Various surgical and anesthesiological risks

Various surgical and anesthesiological risks

OSAdeliriumtransfusion in orthop surgerydifficult

spihypothermiamental illnessblindnesshypotension during

CS

OSA as a risk factor

Frances Chung Balaji Yegneswaran Pu Liao Sharon A Chung Santhira Vairavanathan Sazzadul Islam Ali Khajehdehi Colin M

Shapiro STOP QuestionnaireA Tool to Screen Patients for Obstructive Sleep Apnea Anesthesiology 2008 108812ndash21

bull Background Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events However no screening tool for OSA has been validated in surgical patients

bull This study was conducted to develop and validate a concise and easy-to-usebull questionnaire for OSA screening in surgical patientsbull Methods After hospital ethics approval preoperative patients aged 18 yr or

older and without previously diagnosed OSA were recruited After a factor analysis reliability check and pilot study four yesno questions were used to develop this screening tool The four questions were respectively related to

bull snoring tiredness during daytime observed apnea and high blood pressure (STOP) For validation the score from the STOP questionnaire was evaluated versus the apneandashhypopnea index from monitored polysomnography

Stop questionnaire A Tool to Screen Patients for Obstructive Sleep Apneabull Results The STOP questionnaire was given to 2467 patients

275 classified as being at high risk of OSA Two hundred eleven patients underwent polysomnography 34 for the pilot test and 177 for validation In the validation group the apneandash hypopnea index was 20 6 The sensitivities of the STOP questionnaire with apneandashhypopnea index greater than 5 greater than 15 and greater than 30 as cutoffs were 656 743 and 795 respectively When incorporating body mass index age neck circumference and gender into the STOP questionnaire sensitivities were increased to 836 929 and 100 with the same apneandashhypopnea index cutoffs

bull Conclusions The STOP questionnaire is a concise and easyto- use screening tool for OSA It has been developed and validated in surgical patients at preoperative clinics Combined with body mass index age neck size and gender it had a high sensitivity especially for patients with moderate to severe OSA

STOP QuestionnaireA Tool to Screen Patients for Obstructive Sleep Apnea Anesthesiology 2008

108812ndash21

bull OBSTRUCTIVE sleep apnea (OSA) is the most prevalent breathing disturbance in sleep affecting 2ndash26 of the general population depending on sex age and the definition of criteria

bull OSA is associated with significant morbidity including excessive daytime sleepiness loud snoring during sleep refractory hypertension and impaired quality of life

bull Studies have also shown that OSA is associated with a high risk for traffic accidents and cardiovascular disease


108812ndash21bull It is estimated that nearly 80 of men and 93 of women

with moderate to severe sleep apnea are undiagnosed bull Undiagnosed OSA may pose a variety of problems for

anesthesiologists A number of case reports have documented an increase in the incidence of postoperative complications and deaths among patients suspected of having OSA

bull Untreated OSA patients are known to have a higher incidence of difficult intubation postoperative complications increased intensive care unit admissions and greater duration of hospital stay

bull Identifying patients with OSA is the first step in preventing postoperative complications due to OSA

STOPsnoretiredobserved(stopped breathing)pressure

bull (STOP Q1ndash4)bull related to snoring tiredness during the daytime

stopped breathing during sleep and hypertension were designed

bull SmdashldquoDo you snore loudly (louder than talking or loud enough to be heard through closed doors)rdquo

bull TmdashldquoDo you often feel tired fatigued or sleepy during daytimerdquo

bull OmdashldquoHas anyone observed you stop breathing during your sleep

bull rdquo PmdashldquoDo you have or are you being treated for high blood pressure

