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Original Research: SLEEP DISORDERS |

Postoperative Complications in Patients With Obstructive Sleep ApneaPostoperative Complications and Sleep Apnea FREE TO VIEW

Roop Kaw, MD; Vinay Pasupuleti, MD, PhD; Esteban Walker, PhD; Anuradha Ramaswamy, MD; Nancy Foldvary-Schafer, DO
Author and Funding Information

From the Department of Hospital Medicine (Dr Kaw) and the Department of Anesthesia Outcomes Research (Dr Kaw); the Department of Molecular Cardiology (Dr Pasupuleti) and the Department of Quantitative Health Sciences (Dr Walker), Lerner Research Institute; and the Department of Hospital Medicine (Dr Ramaswamy), Medicine Institute, and the Department of Sleep Medicine (Dr Foldvary-Schafer), Neurology Institute, Cleveland Clinic, Cleveland, OH.

Correspondence to: Roop Kaw, MD, Departments of Hospital Medicine and Anesthesia Outcomes Research, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: Kawr@ccf.org


Funding/Support: This study was funded internally by the Research Program Committee (Cleveland Clinic) [RPC Grant 2005-1037].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(2):436-441. doi:10.1378/chest.11-0283
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Published online

Background:  Unrecognized obstructive sleep apnea (OSA) is associated with unfavorable perio-perative outcomes among patients undergoing noncardiac surgery (NCS).

Methods:  The study population was chosen from 39,771 patients who underwent internal medicine preoperative assessment between January 2002 and December 2006. Patients undergoing NCS within 3 years of polysomnography (PSG) were considered for the study, whereas those < 18 years of age, with a history of upper airway surgery, or who had had minor surgery under local or regional anesthesia were excluded. Patients with an apnea-hypopnea index (AHI) ≥ 5 were defined as OSA and those with an AHI < 5 as control subjects. For adjusting baseline differences in age, sex, race, BMI, type of anesthesia, American Society of Anesthesiology class, and medical comorbidities, the patients were classified into five quintiles according to a propensity score.

Results:  Out of a total of 1,759 patients who underwent both PSG and NCS, 471 met the study criteria. Of these, 282 patients had OSA, and the remaining 189 served as control subjects. The presence of OSA was associated with a higher incidence of postoperative hypoxemia (OR, 7.9; P = .009), overall complications (OR, 6.9; P = .003), and ICU transfer (OR, 4.43; P = .069), and a longer hospital length of stay (LOS), (OR, 1.65; P = .049). Neither an AHI nor use of continuous positive airway pressure at home before surgery was associated with postoperative complications (P = .3 and P = .75, respectively) or LOS (P = .97 and P = .21, respectively).

Conclusions:  Patients with OSA are at higher risk of postoperative hypoxemia, ICU transfers, and longer hospital stay.

Figures in this Article

Obstructive sleep apnea (OSA) has been known to be associated with heterogenous manifestations of cardiovascular disease1 and is now known to be an independent risk factor for increased mortality.2 Studies have also reported OSA to be a risk factor for increased postoperative morbidity and mortality.38 In 1993, approximately 4% of men and 2% of women in the age group of 30 to 60 years were estimated to have OSA syndrome.9 No epidemiologic studies have been conducted to determine the prevalence of OSA in the general surgical population. The problem is further hindered by the difficulty in diagnosing OSA, because patients with OSA may present for surgery without a prior diagnosis. Depending on the reported series, the prevalence in patients presenting for surgery has been estimated to be 1% to 9%,10 and 24% when the Berlin questionnaire was used for preoperative screening.11 It is notable that OSA has not been diagnosed in the majority of the preoperative population.

It is estimated that between 1990 and 1998, there was a 12-fold increase in the diagnosis of OSA in surgical outpatients.12 In a more recent series of 433 patients undergoing general surgery, 18 of 41 patients suspected to have sleep apnea agreed to undergo polysomnography (PSG), and the majority (78%) were found to have OSA as defined by an apnea-hypopnea index (AHI) ≥ 5.13 As such, a significant number of patients with sleep apnea may present for surgery without receiving a prior diagnosis. Although published guidelines exist, OSA is often neither suspected preoperatively nor considered clinically relevant enough to warrant preoperative screening or intervention.6 Additionally, the existing guidelines lack scientific evidence and for the most part are based on expert consensus.

