Manejo peri-operatório dos pacientes
com SAHOS
V Curso Nacional de Ventilação Mecânica
II Curso Nacional de Sono
22 a 24 de março de 2012
Realização - SBPT
MEDICINA DO SONO HOSPITAL SÍRIO LIBANÊS
NÚCLEO AVANÇADO DE TÓRAX (NAT) – HSL
PNEUMOLOGIA EPM - UNIFESP
Maurício C. Bagnato
Síndrome da Hipoventilação-Obesidade - SHO
Síndrome da Hipoventilação-Obesidade - SHO
Piper 0 A. J. Sleep Med Rews 2010
Síndrome da Hipoventilação-Obesidade - SHO
Upper Airway Management of the Adult Patient with
Obstructive Sleep Apnea in the Perioperative Period Avoiding Complications.
Clinical Practice Review Committee - American Academy of Sleep Medicine
SLEEP 2003;26(8):1060-5.
Fatores que contribuem para o risco peri-operatório
• ↑ Instabilidade de VVAASS devido a anestésicos e analgésicos
narcóticos
• Efeitos cardiopulmonares devido a SAHOS
• ↓ Capacidade residual funcional e reserva oxigenação no obeso
• ↓ do “drive” ventilatório devido a agentes anestésicos
Upper Airway Management of the Adult Patient
with Obstructive Sleep Apnea in the
Perioperative Period - Avoiding Complications.
Clinical Practice Review Committee - American Academy of Sleep Medicine
SLEEP 2003;26(8):1060-5.
SAHOS (PSG no prontuário / CPAP ideal / doença residual (↑peso) / CPAP pré e POI
S/ diag SAHOS (Hist / EF / menop / acompanhante / questionário / obeso ou não / CPAP
empírico no POI se urgência – aceitação?, auto-CPAP? )
Entubação preparo (drogas anti-refluxo e antisilogogas? / pré-oxigenação / masc laríngea?
Entubação (s/n fibr óptica / se insucesso – masc, obturador esof,, jet vent transtr s/n traqueo)
Anestésico (c/ ou s/ sedação? – melhor sem – geral / se possível bloq regional / epidural?
Extubação (perder control VVAA / edema pulmonar / tônus musc adeq / dec elevado
apenas? – CPAP
POI (primeiras 24hs críticas – UTI / rebote REM / analgesia cautelosa / sinergismo / co-
morbidades / PCA c/ limite / Oximetria e Fc c/ alarmes / CPAP adequado se rc ↑ pressão
Obstructive Sleep-Related Breathing Disorders in
Patients Evaluated for Bariatric Surgery
Obesity Surgery, 13, 2003
Summary
The incidence of OSRBD in our bariatric study population
was very high. Cardiovascular consequences
of OSRBD are well documented. These consequences
may be increased in the postoperative period
when the combination of REM rebound and narcotic
analgesia increase oxyhemoglobin desaturations.
Health-care providers evaluating patients for
bariatric surgery should consider referral for a sleep
Obstructive Sleep-Related Breathing Disorders in
Patients Evaluated for Bariatric Surgery
Obesity Surgery, 13, 2003
Evaluation and PSG as part of the preoperative evaluation.Clinical
evaluation with BMI, Epworth Sleepiness Scale and the
Mallampati airway classificationfailed to predict the severity of
OSRBD. Therapy for OSRBD should be initiated prior to
surgeryto minimize the hemodynamic complications of OSRBD
and to familiarize the patient with CPAP. Patients should be
educated about the importance of CPAP use to correct OSRBD.
Continued use of CPAP in the postoperative period will
theoretically decrease the potential morbidity and mortality of
OSRBD in the hospital and after discharge from the hospital.
Evidence Supporting Routine
Polysomnography
Before Bariatric Surgery
Obesity Surgery, 14, 23-26, 2004
Conclusions: In this large patient cohort, sleep
apnea was prevalent (77%) independent of BMI, and
most cases were not diagnosed before bariatric
surgical consultation. These data support the use of
routine screening polysomnography before bariatric
surgery.
Postoperative Complications in Patients With
Obstructive Sleep Apnea Syndrome Undergoing
Hip or Knee Replacement: A Case-Control Study
Mayo Foundation for Medical Education and Research Volume
76(9), September 2001, pp 897-905
CONCLUSIONS
In this study, we have shown that the presence of OSAS in patients
undergoing elective hip replacement or knee replacement is associated
with a considerable number of complications in the postoperative
period. Almost one third of the patients with OSAS in our study
suffered a substantial respiratory or cardiac complication. Patients
who were not using CPAP prior to hospitalization had a significantly
higher incidence of serious complications. Patients diagnosed with
OSAS have been shown to be heavy consumers of health care
resources for several years prior to diagnosis and the utilization
decreases after starting treatment in patients who adhere to the
treatment.
Postoperative Hypoxemia in Morbidly Obese Patients
With and Without Obstructive Sleep Apnea Undergoing
Laparoscopic Bariatric Surgery
(Anesth Analg 2008;107:138 –43)
CONCLUSIONS: In morbidly obese subjects, in the first 24 h
after laparoscopic bariatric surgery, OSA does not seem to
increase the risk of postoperative hypoxemia. Our data
confirm that morbidly obese subjects, with or without OSA,
experience frequent oxygen desaturation episodes
postoperatively, despite supplemental oxygen therapy
suggesting that perioperative management strategies in
morbidly obese patients undergoing laparoscopic bariatric
surgery should include measures to prevent postoperative
hypoxemia.
Identification of patients at risk for postoperative
respiratory complications using a preoperative
obstructive sleep apnea screening tool and
postanesthesia care assessment.
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
55905, USA. [email protected]
Anestthesiology 2009 Apr;110(4):869-77.
CONCLUSIONS:
Combination of an obstructive sleep apnea screening tool
preoperatively (SACS) and recurrent PACU respiratory events
was associated with a higher oxygen desaturation index and
postoperative respiratory complications. A two-phase process
to identify patients at higher risk for perioperative respiratory
desaturations and complications may be useful to stratify and
manage surgical patients postoperatively.