Sleep apnea patients require special handling
Sleep apnea patients require special handling
Because most sleep apnea cases have not been identified, it is not sufficient for same-day surgery providers to simply ask patients if they have sleep apnea, according to the Washington, DC-based American Sleep Apnea Association.1
Instead, health care providers must ask proper screening questions of patients, especially those individuals at risk for sleep apnea and those children undergoing a tonsillectomy and adenoidectomy, before making decisions on patient care, according to the association. Obstructive sleep apnea occurs frequently (30% to 40%) in obese children who have enlarged tonsils.2
In the preoperative area, routinely ask patients whether they have symptoms, advises Yvonne Mull, RN, CNOR, former director of nursing at HealthSouth Alaska Surgery Center in Anchorage.
Ask specifically about whether patients snore or are having problems sleeping at night, advises Grover R. Mims, MD, medical director of the Outpatient Surgical Center at Wake Forest University Baptist Medical Center in Winston Salem, NC. "Most of these people are world class snorers." Spouses often volunteer information, he says.
Also look for sleepiness, because these patients often don’t sleep well at night, Mims adds.
If they have symptoms, ask if they have been diagnosed with sleep apnea, Mull advises. If they aren’t diagnosed, alert the anesthesia provider, she suggests.
Sometimes patients arrive with a continuous positive airway pressure (CPAP) machine, and the staff wasn’t aware that the patient used one. "Even if at the last minute, if they have CPAP machine, they were encouraged to use it," beginning the evening of discharge from the facility, Mull says.
According to the American Sleep Apnea Associ-ation, monitor the pressure of the CPAP to ensure that it is adequate.1
Consider these additional suggestions:
• Examine use of medications. "Logic would suggest that shorter-acting drugs would be preferable, although this remains to be proven," says David O. Warner, MD, professor of anesthesiology and vice chair for research at the anesthesia clinical research unit in the department of anesthesiology at the Mayo Clinic in Rochester, MN.
If you’re going to err with medication, err on the light side, Mims advises. "We give narcotics to these patients very gingerly," he says.
These patients are especially sensitive to morphine, Mims said in a discussion published by the Park Ridge, IL-based Society for Ambulatory Anesthesia.3
• Be particularly cautious with patients having airway surgery. Patients who have had airway surgery can have problems recovering after surgery, Mims said. "I feel that these patients should be admitted overnight after general anesthesia and airway surgery," he said.3
• Consider keeping all sleep apnea patients overnight. HealthSouth Alaska Surgery Center keeps all sleep apnea patients overnight, Mull says. If they refuse, the medical director is consulted and the patient can be given the option of leaving against medical advice. The first 24 hours are critical, she says. "They may look like they’re sleeping, but their oxygenation can be so low," Mull adds. "They desaturate."
Although the American Sleep Apnea Associa-tion stops short of saying all sleep apnea patients should be admitted, the association suggests letting sleep apnea patients remain under medical care until you’re certain that their breathing will not be obstructed.1
• Develop and maintain a good working relationship between the nurses, anesthesia providers, and the medical director. The outpatient surgery staff must be cohesive, Mull says. "They need to be helping each other to identify patients [with sleep apnea] for their safety and well-being, even if they have only a hint of this syndrome," she explains. Ensure that the anesthesia staff realize the important of this issue, Mull suggests. "You need cooperation between anesthesia and nursing to provide these patients with the optimum post-anesthesia recovery," she adds.
• Develop policies and procedures. There is a desperate need for policies and procedures on acceptable outpatient surgery candidates that takes into consideration the particular problems and risks of obstructive sleep apnea (OSA) patients, sources say.
"Writing down the acceptable boundaries will necessarily increase medical awareness of the disease and help to decrease the administration of anesthetics to risky patients in risky environments," said Jonathan L. Benumof, MD, professor of anesthesiology at the University of California — San Diego Medical Center, in a published letter to the editor in the Anesthesia Patient Safety Foundation Newsletter.4 [For a sample policy and procedure on OSA patients, go to www.same-daysurgery.com. Your user name is your subscriber number on your mailing label. Your password is sds (lowercase) plus your subscriber number (no spaces). Look for the policy and procedure in the "toolbox" under "policies and procedures."]
For example, there can be inappropriate scheduling of morbidly obese and/or severe OSA patients for outpatient surgery, Benumof tells SDS. "Many outpatient surgery facilities do not have the immediate availability of special equipment and personnel to handle these medically complex and challenging patients," he says. The wrong place equals adverse outcomes, he adds.
"The frequency and severity of adverse outcomes in OSA patients undergoing anesthesia and surgery will likely not decrease until these preoperative evaluation deficiencies, intraoperative airway, postoperative pain management, and outpatient scheduling problems are solved," Benumof wrote.
References
1. American Sleep Apnea Association. Sleep apnea and same-day surgery. Web: www.sleepapnea.org/sameday.html. Accessed Sept. 23, 2003.
2. Removing Tonsils and Adenoids Improves Quality of Life in Obese Children. Press release for September 2003 meeting of American Academy of Otolaryngology — Head and Neck Surgery Foundation. Web: www.newswise.com/articles/view/500942/. Accessed Oct. 1, 2003.
3. SAMBA Talks August 2003. Web: www.sambahq.org/professional-info/enewsletter.html. Accessed July 3, 2003.
4. Benumof JL. Policies and procedures needed for sleep apnea patients. Anesthesia Patient Safety Foundation Newsletter Winter 2002-2003; 17:49-68.
Because most sleep apnea cases have not been identified, it is not sufficient for same-day surgery providers to simply ask patients if they have sleep apnea, according to the Washington, DC-based American Sleep Apnea Association.Subscribe Now for Access
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