Specific Aims

Our study had the following specific aims:

  • 1. To study the frequency and nature of postoperative complications in patients with unrecognized or previously diagnosed OSA undergoing elective noncardiac surgery (NCS)

  • 2. To analyze the impact of severity of OSA as measured by the AHI on the incidence of postoperative complications.

Study Population

The study population was chosen from 39,771 patients who underwent preoperative physical examination and assessment at the Internal Medicine Preoperative Assessment Consultation and Treatment center between January 2002 and December 2006. This electronic record was cross-referenced with the sleep laboratory database to identify patients who underwent NCS within 3 years of PSG. We chose an arbitrary cutoff of 3 years, given that OSA develops over time and patients tested later may have had OSA at the time of surgery. All patients undergoing an NCS procedure within 3 years of the PSG procedure were included in the analysis. Patients under the age of 18 years (n = 178); those who underwent upper airway surgery (including tonsillectomy [n = 14], tracheostomy, or ear, nose, and throat surgery [n = 5 each]); and those who underwent minor procedures under local or regional anesthesia (n = 184) were excluded. Also excluded were patients who had had preoperative visits for multiple surgeries and those who did not undergo surgery (n = 675), patients with incomplete PSG data (n = 278), and patients with duplicate patient identification numbers (n = 25). Among patients who underwent multiple surgeries, the NCS in closest approximation to the date of PSG was chosen for analysis. Demographic, clinical, diagnostic, and postoperative data were collected from outpatient electronic records, inpatient hospital admission records, and surgical procedure dictation records. Patients with OSA were defined as those with an AHI > 5. Preoperative morbidity data and postoperative outcomes were collected for the NCS procedure in closest approximation to the date of the overnight PSG. Respiratory events were characterized on PSG using nasal pressure transducers, oronasal thermal sensors, thoracic/abdominal-effort piezo belts, and pulse oximetry. Hypopnea was defined as a ≥ 50% reduction in nasal pressure signal excursions from baseline lasting for ≥ 10 s, associated with a ≥ 3% oxygen desaturation and/or arousal. Major comorbid conditions were defined according to Hosking et al.14 We did not have information about perioperative opioid use for pain control. The study protocol was approved by our institutional review board, IRB No. 09-383 (approved on May 8, 2009). The approval included a waiver of informed consent.

Definitions of Postoperative Morbidity

The clinical outcome end points for this study were significant postoperative complications, including postoperative hypoxemia, respiratory failure (RF), congestive heart failure (CHF), myocardial infarction (MI), atrial fibrillation, and delirium as defined in the medical record; death within 30 days; and hospital length of stay (LOS). These data were obtained from electronic medical records, operative notes, postanesthetic care unit records, and discharge summary notes. Postoperative hypoxemia was considered present if the patient developed postoperative RF or oxygen desaturations with a < 90% or > 4% reduction from last recorded value, or if confirmed by arterial blood gas measurements postoperatively. Postoperative RF was defined as the need for prolonged mechanical ventilation (> 24 h), endotracheal reintubation, or tracheostomy. Postoperative CHF was defined as new pulmonary edema, elevated JVP > 10 mm Hg, use of diuretic or afterload/preload reducing agents, or physician documentation of CHF. Postoperative MI was defined as the appearance of new Q waves > 0.04 s wide and 1 mV in depth accompanied by elevated levels of troponin T (0.03 ng/mL) and creatine kinase-MB (> 100 IU/L).

Statistical Methods and Analysis

t Tests and χ2 tests were used to compare the OSA and non-OSA groups with respect to baseline characteristics. For purposes of analysis, comorbidities and complications were dichotomized as either present or absent. Because of the extreme skewness, the LOS data were dichotomized using the median as > 2 days and ≤ 2 days. To adjust for baseline differences, a propensity score for each patient was calculated using logistic regression. The propensity score has the advantage of summarizing the information of a large number of covariates into one score. This is particularly important in calculating adjusted effects when outcomes are rare.15 The propensity score is an estimate of the probability that each patient has OSA, given the baseline values of the covariates. The propensity model used the presence of OSA as the response and included age, sex, race, BMI, use of general anesthesia, American Society of Anesthesiology (ASA) class, and number of comorbidities and their interactions as covariates. The C statistic for the propensity model was 0.83, indicating a strong predictive power. The baseline characteristics are compared between the groups in Table 1. The unadjusted P values show that the differences between five of the seven baseline variables were highly significant. However, none of the differences remained significant after adjustment for the propensity score. This means that the propensity score was effective in balancing the differences and allowed a fair comparison between the two groups with respect to outcomes. The effect of OSA on a given outcome was estimated using logistic regression that was adjusted by the propensity score and the covariates. Statistical analysis was done using JMP 8.2 software (SAS Institute).

