An order-based approach to facilitate postoperative decision-making for patients with sleep apnea

Correspondence

DOI: 10.1007/s12630-012-9844-z

Cite this article as:
Swart, P., Chung, F. & Fleetham, J. Can J Anesth/J Can Anesth (2013) 60: 321. doi:10.1007/s12630-012-9844-z

To the Editor,

The clinical practices pertaining to the perioperative management of patients with sleep apnea are inconsistent,1,2 and the introduction of a practical approach remains a challenge for a variety of reasons, including diagnostic challenges.3 In addition, the failure to provide the proper follow-up instructions for patients with suspected sleep apnea may have potential medico-legal ramifications, e.g., if accidents occur while driving or performing occupations wherein safety is critical.4

In July 2012, the Vancouver Acute Department of Anesthesia (VADA), serving both Vancouver General Hospital (VGH) and the University of British Columbia Hospital (UBCH), introduced a postanesthesia care unit (PACU) order-based sleep apnea protocol (henceforth referred to as “the protocol”) in an attempt to address the above-mentioned challenges. The protocol (Figure Panel A) was introduced as an alternative to the established standard three-hour minimum PACU stay for patients with sleep apnea.

The protocol is based on three components:
  1. 1.

    A validated screening tool for sleep apnea, i.e., the STOP-Bang questionnaire.3

     
  2. 2.

    The preoperative prediction of the risk of perioperative complications from sleep apnea based on the severity of sleep apnea, the invasiveness of the surgery, and the requirement for opioids.1

     
  3. 3.

    The risk of postoperative respiratory complications based on observation in the PACU for the occurrence of recurrent respiratory events,5 and/or the requirement for opioids, and/or the need for supplemental oxygen to maintain the patient’s baseline hemoglobin oxygen saturation above 90%.1

     
The protocol prompts the PACU nursing staff to gather and convey the relevant information for appropriate postoperative decision-making for patients with sleep apnea. In addition, the anesthesiologists are prompted to:
  • Consider all the relevant factors when estimating the postoperative risk from sleep apnea;

  • Instruct all patients with suspected sleep apnea to obtain a sleep disorder consultation;

  • Request a respirology consult for patients at high postoperative risk from sleep apnea;

  • Identify the subset of patients with sleep apnea who would not require extended stay in the PACU1; and

  • Admit the patient to a monitored bed if at increased postoperative risk from sleep apnea.

The reverse side of the orders (Figure Panel B) features a table3 and a diagram4 to help facilitate decision-making.

In October 2012, a questionnaire was distributed to the 58 members of VADA to assess their initial impressions regarding the usefulness of the protocol, and the response rate was 77.6%. At that point, the responders had collectively completed 103 to 127 of the questionnaires (some of the responders selected a range of numbers). One question queried whether the new protocol would be helpful to facilitate appropriate postoperative care for patients with sleep apnea: 47% of respondents indicated “definitely”, 36% indicated “probably”, 16% “possibly”, and 2% indicated “no”.

Over the last fiscal year, 17,433 patients had surgical procedures in the operating rooms at VGH, and 8,443 patients had surgical procedures at UBCH. At this point, no data are available regarding the percentage of diagnosed sleep apnea in our perioperative population at VGH or UBCH.

A practical way to implement the increasing body of literature on the perioperative management of patients with sleep apnea remains a challenge. This example of a PACU order-based protocol may be useful for other institutions trying to formulate a practical approach to the postoperative management of sleep apnea.
Panel A

Postanesthesia care unit (PACU) orders: patients with diagnosed or suspected sleep apnea

Panel B

STOP-Bang Questionnaire, and flow diagram for the postoperative management of the OSA patient after general anesthesia

Disclosures

None.

Competing interests

None declared.

Copyright information

© Canadian Anesthesiologists' Society 2013

Authors and Affiliations

  1. 1.University of British Columbia, Faculty of MedicineVancouver General Hospital and University of British Columbia HospitalVancouverCanada
  2. 2.Toronto Western Hospital, University Health NetworkUniversity of TorontoVancouverCanada
  3. 3.University of British ColumbiaVancouverCanada

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