Stop tradottoquasi corrisponde

bull SmdashldquoDo you snore loudly (louder than talking or loud enough to be heard through closed doors)rdquoRussi forte+ che parlare a voce alta

tanto da essere udito a porta chiusaSornacchiare

bull TmdashldquoDo you often feel tired fatigued or sleepy during daytimerdquoti senti stancoaffaticato o sonnolento durante il giorno Tiratohelliphellip

bull OmdashldquoHas anyone observed you stop breathing during your sleepNessuno ti ha osservato fermare il respiro durante il sonnoosservato

bull rdquo PmdashldquoDo you have or are you being treated for high blood pressure Hai o sei stato in terapia per ipertensionePressione

clinical diagnosis of OSA

bull The clinical diagnosis of OSA was defined as AHI(apnea hypopnea) greater than 5 with fragmented sleep and daytime sleepiness

bull According to the American Academy of Sleep Medicine practice guideline the severity of OSA is determined by the AHI 5ndash15 mild greater than 15ndash30 moderate greater than 30 severe

Stop Bang

bull incorporating BMI age neck circumference and gender into the STOP scoring (STOP-Bang) the sensitivity and NPV significantly increased They were both more than 90 for the patients with moderate and severe OSA


108812ndash21

bull Appendix 1 STOP Questionnairebull Height _____ inchescm Weight _____ lbkgbull Age _____ MaleFemale BMI _____bull Collar size of shirt S M L XL or _____

inchescmbull Neck circumference _____ cm

Stop

Appendix 2 STOP-Bang Scoring Model

bull 1 Snoring Do you snore loudly (louder than talking or loud enough to be heard through c losed doors) Yes No

bull 2 Tired Do you often feel tired fatigued or sleepy during daytime Yes No

bull 3 Observed Has anyone observed you stop breathing during your sleep Yes No

bull 4 Blood pressure Do you have or are you being treated for high blood pressure Yes No

bull 5 BMI BMI more than 35 kgm2 Yes Nobull 6 Age Age over 50 yr old Yes Nobull 7 Neck circumference Neck circumference greater than 40 cm Yes Nobull 8 Gender Gender male Yes Nobull High risk of OSA answering yes to three or more itemsbull Low risk of OSA answering yes to less than three items


108812ndash21bull Studies have documented an increased incidence of coronary artery diseases hypertension cerebrovascular accidents gastroesophageal reflux disease congestive heart failure and myocardial infarction in OSA patients

bull It is estimated that the average life span of an untreated OSA patient is 58 yr which is 20 yr shorter than the average life span of the general population (men 79 yr women 83 yr)

bull OSA is also associated with an increased incidence of postoperative adverse events Undiagnosed OSA in surgical patients have a serious impact on the postoperative outcome

bull Identifying patients with a high risk of OSA is the first step for the prevention of adverse health events adverse perioperative outcomes and its treatment Screening tools work as a filter to separate the patients with a high risk of OSA from the patients with a low risk of OSA A good screening tool should be validated in the target population against an accepted standard It should be easy to use and have a high sensitivity and acceptable specificity


108812ndash21bull Most screening tools for OSA so far have been validated in patients referred to sleep clinics or

sleep laboratoriesbull Seven predictive models based on the different combinations of witnessed apneas snoring

gasping BMI age gender and hypertension were developed and validated in the patients from sleep centers1618192123243940

bull The Sleep Disorders Questionnaire41 Apnea Score25 and Global Sleep Assessment Questionnaire were all tested in patients mainly from sleep centers42 Patients referred to sleep centers are suspected of having sleep related disorders especially OSA They are preselected patients Screening tools for OSA developed and validated in the sleep center patient population cannot be applied to other patient populations without validation in the target patient population

bull The Berlin questionnaire is one of the few questionnaires that have been validated in primary care patients30 However instead of monitored polysomnography in a sleep laboratory home portable sleep monitoring was used for the validation of the Berlin questionnaire Home portable sleep monitoring has not been accepted as the standard for the diagnosis of OSA The STOP questionnaire is currently the only questionnaire developed and validated in surgical patients

bull Although there was some self-selection from the patientsrsquo perspective our study was designed to include all surgical patients in our preoperative clinics regardless of their score of the STOP questionnaire to avoid selection biases

