new perioperative aspects of osa post op opioids post covid lab … · 2020. 9. 22. · 33...
TRANSCRIPT
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Patient Safety/Ethics
Perioperative Aspects of OSA
Post–Op Opioids
Post Covid Lab Operations
Peter Allen, BSRC, RRT-NPS-SDS, RPSGT
Philadelphia Sleep Conference 2020
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Conflicts of Interest
• Main Line Health System
• NBRC Sleep Exam Consultant
• Member: AAST, AASM, AARC, SASM
• Current Board Member PA Sleep
Society
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Questions for Attendees
• How many Night Sleep Technologists?
• How many RTs? How many Directors
• How many labs are back to Pre-Covid #s?
• How many are directly involved with a
Perioperative OSA and Opioid
Management Program?
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Goals
• Brief Overview of Perioperative Aspects
• Discuss Post-Op OSA & Opioids
• Discussion of Attendees Experiences
• Patient/Technologist Safety Post Covid
• Lab Start-up after Covid
• Solutions
• One or Two Ideas Back to Labs
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Learning Objectives
• Identification of the “At Risk” Patient
• Review of Adverse Outcomes
• Tools
• Why, Who, Where, What, How
• Supporting Perioperative OSA
Management
• Raising Questions for Discussion
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Why Perioperative Management?
• At Risk OSA Population is Growing
• More OSA Patient Post-Op Complications
• Respiratory Failure
• Re-Intubation
• Unexpected ICU Admissions
• Increased PACU Time
• Increased Suffering/Liability/Cost
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Raising Questions
• How often do you see respiratory
emergencies in the hospital?
• How many could OSA have been factor?
• Unexpected Deaths in the PACU
• Unexpected Deaths 24 hrs after Surgery
• Within one week of Surgery?
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Payment for Performance
• Value-Based Purchasing
• Rewards
• Disincentives
• Quality-Payment Alignment
http://www.ahrq.gov/qual/qpayment.htm
• Implementation Timelines
http://healthreform.kff.org/timeline.aspx
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American Society of Anesthesiologists
• 2006 Commissioned a Task Force that
Identified the Importance of Pre-Screening
surgery patients for the presence of
Obstructive Sleep Apnea (OSA).
• Purpose: Prevent Post-Surgical
Respiratory Events
• Anesthesiology 2006; 104:1081-93
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2008 National Patient Safety Goals
• Proposed Goal 17 from Task Force
• Reduce Risk of Post-Operative
Complications for Patients with
Obstructive Sleep Apnea
• Organization screens potential OSA
patients prior to surgical procedures
involving centrally acting anesthetic and/or
analgesic agents.
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Epidemiology of OSA
• It is estimated that 75% to 95% of patients
with OSA are not yet diagnosed.
• Many who are diagnosed are not being
treated effectively.
• Body Mass Index>30
• Estimates are that 26% of Adults are at
Risk
• 80%-Bariatric/60%-Diabetic/40%-CHF
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Pathophysiology of OSA
• Awake: Airway Patent/Neuromuscular Compensation
• Sleep Onset
• Neuromuscular compensation is lost
• Airway Collapses
• Apnea Occurs
• Hypoxia & Hypercapnia ensue
• Ventilatory effort increases
• Arousal from sleep
• Pharyngeal muscle tone increases
• Patent airway restored
• Hypoxia and Hypercapnia improved by hyperventilation
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OSA Increasing
• Obesity is increasing at epidemic
proportions which is only adding to the
problem of increasing numbers of “at risk”
patients presenting for surgery.
• Obesity Maps
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Associated OSA Conditions
• Obesity Hypertension
• Depression Coronary Artery Disease
• Accidents Arrhythmias
• Diabetes Left side heart enlargement
• GERD LV Dysfunction
• Stroke Congestive Heart Failure(CHF)
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Anesthesia Concerns with OSA
• OSA patients are more susceptible to airway collapse without anesthesia.
• OSA can affect all three phases of perioperative period.
• Anesthesiologists role in identification of the at risk OSA patient.
• Upper airway dilator muscles impaired.
• Effect may last for hours
• Eikermann, et. Al., AmJRespirCritCareMed 2007 175:9-15
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Anesthesia
• Impairs airway patency
• Increases difficulty of intubation
• Brain response less effective
• Narcotics decrease sensitivity to CO2
• Respiratory drive/rate depressed
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Anesthesia
• Upper airway muscle tone reduced with
opiates, sedatives and volatile agents.
