue, position of hyod boneHypertrophic tonsils, big tongue, position of hyod bone Maxillar hypoplasia, narrow oropharynx, shape of airwayMaxillar hypoplasia, narrow oropharynx, shape of airway (Ishiguro, Oral Surg Med Path Radiol Endosc 2009) Preop OSA: symptoms

9 CHEST August 2005 vol. 128 no. 2 896-901 Igor FajdigaIgor Fajdiga, MD, PhD

10 CHEST August 2005 vol. 128 no. 2 896-901 Igor FajdigaIgor Fajdiga, MD, PhD NormalApneic

11 American Journal of Respiratory and Critical Care Medicine Vol 168. pp. 522-530, (2003) Richard J. Schwab et al. BMI = 32

12 Preop OSA: symptoms Arousal O 2 ↓, CO 2 ↑, ventilatory effort↑, stretch-receptors↑O 2 ↓, CO 2 ↑, ventilatory effort↑, stretch-receptors↑  “awake” Not totally conscious - muscle tone↑- obstruction↓Not totally conscious - muscle tone↑- obstruction↓ Massive sympathetic activationMassive sympathetic activation  bradycardia  tachycardia  AHT  Cardiac ischemia - CVA

13 OSA: pathophysiology

14 Pharyngeal collapse in OSA Sympathetic Drive Intrathoracic Pressure Myocardial OxygenSupply Vasoconstriction Periph. Resistance Heart rate Oxygen demand Venous return Afterload Preload * LVH * RV dilatation *Stroke Volume *LVEF *TD velocities of LV and RV BP Structural alterations Functional alterations Cardiovascular changes

15 OSA: consequences AHT: related to severity OSA (risk 10X↑)AHT: related to severity OSA (risk 10X↑) Arrhythmia's: nocturnal in 50%, risk2-4X↑ if hypoxemia↑Arrhythmia's: nocturnal in 50%, risk2-4X↑ if hypoxemia↑ Mostly NSVTMostly NSVT Sinus arrest, second degree AV-block, VES, AFSinus arrest, second degree AV-block, VES, AF Cardiac ischemia:14-28%= 5x normalCardiac ischemia:14-28%= 5x normal Heart-failure: 11-37%Heart-failure: 11-37% Pulmonary HT 20-42%  Right heart-failurePulmonary HT 20-42%  Right heart-failure

16 OSA: consequences Hypoxemia  polycythemiaHypoxemia  polycythemia Stroke: 62-77% of stroke has OSAStroke: 62-77% of stroke has OSA Severity↑ of OSA = Risk↑ of strokeSeverity↑ of OSA = Risk↑ of stroke Terminal renal insuff: 40-60% = f(duration) of OSATerminal renal insuff: 40-60% = f(duration) of OSA DiabetesDiabetes Edema UAEdema UA Impaired chemosensitivityImpaired chemosensitivity

17 OSA: consequences Cardio vascular risk ↑ with severity and duration OSA Overall risk of CVD = x11 = 15-20% fatal complication if severe OSA >10j Risk post therapy = mild OSA = 4-5% Control = ±2% Marin et al. Lancet 2005 Marin et al. Lancet 2005

18 Preop OSA: premedication Benzodiazepines: CAVEBenzodiazepines: CAVE  Muscle tone↓  collapse  apnea  Sat↓ Pulsoxymetry / CPAP Pulsoxymetry / CPAP Anti-sialorrhea: GlycopyrrolateAnti-sialorrhea: Glycopyrrolate CPAP : to be started, if possible, 2w before surgery CPAP : to be started, if possible, 2w before surgery

19 OSA + Consequences + Co-pathology = perop / postop risk = perop / postop risk

20 Perop OSA: anesthetics ALL ANESTHETICS : Negative effect on cardiac functionNegative effect on cardiac function Collapsibility↑Collapsibility↑ Arousal response↓↓ if O 2 ↓, CO 2 ↑, obstructionArousal response↓↓ if O 2 ↓, CO 2 ↑, obstruction Ventilatory response↓ if O 2 ↓, CO 2 ↑Ventilatory response↓ if O 2 ↓, CO 2 ↑ UA reflexes↓UA reflexes↓