Delirium postanesthesia

Apolipoprotein E e4 Allele Increases the Risk of Early

Postoperative Delirium in Older Patients UndergoingNoncardiac Surgery

Apolipoprotein E e4 Allele Increases the Risk of EarlyPostoperative Delirium in Older Patients Undergoing

Noncardiac Surgery Leung JM Sands LP Yun Wang Poon A Kwok P Kane JP Pullinger CR Anesthesiology 2007 107406ndash11

bull Methods The authors conducted a nested cohort study to include patients aged gt 65 yr who were scheduled to undergo major noncardiac surgery requiring anesthesia A structured interview was conducted preoperatively and for the first 2 days postoperatively to determine the presence of delirium defined using the Confusion Assessment Method

bull Blood was drawn for measurement of the apolipoprotein genotypes Bivariate tests of association were conducted between delirium and apolipoprotein genotypes and other potentially important risk factors

bull Variables that had significant bivariate association with postoperative delirium were entered in a forward multivariable logistic regression model

bull Results Of the 190 patients studied 153 developed delirium on both days 1 and 2 after surgery Forty-six patients (242) had at least one copy of the apolipoprotein e4 allele

bull The presence of one copy of the e4 allele was associated with an increased risk of early postoperative delirium (283 vs 111 P 0005) Even after adjusting for covariates patients with one copy of the e4 allele were still more likely to have an increased risk of early postoperative delirium (odds ratio 364 95 confidence interval 151ndash877) compared with those without the e4 allele

bull Conclusions Apolipoprotein e4 carrier status was associated with an increased risk for early postoperative delirium after controlling for known demographic and clinical risk factors

bull These results suggest that genetic predisposition plays a role and may interact with anestheticsurgical factors contributing to the development of early postoperative delirium

Importance of the E4 allele of the apolipoprotein E(APOE) gene

bull Genetic studies in population-based investigations23 have demonstrated a relation between certain genotypes and the risk of dementia and cognitive decline Specifically elevated risk of Alzheimer disease has been demonstrated among individuals with the E4 allele of the apolipoprotein E(APOE) gene in many populations45 The E4 allele of APOE is associated with a shift to an earlier age at onset of Alzheimer disease6 However the APOE E4 genotype is neither necessary nor sufficient for the occurrence ofAlzheimer disease6 The APOE polymorphism also affects response to trauma age-related cognitive decline7 and several other disorders8ndash10

bull APOE is a polymorphic protein associated with plasma lipoproteins Three major isoforms can be recognized designated as APOE2 APOE3 and APOE4 according to their relative position after isoelectric focusing11 APOE is unique among apolipoproteins in that it has a special relevance to nervous tissue12

bull APOE is involved in the mobilization and redistribution of cholesterol in repairgrowth and maintenance of myelin and neuronal membranes during development or after injury13ndash15 Whether patients who subsequently develop postoperative delirium have a genetic predisposition that renders them at risk for early postoperative delirium has not been determined



bull The covariates includedbull age bull educationbull amount of alcohol intakebull History of central nervous system disorders bull preoperative depressive symptoms bull preoperative functional statusbull pain levels bull amount of alcohol intake (more than 2 drinks vs 2 drinks or fewer per day)bull depression bull functional statusbull Depression was measured using the Geriatric Depression Scale and defined as the presence of six or more symptoms

of depression23bull bull Preoperative demographics included bull age bull highest education level achieved bull perioperative blood pressure measurementsbull Other perioperative data bull type of surgery bull the American Society of Anesthesiologists physical status26 which incorporatesbull the number and severity of preoperative comorbid conditions bull the type of anesthesia (general regional or combined) bull Surgical risk was estimated using the guidelines from the American College of Cardiology and American Heart

