Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2024
Positive Airway Pressure in Surgical Patients with Sleep Apnea: What is the Supporting Evidence?
Obstructive sleep apnea (OSA) is prevalent amongst surgical patients and associated with an increased incidence of perioperative complications. The gold standard treatment for moderate-to-severe OSA is positive airway pressure (PAP) therapy. Practice guidelines by the American Society of Anesthesiologists and the Society of Anesthesia and Sleep Medicine have recommended preoperative screening for OSA and consideration of initiation of PAP therapy for patients with severe OSA. ⋯ Our review provides an update on the existing literature on the efficacy of PAP therapy in surgical patients with OSA. We focus on the postoperative complications associated with OSA, potential mechanisms leading to the increased risk of postoperative adverse events, and summarize the perioperative guidelines for the management of patients with OSA, evidence supporting perioperative PAP therapy, as well as limitations to PAP therapy and alternatives. An update on the existing literature of the efficacy of PAP therapy in surgical patients with OSA is critical to assess the impact of prior guidelines, determine when and how to effectively implement PAP therapy, and target barriers to PAP adherence in the perioperative setting.
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Anesthesia and analgesia · Feb 2024
Integrated Feedforward and Feedback Mechanisms in Neurovascular Coupling.
Neurovascular coupling (NVC) is the mechanism that drives the neurovascular response to neural activation, and NVC dysfunction has been implicated in various neurologic diseases. NVC is driven by (1) nonmetabolic feedforward mechanisms that are mediated by various signaling pathways and (2) metabolic feedback mechanisms that involve metabolic factors. However, the interplay between these feedback and feedforward mechanisms remains unresolved. ⋯ Thus, feedback mechanisms ensure the brain milieu's stability when feedforward mechanisms are impaired. Our proposal integrates the feedforward and feedback mechanisms underlying NVC and suggests that these 2 mechanisms work like a fail-safe system, to a certain degree. We also discussed the difference between NVC and cerebral metabolic rate-CBF coupling and the clinical implications of our proposed framework.
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Anesthesia and analgesia · Feb 2024
Effect of Changing Estimated Glomerular Filtration Rate Formula on Sugammadex Use and Pulmonary Complications for African American and non-African American Patients.
Sugammadex is associated with fewer postoperative pulmonary complications than is neostigmine reversal of neuromuscular blockade. However, the Food and Drug Administration-approved package insert states that its use is "not recommended" in severe renal impairment, separately defined as creatinine clearance <30 mL/min. Recently, the formula for estimating glomerular filtration rate (GFR) was updated to remove the race variable. Compared to the prior formula, the new consensus equation lowers the estimated GFR for African American patients and raises it for everyone else. We sought to determine how this change could differently impact the use of sugammadex, and thus the rate of pulmonary complications, for both African American and non-African American patients. ⋯ The recent change in GFR formulas may potentially be associated with an increase in postoperative pulmonary complications in African American patients and a decrease in postoperative pulmonary complications in non-African American patients through GFR-driven changes in sugammadex use.