Postoperative Critical Events Associated With Obstructive Sleep Apnea: Results From the Society of Anesthesia and Sleep Medicine Obstructive Sleep Apnea Registry.

BACKGROUND: Obstructive sleep apnea (OSA) patients are at increased risk for pulmonary and cardiovascular complications; perioperative mortality risk is unclear. This report analyzes cases submitted to the OSA Death and Near Miss Registry, focusing on factors associated with poor outcomes after an OSA-related event. We hypothesized that more severe outcomes would be associated with OSA severity, less intense monitoring, and higher cumulative opioid doses. METHODS: Inclusion criteria were age ≥18 years, OSA diagnosed or suspected, event related to OSA, and event occurrence 1992 or later and <30 days postoperatively. Factors associated with death or brain damage versus other critical events were analyzed by tests of association and odds ratios (OR; 95% confidence intervals [CIs]). RESULTS: Sixty-six cases met inclusion criteria with known OSA diagnosed in 55 (83%). Patients were middle aged (mean = 53, standard deviation [SD] = 15 years), American Society of Anesthesiologists (ASA) III (59%, n = 38), and obese (mean body mass index [BMI] = 38, SD = 9 kg/m); most had inpatient (80%, n = 51) and elective (90%, n = 56) procedures with general anesthesia (88%, n = 58). Most events occurred on the ward (56%, n = 37), and 14 (21%) occurred at home. Most events (76%, n = 50) occurred within 24 hours of anesthesia end. Ninety-seven percent (n = 64) received opioids within the 24 hours before the event, and two-thirds (41 of 62) also received sedatives. Positive airway pressure devices and/or supplemental oxygen were in use at the time of critical events in 7.5% and 52% of cases, respectively. Sixty-five percent (n = 43) of patients died or had brain damage; 35% (n = 23) experienced other critical events. Continuous central respiratory monitoring was in use for 3 of 43 (7%) of cases where death or brain damage resulted. Death or brain damage was (1) less common when the event was witnessed than unwitnessed (OR = 0.036; 95% CI, 0.007-0.181; P < .001); (2) less common with supplemental oxygen in place (OR = 0.227; 95% CI, 0.070-0.740; P = .011); (3) less common with respiratory monitoring versus no monitoring (OR = 0.109; 95% CI, 0.031-0.384; P < .001); and (4) more common in patients who received both opioids and sedatives than opioids alone (OR = 4.133; 95% CI, 1.348-12.672; P = .011). No evidence for an association was observed between outcomes and OSA severity or cumulative opioid dose. CONCLUSIONS: Death and brain damage were more likely to occur with unwitnessed events, no supplemental oxygen, lack of respiratory monitoring, and coadministration of opioids and sedatives. It is important that efforts be directed at providing more effective monitoring for OSA patients following surgery, and clinicians consider the potentially dangerous effects of opioids and sedatives-especially when combined-when managing OSA patients postoperatively.

High intraoperative inspired oxygen does not increase postoperative supplemental oxygen requirements.

BACKGROUND: Although a high fraction of inspired oxygen (FIO2) could reduce surgical site infection, there is concern it could increase postoperative pulmonary complications, including hypoxemia. Intraoperative positive end-expiratory pressure can improve postoperative pulmonary function. A practical measure of postoperative pulmonary function and the degree of hypoxemia is supplemental oxygen requirement. We performed a double-blind randomized 2 × 2 factorial study on the effects of intraoperative FIO2 0.3 versus more than 0.9 with and without positive end-expiratory pressure on the primary outcome of postoperative supplemental oxygen requirements in patients undergoing lower risk surgery. METHODS: After Institutional Review Board approval and consent, 100 subjects were randomized using computer-generated lists into four treatment groups (intraoperative FIO2 0.3 vs. more than 0.9, with and without 3-5 cm H2O positive end-expiratory pressure). Thirty minutes and 24 h after extubation, supplemental oxygen was discontinued. Arterial oxygen saturation by pulse oximetry was recorded 15 min later. If oxygen saturation decreased to less than 90%, supplemental oxygen was added incrementally to maintain saturation more than 90%. RESULTS: Nearly all subjects required supplemental oxygen in the postanesthesia care unit. Nonparametric Wilcoxon rank sum test demonstrated no statistically significant difference between groups in supplemental oxygen requirements at 45 min and 24 h after tracheal extubation (P = 0.56 and 0.98, respectively). CONCLUSIONS: Use of intraoperative FIO2 more than 0.9 was not associated with increased oxygen requirement, suggesting it does not induce postoperative hypoxemia beyond anesthetic induction and surgery. Therefore, it may be reasonable to use high inspired oxygen in surgical patients with relatively normal pulmonary function.

Long-term results of innominate artery reimplantation for tracheal compression.

OBJECTIVE: To evaluate the safety and long-term efficacy of innominate artery reimplantation as treatment for innominate artery compression syndrome. DESIGN: Retrospective medical record review from January 1, 1992, to December 31, 2007, and telephone interview. SETTING: Children's hospital. PATIENTS: Twenty-two children with innominate artery compression of the trachea requiring surgical intervention. INTERVENTION: Innominate artery reimplantation for innominate artery compression syndrome. MAIN OUTCOME MEASURES: Respiratory symptoms, rigid bronchoscopy results, operative time, estimated blood loss, duration of hospitalization, and complications. RESULTS: Twenty-two patients were seen with innominate artery compression of the trachea causing respiratory distress. The diagnosis was made based on chest magnetic resonance images, computed tomographic angiograms, and rigid bronchoscopy results demonstrating significant (>75%) tracheal stenosis. Following innominate artery reimplantation, 19 patients (86%) had complete resolution of symptoms and discontinuation of respiratory support. Two patients had partial resolution, and 1 patient had no improvement. The time course of resolution was immediate in 13 patients, after 3 months in 1 patient, and unknown in 5 patients. The mean operative time was 73 minutes, with a mean estimated blood loss of 18 mL. The mean postoperative duration of hospitalization was 6.5 days, with a mode and median stay of 3 days. One patient required prolonged intubation (5 days), and another patient developed postpericardiotomy syndrome. Telephone interview of 10 patients at a mean of 5 years after surgery revealed continued resolution of respiratory symptoms if previously resolved and no long-term complications. CONCLUSIONS: Innominate artery reimplantation is a safe and effective treatment for innominate artery compression syndrome. Resolution of symptoms occurs quickly in most patients, with excellent long-term results.