Association update for the perioperative cardiovascular evaluation for noncardiac surgery which takes into consideration the type and duration ofsurgery and intraoperative blood loss2

patients who developed postoperative delirium that persisted for 2 days after surgery

Apolipoprotein E e4 Allele Increases the Risk of Early Postoperative Delirium in Older Patients UndergoingNoncardiac Surgery Leung JM Sands LP Yun Wang Poon A Kwok P Kane JP Pullinger CR

Anesthesiology 2007 107406ndash11

bull were olderbull Dependent in one or more independent activities of daily livingbull Had a history of central nervous system disorder bull had lower systolic postoperative blood pressures on postoperative day 1bull had increased pain levels at rest on postoperative day 1 bull Patients who had postoperative delirium that persisted for 2 days after

surgery had significantly longer hospital stay than those without delirium (81 67 vs 51 35 days P 00008)

bull Of the 190 patients studied 46 (242) had at least one copy of the e4 allele The presence of one copy of the e4 allele was associated with an increased risk of postoperative delirium that persisted for 2 days after surgery (283 vs 111 P 0005) Even after adjusting for covariates associated with postoperative delirium which included age change in postoperative pain levels history of central nervous disorders and so on patients with at least one copy of the e4 allele were still more likely to have an increased risk of postoperative delirium

Factors associated with postop deliriumApolipoprotein E e4 Allele Increases the Risk of Early Postoperative Delirium in Older Patients

Undergoing Noncardiac Surgery Leung JM Sands LP Yun Wang Poon A Kwok P Kane JP Pullinger CR Anesthesiology 2007 107406ndash11



bull What is the possible mechanism between apolipoprotein and postoperative delirium Previous studies suggest that the effects of APOE are mediated through alterations in lipid transport in regenerating neuronsproinflammatory cytokine release from activated microgliaamyloid precursor protein metabolism increasedblood brain carrier permeability alterations in plateletfunction and systemic inflammation414243 One hypothesized mechanism is that APOE e4 allele diminishes the capacity for repair in cases of cerebral injury or capacity for homeostasismaintenance

Prevedibilitagrave delle trasfusioni in chirurgia protesica ortopedica

bull Anesth Analg 2004 Oct99(4)1239-44Predicting allogeneic blood transfusion use in total joint arthroplastyRashiq S Shah M Chow AK OConnor PJ Finegan BA

bull essa si basa su un semplice punteggio derivato

da etagravesessopesoHbASAe se revisione o no

Anesth Analg 2004 Oct99(4)1239-44Predicting allogeneic blood transfusion use in total joint arthroplastyRashiq S

Shah M Chow AK OConnor PJ Finegan BA

punteggio Rischio di trasfusione

0-100 10 o meno

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Equazione completa ricavata dalla tavola

Anesth Analg 2004 Oct99(4)1239-44Predicting allogeneic blood transfusion use in total joint arthroplastyRashiq S Shah M Chow AK OConnor PJ Finegan BA

Anesth Analg 2004 Oct99(4)1239-44Predicting allogeneic blood transfusion use in total joint arthroplastyRashiq S Shah M Chow AK

OConnor PJ Finegan BA


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Predicibilitagrave di anestesia spinale difficileBr J Anaesth 2004 Mar92(3)354-60 Epub 2004 Jan 22Development of a difficulty score for spinal anaesthesiaAtallah MM Demian AD

Shorrab AA

Prevedibilitagrave dellrsquoipotermia in anestesia generaleAnesth Analg 2002 Nov95(5)1381-3 Preoperative risk factors of

intraoperative hypothermia in major surgery under general anesthesiaKasai T Hirose M Yaegashi K Matsukawa T Takamata A Tanaka Y

bull modello Z = -15014 + 0097 x (Age) + 0263 x (Height) - 0323 x (Weight) - 0055 x (Preoperative systolic blood pressure) - 0121 x (Preoperative heart rate)

bull La probabilitagrave di andare incontro ad ipotermia puograve poi essere stimata secondo = 1(1 + e(-)(Z))

bull La core tempinfatti ha dimostrato un decremento significativo in pazienti con P gt07Quindi aumenti di etagrave e altezza e decrementi nella formula peso PAS e FC(pesoPAS e FC + bassi) sono in grado di fornire una discreta stima della evenienza della ipotermia intraop durantre chirurgia maggiore

