http://informahealthcare.com/hop ISSN: 2154-8331 (print) Hosp Pract, 2014; 43(1): 56–63 DOI: 10.1080/21548331.2015.1001709

REVIEW

Obstructive sleep apnea in the perioperative setting: complications and management strategies Melissa C. Lipford1, Kannan Ramar2 & Salim R. Surani3 1

Center for Sleep Medicine and Department of Neurology, Mayo Clinic, Rochester, MN, Center for Sleep Medicine and Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, and 3 Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Texas A and M University, Corpus Christi, TX, USA Hospital Practice Downloaded from informahealthcare.com by Nyu Medical Center on 07/27/15 For personal use only.

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Abstract

Keywords:

Obstructive sleep apnea (OSA) is frequently encountered in an undiagnosed, untreated state in perioperative patients. It increases the risk of respiratory, cardiac, and infectious complications following surgical procedures. Patients with OSA may require additional monitoring, unplanned escalations in care, and prolonged hospitalization. It is important to identify patients at risk for OSA during the preoperative assessment so that appropriate anesthesia, postsurgical monitoring, and pain control can be planned. Herein, we discuss data regarding perioperative outcomes in patients with OSA, methods to quickly identify patients at high risk for OSA, and implementation of clinical safeguards to minimize OSA-associated complications. An algorithm is provided to guide the perioperative management of patients with OSA.

Obstructive sleep apnea (OSA), anesthesia, surgery, airway, perioperative risk

Introduction Obstructive sleep apnea (OSA) is characterized by cycles of collapse of upper airway tissues, resulting in apneas (cessation of breathing for 10 seconds) and hypopneas (significantly reduced airflow with ‡ 3% oxyhemoglobin desaturation) [1]. It is a common disorder, estimated to affect 9% to 24% of middle-aged adults, reaching levels from 24% to 62% in those aged > 65 years [2-4]. Obstructive sleep apnea poses both immediate and delayed adverse health consequences. The disease is associated with oxygen desaturation, hypercapnia, arousal-mediated sympathetic surges [5], and the development and worsening of hypertension. It leads to an increased risk of myocardial infarction, and entails a 4-fold increase in the risk of developing atrial arrhythmia [6,7]. Recent work also demonstrates that OSA is an independent risk factor for stroke, elevating stroke risk by a factor of 3 in men [8]. Despite these serious adverse health consequences, OSA remains undiagnosed in up to 80% of patients with moderate to severe disease [9,10]. This untreated and at-risk population poses specific concerns in the context of perioperative care. Obstructive sleep apnea is associated with postoperative complications, including myocardial injury, unanticipated admission to the intensive care unit (ICU), and death [11]. This article discusses the specific perioperative risks posed by untreated OSA and specific clinical safeguards that can be implemented to prevent OSA-associated complications. But

History Received 29 August 2014 Accepted 15 September 2014 Published online 6 January 2015

first and foremost, at-risk patients must be identified preoperatively through the employment of screening tools. An algorithm is provided to guide the perioperative management of patients with OSA (Figure 1).

Methods A literature search was conducted utilizing PubMed (from 1966 to August 2014) and Ovid MEDLINE (from 1946 to August 2014) to identify studies evaluating perioperative risk associated with OSA. Studies were restricted to those published in English. Both case-control and cohort studies were evaluated. The management recommendations are based on a summarization of study results as well as on the opinions of the authors, who are sleep medicine specialists with additional training in pulmonary and critical care medicine and neurology.

Pathophysiology of obstructive sleep apnea The airway can be modeled as a collapsible tube. At the airway opening, there is atmospheric pressure, and at the base of the tube there is tracheal pressure. Air flows freely through the tube as long as upstream pressure exceeds external surrounding pressures [12]. The maintenance of an open lumen depends on a delicate balance between external and internal forces of collapse and expansion. Pharyngeal critical pressure (Pcrit) is the pressure of passive closure of the upper airway.

Correspondence: Salim R. Surani, MD, Associate Professor of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Texas A&M University, 7613 Lake Bolsena, Corpus Christi, TX 78413, USA. Tel: +1 361 885 7722. Fax: +1 361 850 7563. E-mail: [email protected]  2015 Informa UK Ltd.

