This post originally appeared on Advance for Nurses. As that publication winds down, we have archived it here.
Nurses should be vigilant against obstructive sleep apnea
By Maureen F. Cooney, DNP, FNP-BC and Denise Sullivan, MSN, ANP-BC
Posted on: April 29, 2015
One in three U.S. adults (34.9% or 78.6 million) are obese, and from a health perspective, the odds are stacked against them. Along with being at a higher risk for heart disease, stroke and type 2 Diabetes, they are far more likely to suffer life-threatening respiratory compromise-particularly obstructed sleep apnea (OSA)-while receiving post-operative opioids.
Even more alarming:
- OSA occurs in 40% of obese female and 50% of obese males
- Incidences of OSA increase in proportion to patients’ levels of obesity
- The prevalence of OSA in patients deemed as extremely or morbidly obese is more than 77%
SEE ALSO: Treatment of Obesity
Obesity, opioids and OSA are a “deadly trio” that can alter the airway tone of obese patients; lead to chronic hypoventilation with mild hypercarbia when patients are resting before surgery; and increase the risk for aspiration and acute airway obstruction after extubation. In fact, airway obstruction and death have been reported in obese patients treated with only minimal doses of opioids.
Vigilance in All Phases of Treatment
- Although obese patients are most at risk for OSA after surgery, their pain management plans should incorporate all phases of their treatment. Keeping that perspective in mind, caregivers should:
- Identify an anesthesiologist with special interest in anesthetic care and pain management to serve as interdepartmental liaison
- Adopt “opioid sparing strategies” whenever possible
- Avoid opioids in combination with sedatives
- Continually monitor obese patients — no matter what dosage of opioids are used in their treatment
To help protect the safety of obese patients at every stage of treatment, we offer the following tips and recommendations.
PRE-OP RECOMMENDATIONS
- Conduct an anesthesiology consult at least one day prior to surgery
- Assess the patients for sleep apnea-polysomnography
- Instruct the patient to quit smoking at least six weeks before surgery
INTEROPERATIVE TIPS
- Use regional blocks as a sole anesthetic technique
- Use intraoperative capnography for monitoring of respiration
- Place patients in a non-supine posture during extubation and recovery
- Resume use of positive airway pressure device
POST-OPERATIVE/MONITORING RECOMMENDATIONS
- Use pulse oximetry for every patient with clinically significant obesity and/or if OSA was suspected during assessment
- Set alarms for less than 90% saturation for 10 seconds
- Treatment postop hypoxemia with early nasal intermittent positive pressure ventilation (NIPPV)
- Don’t rely entirely on intermittent “spot checks” of oxygenation (pulse oximetry) and ventilation (nursing assessment) to recognize indications of drug-induced respiratory depression in the postoperative period
- Continuously monitor oxygenation and ventilation of all obese patients receiving opioids postoperatively should be used
- Use capnography in patients requiring supplemental oxygen
Because they face an increased risk of suffering life-threatening OSA while receiving post-surgical opioids, obese patients should always be continuously monitored. Continuous electronic monitoring of obese patients is among the key ways that caregivers can protect obese patients from OSA-and steer clear of the potentially high costs of litigation and extended hospital stays that can result from OSA.
Maureen F. Cooney, DNP, FNP-BC, is a nurse practitioner in pain management at Westchester Medical Center, Valhalla, NY. Denise Sullivan, MSN, ANP-BC, is a nurse practitioner in pain management at Jacobi Medical Center, Bronx, NY.