Impact on clinical outcomes, surgical interventions, anaesthetic decisions and complication rates following implementation of the NICE obstructive sleep apnoea guidelines during preoperative screening

Abstract

Introduction: Unidentified obstructive sleep apnoea (OSA) can lead to unexpected perioperative complications, unplanned postoperative admissions and increased length of hospital stay. NICE (National Institute for Health and Care Excellence) recommends a rapid preoperative assessment for patients undergoing elective surgery. Methods: We have evaluated the impact on implementing the NICE guidelines on clinical outcomes, surgical interventions, anaesthetic decisions and complication rates in surgical patients referred from the pre-assessment clinic prior to an elective intervention. All patients with a clinical suspicion of OSA based on a STOP-Bang score of 3 or more were referred for an overnight oximetry. Demographics, clinical outcomes and the impact on the planned surgical procedures were evaluated. Results: 450 patients (Age 55 ± 14 years, male 69%, Epworth Sleepiness Scale (ESS) 7 ± 5) with a STOP-Bang score of 3 or more underwent overnight oximetry (32%; normal, 44%; mild, 15%; moderate and 9%; severe OSA). All patients with moderate and severe OSA were recommended for continuous positive airway pressure (CPAP) therapy to facilitate their surgical procedures and for long-term cardiometabolic benefits. Diagnosis of moderate/severe OSA had an impact on the surgical decision (P < 0.0001, odds ratio (OR) = 3.79, 95% confidence interval (CI) = 2.39–6.02). Severity of OSA affected the planned anaesthetic route (P < 0.0001, OR = 3.94, 95% CI = 2.21–7.05). No significant difference in day case vs non-day case, or need for unplanned admissions to critical care due to better planning pre-procedure. CPAP was initiated preoperatively in a third of patients (mean compliance 3.75 hours/day) and the overall complication rate was 11.6% in the moderate/severe OSA group vs 9.6% in the normal/mild OSA group. Conclusion: Prevalence of OSA is high in presurgical patients identified through preoperative screening. A diagnosis of moderate to severe OSA impacts surgical decision and planned anaesthetic route. Prior awareness of the diagnosis may help clinicians to identify the at-risk group. Timely CPAP initiation to facilitate surgery remains a challenge and, despite low compliance, CPAP may reduce postoperative complications. A multidisciplinary team (MDT) approach and a dedicated CPAP pathway post-diagnosis may help the clinicians and patients.

Keywords

• OSA
• Preoperative screening
• CPAP
• Complications
• NICE guidelines