Obstructive sleep apnea in the perioperative setting

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Preoperative management: • Inform anesthesiologist that OSA is suspected • Consider baseline overnight oximetry and/or arterial blood gas (ABG) to assess degree of hypoxemia and possibility of hypoventilation

• • • • •

Intraoperative management: Avoid sedative/opiate premedications Use short-acting general anesthetic agents Consider regional nerve block or conscious sedation if appropriate Extubation after fully alert and able to protect airway Nasal airway devices or positive airway pressure (PAP) therapies should be available

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Immediate postoperative management: • Monitored environment with continuous pulse oximetry • Snoring, observed apneas → initiate PAP • Consider regional nerve block for pain management rather than use of oral or parenteral opioids • Release to floor only after maintaining normal O2 saturations, fully alert, and following commands

Postoperative recovery: • Overnight oximetry→ if suggests moderate/severe OSA, initiate autotitrating countinuous positive airway pressure (CPAP) empirically • Arterial blood gas to assess for hypoxemia, hypercapnia • Supplemental oxygen if needed (corrects hypoxemia but not hypercapnia), or if CPAP not available/tolerated • Consider elevation of head of bed Pain management: • Minimize opiates, use patient-controlled analgesia (PCA) without basal rate for severe pain

Discharge management: • • • •

Avoid outpatient opiate medications Instruct family members to observe for apneic episodes, shallow breathing, or loud snoring. Consider lateral positioning or head of bed elevation during sleep Arrange for expedited Sleep Medicine consultation for the diagnosis and treatment of OSA for those undiagnosed and follow-up visit for those diagnosed

Figure 1. Algorithm for perioperative management of high-risk patients with OSA. Abbreviation: OSA = Obstructive sleep apnea.

In normal individuals, Pcrit is negative, favoring an open airway. In those with snoring, Pcrit is less negative, making the airway more vulnerable to collapse. In patients with OSA, Pcrit is positive, favoring airway closure [13,14]. Mechanical, chemical, and neurogenic factors can increase Pcrit and shift the balance toward airway collapse [12]. Factors that contribute to OSA by generating a more positive Pcrit include crowded upper airway anatomy, reduced activity of upper airway dilator muscles, ventilatory instability, obesity, cardiopulmonary disease, and hormonal and genetic factors. During sleep, supine positioning, decreased activity of the airway dilator musculature (ie, genioglossus, tensor palatini), and reduced airway protective reflexes further shift the balance toward cycles of airway collapse [15,16].

Apnea-induced hypoxemia and hypercapnia signal a rise in respiratory effort. As the body struggles to draw in breath against a closed airway, there are marked swings in intrathoracic pressure. Negative intrathoracic pressure during apneic episodes leads to an increase in right ventricular preload. Hypoxia causes pulmonary vasoconstriction, increasing right ventricular afterload. As respiratory effort reaches a crescendo, the airway opens, usually coupled with an arousal from sleep. The bursts of respiratory dysfunction and arousals are associated with surges in sympathetic activity [17]. Obstructive sleep apnea induces cycles of bradycardia and tachycardia as well as elevated blood pressures [18]. Patients with OSA have the highest incidence of sudden cardiac death during sleeping hours [19].

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Obstructive sleep apnea in the perioperative setting Epidemiology of OSA in the surgical population The prevalence of OSA in the surgical population is not well characterized; however, rates appear higher than in the general population. Approximately 22% of adults undergoing elective surgery were found to have OSA. Rates increase in populations with specific comorbidities such as obesity [20]. An estimated 70% of patients undergoing bariatric surgery have OSA, with the vast majority being undiagnosed [21].

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Postsurgical outcomes in OSA patients A study comparing outcomes of 100 patients and matched controls undergoing hip or knee replacement surgery at Mayo Clinic demonstrated complications in 39% of patients with OSA versus 18% of controls. Serious complications (such as urgent respiratory intervention requiring unplanned ICU transfer) were observed in 24% of patients with OSA versus 9% of controls. The majority of complications occurred during the first postoperative day. Hospital stay is also lengthened in patients with OSA [22]. Liao et al [11] studied adult patients with OSA who were scheduled to undergo elective surgery. Complication rates in this group were significantly higher compared with controls (44% in the OSA group vs 28% in controls; P < 0.05). The majority of complications were related to oxygen desaturation. Overnight oximetry was utilized by Hwang et al [23] to identify elective surgical patients at high risk for OSA. Patients with ‡ 5 nocturnal desaturations per hour had significantly more postsurgical complications than controls (15.3% vs 2.7%; P < 0.01). Multiple complication types were identified, including respiratory, cardiovascular, gastrointestinal, and bleeding. The higher the desaturation index severity, the higher the complication rate [23]. The meta-analysis study by Kaw et al [24] (n = 3942) found an increased incidence of postoperative desaturation, respiratory failure, and cardiac events. This was further validated by another meta-analysis including 18 eligible studies on postoperative outcomes in adult patients undergoing non–upper-airway surgeries showing a statistically significant increased incidence of postoperative respiratory complications, hypoxemia, unplanned ICU transfers, and cardiac and neurologic complications [25]. Key studies demonstrating OSA-induced perioperative risks are listed in Table 1. Specific perioperative respiratory complications in patients with OSA Obstructive sleep apnea is inherently a condition of an unstable airway. A myriad of factors impact the physiologic dynamics and patency of the upper airway and thus the severity of OSA. In the postsurgical setting, anesthetics, sedatives, pain medications, and supine positioning can dramatically worsen the disease. Complications related to OSA may be even more significant in surgical patients with acute illnesses or other chronic comorbidities.

