Anaesthetic management for bariatric surgery in a patient diagnosed with Arthrogryposis Multiplex Congenita: a case report

The accuracy of obstructive sleep apnea (OSA) screening instruments in seniors may change as the predictive role of sex, age, and body mass index (BMI) changes with aging. We investigated the diagnostic performance of the STOP-BANG questionnaire in older individuals with aging-adapted scores and thresholds. Independent community-dwelling adults aged 65 years or older were screened for OSA. The STOP-BANG questionnaire was tested with different configurations and compared to the apnea-hypopnea index (AHI) obtained from home sleep apnea testing (HSAT). Epworth Sleepiness Scale (ESS) and Athens Insomnia Scale (AIS) were tested as possible supplementary screening criteria. We recruited 458 individuals with a mean age of 71 ± 5 years, 41% men, BMI of 28.5 ± 4.6 kg/m². Mild, moderate, and severe OSA were present in, respectively, 34%, 30%, and 19% of the sample. The STOP questions had an area under the curve (AUC) of the receiver operating characteristic curve significantly lower than the STOP-BANG and the STOP+BMI > 28 kg/m² (STOP-B28). Both STOP-BANG and STOP-B28 had high sensitivity and low specificity in all OSA levels with similar AUC to predict AHI ≥ 5 events/h, 0.64. ESS and AIS were nonsignificant as adjunctive instruments. Novel modifications of a standard instrument created the STOP-B28, a simpler-to-obtain and similarly performing variation of the STOP-BANG using fewer inputs, and useful to exclude OSA. Screening seniors via questionnaires to detect OSA is problematic. Considering the 83% OSA prevalence in this age group, it may be a sensible option to indicate objective tests, oximetry, HSAT, or even polysomnography, as a first step in OSA investigation.

Perioperative anaesthetic management in bariatric surgery presents unique challenges due to patient comorbidities and elevated perioperative risk. This study aimed to evaluate perioperative anaesthetic practices and determine factors associated with postoperative high-dependency unit (HDU) admissions among bariatric surgery patients at a tertiary centre in Malaysia. A retrospective cohort study was conducted involving 104 adult patients who underwent elective bariatric surgery between 2016 and 2022 at Hospital Pakar Universiti Sains Malaysia. Demographic, clinical, surgical, and anaesthetic data were collected. Univariate and multivariate logistic regression analyses were performed to identify factors associated with postoperative HDU admission. The mean age of the patients was 42.5 years (standard deviation [SD] = 9.7), with a female predominance (68.3%) and a mean body mass index (BMI) of 49.6 kg/m2 (SD = 11.3). Obstructive sleep apnoea (OSA) (56.7%) was the most common comorbidity. Laparoscopic sleeve gastrectomy was the most frequently performed procedure (66.3%). The overall HDU admission rate was 34.6%, with a decreasing trend from 2020 to 2022. Patients admitted to the HDU had a significantly higher BMI, more comorbidities, longer operative times, and a higher prevalence of OSA. Multivariate analysis identified OSA (adjusted odds ratio [OR] = 2.6; 95% confidence interval [CI]: 1.003-6.781; P = 0.049) and longer duration of surgery (adjusted OR = 2.1; 95% CI: 1.018-4.375; P = 0.045) as independent predictors of HDU admission. There were no cases of difficult intubation, postoperative pneumonia, or in-hospital mortality. Obesity-related diseases, particularly OSA, were highly prevalent. The incidence of difficult intubation was negligible with the use of video laryngoscopy in the ramped position. The HDU admission rates were higher than international benchmarks, influenced primarily by BMI, comorbidities, and surgery duration.

Is Airway Management More Risky in Bariatric Surgery?

