Enhanced Recovery After Surgery Protocols: Clinical Pathways Tailored for Obstructive Sleep Apnea Patients

Obstructive sleep apnea (OSA) is the most prevalent sleep-related breathing disorder. The prevalence of OSA has been growing for the last 2 decades, mainly as a consequence of an increase in obesity severity.1 OSA represents a significant risk factor for postoperative complications, but all OSA patients do not exhibit the same risk. Indeed, Mutter et al2 and more recently Chan et al3 demonstrated that only severe OSA patients, that is, with an apnea–hypopnea index (AHI) ≥30 events/h, and predominantly those with untreated severe OSA are at high risk for postoperative complications. These findings underlie the concern and efforts over the last decade to improve the detection of severe OSA patients during the preoperative anesthetic consultation.4 Established or suspected OSA diagnosis leads to an increase in the utilization of health care resources.5 However, cost-effectiveness in health care represents a major concern and factor when designing care paradigms. With regards to OSA patients, solutions reside in the development of specific pathways to avoid the unnecessary utilization of limited monitored beds and thus reduce inherent costs, while assuring a safe postoperative course. In this context, enhanced recovery after surgery (ERAS) protocols represent potential clinical pathways suitable for patients with OSA. Our goal is to highlight how existing ERAS protocols, as currently written, are highly beneficial to OSA patients and how they can be further adapted to benefit this population. We advocate all OSA patients be managed using a relevant ERAS protocol. The ERAS concept consists of multimodal, multidisciplinary patient-centered care in which patients are actively involved.6 It aims to mitigate surgical stress, the inflammatory response secondary to surgical trauma, and their consequences. The result of such an approach is postoperatively improved and accelerated recovery. In the case of colorectal surgery, ERAS protocol implementation results in a 50% reduction in the incidence of medical complications, including postoperative infection.7 As a consequence, the length of hospital stay (LOS) can be significantly shortened. Supported by research, the ERAS concept has now been applied to other surgical settings including in orthopedics, gynecology, urology, thoracic, and others. Despite the benefits of ERAS protocols, some clinicians restrict this pathway only to young healthy patients because of concern that patients with significant comorbidities may not tolerate this expedited approach. However, the literature suggests that high-risk patients, such as the elderly, equally benefit from ERAS protocols.8Figure 1.: Schematic representation of the ERAS guidelines and their implication in the management of OSA patients. Figure composed from previously published data.6–9 ERAS indicates enhanced recovery after surgery; OSA, obstructive sleep apnea.ERAS protocols comprised multiple measures such is the case in the example of colorectal surgery.9 Further, it has been suggested that the closer the adherence to the protocol, the shorter the LOS and the lower the incidence of complications. Such relationships were reported in cases of both visceral and orthopedic surgery. Despite common misperceptions, most of the perioperative recommendations in these approaches are adapted to the pathophysiological changes of OSA. These protocols may be therefore particularly suitable for OSA patients if selected carefully, and this can be practically demonstrated in the setting of colorectal surgery (Figure 1), where ERAS protocols have successfully applied for >20 years. We therefore propose the following approach taking into account the various perioperative stages. PREOPERATIVE ELEMENTSFigure 2.: Description of 3 major predictive scores for OSA patients screening. For the STOP-Bang score, 1 point is attributed by item. The result of the score is the sum of the points obtained by the patient. A score of ≥5 is correlated with a high probability of OSA syndrome. For the P-SAP score, 1 point is attributed by item. The result of the score is the sum of the points obtained by the patient. A score of ≥4 is correlated with a high probability of OSA syndrome. For the DES-OSA score, each item is weighted by 1, 2, or 3 points. The result of the score is the sum of the points obtained by the patient. A score of ≥7 is correlated with a high probability of severe OSA syndrome. Each of the scores have different sensitivities and specificities to detect OSA patients in a