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Intraoperative respiratory complications. General anesthesia reduces the activity of the upper airway musculature (pharyngeal dilator muscles) and promotes airway collapse in a dose-dependent fashion [26]. Morbidly obese patients who are at high risk for OSA are also at high risk for respiratory obstruction soon after extubation [27]. Factors such as obesity, operative positioning (supine, neck flexion), and muscle relaxant medications all serve to decrease airway caliber, increase compliance (degree of flaccidity) of the pharyngeal walls, and reduce activity of the upper airway dilator musculature [26]. During surgical procedures requiring general anesthesia, patients at risk for OSA appear to have higher rates of difficult intubation and more complicated intraoperative airway maintenance [28]. Postoperative respiratory complications. Kim et al [29] reported a retrospective study involving 90 patients undergoing uvulopalatopharyngoplasty for the treatment of OSA. Complications were reported in 21% of patients, with respiratory complications being more frequent in patients with more severe OSA. Observed respiratory complications included the need for an oral or nasal airway (which in one patient needed to be retained during the first postoperative night). Hypoxemia postoperatively was noted in an additional 9% of patients. Other respiratory complications observed postoperatively in patients with OSA included atelectasis, wheezing (requiring bronchodilator therapy), and postoperative pneumonia [23]. Special populations. Patients with known OSA experience exacerbation of disease following surgery. Peak levels of severity appear to be reached on postoperative night three. Baseline OSA levels return by postoperative night seven. Factors associated with higher postoperative OSA severity include higher baseline severity, older age, and opioid use [30]. Sleep deprivation is common in the immediate perioperative period. Following nights of fragmented sleep, the phenomenon of ‘rapid eye movement rebound’ typically occurs. Patients have increased periods of rapid eye movement sleep, which is associated with worsening severity of sleep apnea, lasting for several days [31-33]. Although formal perioperative studies are missing, we can extrapolate that patients with morbid obesity, pulmonary disease, or neuromuscular disorders in the setting of OSA are at further risk of respiratory complications. Patients with chronic obstructive pulmonary disease or obesity hypoventilation syndrome and OSA are at increased risk of hypoxemic and hypercapnic respiratory failure. These patients may have baseline chronic hypoxemia or hypercapnia, which worsens significantly during sleep as a result of OSA [34-36]. As OSA severity increases postoperatively, these patients may be at even higher risk for cardiopulmonary complications. Specific perioperative nonrespiratory complications in patients with OSA Patients with OSA also experience nonrespiratory complications in the perioperative setting. There is a strong association between atrial fibrillation and untreated OSA [37]. Van

Retrospective matched cohort

Prospective case-control

Meta-analysis

Meta-analysis

Liao et al [11]

Hwang et al [23]

Kaw et al [24]

Gaddam et al [25]

15 studies included in metaanalysis

13 studies analyzed; n = 3942

74 cases; 98 controls

240 OSA cases; 240 matched control

101 OSA cases; 101 matched control

Subject size

Polysomnography, screening questionnaires, and overnight oximetry

Polysomnography, screening questionnaires, and overnight oximetry

Elective abdominal, urologic, thoracic, gynecologic, cardiothoracic, neurosurgical, orthopedic procedures Orthopedic, general, bariatric, gynecologic, thoracic, urologic, vascular, otolaryngologic, neurosurgical Orthopedic, general, gynecologic, thoracic, urologic, vascular, otolaryngologic, neurosurgical

General, cardiac, urologic, orthopedic, gynecologic, and other elective procedures (upper airway surgeries excluded)

Documented history of OSA diagnosis

Overnight oximetry demonstrating 4% ODI ‡ 5/hr

Hip or knee replacement

Surgical procedure(s)

Polysomnography

OSA diagnosis

Abbreviations: ODI = Oxygen desaturation index; OSA = Obstructive sleep apnea.