See Article, p Obstructive sleep apnea (OSA) is a common condition in the general population, with an estimated prevalence of 22% (range, 9%–37%) in men and 17% (range, 4%–50%) in women.1 The rates of OSA are not only more prevalent in males but also increase with age and body mass index. Unfortunately, in many patients, OSA still remains undiagnosed, which is a major concern in the surgical population undergoing both ambulatory and inpatient procedures.2 The danger is real because OSA is associated with a 3- to 4-fold higher risk of difficult intubation or mask ventilation.3 It is also well established that surgical patients with OSA may have multiple comorbidities and are at an increased risk for perioperative complications such as a need for respiratory interventions, prolonged length of hospital stay, and perioperative mortality.4,5 In fact, a recent, large systematic review of 61 studies with >400,000 OSA patients and 8.5 million non–OSA patients suggests that the presence of OSA is associated with an increased risk of postoperative complications.6 A recent 2018 Guideline from the Society of Anesthesia and Sleep Medicine by Memtsoudis et al7 regarding intraoperative management of adult patients with OSA outlines recommendations for various aspects of perioperative care; these recommendations include screening patients for OSA, using positive-pressure airway therapy, and carefully selecting anesthetic drugs, analgesics, and anesthesia type. The Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on preoperative selection of adult patients with OSA by Joshi et al8 specifically addresses the ambulatory patient population. Published in 2012, the authors conducted a systematic review of the literature and came to a conclusion that patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery if they are able to use a continuous positive airway pressure device in the postoperative period. Patients with a presumed diagnosis of OSA, based on screening tools such as the Snoring, Tiredness, Observed apnea, Blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-BANG) Questionnaire,9 and with optimized comorbid conditions, can also be considered for ambulatory surgery, given that postoperative pain can be managed predominantly with nonopioid analgesic techniques. On the other hand, the authors concluded that OSA patients with nonoptimized comorbid medical conditions may not be good candidates for ambulatory surgery. This SAMBA Consensus Statement specifically recommended the use of the STOP-BANG criteria for preoperative OSA screening and comorbid conditions during the patient selection process. Finally, the American Society of Anesthesiologists put forward the Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea.10 Published in 2014, it addresses patient selection for inpatient versus outpatient (OP) setting, essentially concluding that there is a lack of strong evidence to provide guidance regarding triaging these patients, although it acknowledged that OSA patients are at an increased perioperative risk. In the retrospective study by Szeto et al11 published in this issue of Anesthesia & Analgesia, entitled “Outcomes and safety among patients with OSA undergoing cancer surgery procedures in a free-standing ambulatory surgical facility,” the authors address an important and controversial topic of whether patients undergoing cancer surgery in the ambulatory setting with a known diagnosis of OSA or who are likely to have OSA based on STOP-BANG Questionnaire results are at an increased risk for developing complications. The STOP-BANG scoring algorithm for general population identifies patients with a low risk of OSA with “Yes” to 0–2 questions, moderate risk with “Yes” to 3–4 questions, and high risk with “Yes” to 5–8 questions.12 The authors used data from their free-standing ambulatory surgery facility and included patients who underwent typical OP cancer surgeries as well as those who had more complex cancer procedures that required a planned overnight stay (ie, “ambulatory extended recovery” [AXR]). Surgical specialties included breast, gastric mixed tumor, gynecology, head and neck, plastics, and urology. Their study sample contained a total of 5721 patients, of whom 526 patients (9.2%) were previously diagnosed with OSA or were at high or moderate risk for OSA based on the STOP-Bang Questionnaire score. They tested for the association of OSA risk with several important patient outcomes such as length of stay (LOS), adverse respiratory events, a need for a transfer to the main hospital, Urgent Care facility visits postdischarge, and hospital readmission within 30 days. For the purposes of the analysis, the authors separated their study population into 2 groups: those who have an OSA diagnosis or are high risk for OSA and those who are moderate or low risk for OSA. This study raises several important issues for the anesthesia provider. One major concern is that ambulatory patients with OSA will have an increased rate of perioperative complications due to OSA or associated comorbidities.3 However, in this study, the authors demonstrate that the LOS did not differ for high-risk or diagnosed OSA patients compared to those who are moderate or low risk, and the same was true for both OP and AXR groups. Not surprisingly, the authors found a higher incidence of postoperative respiratory events, such as repeated desaturations (<90% oxygen saturation measured by pulse oximetry [Spo2] in an unstimulated environment or obstruction [apnea or snoring] lasting 20 seconds) in the high-risk or diagnosed OSA patients, but the rates of Urgent Care facility visits or 30-day hospital admission were similar between the 2 groups. Also, even though high-risk and diagnosed OSA patients had a significantly longer postoperative AXR stay, the actual difference was only 15 minutes, which may not be clinically significant. In addition, and perhaps not surprisingly, the rate of postoperative events was higher in the high-risk/diagnosed OSA patients compared to moderate-risk patients (15% and 2.2%, respectively). Based on these data, the authors concluded that it is safe for patients who are moderate, high risk, or who are diagnosed with OSA to undergo typical OP and more complex ambulatory cancer procedures without a significant increase in complication rates or increased LOS. This study adds to our current knowledge in several ways. The authors included both traditional OP procedures and more complex cancer surgeries that required an extended stay, specifically demonstrating that patients who are high risk or diagnosed with OSA can safely undergo more complex ambulatory procedures. The study also explores meaningful patient outcomes that can impact efficiency, patient satisfaction, and quality of care. Finally, the authors have implemented specific clinical pathways and enhanced recovery protocols that emphasize opioid-sparing analgesia, patient education, and other intraoperative management strategies. The authors demonstrate that applying the principles outlined in the aforementioned professional society guidelines for the management of patients with suspected or diagnosed OSA may lead to improved outcomes. For example, they used the STOP-BANG Questionnaire for all patients, made attempts to optimize their existing