Anesthesia Plan of Care for Obstructive Sleep Apnea Patients

[Kooky Korky, BSN, RN]

Is there anything you do differently for OSA patients thank for non-OSA's?

You know in advance, having done your History, that they might already pre-operatively be on narcotic pain meds, which depress respirations. How does that affect your choice of pre-op and intra-op anesthetics or sedatives?

Are you willing and able to do general for them or do you prefer sedation/amnesia/local-regional whenever possible?

Do you routinely keep them in RR longer or send them to a particular ICU or semi-ICU afterwards or just out to regular ward if ICU is otherwise not warranted? What are your orders for post-op care with regard to their OSA?

Do you require that they use CPAP post-op?

Anything else you do or don't do special for OSA patients?

Thank you. Just comparing our hospital to yours. We do keep them in RR for an extra hour if they've had general and we do put CPAP on them. We then send them to our special step-down/Resp Unit overnight, where we do continuous cardiac and O2 Sat monitoring. Some do continue to use CPAP in our unit. We have a CRNA immediately present around the clock to intubate if needed, and our nurses are able to tube, also, in case the CRNA is briefly unavailable. So far, haven't ever seen this happen but it's a good feeling that we are doing all that we can do. Or are we missing anything?

[RedCell]

you are asking a question that does not have a generic vanilla answer. each situation will play out differently. things to consider though are fat content of the patient, degree of rv involvement, narcotic load, muscle relaxants utilized, surgical and/or anesthesia complications...the list goes on and on. in the end anesthesiologists/crnas/aas are just consultants and the plan of care is ultimately up the dude wielding the bovie. actually, it really is okay to sometimes just send them home. there is a lot of literature out there on this topic if you want to look into true outcomes/recommendations and not just anecdotal responses/opinions.

[foraneman]

in the end anesthesiologists/crnas/aas are just consultants and the plan of care is ultimately up the dude wielding the bovie.

wrong. no patient may leave the pacu without anesthesia discharging the patient...no one else may make that decision. nor may a patient be moved to any particular level of care without anesthesia approval. anesthesia says icu overnight...then it is icu over night.

[foraneman]

I am assuming we are talking about OSA patients who are having surgery which is NOT to treat the OSA. Obviously it all depends on the patient and the procedure being performed. This goes for every question you asked. Some may get CPAP and a monitored bed...some may not. Regional may be preferable for one and not for the next. Your approach sounds reasonable. I am very curious regarding your statement that your nurses are able to "tube". Perhaps you have some advanced transport/EMS nurses? It IS unusual and there can be quite a surprise when trying to intubate a sleep apnea patient the first dozen times. Fiberoptic laryngoscopy should readily be available.

[Kooky Korky, BSN, RN]

I am assuming we are talking about OSA patients who are having surgery which is NOT to treat the OSA. Obviously it all depends on the patient and the procedure being performed. This goes for every question you asked. Some may get CPAP and a monitored bed...some may not. Regional may be preferable for one and not for the next. Your approach sounds reasonable. I am very curious regarding your statement that your nurses are able to "tube". Perhaps you have some advanced transport/EMS nurses? It IS unusual and there can be quite a surprise when trying to intubate a sleep apnea patient the first dozen times. Fiberoptic laryngoscopy should readily be available.

They're all ACLS so, theoretically anyway, can tube. Right? Certainly some intubations are much more difficult than others, though, so we do much prefer to have our Anesthetist present, but she has to have a break some time. She will come running if we holler (unless "potted", you know, on one of those rare potty breaks. I swear, she is really camel-like in that regard.)

I will look into the fiberoptic laryngoscopy, thanks for mentioning that.

[Kooky Korky, BSN, RN]

I am assuming we are talking about OSA patients who are having surgery which is NOT to treat the OSA. Obviously it all depends on the patient and the procedure being performed. This goes for every question you asked. Some may get CPAP and a monitored bed...some may not. Regional may be preferable for one and not for the next. Your approach sounds reasonable. I am very curious regarding your statement that your nurses are able to "tube". Perhaps you have some advanced transport/EMS nurses? It IS unusual and there can be quite a surprise when trying to intubate a sleep apnea patient the first dozen times. Fiberoptic laryngoscopy should readily be available.

Yes, surgery for other than OSA.

What do you do for OSA surgery patients, though? Are we talking uvula revision and that type of procedure that widens the airway at the pharynx?

[foraneman]

They're all ACLS so, theoretically anyway, can tube. Right? Certainly some intubations are much more difficult than others, though, so we do much prefer to have our Anesthetist present, but she has to have a break some time. She will come running if we holler (unless "potted", you know, on one of those rare potty breaks. I swear, she is really camel-like in that regard.)

I will look into the fiberoptic laryngoscopy, thanks for mentioning that.

Completion of ACLS does not license an individual to do anything. Endotracheal intubation does not become part of the scope of practice of an RN based on ACLS certification. Unless the institution has a written policy for allowing intubation by RNs (which of course should include the training required which must include training on live patients in the OR , or this is a disaster waiting to happen...and i have to say I have never seen floor RNs who intubate as part of their job discription), then RNs may not intubate or risk their license and huge malpractice liability. OSA patients are very often some of the most difficult intubations there are. They are often obese with short stocky necks, and the excess tissue which mechanicaly causes the airway obstruction during sleep also obstructs the view of the trachea during intubation. A novice at intubating should never be the individual responsible for their airways.