Table Graphic Jump Location
Table 1 —Baseline Characteristics of Patients With and Without OSA

Data are presented as No. (%) unless indicated otherwise. AHI = apnea-hypopnea index; ASA = American Society of Anesthesiologists; CAD = coronary artery disease; OSA = obstructive sleep apnea.

a 

Propensity model includes the first seven baseline characteristics and their interactions.

b 

Spinal anesthesia, local anesthesia, epidural block, and paravertebral block.

c 

Current or previous smoker.

A total of 1,759 patients underwent both PSG and NCS between February 2002 and June 2006 at a major tertiary care center. After exclusion criteria were applied, 471 patients were eligible for the study, of which 282 (59.8%) had OSA (AHI > 5) (Fig 1). Patients with OSA were older, with a mean age of 55.9 years (compared with 46.3 years for patients without OSA), were predominantly men (44.7% vs 21.7%), and had a higher BMI (38.3 vs 33), higher ASA class, and greater medical comorbidities (ie, COPD, hypertension, diabetes mellitus, coronary artery disease) than patients without OSA. These differences between the two groups, however, were balanced successfully with the propensity score (Table 1). Among the surgical procedures, the majority (> 80%) were intermediate risk, with abdominopelvic and orthopedic procedures dominating in both groups (Table 2). No differences existed between the types of anesthesia used in the two groups, of which general anesthesia was more common (> 80%). After adjustment for the propensity score, the presence of OSA was associated with a higher incidence of overall complications (OR, 6.9; P = .003), postoperative hypoxemia (OR, 7.9; P = .009), ICU transfer (OR, 4.43; P = .069), and longer LOS (OR, 1.65; P = .049) (Table 3). A total of 131 patients (46%) had severe OSA defined as an AHI > 30, 79 (28%) had moderately severe OSA (AHI = 15-30), and the rest were mild OSA cases. Severity of OSA measured by the AHI was not associated with postoperative complications (P = .3), ICU transfer (P = .9), or LOS (P = .97). The median LOS was 2 days in the OSA group (interquartile range: 0-4) and 1 day in the control group (interquartile range: 0-3).

Figure Jump LinkFigure 1. Flow diagram of patient selection. I/E = inclusion/exclusion; IMPACT = Internal Medicine Preoperative Assessment Consultation and Treatment; OSA = obstructive sleep apnea.Grahic Jump Location
Table Graphic Jump Location
Table 2 —Types of Noncardiac Surgical Procedures

Data are presented as No. (% of AHI group). ENT = ear, nose, and throat. See Table 1 legend for expansion of other abbreviation.

Table Graphic Jump Location
Table 3 —Postoperative Complications/Outcomes Among Patients With and Without OSA

Data are presented as No. (% of AHI group) unless indicate otherwise. LOS = length of stay. See Table 1 legend for expansion of other abbreviation.

a 

Propensity model includes the first seven baseline characteristics and their interactions.

b 

JMP software will not compute a correct P value when numbers in the comparison group are small.

Of the 282 patients with OSA, 153 (57%) were recommended some form of positive airway pressure (PAP) treatment after the diagnosis, and 106 (70%) were adherent as self-reported at their preoperative assessment. Home PAP use prior to NCS was not associated with lower overall postoperative complications (P = .75) or LOS (P = .21).

Although it may be intuitive to suspect that patients with OSA are at a higher risk of postoperative complications, the literature supporting the claim is conflicting. One of the major limitations in confirming such a claim in case-controlled studies has been having an adequate number of polysomnographically tested control subjects without OSA (AHI < 5) at baseline or after treatment with continuous PAP (CPAP) or surgery. To the best of our knowledge, ours is the largest study to date using PSG to define OSA status among surgical patients. All the patients in the control group had an AHI < 5 at the time of NCS. A propensity score was used to balance the effect of medical morbidities associated with OSA, including BMI, which may have confounded the perioperative outcomes reported in previous studies. Our study confirms that OSA is independently associated with postoperative hypoxia, higher rates of RF and ICU transfer, and longer hospital stay after NCS. Sample size limitations prevented us from studying the possible role of OSA in the development of cardiac complications such as postoperative arrhythmias, especially atrial fibrillation, MI, and CHF.