medical conditions, and used multimodal analgesia techniques while minimizing opioid use postoperatively. It is worth noting, however, that opioid use was still very high intraoperatively (97%–99%) and postoperatively (58%–63%), making room for future efforts to reduce or eliminate perioperative opioid use when appropriate. We would hope that highly protocolized management of these patients will lead to better outcomes. Also, patients were evaluated by a respiratory therapist who was available on-site to assess for a need for positive-pressure ventilatory support postoperatively and to monitor their postoperative respiratory recovery. It appears that the involvement of respiratory therapists was important to ensure proper and timely management of respiratory compromise in high-risk patients. In addition, all patients wore a Real-Time Location System badge (Versus Technology Inc, Traverse City, MI) to help provide continuous location updates of each patient, contributing to greater accuracy of times recorded for different phases of care. Another key point regarding the low rate of adverse outcomes seen in this study is that among the 233 patients with diagnosed OSA, 65% had home devices with the majority of them being compliant with home device use. A recent review on the polysomnographic parameters for predicting postoperative adverse events in patients with OSA indicated that complications may be more likely to occur in the category of moderate-to-severe OSA with apnea hypopnea index ≥15 events per hour.13 In this study, 527 patients were high risk or diagnosed OSA, yet the number of patients with moderate-to-severe OSA with apnea hypopneas index ≥15 events per hour is not known and could be substantially smaller. The authors showed that although greater frequencies of postoperative respiratory events were reported in high-risk or diagnosed OSA patients, the rate of hospital transfer was not significantly different between the groups (P = .10). Because the P value is .1, the results could be significant with a larger sample size. It is important to point out a few important limitations of this study. One drawback is that the study describes the experience of a single facility, which predisposes it to patient selection bias and susceptibility to institution-specific surgical and anesthetic practices that may not be reflective of national practices. The sample size was also relatively small and limited to a few surgical subspecialties, potentially making it subject to various patient, anesthesia, and procedure-related confounding factors. In addition, as the authors themselves acknowledge, the prevalence of OSA in the study was low, with 4.1% diagnosed and 3.5% screened high risk, compared to a general population or surgical population where the rates are cited as high as ≥25%, depending on gender.1,3 Their study group was recruited on the basis of likely presence of OSA (presumably on the basis of a sleep study) or OSA risk identified from questionnaire data. This group will include many patients with trivial OSA and a large number (given the low specificity of STOP-Bang and other questionnaires) with no OSA at all. However, within this large group will exist patients with high arousal thresholds, lengthy obstructive events, and substantial associated hypoxemia who are likely to be at considerably greater risk if exposed to postoperative opioids or sedatives. In fact, the study by Szeto et al11 contained a relatively low percentage of males, perhaps due to a large number of gynecological procedures performed at their facility. Yet, despite the fact that at-risk patients had higher body mass index (BMI), were more likely to have multiple comorbidities, longer surgery, and general anesthesia, the overall outcomes were similar between the 2 OSA study groups. Part of the reasons that only 3.5% of cancer patients were screened high risk is that the authors used a 2-step–modified nonvalidated approach to STOP-BANG scoring. The authors asked the 4 STOP questions first. The BANG questions were only applied subsequently if patients answered “Yes” to ≥2 questions of STOP. If patients had only 1 positive answer on STOP, these patients were not considered at risk for OSA. However, they may actually not be low risk as they may be obese, male or >50 years even with just 1 positive answer to STOP questions. The authors automatically misclassified these patients as low risk, resulting in only 3.5% of cancer patients being high risk for OSA. Another reason for no difference in outcomes between the 2 groups could be that the high risk or diagnosed OSA leads to early effective intervention, which decreases adverse outcomes, while the population of patients without high risk or diagnosed OSA includes patients with OSA who experience adverse outcomes because of failure to identify OSA.5 In addition, the authors used a single screening tool for OSA—STOP-Bang Questionnaire, which, while used frequently in clinical practice due to ease of administration and high predictive value, still does not have perfect sensitivity or specificity.9 The sensitivity for detecting any OSA in a surgical population at a cutoff score of ≥3 is 84%, while specificity is low at 43%, meaning a high false-positive rate.3 Based on the results of this study, the use of an OSA screening tool appears feasible in a busy ambulatory setting to help risk-stratify patients undergoing both simple and more complex procedures. Also, although helpful, it may not be practical or cost-effective to have respiratory therapist(s) present in an ambulatory facility to routinely monitor and intervene in patients who experience a respiratory event. As ambulatory surgery across the country has shown good track record in patient outcomes, there is an increasing pressure on anesthesia providers to include more complicated patients (eg, higher body mass index, OSA, airways challenges, multiple comorbidities) in an ambulatory surgery center.14 In summary, this study from a highly specialized single center demonstrates that with careful patient selection and appropriate resources, patients with a diagnosis or at high risk of OSA may safely undergo ambulatory surgery. Multicenter studies with larger sample size are needed to confirm these findings and to make a final clinical practice recommendation. We urge caution on this topic as one death is too many.15 Nonetheless, the boundary of patient inclusion in ambulatory surgery is being further stretched. DISCLOSURES Name: Richard D. Urman, MD, MBA. Contribution: This author helped analyze and interpret the data, draft the initial manuscript, and critically revise the manuscript. Conflicts of Interest: R. D. Urman received funding for unrelated research by Medtronic and honoraria from Merck, Acacia, and 3M. Name: Frances Chung, MBBS, FRCPC. Contribution: This author helped analyze and interpret the data, draft the initial manuscript, and critically revise the manuscript. Conflicts of Interest: None. Name: Tong J. Gan, MD, MBA, MHS, FRCA. Contribution: This author helped analyze and interpret the data, draft the initial manuscript, and critically revise the manuscript. Conflicts of Interest: T. J. Gan received honoraria from Acacia, Malinckrodt, Medtronic, and Merck. This manuscript was handled by: David Hillman, MD.

