You are asked to evaluate a 45-years-old female who is scheduled to undergo elective laparoscopic cholecystectomy. Her past medical history includes hypertension, which is controlled with an angiotensin-receptor blocker (ARB), and obesity (BMI 39 kg/m2 ). Upon questioning, she tells you she snores loudly during the night and often dozes off during the day. Investigating further, she reports she has been told she sometimes stops breathing during the night. Her vital signs during your examination are:
She presents you with a recent echocardiogram, which is unremarkable. You take an arterial blood gas, which shows:
What is the MOST appropriate management of this patient?A. Advise the patient immediate further testing is necessary and postpone surgery
Correct Answer: B
In the presented case, the patient has a STOP-Bang (1) score of at least 5 (snoring, tiredness, hypertension, observed apneas, and BMI; no information is given on neck circumference), identifying her as a high-risk patient for OSA. Her vital signs and arterial blood gas are normal (no sign of resting hypoxemia or hypoventilation), and her recent echocardiogram shows no signs of pulmonary hypertension. The Society for Anesthesia and Sleep Medicine guidelines (2, 3) recommend that all perioperative providers, and the patient, are made aware of the high likelihood of OSA and its potential impact on morbidity and recommend proceeding to surgery without further testing provided: (A) there is no indication of uncontrolled systemic condition or additional problems with ventilation or gas exchange (hypoventilation syndromes, pulmonary hypertension, or resting hypoxemia), as in this case and (B) strategies for mitigation of postoperative complications are implemented (option B).
Considering the nature of the surgery (not major) and the stable conditions of the patient, immediate further testing is not necessary and is not a reason to delay surgery (option A). Initiation of PAP treatment in the absence of a confirmed diagnosis of OSA is incorrect, albeit it is a likely therapy the patient will undergo after her diagnostic workup (option C). A further echocardiogram, in the presence of a recent normal one, is unlikely to add any clinical information (option D).