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OSA & the Perioperative Orthopaedic Patient
Who Has OSA?
OSAUnderdiagnosed
OSA is linked to increased risk for HTN, C-V events including nocturnal arrhythmias, including afib & V-tach, MI, stroke, & DM.
Considered an independent risk factor for increased postoperative morbidity.
Those with OSA frequently have multiple co-morbidities: COPD, HTN, DM, CAD, obesity.
OSA & Obesity• Attributed to a concommittant rise in prevalence
of obesity. A 10% increase in body weight can increase your risk of OSA by 6 fold.
• Caused by fat deposits around your upper airway and decreased chest excursion from abdominal obesity.
In one study Obesity is 5X more prevalent among the those with OSA (Memtsoudis et al).
http://youtu.be/A9lLSw9Rtjs
OSA
OSA is a partial or complete airway obstruction resulting in repetitive incomplete or complete cessation of airflow during sleep a/w strenuous breathing against resistance followed by period of desaturation, hypercarbia and then subsequent arousal.
OSA Video
http://www.mayoclinic.org/diseases-conditions/sleep-apnea/multimedia/obstructive-sleep-apnea/vid-20084717 - 31k
• OSA Can provoke long term C-V consequences such as right ventricular dysfunction, atrial fibrillation, heart failure and stroke.
• OSA can also cause a higher incidence of complications in the perioperative period including: post op deliriumhypoxiaaspiration pneumoniaARDSPEIntubation/mechanical ventilation and increased use of ICU’s
Diagnosis• Timely diagnosis is difficult
• While PSG remains the gold standard for diagnosis, it requires an overnight stay, complex equipment, expensive, & need available facilities.
• Screening Instruments help estimate the risk of OSA:- American Society of Anesthesiologists (ASA) check list- Berlin Questionnaire- Stop Model/Stop-Bang Questionnaire.
• These look at S&S of OSA: snoring, observed apnea,, obesity, neck circumference….
• Chung, et al. evaluated use of serum HCO3 as an indicator of chronic metabolic compensation for chronic recurrent respiratory acidosis (HCO3 > 28mmol) & a score of > 3 on the STOP-BANG questionnaire increased specificity to 85%.
Stop-Bang Questionnaire
1. Snoring: Do you snore loud enough to be heard thru closed doors? Yes/No
2. Tired: Do you often feel tired, fatigued, sleep during day? Yes/No
3. Observed: Has anyone observed you stop breathing during sleep? Yes/No
4. Pressure: Do you have HBP? Yes/No
5. BMI: BMI > 35? Yes/No
6. Age: > 50 y/o? Yes/No
7. Neck Circumference: Greater than 40cm? Yes/No
8. Gender: Male? Yes/No
High Risk of OSA: yes to 3 or more questions Indicates high probability of OSA
Low Risk of OSA: yes to less than 3 questions
Chung, F., Subramanyam, R., Liao, P., Sasaki, E., Shapiro, C. & Sun, Y. High STOP-BANG score indicates a high probability of obstructive sleep apnea. British Journal of Anesthesia, 2012.108(5), 774.
ASA GuidelinesAmerican Society of Anesthesiologists
• Preoperative Evaluation: interview, MR review, PE, PSG,…Anesthesiologists should work with surgeon to develop a protocol where pts with possibility of OSA are evaluated long before day of surgery.
• Preop initiation of NIPPV (noninvasive positive pressure ventilation ) if severe OSA. Mandibular advancement devices and preop weight loss should be considered.
ASA Guidelines (continued)American Society of Anesthesiologists
• Use regional anesthesia – spinals and peripheral nerve blocks; peripheral nerve catheters. Also agreement that excluding opioids from spinals reduces risk.
• Recommendation is to avoid general anesthesia and intubation.
• Use local anesthesia when possible.
• Caution against concomitant use of Benzo’s/barbituates which increase risk of respiratory depression.
• Avoid PCA’s with basal infusions.
• Use NSAIDS as much as possible.
• Patient positioning: lateral, prone or 45 degree sitting. Avoid supine.
