By Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD)
The American Society of Anesthesiologists recently updated its practice guidelines for the perioperative management of obstructive sleep apnea (published February 2014).
The purpose of these practice guidelines are to:
improve the preoperative care and reduce the risk of adverse outcomes in patients with confirmed or suspected OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist.
These guidelines provide a scoring system for perioperative risk for obstructive sleep apnea, which assigns a numerical score for severity of sleep apnea, invasiveness of surgery and anesthesia, and requirement for postoperative opioids. Surprisingly, this scientific-looking table has had no clinical validation whatsoever—but it is included in the guidelines.
Attempting to stratify the level of risk, and providing only some sleep apnea patients with postoperative monitoring could lead to adverse events and death. Perhaps no one has experienced the tragic consequences of this more than the family and friends of John LaChance.
As recounted in this video by his wife, Patricia LaChance, John suffered from sleep apnea. Despite this diagnosis, John died because his medical history was ignored and because he wasn’t properly monitored after he was placed on a powerful intravenous opioid to ease the pain from his surgery to repair a torn rotator cuff in his shoulder.
As I noted in my letter to the editor published in Anesthesiology:
Risk stratification for opioid-induced respiratory depression is by no means an exact science, and failure to rescue remains a significant source of human suffering and healthcare expense. The Anesthesia Patient Safety Foundation recognizes this fact, and has stated “…risk stratification for increased postoperative electronic monitoring would potentially miss a large population of patients that is at increased risk for opioid-induced respiratory depression.” Not surprisingly, the Anesthesia Patient Safety Foundation has advocated for continuous respiratory monitoring for all postoperative patients receiving parenteral opioids.
Practice guidelines, like those for the perioperative management of obstructive sleep apnea, are needed and may be helpful to providers to help make sound clinical decisions. However, the inclusion of an untested numerical risk assessment scale, which goes against the recommendations of the Anesthesia Patient Safety Foundation for risk stratification should be read with caution, even if there is a disclaimer in fine print at the bottom of the table shown above.