Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

Stavros G. Memtsoudis, MD, PhD; Crispiana Cozowicz, MD; Mahesh Nagappa, MD; Jean Wong, MD, FRCPC; Girish P. Joshi, MBBS, MD, FFARCSI; David T. Wong, MD, FRCPC; Anthony G. Doufas, MD, PhD; Meltem Yilmaz, MD; Mark H. Stein, MD; Megan L. Krajewski, MD; Mandeep Singh, MBBS, MD, MSc, FRCPC; Lukas Pichler, MD; Satya Krishna Ramachandran, MD; Frances Chung, MBBS, FRCPC

Disclosures

Anesth Analg. 2018;127(4):967-987. 

In This Article

Abstract and Introduction

Abstract

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Introduction

The purpose of the Society of Anesthesia and Sleep Medicine (SASM) Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on the available scientific evidence. In light of a paucity of well-designed, high-quality studies in this perioperative field, a large part of the present recommendations was developed by experts in the field taking into account published evidence in the literature and utilizing consensus processes, including the grading of the level of evidence. At times, when specific information on patients with OSA was not available in the literature, evidence in highly correlated patient populations, specifically those with obesity, was considered if appropriate. When this was the case, it is explicitly stated in various parts of this document.

The guideline presented may not be suitable for all clinical settings and patients. Thus, its consideration requires an assessment of appropriateness by clinicians on an individualized basis. Among many factors, the existence of institutional protocols, individual patient-related conditions, the invasiveness of an intervention, and the availability of resources need to be considered. The present practice guideline is not intended to define standards or represent absolute requirements for patient care. Adherence to this guideline cannot guarantee successful outcomes but rather should aid health care professionals and institutions to formulate plans for improved management of patients with OSA. The present recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. Periodic reevaluations of the literature will be needed, and novel scientific evidence should be considered between updates. Deviations from this guideline in the practical setting may be justifiable, and such deviations should not be interpreted as a basis for negligence claims.

OSA is a common and frequently undiagnosed disorder defined by the repeated collapse of the upper airway with resultant blood oxygen desaturation events during sleep.[1,2] OSA has been associated with adverse long-term health outcomes and has been linked to increased perioperative complication risk.[3–5] Indeed, a comprehensive review of the literature performed by a task force appointed by SASM revealed substantial risk for adverse events, especially pulmonary complications, to be associated with OSA in the perioperative period.[6] Based on the elevated risk for perioperative complications, the recently published SASM Guideline on Preoperative Screening and Assessment of Adults With Obstructive Sleep Apnea recommends that attempts should be made to appropriately identify patients with OSA, with the goal to raise awareness among providers, mitigate risk, and improve outcomes.[7] While recommendations for preoperative screening and assessment of patients with OSA and their optimal preparation for surgery are now available, there is a paucity of evidence-based guidance for the intraoperative management of this patient population. Thus, there remains a lack of evidence-based practice recommendations regarding techniques for airway management, selection of anesthetic agents, and drugs, as well as choice of anesthetic technique.

This document is derived from results of an extensive consensus process based on a systematic literature search, review, and analysis performed by experts in the field. It is a follow-up to the previously published SASM Guideline on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea.[7] Given the large amount of related literature in this arena, this study focuses only on intraoperative patient care. Postoperative care issues are not considered and may be the subject of future projects.

What Other Guidelines and Reviews are Available?

Previous OSA-related practice guidelines[8–12] have been published by the American Society of Anesthesiologists,[8,9] the Society for Ambulatory Anesthesia,[10] the American Academy of Sleep Medicine,[11] the SASM,[7] the International Bariatric Consensus Guideline Group,[13] and the task force on best practice recommendations for the anesthetic perioperative care and pain management in weight loss surgery.[14]

Why was This Guideline Developed and how Does it Differ From Existing Guidelines?

This guideline was developed to provide evidence-based recommendations for the intraoperative management of patients with OSA. Therefore, a careful examination of the current literature using a systematic review approach with a focus on airway management, commonly used anesthesia-related drugs and agents, and anesthetic techniques in this patient population was conducted. The task force recognizes that there has been recent progress in attempts to subcategorize patients with OSA according to anatomic predisposition, arousal thresholds, muscle responsiveness, and ventilatory control characteristics.[15] However, given the lack of evidence in this context, statements were made referring to patients with OSA as a general group. Nevertheless, phenotypic subcategorization may allow the development of individual risk profiling in the future.

Aims

The aim of this guideline was to present recommendations based on the best current evidence. Clinical research as it relates to best perioperative practices in OSA is burdened by numerous difficulties. The intraoperative setting involves a multitude of concurrent interventions and use of anesthetic medications, making it difficult to single out specific factors that potentially drive the adverse outcome. Lack of preoperative polysomnography data within publications represents a further challenge, making it difficult to include information of the impact of disease severity. Ethical considerations in study designs regarding the randomization of patients with known OSA were additional obstacles in this context. Furthermore, the task force recognizes that there is a tendency to underreport medical complications, rendering it difficult to establish the true perioperative risk.[16] Presenting the current available evidence and its limitations should raise awareness regarding the need for high-quality studies in the future.

Specific aims were to: (1) evaluate considerations of difficult airway management in patients with OSA, (2) assess the impact of individual anesthesia-related drugs and agents in the care of patients with OSA, and (3) evaluate best anesthetic techniques in this patient population. To achieve these aims, a question-driven approach was sought.

In areas lacking sufficient published evidence, the task force sought to establish expert consensus while considering related literature. Patients affected by sleep-disordered breathing unrelated to OSA, including hypoventilation syndromes, periodic breathing, and central apnea unrelated to OSA, were not considered in this project. This decision was made a priori to reduce the influence of heterogeneity in our assessment given the lack of evidence on which to base recommendations for these specific populations.

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