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UntitledSleep_19-20-V3N5 10/17/08 6:19 PM Page 19 Sleep Diagnosis and Therapy 2008; V3 N5, P19-20 K. Hansen Care of Patients at Risk for Sleep Apnea Who Receive Sedation
Sleep apnea is the most widely known sleep disorder besides patient for the effects of sedation, it is critical to differentiate insomnia. Estimates are that more than 18 million people have between sedation and sleepiness: does the patient need to be sleep apnea, and it is more common in men than women. People stimulated often to respond to your requests, and does the of all ages and both sexes can have sleep apnea. Due to apneic patient fall asleep easily without stimulation.2 events, restful sleep patterns are interrupted resulting in Increased sedation also increases the patient’s risk for falls, excessive sleepiness and next-day fatigue. Increasing preva- especially later in the night when sedation and sleepiness lence for sleep apnea requires the integration of a sleep apnea management (SAM) program to reduce the risk of experiencingan adverse event after receiving sedation.1 Intervention to Prevent Adverse Events
With the integration of a dedicated sleep apnea management
What are the Consequences of Untreated Sleep Apnea?
program, continuous monitoring of oxygenation and ventila- Patients with sleep apnea are four times as likely to have serious tion reduces the possibility of adverse events. The post- complications, two times as likely to have some post-surgical operative or post-procedure management plan should take and post-procedure complications and have significantly into consideration the need for close observation by the longer hospital stays. If you suspect your patient has sleep clinical team and should be combined with the use of PAP apnea, evaluation by a doctor specializing in sleep disorders when sedated and asleep. Standing Orders used with patients is recommended. A screening for sleep apnea should be done diagnosed or at risk for sleep apnea receiving sedation, pain prior to receiving pain medications, sedation, or anesthesia.
control, anxiolytics, and antiemetics provide a standardized At a minimum, ask your patients who are preparing to receive treatment plan to reduce the risk of a negative outcome when a sedating drug: “Do you snore?” “Have you been noted to stop caring for the patient with sleep apnea.3 breathing during your sleep?” and “Do you have difficultystaying awake when sitting quietly or while driving?” Impact on Care Continuum of Sleep Apnea
Without proactive treatment of sleep apnea the patient A sleep apnea management program requires a number of receiving drugs that cause sedation has an increased risk for other clinical services and a diverse care team to effectively reduce health risk factors such as elevated blood pressure due to increased effort to sustain adequate oxygenation and ventilation duringsleep. The risk for ischemic heart disease is elevated and atrial • Anesthesia – risk for respiratory depression due to anes- fibrillation is twice as likely to occur if sleep apnea is untreated.
Sleep deprivation contributes to elevated blood sugar and blood • Operating Services and Surgeons – risk for adverse events pressure plus weight gain. Left untreated, elevated insulin con- tributes to diabetes. Also, with increased weight gain, sleep apnea • Radiology – monitoring for over-sedation during invasive becomes more severe, contributing to elevated blood pressure. • Endoscopy – monitoring sedation used during procedure Medications that Affect Sleep Apnea
• Emergency Department – management of pain control Drugs, which create respiratory suppression, are commonly • Heart Institute – monitoring for increased sedation used in a perioperative and invasive procedural care plan: benzodiazepines for relaxation, narcotics for pain control, • Cardiology – management of ischemic heart disease antiemetics (phenergan) for nausea, hypnotics for sleep and • Pulmonology – treatment of pulmonary hypertension antidepressants for mood or sleep. Close observation and con- • Gastroenterology – treatment of acid reflux or GERD tinuous respiratory monitoring is required when substantial • Endocrinology – management of co-morbid diabetes analgesia is required, especially when delivered intravenously • Internal Medicine – management of co-morbid hypertension with a Patient Controlled device. IV PCA used with patients at • Psychiatry – depression from loss of sleep and reduced risk for sleep apnea creates increased risk for over sedation by the patient, who has increased need for pain control leading to • Risk Management – impact of adverse events increased sedation: increased somnolence from chronic sleep • Administration – Support for equipment and staffing deprivation coupled with drug induced sedation promotes risk for an adverse event. To protect the patient, PAP therapy isrequired to sustain ventilation while managing pain control.
The evidence suggests that there is a significant and under- Anesthesia may cause re-sedation in many patients 6–12 appreciated risk for serious injury from sedating agents, opioids, hours after recovery. This creates a risk for an adverse event and other drugs in the post-procedure or postoperative period.
and requires increased nursing assessment and continuous These agents cause life-threatening respiratory depression in respiratory monitoring. This is exacerbated by the presence of the patients at risk for sleep apnea. To protect these patients from excessive daytime sleepiness due to the accumulated sleep an adverse event, and still maintain control of pain, monitoring deprivation from untreated sleep apnea. When observing your of ventilation and oxygenation with audible alarms and frequent Sleep Diagnosis and Therapy ♦ Vol 3 No 5 September-October 2008 Sleep_19-20-V3N5 10/17/08 6:19 PM Page 20 assessment of vital functions is required. Treatment of sleep management services for newly diagnosed sleep apnea apnea with the use of positive air pressure implemented in PACU and following a procedure with sedation will protectthe patient from experiencing an unexpected event.
We recommend that patient monitoring must continue after discharge. The newly diagnosed patient must be encouraged to be evaluated with a sleep study. They need to be educatedabout the dangers of ignoring treatment for sleep apnea and References
they need to understand how the risks for respiratory and 1. Den Herder C, Risks of general anaesthesia in people with cardiovascular complications are more serious for patients obstructive sleep apnea. BMJ 2004; 329:955–9.
with sleep apnea. For example, their chance of having an auto 2. Practice Guidelines for the Perioperative Management of Patients related accident due to sleepiness and fatigue is significantly with Obstructive Sleep Apnea. A report by the American Society of Anesthesiologists Task Force on Perioperative Management ofPatients with Obstructive Sleep Apnea. Anesthesiology 2006; Implementing a sleep apnea monitoring program for patients undergoing sedation for medical or surgical proce- 3. Preventing and managing the impact of anesthesia awareness.
dures will reduce patient health risks, reduce professional Sentinel Event Alert Joint Commission on Accreditation of medical liabilities and create new revenue streams for disease Healthcare Organizations October 6, 2004; Issue 32.
Sleep Diagnosis and Therapy ♦ Vol 3 No 5 September-October 2008
Polyfarmacie Optimalisatie Methode (POM) De Polyfarmacie Optimalisatie Methode (POM) is een stappenplan dat gebruikt kan worden om op een gestructureerde wijze ingewikkelde polyfarmacie te optimaliseren. De eerste twee stappen van de POM kunnen door een daartoe aangewezen praktijkondersteuner uitgevoerd worden. De stappen 3 en 4 moeten door de (huis)arts uitgevoerd worden. Voor de stappen 5