Retrospective case-control

Design

Gupta et al [22]

Author

Table 1. Key studies demonstrating perioperative complications associated with OSA.

Hypoxemia, reintubation, hypercapnia, bronchospasm, respiratory failure, pneumonia, need for continuous positive airway pressure

Desaturation, acute respiratory failure, tracheal reintubation

Desaturation (SaO2 < 90%), bronchospasm, hypercapnia, laryngospasm, upper airway obstruction, arrive in postanesthesia care unit intubated Hypoxemia, atelectasis, wheezing, pneumonia

Reintubation, hypoxemia, and acute hypercapnia

Respiratory complications

Nonrespiratory complications

Increased postoperative complications were observed in patients with ODI ‡ 5/hr Patients with OSA had higher incidence of postoperative desaturation, acute respiratory failure, cardiac events, and escalations in care Patients with OSA are at increased risk of postoperative complications affecting respiratory, cardiovascular, and neurologic systems and are at increased risk for unplanned intensive care unit transfer Myocardial infarction/ ischemia, new arrhythmia, hypotension, cardiac arrest, tachycardia, bradycardia, intensive care unit transfer, hospital length of stay Dysrhythmias, myocardial infarction/ischemia, heart failure, abnormal heart rate, neurologic complications, delirium, unplanned intensive care unit transfer, hospital length of stay

Patients with OSA have increased incidence of postoperative complications; oxygen desaturation was noted most frequently

Adverse postoperative outcomes more common in patients with OSA vs controls

Study conclusions

Intraperitoneal bleeding, hypotension, pulmonary embolism, chest pain

Myocardial infarction/ ischemia, arrhythmia, delirium, unplanned intensive care unit transfer, wound infections, deep vein thrombosis, and need for revisions Arrhythmia, bradycardia, cardiac arrest, hypertension, neurologic complications (agitation, confusion, stroke, or transient ischemic attack)

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Oosten and colleagues [38] studied the frequency of atrial fibrillation following coronary artery bypass graft in patients at high-risk for OSA (based on screening questionnaire). Results were compared against patients at low risk for OSA. The presence of OSA strongly predicted the occurrence of atrial fibrillation following coronary artery bypass graft (45.5% in high-risk patients vs 29.7% in low-risk patients; P = 0.007). Those who developed atrial fibrillation had longer hospital stays. Higher rates of tachyarrhythmias, bradycardia, cardiac arrest, and hypertension have also been documented in patients with OSA [11]. A Cleveland Clinic retrospective study examined outcomes of 37 patients with OSA undergoing cardiac surgery compared with matched controls. The results demonstrated a higher incidence of encephalopathy and postoperative infections and longer ICU stays in patients with OSA [39]. A prospective case-control study utilizing overnight oximetry data and clinical history to identify patients at high risk for OSA found greater rates of complications in the OSA group. Nonrespiratory complications included postsurgical bleeding, hypotension, junctional escape rhythms, and chest pain. Rate of complications were highest in subjects with oximetry data that suggested more severe OSA [23]. Other nonrespiratory complications in patients with OSA include increased unplanned ICU admissions, longer stays in the postanesthesia recovery unit, the need for additional monitoring equipment, and longer hospital stays [11,22,23,39]. Sleepiness associated with OSA also has the potential to lead to perioperative complications. Early mobility is key in improving outcomes and shortening the duration of hospitalization following surgery. This has been established for gastrointestinal, cardiovascular, and orthopedic procedures [40-42]. Sleepy patients with untreated OSA may be less apt to participate in mobilization activities and physical therapies and may be more inclined to spend time in bed. Obstructive sleep apnea–induced perioperative complications also serve to increase the costs of hospitalization. The National Surgical Quality Improvement Project found that major complications following surgery increased the cost of hospitalization by an adjusted $11,626 per patient [43]. This is the summary of perioperative complications associated with OSA.