preoperative setting.4 AHI indicates apnea–hypopnea index; OSA, obstructive sleep apnea. During the preoperative visit, the severity of OSA must be assessed using screening scores for OSA patients (STOP-Bang, DES-OSA, P-SAP, …). The major scores are detailed in Figure 2.4 In case of suspicion of severe OSA, patient should be referred for a polysomnography (PSG), treated with continuous positive airway pressure (CPAP) preoperatively if necessary, or managed as a high-risk patient if a preoperative PSG is not possible.4 Smoking cessation should be encouraged to reduce the risks of postoperative pulmonary complications, wound infection, and thromboembolic events, particularly because severe OSA patients are at increased risk of these complications.10 Adherence to fasting guidelines, preoperative drink volume up to 2–3 hours before induction of anesthesia possibly with a carbohydrate load in the absence of contraindication, and avoidance of bowel preparation help the patient reach the operating room in as close a state of euvolemia as possible and contribute to reducing the need for intraoperative fluid, desirable in OSA patients.11 Premedication, specifically with benzodiazepines, should be restrained and must be prescribed only after a strict physical examination, as these drugs increase the AHI.12 Ideally, clinicians should identify the OSA patients (preferentially with an electronic alert or with a wristband) to minimize (or avoid) any administration of benzodiazepines during the entire perioperative process, unless clinically indicated in rare occasions. Similarly, gabapentinoids which could promote upper airway collapsibility especially in combination with opioids should be avoided in these patients. INTRAOPERATIVE ELEMENTS Intraoperative anesthetic management should rely on short-acting anesthetics using opioid-sparing or even opioid-free protocols to allow for rapid awakening with minimal residual effects. This anesthetic management is particularly suitable for OSA patients at risk for developing opioid-induced respiratory depression. The use of locoregional analgesia techniques should be favored possibly together with the administration of anesthetic adjuncts such as ketamine, magnesium sulfate, intravenous lidocaine, and/or agonists of α2-adrenergic receptors to reduce anesthetic needs and improve postoperative analgesia.13 However, more research needs to be done before a firm recommendation of inclusion of these drugs can be made. In case of orthopedic procedures, benefits of neuraxial anesthesia over general anesthesia have been identified especially for OSA patients.14 Locoregional techniques, whether peripheral nerve blocks or periarticular infiltrations, play a major role in providing efficient postoperative analgesia while limiting postoperative opioids requirements. Full reversal of the neuromuscular blockade required to provide adequate surgical working conditions particularly in case of laparoscopy is mandatory in OSA patients to optimize early postoperative ventilation and reduce the risk of worsening of obstructive events. Consequently, monitoring of the neuromuscular blockade is essential, and reversal agents are strongly recommended to reduce postoperative pulmonary complications. Intraoperative fluid therapy to maintain fluid homeostasis must avoid fluid excess and organ hypoperfusion.11 Avoiding fluid and salt excess is especially important for OSA patients to limit edema of the upper airway. In addition to the preoperative items already mentioned, different intraoperative measures facilitate successful management of a restrictive fluid regimen: low intraperitoneal pressure in case of laparoscopy associated with deep muscle relaxation and protective ventilatory strategy which both result in fewer hemodynamic disturbances and intermittent pneumatic compression of the legs. OSA patients are at higher risk for thrombotic events (especially severe OSA patients).10 Thromboprophylaxis should combine a prophylactic systemic anticoagulant, intermittent pneumatic compression devices, and early and enforced postoperative mobilization. Dexamethasone is recommended in the ERAS protocols for several of its effects: prevention of postoperative nausea and vomiting, analgesia, anti-inflammatory effect, as well reduction in postoperative fatigue. Although obese OSA patients may suffer from diabetes or resistance to insulin, dexamethasone is not contraindicated in these patients provided close glycemic control can be achieved.15 The laparoscopic approach provides multiple benefits as compared to laparotomy. The reductions in the postoperative