Anesthesia and analgesia
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One-lung ventilation in children continues to present technical and sometimes physiologic challenges to the clinician. The rarity of these cases at any single institution, however, has led to very few prospective trials to guide best practices. As a result, most clinicians continue to be guided by local tradition and preference. ⋯ The Arndt bronchial blocker continues to represent the most well documented of these devices. Additionally, recent advances have occurred in our understanding of the relevant anatomic constraints of the lower pediatric airway. This review is intended to provide a comprehensive and practical update to practicing pediatric anesthesiologists to further their understanding of the modern practice of one-lung ventilation for thoracic surgery in children.
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Anesthesia and analgesia · May 2021
ReviewIntegrating Sleep Knowledge Into the Anesthesiology Curriculum.
There is common ground between the specialties of anesthesiology and sleep medicine. Traditional sleep medicine curriculum for anesthesiology trainees has revolved around the discussion of obstructive sleep apnea (OSA) and its perioperative management. ⋯ The range of topics include not only the basics of the physiology of sleep and sleep-disordered breathing (eg, OSA and central sleep apnea) but also insomnia, sleep-related movement disorders (eg, restless legs syndrome), and disorders of daytime hypersomnolence (eg, narcolepsy) in the perioperative and chronic pain settings. Awareness of these topics is relevant to the scope of knowledge of anesthesiologists as perioperative physicians as well as to optimal sleep health and physician wellness and increase consideration among current anesthesiology trainees for the value of dual credentialing in both these specialties.
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Anesthesia and analgesia · May 2021
ReviewVulnerability to Postoperative Complications in Obstructive Sleep Apnea: Importance of Phenotypes.
Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing surgical procedures. Patients with OSA are at heightened risk of postoperative complications. Current treatments for OSA focus on alleviating upper airway collapse due to impaired upper airway anatomy. ⋯ Each of these phenotypes respond differently to postoperative factors, such as opioid medications. An understanding of these phenotypes and their highly varied interactions with postoperative risk factors is key to providing safer personalized care for postoperative patients with OSA. Accordingly, this review describes the 4 OSA phenotypes, highlights how the impact on OSA severity from postoperative risk factors, such as opioids and other sedatives, is influenced by OSA phenotypes, and outlines how this knowledge can be applied to provide individualized care to minimize postoperative risk in surgical patients with OSA.
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Anesthesia and analgesia · May 2021
ReviewPerioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review.
The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. ⋯ The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.
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Anesthesia and analgesia · May 2021
ReviewAirway Management in Surgical Patients With Obstructive Sleep Apnea.
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and the difficult airway is perhaps the anesthesiologists' quintessential concern. OSA and the difficult airway share certain similar anatomical, morphological, and physiological features. ⋯ Prudent intraoperative management comprises the use of regional anesthesia where possible and considering an awake intubation technique where there is the presence of notable difficult airway predictors and risk of rapid desaturation following induction of general anesthesia. Familiarity with difficult airway algorithms, cautious extubation, and appropriate postoperative monitoring of patients with OSA are necessary to mitigate perioperative risks.