OSA in the ICU

[TemperStripe]

We've had a rash of elective surgeries that have had to stay overnight in the ICU because the patients have OSA. The policy states they have to be in ICU even though they have q shift vitals! I'm talking about tonsillectomies and vasectomies. Anyone else experience this, and any suggestions on what to do about it? (Ha...yeah right.)

[meandragonbrett]

OSA being?

[TemperStripe]

Obstructive sleep apnea.

[tri-rn]

Is it because of the OSA, or do all of your CPAPs and BIPAPs come to ICU?

[TemperStripe]

It's because the OSA makes them "high risk." However, many of them don't even have their own CPAPs. They're on room air all night long.

[grandmawrinkle]

Many of our surgeons across multiple specialties tried to pull this crap. Our manager put the kabosh on it in a hurry. Our OSA patients go either to the ward with a continuous pulse ox or to the stepdown unit. Patient's are encouraged to bring their own CPAP and wear it the night of surgery and we will bleed in O2 if necessary. If they don't, respiratory will set up a CPAP for them.

On another note, I don't know why your tonsillectomies and vasectomies are getting admitted to the hospital, period, OSA or no OSA. Vasectomies are done in urology clinics these days. I thought tonsillectomies usually got sent home, too. The surgeries they were sending us were, at least, hip and knee replacements.

[meandragonbrett]

We don't admit these folks....at least not yet. I guess I shouldn't speak too loudly!

[grandmawrinkle]

You know, there must have been some study that just came out that said that OSA needs more monitoring post-op than they had been getting in the past or something. I have heard about a lot of surgeons jumping on this bandwagon.

[aCRNAhopeful]

Our hospital does non-invasive end tidal CO2 monitoring on the floors. It is nothing more than a little monitor on an IV pole and a nasal cannula with a funny thing hanging down to "catch" and measure the EtCO2. It also provides a resp. rate more accurate than direct observation (provided the cannula is in the right place) by actually sensing the ventilated air (not just chest wall movements). This machine may be fairly common at other hospitals so forgive me if it is. Its main use is to detect hypoventilation and resp. depression for high risk patients on PCAs and such. In fact the screening tool to used to guide whether or not they meet criteria for EtCO2 monitoring is entirely geared toward s/sx of OSA.

[GreyGull]

On another note, I don't know why your tonsillectomies and vasectomies are getting admitted to the hospital, period, OSA or no OSA.

I can speak from personal experience that an adult tonsillectomy can be nasty. 12 hours on a vent and 24 hours in ICU, I was miserable. I also got some attitude from an ICU RN about occupying an ICU bed for "just a tonsillectomy". Like I had any control over that. Luckily my surgeon was sympathetic and kept me pharmacologically comfortable for 2 days in the hospital and the following 2 weeks at home.

For the OSA patients, we get concerned if their Mallampati score indicates they are a higher risk for obstruction and a difficult intubation. It is also more difficult to open up a sedated airway with just the regular home settings. Even when starting them on the hospital CPAP/BiPAP machine can be tricky. Too little CPAP may actually cause more obstruction and too much may present distention and over inflation issues. CPAP machines are also not meant to be used as "ventilators". And, keep in mind that SpO2 monitoring tells nothing about ventilation. ETCO2 monitoring is preferred.

For adult tonsillectomies we also will attempt to minimize blowing too much dry air into their throats which increases their chance of coughing and bleeding when they are fresh post ops. Humidifiers on CPAP machines can be a hit or a total miss.

New safety rules have also made allowing home CPAP machines in the hospital more difficult. That will exist until RT, JCAHO, BioMed, legal staff and administration come to an agreeable compromise.

[grandmawrinkle]

We have no EtCO2 monitors either. We are behind the times IMO on a few things like that. That will hopefully be my next project.

[GreyGull]

We have no EtCO2 monitors either. We are behind the times IMO on a few things like that. That will hopefully be my next project.

Talk to the Medical Director of the Respiratory Therapists to get him/her on your side. The ICUs and Tele bought equipment that could have the same contract as that used by the RTs. It was easier for approval with the different budgets. We are kind of spoiled since the doctors are in a position to leverage for equipment with the "I want it now" and the administrators usually listens since we get some difficult cases from other hospitals and always have a few research projects going on. The Medical Director of the Cardiopulmonary (RT) department is also Chief of Critical Care Medicine so we do get the latest and greatest.