• Perpheral control of O2 inhibited
• Recovery rooms
• Local and regional nerve block options
• Malampatti Scores 1-4
• Patients now encouraged to bring PAP
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Anesthesia
• Unexpected Risks during
Administration of Conscious Sedation:
Previously Undiagnosed Obstructive
Sleep Apnea
• Annals of Internal Medicine, 2003;139:
707-708
• Pressman, et. Al.
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Case Reports 1of 6
• Male 65 years of age-Radical prostatectomy
• History showed Positive OSA Profile
• Not diagnosed/treated
• Morphine 5 mg, epidural
• 8 hours later found unresponsive
• Apneic with Cyanosis
• Patient recovered
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Case Report 2 of 6
• Male 38 years of age-Emergent mastoidectomy
• History of loud snoring
• Diagnosed with OSA, but never treated
• Upon extubation patient airway collapses
• Reintubated
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Case Report 3 of 6
• Male 41 years of age-Orthopedic surgery
• Diagnosed, but not treated
• Epidural opiods
• Post-op day 2 found unresponsive
• Irregular respiratory pattern
• Cardiac arrest lead to death
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Case Report 4 of 6
• Female 42 years of age-Laproscopic surgery
• Diagnosed with OSA, but not treated
• Post-op prolonged heart block during sleep
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Case Report 5 of 6
• Obese male, 42 years of age-Surgery
• Diagnosed with OSA, not treated
• Morphine
• Cardiac arrest
• Severe hypoxia followed by cerebral silence
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Case Report 6 of 6
• 101 OSA patients and 101 matched controls
• Hip & knee surgery
• OSA patient diagnosis prior to or after surgery
• Controls did not get PSG-????
• Post-op complications greater in OSA patients
• Hospital reported longer stays for OSA group
• Hospital reported more ICU transfers/OSA pts.
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Parker Stewart’s Bill
• Uintah Basin Medical Center
• 3 unexplained deaths post-op
• Parkers death ruled Pneumonia/Ethics
• Post-Op Opioids, common factor
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At Home Monitoring
• Being studied at this time
• Respiratory Rate
• Pulse Oximetry
• Capnography
• Hospital Revenue???
• Masimo
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Peer Review Article
• HOME MONITORING OF POST-OPERATIVE EAR, NOSE & THROAT
(ENT) PATIENTS FOR OPIOID INDUCED RESPIRATORY DEPRESSION-
--MORE THAN OSA
• PRESENTING AUTHOR: Kim Bennion MsHS, RRT, CHC, Intermountain
Healthcare
• CO-AUTHOR: Shaylynn Uresk BSRT, RRT, SDS, Uintah Basin Medical
Center
• BACKGROUND: Opioid related deaths have been rapidly increasing1. A
recent study suggested oxygen saturation (SpO2) & other overnight
oximetry measurements may provide additional Opioid Induced Respiratory
Depression (OIRD) risk stratification insight2.
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Parker References
• CDC’s report on opioid related deaths• https//www.cdc.gov/drugoverdose/epidemic/index.html
• Suen C, Ryan et al
• Sleep study and oximetry parameters for predicting
postoperative complications in patients with OSA.
• Chest ; 155(4):855-867 2019
• https://youtu.be/R-4JwdUC4hO Parker’s Story
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OSA – Diagnosis
• Clinical examination(history and physical
examination) carries a diagnostic sensitivity and
specificity of only 50 to 60% even when
performed by experienced sleep physicians
• Clinics of Chest Med 1998; 19:1-19
• If it walks like, talks like, looks like a ….
• Its OSA
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• If it walks like, talks like, looks like a ….
• Its OSA
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OSA Obvious as a Duck
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Preoperative screening for OSA
• Stop Bang Questionnaire with H&P
• Preoperative diagnosis
• Referral to sleep disorder center
• Preoperative treatment if possible
• PAP Treatment prior to surgery
• PAP Treatment documented prior to surgery
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Identifying the Problem
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Stop-Bang Stop-Bang Stop-Bang
• 1. Do you Snore loudly?
• 2. Do you often feel Tired during the daytime?
• 3. Has anyone Observed you stop breathing during your sleep?
• 4. Do you have or are you being treated for high blood Pressure? Stop
• 5. BMI more than 35 kg/m ?
• 6. Age over 50?
• 7. Neck circumference greater than 40cm?
