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Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery
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Background: Bariatric surgery patients are vulnerable to sleep-disordered breathing (SDB) early after recovery from surgery and anesthesia. The authors hypothesized that continuous positive airway pressure (CPAP) improves postoperative oxygenation and SDB and mitigates opioid-induced respiratory depression.
Methods: In a randomized crossover trial, patients after bariatric surgery received 30% oxygen in the postanesthesia care unit (PACU) under two conditions: atmospheric pressure and CPAP (8 to 10 cm H2O). During 1 h of each treatment, breathing across cortical arousal states was analyzed using polysomnography and spirometry. Arousal state and respiratory events were scored in accordance with American Academy of Sleep Medicine guidelines. Data on opioid boluses in the PACU were collected. The primary and secondary outcomes were the apnea hypopnea index (AHI) and apnea after self-administration of opioids in the PACU. Linear mixed model analysis was used to compare physiologic measures of breathing.
Results: Sixty-four percent of the 33 patients with complete postoperative polysomnography data demonstrated SDB (AHI greater than 5/h) early after recovery from anesthesia. CPAP treatment decreased AHI (8 ± 2/h vs. 25 ± 5/h, P < 0.001), decreased oxygen desaturations (5 ± 10/h vs. 16 ± 20/h, P < 0.001), and increased the mean oxygen saturation by 3% (P = 0.003). CPAP significantly decreased the respiratory-depressant effects observed during wakefulness–sleep transitions without affecting hemodynamics. The interaction effects between CPAP treatment and opioid dose for the dependent variables AHI (P < 0.001), inspiratory flow (P = 0.002), and minute ventilation (P = 0.015) were significant.
Conclusions: This pharmacophysiologic interaction trial shows that supervised CPAP treatment early after surgery improves SDB and ameliorates the respiratory-depressant effects of opioids without undue hemodynamic effects.
CME Credit: 1.00 AMA PRA Category 1 Credit™
Required Hardware / Software:Adobe Acrobat Reader, Internet connection. Web browser version must have been released within the last three years.
Activity Release Date:06/21/2016
Activity Expiration Date:06/20/2019
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Learning Objectives:After successfully completing this activity, the learner will be able to do the following:
Recognize the benefits of...
Recognize the benefits of determining the severity of obstructive sleep apnea (OSA) prior to the procedure (1, 2)
Faculty & Credentials:
Editor-in-Chief: James C. Eisenach, M.D., receives consulting fees from Aerial BioPharma LLC and Cubist Pharmaceuticals, Inc.
CME Editors: Leslie C. Jameson, M.D., receives honoraria from GE Medical International and Masimo Corporation. Dan J. Kopacz, M.D., has an equity position in SoloDex, LLC.
Authors: Sebastian Zaremba, M.D., Christina H. Shin, B.A., Matthew M. Hutter, M.D., Sanjana A. Malviya, B.S., Stephanie D. Grabitz, Cand. Med., Teresa MacDonald, R.N., Daniel Diaz-Gil, Cand. Med., and Atul Malhotra, M.D., report no relevant financial relationships with commercial interests. Satya Krishna Ramachandran, M.D., reports receiving funding from Merck. Dean Hess, Ph.D., R.R.T., has reported relationships with Philips Respironics, Bayer, McGraw-Hill, Jones and Bartlett, UpToDate, and ABIM. Matthias Eikermann, M.D., Ph.D., reports a relationship with Calabash Bioscience Inc. and reports receiving funding from Merck, Baxter Ventures, and the Judy and Jeff Buzen fund.
ASA Staff: Kari L. Lee, Editorial Manager, has reported no relevant financial relationships with commercial interests. Ginger Yarger, Editor, has an equity position in Merck & Co.
Disclosure StatementThe American Society of Anesthesiologists remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our faculty members. It is not the intent of the American Society of Anesthesiologists to eliminate all situations of potential conflict of interest, but rather to enable those who are working with the American Society of Anesthesiologists to recognize situations that may be subject to question by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair to ensure that such situations are properly evaluated and, if necessary, resolved. The American Society of Anesthesiologists educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review process, all American Society of Anesthesiologists CME activities are ensured of independent, objective, scientifically balanced presentations of information. Disclosure of any or no relationships will be made available for all educational activities.
The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.
Core Competencies:Medical knowledge
Target Audience:ANESTHESIOLOGY Journal CME is intended for anesthesiologists. Researchers and other health care professionals with an interest in anesthesiology may also participate.
CME Credit: 1.00 AMA PRA Category 1 Credit™
The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
1.00 Non-physician Credit Non-physicians may receive a Certificate of Completion stating that this activity was designated for 1.00 AMA PRA Category 1 Credit(s)™. Activity Release Date: 6/21/2016 Activity Expiration Date: 6/20/2019
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