Background and objectives: Obstructive Sleep Apnea represents a widespread problem in the population, but it is often not diagnosed and not considered a true pathology. Different diagnostic tools are available for the diagnosis of sleep apnea. This study aims to demonstrate the ability of the STOP-Bang (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender) questionnaire in identifying subjects with Obstructive Sleep Apnea (OSA) Syndrome, highlighting the role of dentists as epidemiological sentinels. Materials and methods: the STOP-Bang questionnaire was administered to a cohort of 1000 patients, assessing three private dental clinics in Italy. Excessive daytime sleepiness was measured using Epworth Sleepiness Scale (ESS) and defined as ≥ 10. Subjects were considered at risk of OSA if they had three or more positive items at STOP-Bang and were invited to undergo further examination with a type 3 polygraph. Presence of OSA was measured with the apnea-hypopnea index (AHI) and defined as AHI ≥ 5. Results: 482/1000 subjects (48.2%) had three or more positive items in the STOP-Bang questionnaire and were considered at risk for Obstructive Sleep Apnea Syndrome (OSAS). Excessive daytime sleepiness (EDS ≥ 10) was more frequent among subjects at risk for OSAS (73/482, 15.1%) vs. those not at risk for OSAS (30/518, 5.8%) (p < 0.0001). Moreover, 153/482 subjects at risk for OSAS (31.7%) accepted further examination with a type 3 polygraph. Presence of OSAS (AHI ≥ 5) was suggested in 121/153 subjects (79.1%, 95% CI 71.6% to 85.1%), with 76/121 subjects (62.8%) needing treatment (AHI ≥ 15). Conclusion: the high prevalence of OSAS highlights the role of dentists as “epidemiological sentinels”. The STOP-Bang questionnaire is a simple and efficacious instrument for screening sleep apnea patients.