• Recommend continuous pulse oximetry until room air sats are above 90% during sleep. Use of supplemental O2, as warranted.
• Risk factors for postop respiratory depression:• Severity of OSA• Systemic use of opiods• Use of sedatives• Potential for apnea during REM rebound on POD #3-#4.
ASA Guidelines (continued)American Society of Anesthesiologists
Implications
•Patients with OSA are at increased risk of perioperative complications. Results in need for more intense monitoring and strategies to prevent adverse events.
•Implementation of a sedation scale. Sedation precedes respiratory depression 2/2 opioid administration. Sedation and respiratory assessments should be done Q1-2h in the first 24h of surgery depending on risk factors and presurgical screening. Increases demand on nursing resources.
•Use of opiod analgesics, anxiolytics (Xanax), antihistamines (Benadryl, scopolamine) and antiemetics can increase risk of postop respiratory and cardiac complications.
Implications (continued)
• Information regarding the effects of length of OR time, and EBL is not available from most of the studies because a lot of the studies are retrospective and taken from databases, and this information is frequently not available.
• Information regarding readmission rates are not available from most of the studies because a lot of the studies are retrospective and taken from databases, and this information is frequently not available.
• The use of simple screening tools now allows us to estimate the likelihood someone has OSA, but what then is the next step?? Delay surgery? Or proceed knowing the risk of complications is higher? Refer pt for workup and treatment before surgery? Rate of noncompliance with treatment is high. How long should a pt be treated with PAP before proceeding with surgery?
• There is little data to support the use of PAP in the acute postoperative setting in improving outcomes, and cost is high so adherence is low.
• Be aware that patients are at risk for prolonged apnea during sleep for up to 1 week after surgery due to interruptions in REM sleep. It is imperative they use their CPAP during this time. REM sleep can be lost during the initial postop period. REM sleep may return in a rebound fashion with decreased pharyngeal tone, hypoxemia and prolonged apnea.
Implications (continued)
References
• American Society of Anesthesiologists Task Force on the Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative management of patients with obstructive sleep apnea. Anesthesiology 120 (2). 268-286. (2014)
• Chung, F., Subramanyam, R., Liao, P., Sasaki, E., Shapiro, C. & Sun, Y. High STOP-BANG score indicates a high probability of obstructive sleep apnea. British Journal of Anesthesia, 2012; 108(5), 774.
• Memtsoudis, Stavros G., Besculides, Melanie C., & Mazumdar, Madhu. A rude awakening- the perioperative sleep apnea epidemic. The New England Journal of Medicine, 2013; 368: 2352-2353.
• Memtsoudis, Stavros; Spencer, Liu S.; Yan, Ma; Chiu, Ya Lin; Walz, J. Matthias; Gaber-Bayllis, Licia K.; & Mazumdar, Madhu. Perioperative Pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesthesia & Analgesia, 2011. 112(1): 113-121.
• Roop, Kaw; Pasupuleti, Vinay; Walker, Esteban; Ramaswamy, Anuradha; & Foldvary-Schafer, Nancy. Postoperative complications in patients with obstructive sleep apnea. Chest, 2012. 141(2): 436-441.
• Studndner, Ottokar; Opperer, Mathias; & Memtsoudis, Stavros G. Obstructive sleep apnea in adult patients: considerations for anesthesia and acute pain management. Pain Management, 2015. 5(1): 37-46.
• Veney, Amy J. Promoting safety of postoperative orthopaedic patients with obstructive sleep apnea. Orthopaedic Nursing, 2013. 32(6): 320-324.