Il rischio perioperatorio nei malati mentaliAnn Surg 2008 Jul248(1)31-8Postoperative complications in the seriously mentally ill a systematic review of the literature

Copeland LA Zeber JE Pugh MJ Mortensen EM Restrepo MI Lawrence VA

bull Da quel poco che egrave stato pubblicato la schizofrenia emerge come fattore di rischio per mortalitagrave e morbilitagravequestrsquoultima peculiare per frequenza di ileo paralitico postop e confusione mentale

bull questi pazienti sembrerebbero resistenti al dolore

bull Pazienti affetti da disordini depressivi seri presentano una elevata incidenza di delirio postop e di confusione mentale

bull Da notare che tali complicanze sono piugrave frequenti quando si sospendono le terapie abituali nel periodo preop ndash Ann Surg 2008 Jul248(1)31-8Postoperative complications in the seriously mentally ill a systematic review of the literature


Il rischio di perdita della vista bull Durante chirurgia oftalmicabull 3 di tutte le controversie legali raccolte dallrsquoASa Closed claim bull Gild WPosner KKaplan RCheney F Eye Injuries Associated with Anesthesia A Closed

Claims Analysis Anesthesiology 76(2)204-208 February 1992bull danno corneale(35)raramente (16) definitivo bull Danno globale dellrsquoocchio(30)derivante dal movimento

improvviso del paziente durante anestesia o sedazione e con esito invariabile in perdita delle visione

bull durante altre chirurgie bull Perioperative Visual Loss After Nonocular surgeryAmerJOphtalmology 2008145604-

10Newmann Jbull 0002 - 02 di tutte le procedurebull Rischio aumentato in chirurgia cardiaca chir colonna vertebrale e del

collo e per posizione pronaLrsquoeziologia egrave sconosciutama egrave attribuita a ischemia del nervo otticoda ipotensionevasocostrizioneaumento della pressione venosaipossiaoltre a fattori anatomici e fisiologici locali propri del paziente

Prevedibilitagrave della ipotensione da spinale nel cesareo

bull Int J Obstet Anesth 2007 Apr16(2)128-34 Prediction of hypotension during spinal anesthesia for Cesarean section and its relation to the effect of crystalloid or colloid preloadDahlgren G Granath F Wessel H Irestedt L

bull supine stress test with measurement of maternal heart rate blood pressure right uterine artery pulsatility index and symptoms in the left lateral and supine positions

bull stress test was positive in 36bull The sensitivity and specificity of the stress test for clinically significant hypotension

(symptomatic hypotension) for patients randomized to the crystalloid group (n=25) were 69 and 92 respectively

bull Patients with a positive stress test receiving a crystalloid preload showed a higher frequency of hypotension compared to all other groups 90 vs 33 (P=0003) and also a greater need for ephedrine mean dose (SD) 200 (97) vs 84 (90) mg (P=0002)

bull CONCLUSIONS Pregnant women with a positive preoperative supine stress test constitute a subset at increased risk for clinically significant hypotension during cesarean delivery under spinal anesthesia These women seem more likely to benefit from prophylactic colloid solution than women with a negative stress test

