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Perioperative Guidelines
Past, Present, Future
Tracey L. Stierer, M.D. Department of Anesthesiology and Critical Care Medicine,
Otolaryngology, Head and Neck Surgery, Johns Hopkins Medicine Sleep Disorders Center
Disclosures
I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
AASM 2003
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AASM 2003
• Clinical Practice Review Committee • Medline 1985-2001
– Risk factors – Diagnosed OSA vs. Non-diagnosed/suspected – Perioperative CPAP use – Preparation for intubation – Type of anesthetic – Transfer of care
AASM 2003
• High index of suspicion • Constant control of the airway • Judicious use of medications • Proper monitoring
“However, details regarding patient management are not fully investigated”
Canadian study
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Canadian Anesthesiologists • April 2004: No Guidelines and insufficient
evidence to guide decision making • Survey-Postal questionnaire sent to 1,063
Canadian anesthesiologists – Opinions – Perioperative care of patients with OSA
• Postoperative monitoring for 2 clinical scenarios • General anesthetic and regional anesthetic
• 75% response rate
Response
Response
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Conclusion
• 25% reported having a personal complication in a patient with OSA
• Majority had no written departmental policy • 83% felt that evidence based/consensus
based practice guidelines would assist them in the perioperative care of patients with OSA.
ASA 2006
ASA 2006
• Task Force- Chair: Jeffrey Gross, MD • 12 members
– Anesthesiologists/ private practice and academic
– Bariatric surgeon – Otolaryngologist – 2 methodologists from the ASA
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ASA 2006
• Review evidence • Obtain opinion of consultant • Build consensus
ASA 2006
• Pre-operative screening and identification • Presumptive diagnosis • Use of CPAP/ Regional anesthesia • Postoperative monitoring
– Median of 3 hours longer than their non-OSA counterparts
– Median of 7 hours after the last episode of airway obstruction
ASA Scoring System
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ASA 2006
• Equivocal: – Superficial procedures with GA as outpatients
• Patient with a score of 5 not good candidates for surgery in a freestanding ASC
• Hospitalized patients at risk of respiratory compromise –continuous pulse oximetry as long as they remain at risk
Seet and Chung 2010
Functional Algorithm
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Functional Algorithm
JHH Algorithm
VA Study 2012
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VA Study
• Survey: 102 facilities – Preoperative screening tool – Existence of formal institutional policy – Postoperative setting
• 80% response rate
VA Study
• Screening tool: – 52% ASA criteria – 10% STOP questionnaire – 4% Berlin questionnaire – 18% other – 17% none
VA Study
• Degree of OSA most important factor influencing postop disposition
• 10% reported a major complication attributable to OSA in the prior 12 mos.
• 74% unaware of an institutional policy for known or presumed
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Attitudes 2014
Survey
• 3000 US physicians: 28.7% response rate • 783 questionnaire returned:
– 27% reported their hospital had a written policy for the perioperative care of OSA patients
2013 Update ASA
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Update?
“The new findings did not necessitate a change in recommendations…The ASA Guidelines differ…because it provides new evidence obtained from recent scientific literature as well as findings from new surveys of expert consultants and randomly selected ASA members….
Synergism
What can be accomplished when major societies representing multiple disciplines collaborate to achieve a common goal?
AHA/ACC Guidelines 1995
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ACC/AHA Guidelines 2014
Future Directions
• Unanswered questions – Optimal method of screening – Impact of screening – Optimal monitoring—type and duration – Impact of treatment-preoperatively and
postoperatively • Goal:
– Shared statement from the great societies