Post-op Hypovolemic Shock
Pathophysiology
(Martel et al)
Post-Op Hypovolemic Shock
Signs and symptomsSystem Early Shock Late Shock
CNS Altered Mental Status
Obtunded
Cardiac TachycardiaOrthostatic hypotension
Cardiac failureArrhythmiasHypotension
Renal Oliguria Anuria
Respiratory Tachypnea TachypneaRespiratory failure
Hepatic No change Liver Failure
Gastrointestinal No change Mucosal Bleeding
Hematological Anemia Coagulopathy
Metabolic None AcidosisHypocalcemiaHypomagnesium
(Martel et al)
Post-Op Hypovolemic Shock
Early Treatment
ORDER:O OxygenateR Restore circulating volume (Crystalloid solutions, blood transfusions)D Drug TherapyE Evaluate response to therapy (VS, Urine output, mental status, CBC, CMP, PTT PTINR)R Remedy underlying cause
Post-Op Hypovolemic Shock
Late Treatment
O OxygenateR Restore circulating volume (Crystalloid solutions, blood transfusions)D Drug Therapy Vasoactive agents Dopamine/ Norepinephrine) considered stress dose steroids or antibioticsE Evaluate response to therapy (VS, Urine output, mental status, CBC, CMP, PTT PTINR)R Remedy underlying cause
Post-Op Hypovolemic Shock
Case Study DF
ED Presentation and Care HPI 85 y/o female fell at home found by aide, on ground
with leg behind her. Hx dementia pt was treated at scene by EMS with zofran 4 mg and Morphine sulfate 10mg IVP
PMH Dementia, asthma, CHF, COPD, PSH rt rev THA Social hx 60yr smoking hx, lives w dtr, no ETOH PE: 50 kg, T 97.9 P 118 R 16 BP 100/57 oxygen saturations
93% 2L NC rt leg deformity, pulses with doppler ECG at fib w VR 113
Post-Op Hypovolemic Shock
Case Study DFSystem ED/2000 UNIT/0600 ICU/0800
CNS Dementia-awake
unresponsive unresponsive
Cardiac HR 118 BP 100/57Hgb 11.9 wbc 11.8 CK 160, SR
HR 112 BP146/115Hgb 10.7 wbcAT Fib w RVR
HR 110BP 102/64CK-437AT Fib w RVR
Renal NCBUN 19 CR1.5 BUN 27 CR
2.6
BUN 29 CR 3.0
Respiratory 16O2 sat-94% 3L
8-12 BG-Ph
7.157 O2 sat-100% NRB
R-12 BG Ph 7.2O2 sat-99% 6L
Hepatic SGOT-22 SGOT- 30 SGOT-48
Gastrointestinal NPO NPO NPO
Metabolic Na 142K+ 4.6
Na 147K+ 6.2
Na 144K+ 4.9
Post-Op Hypovolemic Shock
Post-Op Hypovolemic Shock
Post-Op Hypovolemic Shock
Post-Op Hypovolemic Shock
Case StudyFloor care
O OxygenateR Restore circulating volume (Crystalloid solutions, blood transfusions) none ordered D Drug Therapy none ordered E Evaluate response to therapy (VS, Urine output, mental status, CBC, CMP, PTT PTINR)R Remedy underlying cause
Post-Op Hypovolemic Shock
Case StudyICU care
O OxygenateR Restore circulating volume (Crystalloid solutions, blood transfusions) Normal Saline D Drug TherapyE Evaluate response to therapy (VS, Urine output, mental status, CBC, CMP, PTT PTINR)R Remedy underlying cause
Post-Op Hypovolemic Shock
Conclusions
Think about hypovolemia-early signs
Aggressive fluid resuscitation
Monitor I&O especially urine output
Report abnormal findings
Think about bleeding
References
Barbosa, N, Moraes, B, Souza, N, Rocha, F, Cavalho Barzil J “Hemostatic resuscitation in traumatic hemorrhagic shock case report” Anesthesiology 2013 Jan-Feb;63(1) 99-102
Bartellas, E, Klien, M, Lane, C, Sprague, A, Wilson, A. “ Hemorrhagic Shock”, SOGC Clinical Practice Guidelines. The Journal of Obstet Gynaecol Can 2012:24 (6):504-11
R. S. Braithwaite, N. F. Col, and J. B. Wong, “Estimating hip fracture morbidity, mortality and costs,” Journal of the American Geriatrics Society, vol. 51, no. 3, pp. 364–370, 2003
M. Bumann, T. Henke, H. Gerngross, L. Claes, and P. Augat, “Influence of haemorrhagic shock on fracture healing,” Langenbeck's Archives of Surgery, vol. 388, no. 5, pp. 331–338, 2003.. Martel,M , MacKinnon, C,.