• 8. Gender male? Bang
• High Risk of OSA=Yes to 3 or more items
• Low Risk of OSA= Yes to less than 3 items
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American Society of Anesthesiology
Recommendations
• Anesthesiologists are working with Surgeons
• Develop Protocols
• Get suspected OSA patients diagnosed and
treated prior to surgery whenever possible
• If diagnosis of OSA is made on the day of the
surgery, then patient and family needs to be
informed of the potential implications of OSA on
the perioperative course.
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ASA Recommendations Continued
• Be prepared for difficult intubation
• Choice of anesthetic technique
• Oximetry and end-tidal CO2 monitoring
• Full reversal of neuromuscular blocking agents
• Consider non-supine extubation.
• General anesthesia preferable to deep sedation
• Spinal epidural considerations vs IV
• Use of opioids vs regional anesthesia
• Discharge delay a consideration
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Perioperative Program Awareness
• Contact these areas all at the same time
• Bio-Ethics Department
• All medical staff members
• Grand Rounds Presentations
• Lunch and Learn AMA CEUs
• Community Outreach Programs
• Allied Healthcare Staff
• Home Care Companies
• Manufacturers
• Implement Outcome Tracking Protocols
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Home Monitoring
• Check w Masimo
• DME/Hospital Revenue
• Physician/Patient Education is Key
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Perioperative Management of OSA,
Budget
• Questions to Ask:
• Cost Center vs Revenue Center
• What is it going to cost to implement or
to increase awareness?
• What will it cost if we do not
implement or promote?
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Hospital Implications
• At risk patients not served-Ethical aspects
• Patient Safety/Patient experience
• Hospital revenue
• Hospital reputation
• Hospital recognition
• Physician revenues/Sleep Lab Revenues
• Surgical Risk Liability and SurgSchedules
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HME Considerations
• Perioperative program will:
• Drive PAP business higher
• Drive O2 business higher
• Increase your referral base
• Improved relations with area medical and
surgi-centers
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Sleep Disorder Centers
• Additional Revenue
• Navigators???
• Increase Referral Base
• Reinforces the fact that to survive sleep
disorder centers need to diversify/change
their sales and marketing focus on more
complex patients and new opportunities.
• Periop, Stroke, CHF, Diabetes-In House
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Working Together
• Primary Care Physicians
• Surgeons
• Anesthesiologists
• Allied Health, Nursing, Respiratory Care
• Sleep Disorder Centers
• Home Care Companies
• Hospital Administration
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Post Covid Sleep Lab Thoughts
• Performing HSTs, Performing PSGs/PAP?Note: Market/Referral Sources Lost can stay lost
• Keys to Bringing Back Your Numbers
• Disposable Everything (Even HSTs)
• PPE for Technologists
• Patient Screening at every stage of process
• Room Cleaning Machines
• Negative Air Rooms
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Helpful Organizations
• American Society of Anesthesiology
• ASA
• Society of Anesthesia & Sleep Medicine
• SASM
American College of Chest Physicians
ACCP
American Academy of Sleep Medicine
AASM and AARC
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Summary
• Patients with OSA
• Make up a significant portion of the surgical population and will only
increase as obesity trends move upward.
• Most are not identified before surgery
• Have an increased risk for perioperative complications
• Can be screened diagnosed and treated to manage perioperatively
to reduce risks.
• Programs can be implemented to identify and treat these patients
without substantial increases in costs, resulting in risk reduction,
improved patient safety and better outcomes.(Needs Champion)
• Implement a Post Covid Lab Program – AASM very helpful.
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References
• Stop Bang Questionnaire, Anesthesiology, V 108, No 5 May Chung, et al.
• Anesthesiology News Guide to Airway management-Obstructive Sleep Apnea Anesthesia, and Ambulatory Surgery, Bishop, et. al
• Perioperative Screening for and Management of Patients with Obstructive sleep Apnea-Beth Israel Deaconess Medical Center, Boston, MA, Sundar, et. al
• Avoiding adverse outcomes in patients with obstructive sleep apnea(OSA); development and implementation of a perioperative OSA protocol, Bolde, et. al.
• Postoperative Complications in Patients With Obstructive Sleep Apnea, CHEST 2012; 141;436-44, Kaw, et. Al.
• Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature, Journal of Clinical Medicine, Vol. 8, NO. 2 2012, Vasu, et. Al
• Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study 2001 Mayo Foundation, Mayo Clin Proc. 2001;76:897-905 Gupta, et.al.
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Home Monitoring of High-Risk
Opioid Patients
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• San Diego Patient Safety Council (2014). Monitoring Patient Outside the ICU Took Kit. Located at
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Home Monitoring of High-Risk
Opioid Patients
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Home Monitoring of High-Risk
Opioid Patients