Identification of patients at risk for perioperative complications due to OSA Because the majority of patients with OSA are undiagnosed, most clinicians are unaware of the presence of OSA at the time of the preoperative assessment. The formulation of a strategy of risk stratification through clinical red-flag symptoms and signs of sleep apnea is helpful in identifying these patients as early as possible. When severe disease is suspected, delaying surgery until the disease is formally diagnosed and treated may be appropriate in the setting of elective surgical procedures. A focused clinical history is helpful to screen for sleep apnea in preoperative patients. This should include questions regarding a history of snoring, snort arousals, witnessed

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apneas, waking with a dry mouth or sore throat, morning headaches, evening alcohol consumption, and daytime sleepiness. Physical features suggestive of OSA include obesity (body mass index ‡ 30 kg/m2), a small or posteriorly placed mandible, an enlarged tongue, oropharyngeal crowding, and a widened neck circumference [44]. Craniofacial abnormalities (which may lead to restricted oropharyngeal space or narrowed airway) increase the likelihood of OSA. Men, postmenopausal women, patients with hypertension or cardiac arrhythmia, and the elderly are also at increased risk. The American Society of Anesthesiologists developed an expert opinion-based checklist for the identification and perioperative management of patients with OSA. This includes assessment of many of the above clinical features to alert clinicians to the likely presence of sleep apnea. The type of surgical procedure and the estimated postsurgical opioid requirement also factor into determining the perioperative risk [45]. Using this checklist, screening was performed on 3593 surgical patients at a single institution. The American Society of Anesthesiologists guidelines were used to categorize patients as high risk and low risk for OSA. Those at high risk had a higher incidence of respiratory complications and longer stays in the recovery room [46]. Validated OSA screening questionnaires have also been designed in an effort to quickly screen patients at risk for sleep apnea. These include the STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaire, the Berlin questionnaire, and the NAMES (Neck circumference, Airway classification, co-Morbidities, Epworth scale, and Snoring) questionnaire [47-49]. A consensus statement issued by the Society for Ambulatory Anesthesia recommends the routine use of the STOP-BANG screening tool for preoperative assessment for OSA [50].

Management strategies to reduce the perioperative risk associated with OSA Preoperative and intraoperative management When sleep apnea (particularly severe disease) is suspected, communication of this possibility with the entire surgical care team is essential. The anesthesiologist should be informed of possible OSA, so that an appropriate anesthesia plan can be developed and accommodations made in case of difficulties maintaining airway patency. In general, preanesthesia sedatives should be avoided in the presumed OSA patient. If they are required, it would be prudent to carefully monitor respiratory status while the agents are active. Delay et al [51] demonstrated that administration of oxygen with noninvasive positive pressure ventilation in morbidly obese patients achieved a higher end-tidal oxygen level and led to more rapid oxygenation prior to intubation. Regional anesthesia or minimal sedation approaches are preferable due to reduced respiratory depression. The anesthesiologist may choose to avoid drugs associated with delayed return of consciousness. Additionally, postanesthesia sedation and pain medications should be judiciously used,

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and nonopioid therapies are preferable. Noninvasive positive pressure ventilation should be available if required following extubation. Extubation should be performed only after the patient is fully awake and able to protect the airway adequately. In some cases, a nasal airway may be required shortly after extubation.

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Immediate postoperative management When presumed patients with OSA are recovering immediately postanesthesia, they should be maintained in a highly monitored environment. Continuous pulse-oximetry monitoring should be performed. Nursing staff may notice loud snoring and apneic pauses in these patients. Empiric initiation of continuous positive airway pressure or bilevel positive airway pressure devices may be helpful in maintaining airway patency. Alternatively, a nasal airway may be required in some patients. Patients should be maintained in the postanesthesia care unit until fully conscious and able to follow commands, and they are reliably protecting the airway. Ideally, oxygen saturations on room air should be normal prior to dismissal from the postanesthesia care unit. Opiate medications should be minimized to the extent possible. Consideration should be given to lower potency and shorter acting agents when narcotics are required versus nonopioid therapies such as intravenous acetaminophen. Postoperative recovery management of OSA Patients with presumed OSA should be maintained under close nursing surveillance when released to the hospital floor. Nocturnal oximetry monitoring should be considered. Empiric initiation of continuous positive airway pressure using an autotitrating device should be considered in those in whom oximetry demonstrates a pattern of oscillatory desaturations strongly suggestive of OSA. Arterial blood gas measurements may be considered if oximetry reveals sustained hypoxemia (suggesting hypoventilation). In patients who are acutely hypercapnic or significantly hypoxemic, transferring to higher level of care should be considered. In these patients, noninvasive positive pressure ventilation should be instituted. Body position is an important tool in reducing the severity of OSA. In the majority of patients with OSA (56%), the severity worsens by 50% when sleeping in the supine position [52]. The effects of gravity increase collapsibility of the upper airway tissues when sleeping on the back [53]. If feasible, positioning patients in the lateral position during sleep will limit the severity of OSA. Special pillows are available for this purpose. Avoiding the supine position also reduces the severity of central sleep apnea [54]. If lateral positioning is not possible in the postsurgical period, raising the head of the bed is recommended. Supplemental oxygen is recognized as an alternative treatment for OSA if positive airway pressure therapies cannot be implemented. Oxygen ameliorates the hypoxemia associated with hypopneas and elevates mean saturation [53]. Oxygen also serves as a treatment modality for central sleep apnea [55]. However, supplemental oxygen therapy will not correct hypercapnia.