Characterization of Postoperative Respiratory Complications

We report a total of 40 (14.2%) complications in 282 patients with OSA undergoing elective NCS compared with a total of five (2.5%) complications in a propensity-matched control group (P < .0001). As many as 50% (19) of these patients with postoperative complications were transferred to the ICU for further management; only three transfers had been planned preoperatively. Of all the different postoperative complications, RF accounted for > 35% of the total. Although most studies to date have not reported postoperative RF in patients with OSA undergoing NCS, the few studies that did define RF as a postoperative outcome measure3,5,16 did not find it to be statistically significant. A recent study reporting a large sample of patients from a national inpatient database reported a fivefold increase in intubation and mechanical ventilation among OSA patients undergoing NCS, and ARDS was reported as a complication for the first time.8

About 10% of patients in the OSA group experienced postoperative hypoxia. This compared with the results of a similar study by Liao et al,16 which reported 30% of patients having postoperative desaturation, although only two patients (0.8%) developed RF. This may be attributed to a higher rate of “planned ICU transfers” in that study compared with ours. The ASA recommends longer (3-h) postoperative monitoring in OSA patients after ambulatory surgery and 7 h of monitoring after the last episode of airway obstruction or hypoxemia while breathing room air in an unstimulated environment prior to discharge from the facility.6 The guidelines are equivocal about full monitoring in the ICU setting, continuous oximetry by a dedicated observer in the patient’s room, and low-risk patients no longer on continued parenteral narcotics. In a study of patients undergoing predominantly open Roux-en-Y gastric bypass surgery, one patient out of 318 among patients undergoing mandatory screening by PSG developed a respiratory complication requiring ICU stay, compared with 11 out of 572 patients who did not get PSG before surgery.17 A more recent study18 among patients with OSA undergoing laparoscopic Roux-en-Y gastric bypass did not show any higher postoperative complication rates among patients with OSA, hence suggesting that routine ICU admission after laparoscopic Roux-en-Y gastric bypass be discontinued.

In patients with OSA undergoing elective NCS, early postoperative complications may be attributed intuitively to the negative effects of sedative, analgesic, and anesthetic agents, which can worsen OSA by decreasing pharyngeal tone, and the arousal responses to hypoxia, hypercarbia, and obstruction.19 However, later events are more likely to be related to postoperative rapid eye movement (REM) sleep rebound.20 In a recent study, Liao et al21 reported a higher AHI and oxygen desaturation index among OSA patients on the third postoperative night compared with preoperatively or on the first postoperative night.

Severity of OSA and Incidence of Postoperative Complications

Our study did not find an association between the severity of OSA, as measured by the AHI, and RF (P = .3), ICU transfer (P = .9), or LOS (P = .97). Literature is conflicting regarding the severity of OSA and the occurrence of postoperative complications. In a study by Gupta et al,3 the severity of OSA as measured by the total respiratory disturbance index was not associated with postoperative complications; however, the supine respiratory disturbance index was reported to be high in most patients. More recent literature supports a higher oxygen desaturation index in patients for whom PSG could not be done, linked with an incidence of higher postanesthesia care unit events and postoperative complications.7,22 Hence, PSG may be neither practical nor necessary in the preoperative assessment.

No studies so far have reported any postoperative deaths directly attributed to OSA. Although respiratory complications dominate, REM rebound has been suggested to contribute to myocardial ischemia and infarction, stroke, mental confusion, and wound breakdown.2327 REM sleep rebound and the link to sympathetic tone may be particularly dangerous, leading to myocardial ischemia, infarction, and even unexplained postoperative death. This hypothesis is supported by the finding that the majority of unexpected and unexplained postoperative deaths occur at night within 7 days of surgery.28

Limitations

Our study is retrospective and used PSG data within the 3 years before or after NCS. Getting PSG before NCS in suspected cases is not standard practice and, unlike some other disorders, the symptoms of OSA present and evolve gradually over time. Also, we did not have complete information regarding the pre- or postoperative use of CPAP or objective PAP adherence data and, hence, are unable to comment on the impact of perioperative use of PAP and or possible carry-over effects from use of home CPAP. If resuming PAP after surgery in patients with known OSA becomes a clinical standard of care, randomized trials addressing the role of PAP in preventing postoperative complications are unlikely to be completed in the future. We did not have pharmacy data to study the impact of the pain medications, sedatives, and anesthetic agents used on the perioperative outcomes.