Heart rate variability predicts severe hypotension after spinal anesthesia

bull Heart rate variability predicts severe hypotension after spinal anesthesia Anesthesiology 2006 Mar104(3)537-45

bull Hanss R Bein B Weseloh H Bauer M Cavus E Steinfath M Scholz J Tonner PHbull low to high frequency ratio (LFHF) before SA bull Sensitivity and specificity of LFHF for prediction of decrease of SBP greater 20 of baseline

were tested bull Retrospective analysis showed differences of LFHF depending on the degree of hypotension

after SA bull Prospective analysis demonstrated significant differences of SBP after SA depending on

baseline LFHF (mean +- SD) low LFHF (13 +- 07) = gt SBP 91 +- 8 of baseline versus high LFHF (55 +- 24) = gt SBP 66 +- 10 of baseline (P lt 005) Baseline LFHF as well as high frequency and proportional decrease of SBP after SA correlated significantly A receiver operator curve characteristic analysis showed a sensitivity and specificity of LFHF gt 25 of 85 to predict SBP decrease of greater than 20 of baseline after SA CONCLUSIONS Heart rate variability analysis before SA may predict hypotension after SA with high sensitivity and specificity LFHF may be a tool to detect patients at high risk of hypotension due to SA This indicates that the predictive value of LFHF is superior to established predictors

Heart rate variability predicts severe hypotension after spinal anesthesia Anesthesiology 2006 Mar104(3)537-45

Hanss R Bein B Weseloh H Bauer M Cavus E Steinfath M Scholz J Tonner PH

bull Heart rate variability analysis was performed according to the Task Force recommendations13 Five-minute recordings of the fast peaks of R waves on the electrocardiogram were detected with a sample rate of 1024 Hz (TF4 Varia Cardio Olomouc Czech Republic) The beat to- beat variability of consecutive R waves of the sinus rhythm was measured Data were investigated based on time as well as frequency domain analysis For time domain analysis the mean interval of consecutive beat to- beat intervals and the SD of mean beat-to-beat intervals were investigated both known to reflect parasympathetic activity1415 Frequency domain analysis was based on fast Fourier transformation Power spectrum densities were calculated for low frequencies (LF 004ndash 015 Hz) and high frequencies (HF 015ndash 04 Hz) in normalized units defined as the LF or HF proportional part of the total power Breathing was controlled at a rate of 14ndash16 breathsmin as recommended for HRV measurements16



bull Patients demonstrated significant differences of SBP after SA depending on LFHF at DOS-BL (fig 1B) SBP of LFHF 25 patients decreased to 91 8 of baselinewhereas SBP of LFHF 25 patients decreased significantly to 66 10 of baseline (P 005 vsbaseline P 005 vs LFHF 25) LFHF 25 patients required no vasopressor intervention whereas in LFHF 25 patients a mean of 10 01 ml was administered to restore blood pressure (P 005)

1 Hemodynamic data Decrease of systolic blood pressure (SBP) demonstrated as proportional decrease from baseline (BL) (A) SBP retrospective groups (B) SBP prospective groups DOS-PRE day of surgery after prehydration LFHF lt 25 baseline low to high frequency ratio less than 25 LFHF gt 25 baseline low to high frequency ratio greater than 25 LOW lowest value after spinal anesthesia MILD

mild hypotension MOD moderate hypotension SA5 5 min after spinal anesthesia SA15 15 minafter spinal anesthesia SEV severe hypotension Data are presented as mean SD P lt 005 MILD

versus MOD as well as SEV P lt 005 versus changes within group versus baseline P lt 005 LFHF lt 25 versus LFHF gt 25


Hanss R Bein B Weseloh H Bauer M Cavus E Steinfath M

Scholz J Tonner PH



bull We conclude that LFHF of 25 may be a cutoff value independent from underlying individual conditions To evaluate its predictive value preoperative LFHF was correlated with the degree of SBP decrease after SA A significant correlation was demonstrated and a high sensitivity and specificity of LFHF 25 to predict hypotension was shown In addition baseline HF (reflecting vagal activity) was correlated with the percentage decrease of SBP

OSA as a risk factor











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Health & Medicine

Various surgical and anesthesiological risks