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Pain management Pain control measures should focus on maintaining a balance of appropriate reduction of pain and maintaining alertness and airway patency. During the surgical procedure, infiltrating the wound with long-acting local anesthetics can reduce the requirements for systemic agents [56]. For severe postoperative pain, patient-controlled analgesia may be a safer consideration for the OSA patient. This form of therapy requires the patient to be alert enough to self-administer pain medications. Patient-controlled analgesia is generally associated with low rates of respiratory depression, especially when used without a basal rate. Continuous pulse oximetry monitoring should be utilized in the presumed OSA patient, especially when basal rates are being infused. Hypercapnia is another consequence to monitor in such situations [57]. Evaluations for hypercapnia include respiratory rate monitoring, transcutaneous CO2 or end-tidal CO2, or arterial blood gas analysis. The use of transcutaneous or end-tidal CO2 as a tool has not been validated in this setting yet and may need to be considered as a supplement to continuous pulse oximetry. In general, as opiate dosing is increased, the threshold for pain relief is reached first, followed by a reduced level of alertness, progressing finally to respiratory depression [58]. Nursing assessments should measure the level of sedation routinely in patients with OSA. If a patient is falling asleep during a conversation or unable to follow simple commands appropriately, the dosing of analgesia should be immediately reduced [59]. In addition to OSA, opiates can also precipitate central apnea and hypoxemia [60,61]. Opiate-based analgesia should be transitioned to alternative agents as soon as possible. Some effective choices that do not entail the risk of respiratory depression include nonsteroidal anti-inflammatory drugs (naproxen, indomethacin, ketorolac, ibuprofen), acetaminophen (either PO or IV), clonidine, gabapentin, and pregabalin [56]. Peripheral nerve block procedures may also be considered, as they provide safe and effective pain relief following localized procedures [56].

Postdischarge management In the presumed OSA patient, outpatient pain management is a challenging issue. If opiates must be utilized in the outpatient setting, low-potency agents with the lowest effective dose should be utilized. Patients who demonstrate oxygen desaturations with opiate use while in the hospital should not be prescribed opiate-based medications at discharge. The alternative agents listed above should be utilized as the primary pain control agents. Patients and ideally their caregivers or bed partners should be educated regarding watching for evidence of excessive somnolence, loud snoring, or apneic pauses during sleep following discharge. All patients in whom OSA is suspected should receive expedited referral for sleep medication evaluation for formal diagnosis and commencement of treatment. In areas where the availability of in-lab polysomnography is limited or requires long wait times, the recent advent of home-based testing can improve access.

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Conclusion Sleep-disordered breathing is a common but greatly underdiagnosed condition affecting many patients in the perioperative setting. Presurgical identification is crucial in order to formulate an appropriate perioperative plan to minimize respiratory and other complications. In the presumed patient with OSA, intubation and extubation may be challenging, and the anesthesiologist should be forewarned so that appropriate airway protection plans can be developed. Shorter acting general anesthetics should be considered as well as instillation of long-acting local agents into the surgical wound. In the immediate postoperative period, continuous pulse oximetry and in some cases arterial blood gas (ABG) or end-tidal CO2 monitoring is required. Nasal airway or institution of noninvasive positive airway pressure modalities may be necessary to maintain airway patency. Following transfer to the hospital floor, the nursing staff should make multiple careful assessments of patient respiratory status and level of consciousness. Overnight oximetry plays an important role in identifying moderate to severe OSA in perioperative patients. Empiric use of nocturnal positive airway pressure therapies may be appropriate. As soon as possible, transitioning to non–opiate-based therapies for pain control is appropriate. Nonopioid agents are preferred for postdischarge pain control. All patients should receive expedited referral for sleep evaluation and testing at the time of hospital discharge.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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