restrictive pulmonary syndrome, postoperative pain, and opioid needs are particularly beneficial in severe OSA patients.16 POSTOPERATIVE ELEMENTS Early drinking and feeding, a key element of ERAS protocols,17 allows for the shortening of the duration of postoperative administration of intravenous fluid, thus restricting the administration of excess fluid and salt initiated pre- and intraoperatively. This intervention might therefore help decrease the risk of postoperative pulmonary complications. Early mobilization contributes to improved outcomes in both visceral and orthopedic surgery.17 Early upright positioning, mobilization, and ambulation recommended in all ERAS protocols are important in OSA patients. Indeed, the supine position facilitates apneic events and should be avoided as much as possible in these patients. Therefore, locoregional analgesia technique should be chosen to allow not only early mobilization but also walking. Multimodal analgesia is a key factor in ERAS irrespective of the surgical procedure.13 The opioid-sparing effect of balanced analgesia is essential to facilitate early mobilization, postoperative recovery, and return of bowel function, as well as reduce opioid-induced side effects such as ileus and respiratory depression. Nonsteroidal anti-inflammatory drugs are very effective components of balanced analgesia and should be given unless contraindicated.18 Locoregional techniques contribute greatly to the efficiency of multimodal analgesia particularly after orthopedic surgery. The postoperative disposition of OSA patients remains a matter of debate. If the patient has nonsevere OSA and does not undergo an upper airway surgery, anesthesiologists might consider discharge of patients to a regular ward provided their pain is controlled and their respiratory status satisfactory. If the patient with severe OSA is not scheduled for an upper airway surgery and if the elements of ERAS protocols are implemented, observation in a monitored ward may be considered. For OSA patients treated before surgery with CPAP, it is mandatory to carry on this noninvasive respiratory support during the postoperative period, both in the hospital and at home. All the elements of the protocols described above and highlighted in the red box ofFigure 1can improve OSA patients’ outcome.6–9 It is therefore likely that OSA patients will benefit from the protocols irrespective of the severity of this disorder. Because severe OSA patients are especially at increased risk of postoperative complications risk,2,3 they may benefit from inclusion in ERAS protocols. So Jonsson et al19 reported that in treated OSA patients enhanced recovery pathway significantly reduced length of stay. This article focuses on the elements of ERAS protocol in OSA patients. Inclusion in ERAS protocol must not exclude other beneficial perioperative measures for these patients not considered in these programs such as difficult airway management, use of nCPAP, consideration of pharmacokinetic changes in case of morbid obesity, management of associated comorbidities, etc. In conclusion, anesthesiologists will continue to expand their roles in perioperative medicine, personalized medicine, and in the implementation of the concept of the Perioperative Surgical Home (PSH). ERAS protocols where the anesthesiologist plays a front-line role18 offer adapted clinical perioperative pathways with the goal to reduce the elevated risk for postoperative complications in undiagnosed OSA patients. The application of ERAS protocols in OSA patients as shown by Raub et al20 illustrates approaches that might improve health care and safety and reduce complications and the duration of hospitalization without extracost. Therefore, ERAS protocols should not be denied to OSA patients, but rather adopted and adapted to this patient population, as many recommendations appear tailored to their underlying pathophysiological changes. DISCLOSURES Name: Eric Deflandre, MD, PhD, FCCP, FAHA. Contribution: This author helped write the manuscript. Conflicts of Interest: None. Name: Stavros Memtsoudis, MD, PhD, MBA, FCCP. Contribution: This author helped review the manuscript. Conflicts of Interest: S. Memtsoudis is a owner of SGM Consulting, LLC, Rumson, NJ; a co-owner of Centauros Healthcare Analytics and Consulting, LLC, Rumson, NJ; is a consultant for Teikoku Pharma, San Jose, CA and Sandoz, Princeton, NJ; and is a shareholder of HATH, Bedford Hills, NY. Name: Jean Joris, MD, PhD. Contribution: This author helped write the manuscript. Conflicts of Interest: None. This manuscript was handled by: Toby Weingarten, MD.