1

Introduction

Sleep apnea surgeries are some of the most common procedures performed by the otolaryngologist. Despite the frequency of these procedures, there is still debate about the optimal postoperative disposition of these patients . Even within the highly centralized Veterans Affairs (VA) medical system, there are no approved protocols for preoperatively triaging patients with sleep apnea who are undergoing sleep surgery, and little agreement as to the appropriate level of postoperative care . The otolaryngology literature has numerous publications evaluating the safety of sleep apnea surgery being performed as an outpatient or with routine overnight postoperative monitoring . Despite these findings, some centers, like the Durham VA Medical Center (DVAMC), have historically observed all postoperative sleep apnea surgery patients in an intensive care setting.

Although uncommon, the potential complications from sleep apnea surgery have been well documented in the literature. Airway compromise after sleep apnea surgery is present in less than 10% of patients and can often be linked to aggressive use of narcotics in the OR . Significant postoperative oxygen desaturations below 80% or below preoperative values have also been demonstrated to be extremely uncommon . Bleeding is seen in a bi-phasic pattern either within the first 48 h or 7–10 days later, but rarely occurs before the patient is discharged to home when kept for observation . Hypertension has been shown to be one of the most common complications after sleep apnea surgery, but is almost always evident within two hours of surgery .

Certain factors are predictive of postoperative complications and can allow for preoperative triage of high-risk patients to more intensive postoperative care. Minimum oxygen saturation, the apnea–hypopnea index (AHI), and amount of narcotics administered in the operating room have all been shown to be risk factors for patients undergoing sleep apnea surgery . Esclamado et al. showed a trend toward more intubation difficulties with increase in percentage of ideal body weight, and that extubation issues are associated with increasing amounts of narcotics intraoperatively .

Historically at the DVAMC, any patient undergoing sleep apnea surgery was postoperatively admitted to the surgical intensive care unit (SICU). Almost all of these patients were going home on the first postoperative day without issues or complications, leading some to question the necessity of this intensive level of postoperative care. This policy also utilized limited intensive care resources, which were in high demand given the highly complex nature of the DVAMC’s caseload. A collaborative effort between otolaryngology, nursing, and anesthesia staff led to a new protocol for postoperative disposition based on existing literature concerning the safety of outpatient sleep surgery and the risk factors for complications. The protocol was based on the assumption that patients at high risk for complications could be identified preoperatively, and that those at low risk could be managed safely as outpatients or with routine overnight observation.

This study is the first, to our knowledge, to document the implementation of an evidence-based protocol for determining postoperative level of care for patients undergoing sleep apnea surgery based on preoperative risk factors. The aim of this study was to evaluate the effectiveness of this protocol for postoperative disposition in patients undergoing sleep apnea surgery. Given the historical literature and the DVAMC’s own experience, we felt that properly triaged patients would not have an increase in complication rates. In addition, the protocol would provide for more efficient utilization of SICU resources and lead to cost savings.

2

Materials and methods

A retrospective chart review, which was approved by the DVAMC Institutional Review Board, was conducted for all patients who underwent sleep apnea surgery at the DVAMC between July 2008, when the postoperative disposition protocol was implemented, and January 2012. Sleep apnea surgery was defined as surgery on the upper airway intended either to cure or improve obstructive sleep apnea, or to improve tolerance of a CPAP device. Patients were excluded if they did not have preoperative sleep studies, if they did not keep their follow-up appointments, or if they were having concomitant non-sleep surgery.

The new sleep apnea protocol consisted of three major criteria and two minor criteria. Major criteria included multi-level surgery (e.g. septoplasty and uvulopalatopharyngoplasty), preoperative AHI > 60, and minimum oxygen desaturation < 75% as documented on polysomnogram. Minor criteria included a Body Mass Index (BMI) > 35 and the presence of significant medical comorbidities (e.g. uncontrolled hypertension, congestive heart failure, coronary artery disease or chronic obstructive pulmonary disease). These major and minor criteria were chosen based on literature examining patient characteristics predicting complications . Patients with one major criterion or two minor criteria were considered to be at high risk for postoperative complications and were admitted to the SICU. Patients with one minor criterion were considered to be at intermediate risk for postoperative events and were kept overnight in the observation unit. Finally, those patients with no major or minor criteria were considered to be at low risk for postoperative complications and were discharged home after a 2-h post-anesthesia care unit (PACU) observation. Regardless of preoperative triage status, any patient experiencing problems in the PACU would be scheduled for either overnight observation or ICU admission, depending on the nature and severity of the issue.

The otolaryngology staff was educated on the use of this protocol for preoperative triage of sleep apnea patients. The PACU nurses and providers were educated on the monitoring of patients who were triaged as outpatients and on the protocol for patients who had problems during their observation periods.

Complication rates were evaluated for each of the three disposition groups. A cost analysis based on room charge only was also performed using costs of ICU, observation, and ward stay obtained from the DVAMC administration based on FY2010 costs.

2

Materials and methods

A retrospective chart review, which was approved by the DVAMC Institutional Review Board, was conducted for all patients who underwent sleep apnea surgery at the DVAMC between July 2008, when the postoperative disposition protocol was implemented, and January 2012. Sleep apnea surgery was defined as surgery on the upper airway intended either to cure or improve obstructive sleep apnea, or to improve tolerance of a CPAP device. Patients were excluded if they did not have preoperative sleep studies, if they did not keep their follow-up appointments, or if they were having concomitant non-sleep surgery.

The new sleep apnea protocol consisted of three major criteria and two minor criteria. Major criteria included multi-level surgery (e.g. septoplasty and uvulopalatopharyngoplasty), preoperative AHI > 60, and minimum oxygen desaturation < 75% as documented on polysomnogram. Minor criteria included a Body Mass Index (BMI) > 35 and the presence of significant medical comorbidities (e.g. uncontrolled hypertension, congestive heart failure, coronary artery disease or chronic obstructive pulmonary disease). These major and minor criteria were chosen based on literature examining patient characteristics predicting complications . Patients with one major criterion or two minor criteria were considered to be at high risk for postoperative complications and were admitted to the SICU. Patients with one minor criterion were considered to be at intermediate risk for postoperative events and were kept overnight in the observation unit. Finally, those patients with no major or minor criteria were considered to be at low risk for postoperative complications and were discharged home after a 2-h post-anesthesia care unit (PACU) observation. Regardless of preoperative triage status, any patient experiencing problems in the PACU would be scheduled for either overnight observation or ICU admission, depending on the nature and severity of the issue.

The otolaryngology staff was educated on the use of this protocol for preoperative triage of sleep apnea patients. The PACU nurses and providers were educated on the monitoring of patients who were triaged as outpatients and on the protocol for patients who had problems during their observation periods.

Complication rates were evaluated for each of the three disposition groups. A cost analysis based on room charge only was also performed using costs of ICU, observation, and ward stay obtained from the DVAMC administration based on FY2010 costs.