1. Adherence Adherence to Strict Guidelines Eliminates Respiratory Complications in Obstructive Sleep Apnea Patients U. Nimmagadda, MD, 1 M. R. Salem, MD, 1 M. Friedman, MD, 2 N. N. Knezevic, MD, PhD, 1 G. J. Crystal, PhD 1 1 Department of Anesthesiology, 2 Head and Neck Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA Discussion Abstract References Introduction The high incidence of respiratory complications in the perioperative management of patients undergoing correction of obstructive sleep apnea (OSA) is a major concern for anesthesiologists. 2 In a quality management study in our institution, we found an incidence of 3.9% (5 out of 139 patients) between 1997 and 1999. 1 After adoption of specific guidelines, the complication rate decreased to 0.54% in a 7 year-period between 2000 and 2007 (11 out of 2,037 patients;9 were related to extubation and 2 were during the intraoperative period). 3 This follow-up study was conducted to determine whether stricter guidelines could result in further reduction in respiratory complications. Methods After IRB approval for conversion of quality management data to research purposes, we compiled the respiratory complications in patients who underwent surgery for OSA over the last two years (2008 & 2009) while utilizing the previously applied guidelines (Table 1) and implementing additional guidelines (Table 2). The findings were compared to those obtained before application of specific guidelines (1997-99) and after application of less stringent guidelines (2000-2007). Incidence of respiratory complications in the groups of OSA patients were compared using Pearson’s-Chi-Square test. P<0.05 was considered statistically significant. Results 1. Manjula M, Klowden A, Jospeh NJ, Raman NV, Salem MR. Does the severity of sleep apnea hypopnea syndrome increase the risk of perioerative complications? Anesthesiology 2000: 93: A1158 2. Benumof JL. The New American Association of Anesthesiologists Obstructive Sleep Apnea Guidelines. In: Hagberg, CA ed. Benumof's Airway Management, 2nd edition, Mosby, St. Louis, MO 2007. 3. Nimmagadda U, Salem MR, Friedman M, Joseph NJ. Adoption of specific measures to decrease airway complications in obstructive sleep apnea patients. Anesthesiology 2008: 109 A774. Adherence to strict guidelines eliminated complications related to intubation and intraoperative management. This was an improvement over our previous two studies. Although three extubation-related complications occurred, close examination of these cases revealed that our new guidelines were not strictly followed.; two extubations occurred in the absence of supervising faculty and one extubation occurred because of a miscommunication between the faculty and the resident. Our findings raise the possibility that adherence to stricter guidelines can also eliminate postextubation airway complication. Figure 1 indicates a marked reduction in respiratory complications in the current study (2008-2009) compared to the first study (1997-1999) (p<0.0001). Although the respiratory complications in the current study (0.38%) were less than those in the second study (2000-2007), this did not achieve statistical significance. Table 1. The specific guidelines adopted in 2000 to decrease respiratory complications in OSA patients Placing the patient in a ramped position before intubation Ready availability of various intubation devices Awake fiberoptic intubation, when indicated Perioperative control of blood pressure and heart rate Extubation in semi-sitting position Following strict extubation criteria Extubation over an airway exchange catheter in select patients Use of naso-pharyngeal airways Reinstitution of CPAP in the PACU, whenever possible Table 2. Additional guidelines implemented in 2008 to eliminate respiratory complications in OSA patients More frequent use of awake intubation Use of doxapram hydrochloride (1-2 mg/kg) before extubation More diligent supervision of the resident staff and tracheal extubation only in the presence of supervising faculty 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 1997-1999 2000-2007 2008-2009 Incidence of respiratory complications in OSA patients (percentage) Figure 1. Incidence of respiratory complications in OSA patients in three studies In the 789 patients of the current study, there were no respiratory complications during intubation or in the intraoperative period. Airway obstruction occurred in three patients soon after tracheal extubation (Figure 1); in one of these patients, negative pressure pulmonary edema with hypoxemia developed. All three patients required reintubation and ventilatory support, but were successfully extubated within 1 to 3 hours. Our previous study found a 3.9% incidence of respiratory complications in patients undergoing surgery for obstructive sleep apnea (OSA). 1 This retrospective study was conducted in 789 patients to evaluate respiratory complications in OSA patients in whom stricter guidelines were implemented. The results indicate that a rigorous and meticulous adherence to all the guidelines can virtually eliminate respiratory complications. *