Obesity, obstructive sleep apnoea, and diabetes mellitus: anaesthetic implications

Background:Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder associated with multisystem organ involvement. The STOP-BANG questionnaire is a short and valid questionnaire used to screen OSA. This study aimed to investigate the ability of the STOP-BANG questionnaire to predict postoperative OSA- related respiratory complications in patients undergoing bariatric surgery.Materials and Methods:In this cross-sectional study, all the eligible patients were evaluated in preoperative visits using a predetermined checklist including demographic and clinical information related to OSA and the STOP-BANG questionnaire. After bariatric surgery, patients were assessed for postoperative OSA-related complications. The receiver operating characteristic (ROC) curve was used to determine the cut-off point of the STOP-BANG checklist score based on the patient’s postoperative outcomes.Results:In total, 115 subjects were included in the study. There were significant associations in terms of gender, age, body mass index (BMI), patient’s neck circumference, diabetes, heart diseases, and the mask ventilation grade variables between the two groups of patients with high risk and low risk according to the STOP-BANG questionnaire (P < 0.05 for all comparisons). In addition, ai rway obstruction and hypoxia (mild and moderate) were more prevalent in the high-risk group than in the low-risk one (P < 0.05 for all comparisons). A significant difference was reported with a cut-off score of 2 in the STOP-BANG questionnaire for those with and without airway obstruction. Moreover, the cut-off point of 4 in the STOP-BANG questionnaire was determined as a predictor for both airway obstruction and mild-to-moderate hypoxia.Conclusion:STOP- BANG scores may be used as a preoperative risk stratification tool to predict the risk of intraoperative adverse events and postoperative complications in bariatric surgery.

BACKGROUND Obstructive Sleep Apnoea (OSA) is a highly prevalent disease but remains underrecognized in India. Polysomnography is the gold standard test in the diagnosis of OSA but it is difficult to perform and not frequently done. Simple questionnairebased diagnostic tools can be included in the screening procedure of patients with coronary artery disease (CAD) to detect the need for further OSA evaluation. The present study was undertaken to find out the proportion of OSA in CAD patients using Berlin’s and STOP-BANG questionnaires. METHODS A cross-sectional study was conducted to find out the proportion of OSA in CAD patients among 70 known cases of CAD referred from the Cardiology department of Government Medical College, Kottayam and 70 normal healthy adults as controls using Berlin and STOP-BANG questionnaires and the results were analyzed by SPSS software. RESULTS Among individuals with CAD, 20 %, 51.4 %, 28.6 % were found to be at high, intermediate and low risk for OSA whereas 2.9 %, 31.4 %, 65.7% were only found to have a high, intermediate and low risk for OSA in the control population as per STOP-BANG questionnaire. Around 37.1 % and 62.9 % were found to be at high and low risk for OSA among the CAD patients, whereas in the control group 11.4 % and 88.6 % were at high and low risk for OSA respectively. Hence the proportion of OSA (high risk as per the questionnaires) in CAD patients was 20 % and 37.1 % as per STOP-BANG and Berlin questionnaires respectively. The mean score obtained in CAD patients was 3.31 whereas that in normal individuals was 2.04, using the STOPBANG questionnaire. Similarly, it was 2.97 in CAD patients and 1.11 in normal individuals as per the Berlin questionnaire (P-value =0.001). CONCLUSIONS Increased risk of OSA in CAD patients compared to the normal individuals mean score for OSA was significantly high in CAD patients than in the control group. KEY WORDS OSA, CAD, Polysomnography, STOP BANG Questionnaire, Berlin Questionnaire.