Lichte, P Kobbe, P Pfeifer, R, Graeme, C Rainer, B, Mersedeh, T, Bergmann, C, Kadyrov, M, Fischer, H, Gluer, C, Hildebrand, F Pape, H, Pufe, T “Impaired Fracture Healing after Hemorrhagic Shock” Mediators of Inflammation Volume 2015 (2015), Article ID 132451, 7 pages.
S.-K. Lee and J. Lorenzo, “Cytokines regulating osteoclast formation and function,” Current Opinion in Rheumatology, vol. 18, no. 4, pp. 411–418, 2006.
Small Bowel Obstruction
Definition
• Small bowel obstructions are caused by a variety of pathologic processes.
• An obstruction is a blockage of the intestine (small or large) which does not allow the passage of food or fluids (mechanical or functional).
• It is a frequent cause of hospitalization and surgery consult, representing appx 20% of all surgery admission for abdominal pain.
Types of SBO Mechanical obstruction - is something that physically blocks the small
intestine.
Causes:
1. Intestinal adhesions: #1 cause of SBO (small fibrous tissue in abdominal cavity)
2. Hernia
3. Tumors
4. Inflammatory bowel disease ie. Crohn’s Disease
5. Twisting of intestine (volvulus)
6. Telescoping of the intestine (intussusception)
7. Impacted Feces
Continued Types of SBO
Paralytic Ileus/Functional Bowel Obstruction-can cause s/s of intestinal obstruction, but doesn’t involve a physical blockage. It involves an impaired gastrointestinal motility dysfunction by slowing the movement of food/fluid thru the intestine.
Causes:
1. Abdominal surgery
2. Pelvic surgery
3. Infection
4. Certain Medications-antidepressants, narcotics, anesthesia
5. Muscle/Nerve Disorders-ie. Parkinson’s Disease
6. Constipation is the #1 associated factor for ileus after ortho surgery incidence
The incidence of ileus after lower limb reconstruction ranges from 0.3%-2.0% w/an even higher incidence (5.6%) following revision THA
(Lee et al)
Pathophysiology of SBO
Partial vs Complete
Significant obstruction is associated with increased intestinal contractions proximal to the site of the obstruction and are associated with abdominal cramps.
With complete unrelieved obstruction bowel contents fail to pass distally, resulting in accumulation of fluids causing distention/dilation of the proximal bowel.
As pressure in the bowel proximal to the obstruction increases blood flow decreases which can result in :
1. Hemorrhage
2. Ischemia/Necrosis
3. Infarction of the bowel
4. Perforation-as a result of ischemia
5. Sepsis/peritoneal infections/shock
6. Death
In simple obstruction the proximal bowel appears heavy, edematous, and even cyanosed.
Acute SBO results in volume depletion and electrolyte imbalance. Vomiting Loss in the peritoneal cavity (fecal fluid)
Intestinal contents are cut off from the absorptive surface of the colon
Pathophysiology of SBO (continued)
History Taking Good history taking on admission is important
Last bowel movement and usual pattern Abdominal history of pelvic/colon disease ie. CA, radiation,
inflammatory bowel disease Has the patient ever experienced any complications r/t any previous
surgeries in the past (ie. SBO)
Remember abdominal adhesions is the #1 cause of mechanical SBO Remember Constipation is the #1 cause of functional SBO
Signs & SymptomsSmall bowel obstruction is considered a medical emergency
• Signs & Symptoms:- Nausea- Constipation- Abdominal Pain - colicky in nature- Abdominal distension- Vomiting - is a pronounced symptom in SBO
• Other Sign & Symptoms that are more ominous:- Fever- Tachycardia & associated hypotension
Assessment
In the focused gastrointestinal assessment consider the following:
1. Vial Signs - fever, tachycardia with associated hypotension2. Nausea3. Vomiting4. Bowel Sounds - hypoactive, tinkling, absent5. Abdominal Distension6. Constipation
Other items to consider are: Medications & past medical history
Imaging Work-Up Algorithm
Imaging for SBO• Plain abdominal xrays provide the most valuable
information in the initial diagnosis of acute SBO, in appx 50-60% of cases this type of imaging will provide enough information needed for clinical decision making (proves to be low cost & effective).