Patients with OSA are at higher risk of hypoxia, RF, unplanned ICU transfers, and longer hospital stay. Although PSG may be neither practical nor necessary in screening patients with suspected OSA about to undergo surgery, future studies need to define the highest-risk group among the OSA patients, who may be in particular need of intensive monitoring during and after surgery.

Author contributions:Dr Kaw: contributed to the concept and design of the article, acquisition of data, analysis and interpretation of data, drafting of the article, critical revision of the paper for important intellectual content, final approval of the article, and study supervision.

Dr Pasupuleti: contributed to the acquisition of data, critical revision of the paper for important intellectual content, and study supervision.

Dr Walker: contributed to the concept and design of the article, analysis and interpretation of data, critical revision of the paper for important intellectual content, final approval of the article, statistical expertise, and study supervision.

Dr Ramaswamy: contributed to the acquisition of data.

Dr Foldvary-Schafer: contributed to the analysis and interpretation of data, drafting of the article, critical revision of the paper for important intellectual content, and final approval of the article.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

AHI

apnea-hypopnea index

ASA

American Society of Anesthesiology

CHF

congestive heart failure

CPAP

continuous positive airway pressure

LOS

length of stay

MI

myocardial infarction

NCS

noncardiac surgery

OSA

obstructive sleep apnea

PAP

positive airway pressure

PSG

polysomnography

REM

rapid eye movement

RF

respiratory failure

Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;1631:19-25 [PubMed]
 
Marshall NS, Wong KKH, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;318:1079-1085 [PubMed]
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;769:897-905 [PubMed]
 
Sharma VK, Galli W, Haber A, et al. Unexpected risks during administration of conscious sedation: previously undiagnosed obstructive sleep apnea. Ann Intern Med. 2003;1398:707-708 [PubMed]
 
Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N, Walker E. Incremental risk of obstructive sleep apnea on cardiac surgical outcomes. J Cardiovasc Surg (Torino). 2006;476:683-689 [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management American Society of Anesthesiologists Task Force on Perioperative Management Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;1045:1081-1093 [PubMed] [CrossRef]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;1335:1128-1134 [PubMed]
 
Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg. 2011;1121:113-121 [PubMed]
 
Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;209:705-706 [PubMed]
 
Auckley D, Steinel J, Southwell , et al. Does screening for sleep apnea with the Berlin Questionnaire predict elective surgery postoperative complications? Sleep. 2003;26S:A238-239
 
Chung F, Ward B, Ho J, Yuan H, Kayumov L, Shapiro C. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth. 2007;192:130-134 [PubMed]
 
Namen AM, Dunagan DP, Fleischer A, et al. Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey. Chest. 2002;1216:1741-1747 [PubMed]
 
Fidan H, Fidan F, Unlu M, Ela Y, Ibis A, Tetik L. Prevalence of sleep apnoea in patients undergoing operation. Sleep Breath. 2006;103:161-165 [PubMed]
 
Hosking MP, Lobdell CM, Warner MA, Offord KP, Melton LJ III. Anaesthesia for patients over 90 years of age. Outcomes regional and general anaesthetic techniques for two common surgical procedures. Anaesthesia. 1989;442:142-147 [PubMed]
 
Stürmer T, Joshi M, Glynn RJ, Avorn J, Rothman KJ, Schneeweiss S. A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J Clin Epidemiol. 2006;595:437-447 [PubMed]
 
Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth. 2009;5611:819-828 [PubMed]
 
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Grover BT, Priem DM, Mathiason MA, Kallies KJ, Thompson GP, Kothari SN. Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;62:165-170 [PubMed]
 
Kaw R, Michota FA, Jaffer A, Ghamande S, Auckley D, Golish J. Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting. Chest. 2006;1291:198-205 [PubMed]
 
