Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis.

BACKGROUND: Death and anoxic brain injury from unrecognized postoperative respiratory depression (PORD) is a serious concern for patient safety. The American Patient Safety Foundation has called for continuous electronic monitoring for all patients receiving opioids in the postoperative period. These recommendations are based largely on consensus opinion with currently limited evidence. The objective of this study is to review the current state of knowledge on the effectiveness of continuous pulse oximetry (CPOX) versus routine nursing care and the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting PORD and preventing postoperative adverse events in the surgical ward. METHODS: We performed a systematic search of the literature databases published between 1946 and May 2017. We selected the studies that included the following: (1) adult surgical patients (>18 years old); (2) prescribed opioids during the postoperative period; (3) monitored with CPOX and/or capnography; (4) primary outcome measures were oxygen desaturation, bradypnea, hypercarbia, rescue team activation, intensive care unit (ICU) admission, or mortality; and (5) studies published in the English language. Meta-analysis was performed using Cochrane Review Manager 5.3. RESULTS: In total, 9 studies (4 examining CPOX and 5 examining continuous capnography) were included in this systematic review. In the literature on CPOX, 1 randomized controlled trial showed no difference in ICU transfers (6.7% vs 8.5%; P = .33) or mortality (2.3% vs 2.2%). A prospective historical controlled trial demonstrated a significant reduction in ICU transfers (5.6-1.2 per 1000 patient days; P = .01) and rescue team activation (3.4-1.2 per 1000 patient days; P = .02) when CPOX was used. Overall, comparing the CPOX group versus the standard monitoring group, there was 34% risk reduction in ICU transfer (P = .06) and odds of recognizing desaturation (oxygen saturation [SpO2] <90% >1 hour) was 15 times higher (P < .00001). Pooled data from 3 capnography studies showed that continuous capnography group identified 8.6% more PORD events versus pulse oximetry monitoring group (CO2 group versus SpO2 group: 11.5% vs 2.8%; P < .00001). The odds of recognizing PORD was almost 6 times higher in the capnography versus the pulse oximetry group (odds ratio: 5.83, 95% confidence interval, 3.54-9.63; P < .00001). No studies examined the impact of continuous capnography on reducing rescue team activation, ICU transfers, or mortality. CONCLUSIONS: The use of CPOX on the surgical ward is associated with significant improvement in the detection of oxygen desaturation versus intermittent nursing spot-checks. There is a trend toward less ICU transfers with CPOX versus standard monitoring. The evidence on whether the detection of oxygen desaturation leads to less rescue team activation and mortality is inconclusive. Capnography provides an early warning of PORD before oxygen desaturation, especially when supplemental oxygen is administered. Improved education regarding monitoring and further research with high-quality randomized controlled trials is needed.

Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea?

An understanding of the potential mechanisms underlying recurrent upper airway collapse may help anesthesiologists better manage patients in the postoperative period. There is convincing evidence in the sleep medicine literature to suggest that a positive fluid and salt balance can worsen upper airway collapse in patients with obstructive sleep apnea through the redistribution of fluid from the legs into the neck and upper airway while supine, in a process known as "rostral fluid shift." According to this theory, during the day the volume from a fluid bolus or from fluid overload states (i.e., heart failure and chronic kidney disease) accumulates in the legs due to gravity, and when a person lies supine at night, the fluid shifts rostrally to the neck, also owing to gravity. The fluid in the neck can increase the extraluminal pressure around the upper airways, causing the upper airways to narrow and predisposing to upper airway collapse. Similarly, surgical patients also incur large fluid and salt balance shifts, and when recovered supine, this may promote fluid redistribution to the neck and upper airways. In this commentary, we summarize the sleep medicine literature on the impact of fluid and salt balance on obstructive sleep apnea severity and discuss the potential anesthetic implications of excessive fluid and salt volume on worsening sleep apnea.

Diabetes, intracranial stenosis and microemboli in asymptomatic carotid stenosis.

BACKGROUND: The risk of stroke in patients with asymptomatic carotid stenosis (ACS) is now so low that it is important to have methods to identify those patients most likely to benefit from intervention, or who may require special consideration in choice of medical therapy. We studied the prediction of stroke, death or transient ischemic attacks (stroke/death/TIA) in patients with ACS by intracranial arterial stenosis, and microemboli on transcranial Doppler (TCD), and the effect of diabetes mellitus on microemboli, intracranial stenosis and risk of events. METHODS: Patients with ACS > 60% by Doppler ultrasound were recruited from the Stroke Prevention Clinic of University Hospital, London, Canada. All 339 participants underwent TCD for detection of intracranial stenosis and detection of microemboli, and carotid ultrasound to measure extracranial stenosis and total carotid plaque area. Participants were followed for three years, to determine the risk of stroke/death/TIA. RESULTS: Stroke/death/TIA occurred in 38% of patients with microemboli versus 10% without (p=0.0001), and in 18% of patients with intracranial stenosis, versus 10% without (p=0.042). Diabetics were significantly more likely to have intracranial stenosis (45% vs. 29%, p =0.014), microemboli (38% vs. 10%, p <0.0001), and had significantly higher risk of stroke/death/TIA over three years (21% vs. 11% without; p=0.024). Survival free of stroke, TIA or death was significantly better without microemboli or intracranial stenosis (p<0.0001). CONCLUSIONS: Diabetes, microemboli and intracranial stenosis predicted higher risk of stroke, death or TIA than did extracranial stenosis or total plaque area; diabetics may need more intensive therapy.