• Ct scans are used when xrays are equivocal, normal, or low grade partial SBO is suspected & is 85%-95% accurate in diagnosis.
(Silva et al)
Radiology Classification of SBO
High grade vs Low gradeHigh Grade SBO:• Multiple air fluid levels with a width of 2.5 cm or more• Vertical height of more than 2 cm b/t air fluid levels• Distension of small bowel diameter more than 2.5 cm & a
small bowel-colon diameter ratio greater than 0.5• Delay in passage of CT contrast
Low Grade SBO:• Sufficient flow of contrast material through obstruction• Less air fluid levels• Still will see distension of the small bowel
(Silva et al)
Examples of High grade SBO on Xray
High-grade SBO. Plain abdominal radiograph shows multiple air-fluid levels (arrows), some with a width of more than 2.5 cm. In addition, there is a differential vertical height of more than 2 cm between corresponding air-fluid levels in the same bowel loop (circled area). There is also distention of the small bowel diameter to more than 2.5 cm and a small bowel–colon diameter ratio of greater than 0.5.
(Silva et al)
High grade SBO Xray(AlReefi & Shukri)
Surgical view of High grade SBO
(Al Reefi & Shukri)
Further Diagnostic Work-Up
Other Diagnostic Testing :CBC-leukocytosisBMP-if bun & creatine are elevated may
indicate dehydrationUALFTPancreatic enzymes
Further Diagnostic Work-Up
(continued)
Other Differential Diagnosis to Consider:
• Gastroenteritis
• Pancreatitis
• UTI
• Cholecystitis
• Inflammatory Bowel Disease
• Appendicitis
Treatment of SBO Aggressive resuscitative fluid therapy
Electrolyte imbalance correction
NPO
Decompression of stomach-NGT helps prevents aspiration
Foley Catheter for strict I&O
Labs: CBC, BMP, LFT’s, Pancreatic enzymes, UA
Analgesics – morphine based
Antibiotic Therapy - broad spectrum used for prophylaxis in surgical intervention
General surgery consult
Antimetics: zofran, reglan, tigan, compazine Stay away from scopolamine patches (can cause constipation, decreased gut motility, and
even bowel stasis by mechanism of anticholinergic effect)
(Kulaylat & Doerr)
Prognosis of SBO• With proper diagnosis & txmt of SBO the prognosis is good. Complete
obstructions treated successfully non-operatively have a higher incidence of reoccurrence than do those treated surgically.
• Mortality & Morbidity are dependent on early recognition & correct diagnosis of obstruction. If untreated or strangulation occurs-death is 100%. If surgery is performed within 36 hrs mortality decreases to 8%.
• Factors associated with death & post-operative complications include:
- age
- comorbidity
- txmt delay
(Nobie et al)
Case Presentation #1K.W. a 66 yr female admitted for an elective right THA , last BM was 3 days
PTA
• PMHX: HTN, DM, hypercholesterolemia, CAD, gerd, constipation, hypothyroidism, OA
• PSX Hx: TKA, hysterectomy, goiter removal, right thumb sx
• Recd from recovery with N/V, recd spinal anesthesia non duramorph
• Continued to have N/V up until day of discharge on POD #2 which had resolved prior to dc: had recd mutliple IV boluses, reglan, no abdominal xr was done.
• Assessment: +bs x 4, + flatus per pt, abd soft, nontender, nondistended.
• Zofran. +flatus per patient. No BM on day of DC. Had recd K-dur x 1 for hypokalemia on POD #1
• Readmitted POD #4 with a SBO thu the ED.