BackgroundBariatric surgery is becoming a more widespread treatment for obesity. Comprehensive evidence of the long-term effects of contemporary surgery on a broad range of clinical outcomes in large populations treated in routine clinical practice is lacking. The objective of this study was to measure the association between bariatric surgery, weight, body mass index, and obesity-related co-morbidities.Methods and FindingsThis was an observational retrospective cohort study using data from the United Kingdom Clinical Practice Research Datalink. All 3,882 patients registered in the database and with bariatric surgery on or before 31 December 2014 were included and matched by propensity score to 3,882 obese patients without surgery. The main outcome measures were change in weight and body mass index over 4 y; incident diagnoses of type 2 diabetes mellitus (T2DM), hypertension, angina, myocardial infarction (MI), stroke, fractures, obstructive sleep apnoea, and cancer; mortality; and resolution of hypertension and T2DM. Weight measures were available for 3,847 patients between 1 and 4 mo, 2,884 patients between 5 and 12 mo, and 2,258 patients between 13 and 48 mo post-procedure. Bariatric surgery patients exhibited rapid weight loss for the first four postoperative months, at a rate of 4.98 kg/mo (95% CI 4.88–5.08). Slower weight loss was sustained to the end of 4 y. Gastric bypass (6.56 kg/mo) and sleeve gastrectomy (6.29 kg/mo) were associated with greater initial weight reduction than gastric banding (2.77 kg/mo). Protective hazard ratios (HRs) were detected for bariatric surgery for incident T2DM, 0.68 (95% CI 0.55–0.83); hypertension, 0.35 (95% CI 0.27–0.45); angina, 0.59 (95% CI 0.40–0.87);MI, 0.28 (95% CI 0.10–0.74); and obstructive sleep apnoea, 0.55 (95% CI 0.40–0.87). Strong associations were found between bariatric surgery and the resolution of T2DM, with a HR of 9.29 (95% CI 6.84–12.62), and between bariatric surgery and the resolution of hypertension, with a HR of 5.64 (95% CI 2.65–11.99). No association was detected between bariatric surgery and fractures, cancer, or stroke. Effect estimates for mortality found no protective association with bariatric surgery overall, with a HR of 0.97 (95% CI 0.66–1.43). The data used were recorded for the management of patients in primary care and may be subject to inaccuracy, which would tend to lead to underestimates of true relative effect sizes.ConclusionsBariatric surgery as delivered in the UK healthcare system is associated with dramatic weight loss, sustained at least 4 y after surgery. This weight loss is accompanied by substantial improvements in pre-existing T2DM and hypertension, as well as a reduced risk of incident T2DM, hypertension, angina, MI, and obstructive sleep apnoea. Widening the availability of bariatric surgery could lead to substantial health benefits for many people who are morbidly obese.

Background: OSA affects up to quarter of general population. It is associated with morbid obesity with a higher morbidity and mortality rates. STOP Bang questionnaire is a validated method for OSA screening. OSA patients are at high risk of developing airway obstruction, cardiac events, congestive heart failure, stroke and desaturation post operatively. The aim of this study is to evaluate adverse respiratory events in patients undergoing bariatric surgery in relation to risk of OSA using Stop Bang questionnaire. Methods: This prospective double cohort study was conducted in Tanta University Hospital from Marchto August 2017. During the preoperative assessment, STOP-BANG questionnaire was performed. After extubation, patients were transferred to PACU unit. Respiratory complications were assessed thereafter. Based on STOP-BANG score, patients were divided into two groups, high risk of OSA with STOP-BANG > 3 (Group I) and low risk of OSA with STOP-BANG Results: 104 patients were included in this study. Group I had more comorbidities in the form of CAD (15% versus 2%, P 0.001). Higher number of respiratory complications was noted in high-risk group (31 patients, 59%) compared to (24 patients, 46%) in group II yet, it was not significant. Conclusion: Obese patients with STOP-BANG score > 3 undergoing bariatric surgery are associated with hypertension, dyslipidemia, CAD, and renal insufficiency. High-risk OSA obese patients are at higher risk of developing respiratory compilations like inability to breathe deeply and hypoxia in postoperatively.

To reevaluate and update evidence-based best practice recommendations published in 2004 for anesthetic perioperative care and pain management in weight loss surgery (WLS), we performed a systematic search of English-language literature on anesthetic perioperative care and pain management in WLS published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. We identified relevant abstracts by using key words, retrieved full text articles, and stratified the resulting evidence according to systems used in established evidence-based models. We updated prior evidence-based best practice recommendations based upon interim literature. In instances of controversial or inadequate scientific evidence, the task force reached consensus recommendations following evaluation of the best available information and expert opinion. The search yielded 1,788 abstracts, with 162 potentially relevant titles; 45 were reviewed in detail. Despite more information on perioperative management of patients with obstructive sleep apnea (OSA), evidence to support preoperative testing and treatment or to guide perioperative monitoring is scarce. New evidence on appropriate intraoperative dosing of muscle relaxants allows for greater precision in their use during WLS. A novel application of alpha-2 agonists for perioperative anesthetic care is emerging. Key elements that may enhance patient safety include integration of the latest evidence on WLS, obesity, and collaborative multidisciplinary care into clinical care. However, large gaps remain in the evidence base.