21 Physiology: FRC FRC = O 2 -reserve if apnea BMI↑ = FRC↓ + O 2 -consumption↑BMI↑ = FRC↓ + O 2 -consumption↑ Supine position = FRC↓Supine position = FRC↓ Anesthesia/sedation = FRC↓Anesthesia/sedation = FRC↓ preoxygenation before induction of anesthesia  preoxygenation before induction of anesthesia = filling FRC with ±100% O 2

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24 Perop OSA: UA 21,9% difficult UA if OSA ↔ normal 2,6% ➡ 5% failed intubation (=100x normal) 66% with a difficult intubation had OSA Savva D.1994 Br J Anaesthesia 73(2):149-53 Chung F et al. 2008 Anesth Analg 107(3):915-20

25 Perop OSA: UA Difficult Upper AirwayDifficult Upper Airway Experienced anesthetistExperienced anesthetist  Inadequate face mask ventilation  Difficult ( > 2 attempts) intubation Predictive factorsPredictive factors ComplicationsComplications Dental injury / UA traumaDental injury / UA trauma Severe hypoxia  cerebral ischemiaSevere hypoxia  cerebral ischemia + laryngoscopy  asystole

26 OSA: prediction difficult UA Anatomical factorsAnatomical factors Craniofacial morphology / trauma / surgeryCraniofacial morphology / trauma / surgery Cervical mobility / mouth openingCervical mobility / mouth opening Micro- / retrognathia / macroglossiaMicro- / retrognathia / macroglossia Long soft palateLong soft palate MallampatiMallampati

27 Mallampati Mallampati 3-4 + OSA = difficult intubation until proven otherwise

28 Cormack - Lehane

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30 Difficult intubation = Difficult extubation!!!

31 OSA: Difficult extubation Causes AnatomyAnatomy Residual sedationResidual sedation Instrumentation UAW during intubation / surgery of UAInstrumentation UAW during intubation / surgery of UA EdemaEdema BloodBlood SecretionsSecretions Nasal packsNasal packs

32 OSA: difficult extubation 5% life threatening postextubation obstruction following surgical treatment of OSA5% life threatening postextubation obstruction following surgical treatment of OSA

33 OSA: difficult extubation Pre requisites Complete recovery of muscle relaxationComplete recovery of muscle relaxation Wide awake / communicatingWide awake / communicating Spontaneous breathing  adequate TVSpontaneous breathing  adequate TV  oxygenation  oxygenation Semi sitting position  FRC↑Semi sitting position  FRC↑

34 OSA: difficult extubation Pre requisites Stable haemodynamicsStable haemodynamics CPAP CPAP  +/- O 2 Re-intubation equipment readyRe-intubation equipment ready Perop corticosteroids if necessaryPerop corticosteroids if necessary Intensive care / Medium care if necessaryIntensive care / Medium care if necessary

35 OSA: postop complications Rebound REM ±3 th day postop.Rebound REM ±3 th day postop.  Pain↓, surgical stress↓  ±normal sleep pattern  Pain↓, surgical stress↓  ±normal sleep pattern  Obstruction, apnea, sympathetic activation  Obstruction, apnea, sympathetic activation  Hemodynamic instability (pt not yet recovered)  Hemodynamic instability (pt not yet recovered) Confused / CVAConfused / CVA Disturbed wound healingDisturbed wound healing Myocardial ischemia / infarction / sudden deathMyocardial ischemia / infarction / sudden death NB: respiratory depression lasts for a week (morphine??)NB: respiratory depression lasts for a week (morphine??)

36 OSA: conclusions OSA = cause of cardio-vascular complicationsOSA = cause of cardio-vascular complications OSA = cause of difficult UAOSA = cause of difficult UA Enough reasons to prefer RA and to convince your patientEnough reasons to prefer RA and to convince your patient

37 Obstructive Sleep Apnea, Stroke, and Cardiovascular Diseases Bagai, Kanika MD, MS The Neurologist Issue: Volume 16(6), November 2010, p 329–339 Literature


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