mild and manageable using the intraoperative guidelines, or are we
better off rescheduling the procedure and having the patient first
undergo formal treatment of his apnea?"
2. Using a neuromuscular
blockade may increase risk.
Do you use neuromuscular blockades (NMBA) regularly in your pro-
cedures? If so, then you especially should be closely monitoring your
OSA patients' neuromuscular-blocking agents, which pose an
increased risk to patients with OSA.
"This is because the airway is already compromised in an OSA
patient due to the redundant airway tissue, larger tongue, tonsils and
thick neck," says Timothy Schmidt, CRNA, owner of Sonno
Anesthesia in St. Petersburg, Fla. "The problem with NMBAs occurs
when you have residual NMBA in the body at the end of the case.
Even when the majority of a NMBA is reversed or metabolized, the
small amount that is left can leave the patient's airway muscles signifi-
cantly weakened. When combined with the negative effects of OSA,
residual NMBA can greatly negatively affect a patient's respiratory
effort."
Mr. Schmidt offers an analogy to drive home his point. If sleep
apnea is trying to breathe through a straw, then residual NMBA is
someone sitting on your chest while you breathe through a straw.
"This is why these patients are at even greater risk for respiratory fail-
ure and hypoxemia," he says.
Use of NMBA is associated with residual paralysis in roughly 20% of
patients, notes Dr. Joshi. Residual paralysis is associated with higher
incidence of post-operative pulmonary complications and higher 30-
day readmission rates. Because of this, the guideline recommends
that when using a NMBA in a patient with OSA, you should always
3 8 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 8