Background: Obstructive sleep apnea syndrome (OSAS) is one of the most common sleep disordered breathing and is still under-diagnosed. Screening patients at high risk of OSAS is extremely important. This study aimed at comparing the predictive probabilities of Epworth sleepiness scale (ESS), STOP-Bang questionnaire (SBQ) and Berlin questionnaire (BQ) in screening OSAS. Methods: A cross sectional study was carried out from Mai to December 2017 including 90 patients suspected for OSAS. All the participants answered the ESS, SBQ and BQ. Overnight respiratory polygraphy was done for all patients. The threshold for diagnosis of OSA was set at an AHI ≥5. Sensitivity, specificity and area under receiver operating characteristics curve (AUC) for the three questionnaires were calculated. Results: OSAS was diagnosed in 94% of patients. It was mild in 14%, moderate in 20% and severe in 66% of patients.ESS had the lowest sensitivities for screening OSAS, moderate-to-severe OSAS and severe OSAS (42%;42% and 41%).SBQ and BQ had proximate sensitivities for screening patients with AHI≥5 (95% and 96%) and patients with AHI≥15 (95% and 97%). However SBQ was superior to BQ to screen patients with AHI≥30 (100% and 96%). For screening OSAS, SBQ had the largest AUC (0.73; 95% CI:0.53-0.94) followed by BQ (0.71; 95% CI:0.45-0.95) and ESS (0.56; 95% CI:0.38-0.75) (p>0.05), none of the three scores was significant (p>0.05). Applying SBQ was significant to predict OSAS in patients with AHI ≥15 (0.66; 95% CI:0.51-0.81; p=0.03) and with AHI ≥30 (0.66; 95% CI: 0.54-0.78; p=0.01). Conclusions: SBQ and BQ seem to be the best tools in screening patients with high risk of OSAS. However, SBQ is superior to BQ in detecting severe OSA.

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations. The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. Kent D, Stanley J, Aurora RN, etal. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Recommendations for obesity management and prevention have come a long way.

ObjectiveObesity is a risk factor for idiopathic intracranial hypertension (IIH) and obstructive sleep apnoea (OSA). We aimed to determine the prevalence of OSA in IIH and evaluate the diagnostic performance of OSA screening tools in IIH. Additionally, we evaluated the relationship between weight loss, OSA and IIH over 12 months.MethodsA sub-study of a multi-centre, randomised controlled parallel group trial comparing the impact of bariatric surgery vs. community weight management intervention (CWI) on IIH-related outcomes over 12 months (IIH:WT). OSA was assessed using home-based polygraphy (ApneaLink Air, ResMed) at baseline and 12 months. OSA was defined as an apnoea–hypopnoea index (AHI) ≥ 15 or ≥ 5 with excessive daytime sleepiness (Epworth Sleepiness Scale ≥11 ).ResultsOf the 66 women in the IIH: WT trial, 46 were included in the OSA sub-study. OSA prevalence was 47% (n = 19). The STOP-BANG had the highest sensitivity (84%) compared to the Epworth Sleepiness Scale (69%) and Berlin (68%) to detect OSA. Bariatric surgery resulted in greater reductions in AHI vs. CWI (median [95%CI] AHI reduction of – 2.8 [ – 11.9, 0.7], p = 0.017). Over 12 months there was a positive association between changes in papilloedema and AHI (r = 0.543, p = 0.045), despite adjustment for changes in the body mass index (R2 = 0.522, p = 0.017).ConclusionOSA is common in IIH and the STOP-BANG questionnaire was the most sensitive screening tool. Bariatric surgery improved OSA in patients with IIH. The improvement in AHI was associated with improvement in papilloedema independent of weight loss. Whether OSA treatment has beneficial impact on papilloedema warrants further evaluation.Trial registration numberIIH: WT is registered as ISRCTN40152829 and on ClinicalTrials.gov as NCT02124486 (28/04/2014).