Critical Care Medicine-Pulmonary Disorders>>>>>Sleep Apnea
Question 1#

You assess a 55-year-old male patient who is a candidate for bariatric surgery. He is 175 cm, 120 kg and has arterial hypertension for which he takes ramipril. His wife tells you the patient snores during the night. His blood pressure (BP) is 125/75 mm Hg and pulse oximetry is 89% on room air.

What is the MOST appropriate management of this patient?

A. Proceed to surgery without further testing
B. Postpone surgery and proceed with a sleep study
C. Perform an arterial blood gas analysis
D. Recommend positive airway pressure (PAP) treatment at night and proceed to surgery

Correct Answer is B


Correct Answer: B

In the above case, the patient has a STOP-Bang (1) score of at least 5 (snoring, hypertension, male gender, BMI, and age; no information is given on daytime tiredness, observed apneas, or neck circumference), identifying him as a high-risk patient for OSA. He also has medically controlled hypertension and resting hypoxemia. The Society for Anesthesia and Sleep Medicine guidelines (2, 3) recommend additional evaluation for preoperative cardiopulmonary optimization in patients who have a high probability of having OSA where there is indication of an additional problem with ventilation or gas exchange, as is the case of this patient (option B). 

Considering the increased risk of postoperative complications and the potential optimization of the patient, it is unwise to proceed to elective surgery without further testing (option A). An arterial blood gas analysis would provide further information on gas exchange; however there is already indication of a high-risk patient with impaired gas exchange, so an arterial blood gas analysis would not be the most appropriate (option C). Initiation of PAP treatment (option D) is a likely step in the management of this patient; however, it is only to be started after confirmation of underlying OSA and only a part of the workup and preoperative optimization of the patient.

References :

  1. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821.
  2. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of anesthesia and sleep medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123(2):452-473.
  3. Madhusudan P, Wong J, Prasad A, et al. An update on preoperative assessment and preparation of surgical patients with obstructive sleep apnea. Curr Opin Anaesthesiol. 2018;31(1):89-95.