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Liao P, Sun F, Amirshahi B, et al. A significant exacerbation of sleep breathing disorders in OSA patients undergoing surgery with general anaesthesia. Sleep. 2009;:A223;0684
 
Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology. 2009;1104:869-877 [PubMed]
 
Grote L, Kraiczi H, Hedner J. Reduced alpha- and beta(2)-adrenergic vascular response in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2000;1624 pt 1:1480-1487 [PubMed]
 
Gill NP, Wright B, Reilly CS. Relationship between hypoxaemic and cardiac ischaemic events in the perioperative period. Br J Anaesth. 1992;685:471-473 [PubMed]
 
Goldman MD, Reeder MK, Muir AD, et al. Repetitive nocturnal arterial oxygen desaturation and silent myocardial ischemia in patients presenting for vascular surgery. J Am Geriatr Soc. 1993;417:703-709 [PubMed]
 
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Rosenberg J, Kehlet H. Postoperative mental confusion—association with postoperative hypoxemia. Surgery. 1993;1141:76-81 [PubMed]
 
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Figures

Figure Jump LinkFigure 1. Flow diagram of patient selection. I/E = inclusion/exclusion; IMPACT = Internal Medicine Preoperative Assessment Consultation and Treatment; OSA = obstructive sleep apnea.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Baseline Characteristics of Patients With and Without OSA

Data are presented as No. (%) unless indicated otherwise. AHI = apnea-hypopnea index; ASA = American Society of Anesthesiologists; CAD = coronary artery disease; OSA = obstructive sleep apnea.

a 

Propensity model includes the first seven baseline characteristics and their interactions.

b 

Spinal anesthesia, local anesthesia, epidural block, and paravertebral block.

c 

Current or previous smoker.

Table Graphic Jump Location
Table 2 —Types of Noncardiac Surgical Procedures

Data are presented as No. (% of AHI group). ENT = ear, nose, and throat. See Table 1 legend for expansion of other abbreviation.

Table Graphic Jump Location
Table 3 —Postoperative Complications/Outcomes Among Patients With and Without OSA

Data are presented as No. (% of AHI group) unless indicate otherwise. LOS = length of stay. See Table 1 legend for expansion of other abbreviation.

a 

Propensity model includes the first seven baseline characteristics and their interactions.

b 

JMP software will not compute a correct P value when numbers in the comparison group are small.

References

Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;1631:19-25 [PubMed]
 
Marshall NS, Wong KKH, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;318:1079-1085 [PubMed]
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;769:897-905 [PubMed]
 
Sharma VK, Galli W, Haber A, et al. Unexpected risks during administration of conscious sedation: previously undiagnosed obstructive sleep apnea. Ann Intern Med. 2003;1398:707-708 [PubMed]
 
Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N, Walker E. Incremental risk of obstructive sleep apnea on cardiac surgical outcomes. J Cardiovasc Surg (Torino). 2006;476:683-689 [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management American Society of Anesthesiologists Task Force on Perioperative Management Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;1045:1081-1093 [PubMed] [CrossRef]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;1335:1128-1134 [PubMed]
 
Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg. 2011;1121:113-121 [PubMed]
 
Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;209:705-706 [PubMed]
 
Auckley D, Steinel J, Southwell , et al. Does screening for sleep apnea with the Berlin Questionnaire predict elective surgery postoperative complications? Sleep. 2003;26S:A238-239
 
Chung F, Ward B, Ho J, Yuan H, Kayumov L, Shapiro C. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth. 2007;192:130-134 [PubMed]
 
Namen AM, Dunagan DP, Fleischer A, et al. Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey. Chest. 2002;1216:1741-1747 [PubMed]
 
Fidan H, Fidan F, Unlu M, Ela Y, Ibis A, Tetik L. Prevalence of sleep apnoea in patients undergoing operation. Sleep Breath. 2006;103:161-165 [PubMed]
 
Hosking MP, Lobdell CM, Warner MA, Offord KP, Melton LJ III. Anaesthesia for patients over 90 years of age. Outcomes regional and general anaesthetic techniques for two common surgical procedures. Anaesthesia. 1989;442:142-147 [PubMed]
 
Stürmer T, Joshi M, Glynn RJ, Avorn J, Rothman KJ, Schneeweiss S. A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J Clin Epidemiol. 2006;595:437-447 [PubMed]
 
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