Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed

Abstract

The first step in fixing a problem is identifying the problem. Accordingly, this issue of the Journal includes a survey by Cordovani et al. on the perioperative management of patients with obstructive sleep apnea (OSA) which proves very helpful in that regard. The authors found that approximately half of Canadian anesthesiologists screen for OSA, and approximately half work in a hospital with a functional OSA policy. In my opinion, these main findings most probably correspond with those in the USA. On the one hand, these findings represent an improvement when compared with just 15-20 years ago—there has been a large increase in the number of doctors who systematically screen for OSA and an increase in the number of institutions that have a functional OSA management policy—and such practices decrease the chance of OSA mismanagement. On the other hand, many anesthesiologists still do not screen for OSA and many institutions do not have a working OSA policy, and such practices increase the chance of OSA mismanagement. The real problem with the lack of OSA screening and institutional OSA management policy is that these institutions are largely ignoring the OSA disease, and as a result, they may find some postoperative OSA patients dead in bed (DIB). As a medical expert witness over the past 15 years (from 1999-2014), I have had 12 closed medical malpractice cases wherein postoperative OSA patients have been found DIB within 48 hr of surgery. Each one of these 12 cases clearly shows the lethal consequence of not knowing that a patient has OSA (i.e., no systematic identification) and/or ignoring the clinical significance of a patient having OSA (i.e., no functional institutional policy). The findings in these 12 cases are entirely consistent with the findings of a recent review of the legal literature regarding complications in 24 OSA patients undergoing surgery. The Table (in aggregate form to preserve patient anonymity) details my 12 cases. From the Table, the prototypical OSA-DIB case is as follows: A 58-yr-old continuous positive airway pressure (CPAP)-compliant male (170 cm, 120 kg, body mass index 40 kg m) with polysomnography (PSG)-proven severe OSA undergoes orthopedic, upper airway, or abdominal surgery under general anesthesia. The patient has an uncomplicated stay in the postanesthesia care unit until discharged to an unmonitored bed without CPAP or oxygen. After receiving small (and within standard of care) doses of narcotics for pain for 11 hr, the patient is found DIB. Advanced cardiac life support is either not attempted or fails to return the patient to their baseline state of life. How frequently are postoperative OSA patients found DIB? I do not know and to my knowledge, neither does anyone else but a great effort is underway to find out. The Society of Anesthesia and Sleep Medicine (SASM) and the American Society of Anesthesiology (ASA) Closed Claims Project have together established an OSA Death and Near Miss Registry in the hope of collecting a large number of detailed case reports for analysis. In a few years, it may be possible to get some idea of the numerator (i.e., DIB and near miss cases) and the denominator (i.e., postoperative OSA patients managed in specific ways).