• Assessment: abd mildly distened, mild diffuse tenderness no rebound tenderness or guarding. No flatus since dc, no bm, continues w/N&V
• Abdominal xr revealed a high-grade SBO may be early w/ileus. +leukocytosis. + Electrolyte imbalance. Further information gathering from the patient revealed that she experienced a SBO w/her hysterectomy yrs ago.
• Medications upon admission consisted of: percocet, senna S, zetia, lipitor, insulin, toradol, synthroid, benicar, cozaar, protonix, miralax, xalerto, livalo, dexilant, dilaudid
Case Presentation #1(continued)
• Txmt: consisted of conservative mgt w/fluids, pain mgt, antiemetics, NGT, NPO, strict I&O, serial lab draws & xr. Patient failed conservative mgt & underwent an exp. Lap on POD# 9 w/extensive lysis of adhesions over 2 hrs, small bowel resection. Patient continued to fail txmt & was taken back 9 days later for a 2nd exp lap & at that time sustained a bowel perforation, further bowel resection, G-tube insertion, sepsis, ICU mgt for septic shock. TPN & lipids for nutrition. DC appx 1 month later on the 2nd admission.
• Patient returned to ED w/abdominal pain 2 additional times w/o evidence of SBO
Case Presentation #1(continued)
C.B. a 74 yr female admitted for elective left TKA recd. Spinal anesthesia with a femoral nerve block
• PMHx: AFIb w/cardoversion, HTN, hypercholesterolemia
• PSX Hx: TKA, Shoulder sx, finger sx, back sx, cataract sx
• Day of admission no N&V, abd was soft, non distended, non tender, hypoactive bs, last BM was the day PTA
• Patient experienced pain control issues and narcotic strength was increased to percocet 10/325
• POD #1: +N&V, no flatus, continued w/hypoactive bs. Labs wnl. Recd multiple IV boluses & reglan
• POD #2: in AM nausea resolved; but in PM returns. +flatus per pt. No BM. Abd xr reveals gas filled on dilated transverse/descending colon-non obstructive bowel gas pattern. No mention of an ileus. NGT was inserted, made NPO, continual IV fluids. Consult for general sx placed.
• POD #3: abd xr repeated reveals mildly dilated loop small bowel LUQ likely representing ileus & a large amt of stool. Ducolax suppository was given resulting in lg BM, NGT clamped, & DC tolerated clear liquid diet.
• POD #4 DC home. Narcotics were changed to ultram upon dc
Case Presentation #2
ConclusionsSBO is considered a medical emergency
Intervene early & be aggressive
Consider all hx of pt & when clinical picture isn’t making sense ask again
Evaluate all medications
Do a very focused GI assessment
Tx constipation early in ortho post-op pt
Notify physician early & ask for them to evaluate pt status
Questions??????
Thank You!!!
References Al Reefi, M.A. & Shukri, N. Missed small bowel obstruction that complicated an
acute appendicitis: A Misdiagnosis. Grand Rounds. Specialities: Case Report Article Type: Specialities Paediatric Surgery, 26 March 2013 e-med Ltd. Vol 13, pg 36.44.
Kulaylat, M. N. & Doerr, R. J. Surgical Treatment: Evidence-Based & Problem-Oriented small bowel obstruction, 2001. www.nebl.nlm.nih.gov/book/NBK6873/accessed April 12, 2015.
Lee T.H., Lee, J.S., Hong, S.J., Jany Young J., Jeon, S. R., Byrum, D.W., Park Young, W., Kim S.I., Choi, H.S., Lee, J.C., & Lee, J.S. Risk Factors for Post-Operative Ileus Following Orthopedic Surgery: The Role of Chronic Constipation. J. Neurogastroenterol Motil., 2015 Jan; 21(1): 121-125.
Nobie, Brian A. Small-Bowel Obstruction. Medscape Reference: Drugs, Diseases & Procedures. Updated: Jan 20, 2015.
Silva, A. C, Pimenta, M., and Guimaraes, L. Small Bowel Obstruction: What to Look For. RadioGraphics. March-April 2009, 29 (2).