The anesthetist certainly does not have to be present on the floor...and i assume that when you say she will 'come running' she is in house? In any event it is rare that once an OSA patient has recovered from anesthesia to the point of being discharged from the PACU, that they will have an primary airway event requiring them to be intubated. They should be no more at risk for intubation than the next guy.

[Kooky Korky, BSN, RN]

Completion of ACLS does not license an individual to do anything. Endotracheal intubation does not become part of the scope of practice of an RN based on ACLS certification. Unless the institution has a written policy for allowing intubation by RNs (which of course should include the training required which must include training on live patients in the OR , or this is a disaster waiting to happen...and i have to say I have never seen floor RNs who intubate as part of their job discription), then RNs may not intubate or risk their license and huge malpractice liability. OSA patients are very often some of the most difficult intubations there are. They are often obese with short stocky necks, and the excess tissue which mechanicaly causes the airway obstruction during sleep also obstructs the view of the trachea during intubation. A novice at intubating should never be the individual responsible for their airways.

The anesthetist certainly does not have to be present on the floor...and i assume that when you say she will 'come running' she is in house? In any event it is rare that once an OSA patient has recovered from anesthesia to the point of being discharged from the PACU, that they will have an primary airway event requiring them to be intubated. They should be no more at risk for intubation than the next guy.

Excellent point about tubing and job description. I am going to check that out.

As for no higher risk post-PACU than non-OSA patients, that's the whole point of our unit. Our doctors seem to want OSA's watched more carefully for longer periods, fearing that narcotic pain meds post-op will bring on airway obstruction. We see it only rarely, but it can happen and we are just wanting to do all we can to prevent any and all problems that we can possibly prevent.

We do ABG's if the patient seems to require same. We are also quite judicious in giving 02.

Yes, our CRNA's are in house - just around the corner in their call room, the Anesthesia work area, or the nearby lounge, maybe the cafeteria is about as far as they go on their shift.

I really appreciate your responses, foraneman.

[japaho41]

With a growing (meaning heavier) patient population which then leads to more patients with OSA. It is always a concern of mine once the patient is in the PACU that they will obstruct their airway or be over nacrcotized. I make sure that I extubate these patient when they are alittle more awake than patient without OSA, taking a good tidal volume and adequate RR. Sit them up, unless contraindicated, use a nasal or oral airway if needed. Ideally the patient with OSA should bring there machine with them to the hospital the day of surgery and have it available to use in the PACU. Most patients are not told to do so and think because they are in the hospital that there will be one available for them to use. I guess that all goes back to there pre-op instructions.

[Kooky Korky, BSN, RN]

With a growing (meaning heavier) patient population which then leads to more patients with OSA. It is always a concern of mine once the patient is in the PACU that they will obstruct their airway or be over nacrcotized. I make sure that I extubate these patient when they are alittle more awake than patient without OSA, taking a good tidal volume and adequate RR. Sit them up, unless contraindicated, use a nasal or oral airway if needed. Ideally the patient with OSA should bring there machine with them to the hospital the day of surgery and have it available to use in the PACU. Most patients are not told to do so and think because they are in the hospital that there will be one available for them to use. I guess that all goes back to there pre-op instructions.

I like it when the patients bring their cpap with them and I like when they airways in place.

Is it feasible to have airways in during surgery for the non-general anesthesia patients? Seems like an oral airway would be a great idea. It could just be left in as long as needed, couldn't it?

Do you have plans at your facility to start telling OSA pts to bring their CPAP machines? The patients probably don't give it any thought. They probably think that someone would instruct them on everything to do , not do, what to bring or not bring, etc., especially something as vital as their CPAP machines. It is simple enough to tell them to bring it. But I think a lot of facilities don't, incredibly, think of OSA when they are dealing with pre-op patients. That is why we have a special unit, as mentioned. I'm glad you brought this up.

What percentage of OSA patients have a problem in your experience, either in OR or RR? Does someone from Anesthesia stay immediately at hand post-op for an hour or more? Anything else you can think of re: OSA and surgery/recovery?

[japaho41]

I like it when the patients bring their cpap with them and I like when they airways in place.

Is it feasible to have airways in during surgery for the non-general anesthesia patients? Seems like an oral airway would be a great idea. It could just be left in as long as needed, couldn't it?

Do you have plans at your facility to start telling OSA pts to bring their CPAP machines? The patients probably don't give it any thought. They probably think that someone would instruct them on everything to do , not do, what to bring or not bring, etc., especially something as vital as their CPAP machines. It is simple enough to tell them to bring it. But I think a lot of facilities don't, incredibly, think of OSA when they are dealing with pre-op patients. That is why we have a special unit, as mentioned. I'm glad you brought this up.

What percentage of OSA patients have a problem in your experience, either in OR or RR? Does someone from Anesthesia stay immediately at hand post-op for an hour or more? Anything else you can think of re: OSA and surgery/recovery?

Airways can be placed but the depth of the anesthesia needs to adequate for the patient to tolerate a nasal or oral airway being placed.

Not sure about plans for the facility to tell patient to bring in CPAP because I am not present at the pre-admission interview.

Not sure what % of patient have a problem and yes anesthesia is always available in recovery.