Introduction
The title of the guideline is: “Practice guidelines for the perioperative management of patients with obtrusive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obtrusive Sleep Apnea”. The overall objective of the guideline is to manage and subsequently improve perioperative care as well as reduce risks associated with harmful outcomes among patients that have been diagnosed with obtrusive sleep apnea. The health questions covered by the objective relate to how can risks be reduced in patients receiving sedation, analgesia, or anesthesia; how can perioperative care be improved; and how can an anesthesiologist improve the state of their patient’s under-diagnosis and therapy. The target population of the guideline is patients with either diagnosed or suspected sleep apnea that are at the risk of perioperative morbidity as well as cases of mortality. The recipients of the services are patients that have difficulties with maintaining their airway (American Society of Anesthesiologists Task Force on Perioperative Management of Patients, 2014, p. 268). Furthermore, the target population includes patients that have sleep apnea as a result of the soft tissue of skeletal abnormalities (pregnancy, obesity, etc.)
Stakeholder Involvement
To collect evidence for the guideline, expert consultants were appointed to perform summaries from survey responses. The guidelines were developed through the tight cooperation of the twelve members of the American Society of Anesthesiologists that included an otolaryngologist, a bariatric surgeon, as well as other healthcare professionals experienced in the field. Since the evidence was obtained through surveys that expressed the opinions of the target audience, their preferences were considered in great detail.
Rigor of Development
To develop the guidelines, the scientific evidence was collected from the studies published in journals attained through various sources like PubMed as well as other databases. The opinion-based evidence was collected through surveys developed by the Task Force (American Society of Anesthesiologists Task Force on Perioperative Management of Patients, 2014, p. 271). The criteria for selecting the evidence were based on whether the chosen literature was adequate and related to pertinent studies. Furthermore, the literature had to contain case reports, observational comparisons, associative statistics, as well as non-comparative studies that included descriptive statistics. The strengths of the evidence related to the fact that the published literature contains thorough research on the issue while the opinion-based evidence presents the ‘real picture’ of the problem.
The limitation of the evidence is linked to the literature not meeting the criteria of the guidelines while the opinion-based evidence is subjective. Risks and outcomes like respiratory depression, hypoxic events, as well as rescue events were considered concerning patients with obtrusive sleep apnea. The explicit link between the supporting evidence and recommendation relates to the intention to solve the issue of negative effects in patients with obtrusive sleep apnea. All evidence related to the guidelines was prior reviewed informally by the ASA members to formulate the recommendations. The discussed guideline is an updated version of the previous one, adopted in 2005 and then published in 2006. The revised Guidelines are different from the previous versions in their effectiveness to provide newly-attained evidence from publications as well as newly-developed surveys, reviewed and assessed by the members of ASA. In addition, the revised version contains footnotes to clarify the recommendation that previously was ambiguous.
Clarity and Presentation
Major recommendations outlined in the Guidelines relate to six key areas: preoperative evaluation, inpatient and outpatient surgery, preoperative preparation, intraoperative management, postoperative management, and the criteria for patient discharge in settings that are unmonitored. Each area of recommendations is presented through clear bullet points that are easy to follow. Thus, the preoperative operation recommendation includes principles for anesthesiologists and surgeons to follow when evaluating the patient before the operation. For example, it is stated that the medical professionals should review the patient’s medical records, conduct an interview, check the history of airway difficulties, conduct a physical examination, review the sleep studies on the patient, etc. Thus, as seen from the example, the recommendations are very specific and unambiguous, creating an effective step-by-step guideline for physicians, surgeons, and anesthesiologists.
The options for managing the health condition in question are not identified in the recommendations; however, there is a recommendation related to choosing what kind of surgery, inpatient or outpatient, is the best option for patients with obtrusive sleep apnea. To determine which option is the most suitable, health professionals are recommended to consider the following factors: the status of the patient’s sleeping apnea, abnormalities related to the patient’s physiology and anatomy, existing illnesses, age, the type of anesthesia suitable for the patient, the nature of the surgery, as well as other accompanying factors.
Applicability
The facilitators of the Guidelines’ application relate to the fact that they can be used in different kinds of patients: adult and pediatric in both inpatient and outpatient settings. The barriers to the presented recommendations can also relate to their broad application since there are no specifications related to how medical professionals should treat adult patients in comparison with pediatric patients. There is no advice or tools on how to implement the presented strategy, which also adds to the limitations of the guidelines.
The Guidelines considered the benefits and harms of the recommendations’ implementation. The potential benefits of the recommendations include the improvements in postoperative care, the reduction of morbidity risks associated with surgery or various therapeutic procedures (American Society of Anesthesiologists Task Force on Perioperative Management of Patients, 2014, p. 279). The potential harms of the recommendations relate to the increase of apneic instances caused by supplemental oxygen. In addition, supplemental oxygen can further hinder the diagnosis of transient apnea or detection of hyperventilation through the use of pulse oximetry.
There are no concise monitoring or auditing criteria related to the implementation of the guidelines; however, it is stated that the presented recommendations can be modified or even rejected following the clinical constraints or needs. Thus, since the presented guidelines do not call for strict application in every clinical setting or situation, the monitoring or auditing criteria are not necessary. It is important to note that the recommendations outlined by ASA are not supposed to be “absolute requirements” (American Society of Anesthesiologists Task Force on Perioperative Management of Patients, 2014, p. 274) and the use of them does not necessarily guarantee a positive outcome; thus, there is no point in establishing specific criteria for how medical professionals should be monitored or audited in their application of the outlined recommendations.
Editorial Independence
There are no specific points mentioned concerning keeping the funding (investments from the American Society of Anesthesiologists) separate from the content of the guideline, at the same time as there are no declared conflicts of interest. Since the conflict of interest relates to the situation that can potentially undermine the impartiality of an organization, there are no conflicts of interest in the case of the guidelines since they were created to assist medical professionals without the purpose of benefiting from it in any way. Furthermore, it is stated that the recommendations were formulated through group members’ consensus, there is nothing to be stated about the members’ competing interests.
Summary
The Guideline answers the posed questions on how to improve perioperative care as well as how to reduce the risks of negative consequences in patients with obtrusive sleep apnea (American Society of Anesthesiologists Task Force on Perioperative Management of Patients, 2014, p. 268). The outlined recommendations make up an effective step-by-step guide for medical professionals on how to conduct the preoperative evaluation, determine the appropriateness of outpatient care versus inpatient, how to prepare a patient for an operation, how to conduct intra-operative and postoperative management, as well as how to discharge patients to unmonitored settings. In terms of applying the principles and recommendations in the advanced nurse practice, they are presented in such a way that can be easily interpreted and followed. An advanced nurse can apply the principles to evaluate a patient’s health condition before surgery and after as well as decide whether the patient is ready for discharge from the health facility. Since the recommendations were developed to provide basic but thorough guidelines through the use of literature and current studies, they are effective for nurse practitioners to know how to deal with patients with suspected or already diagnosed adverse sleep apnea.
References
American Society of Anesthesiologists Task Force on Perioperative Management of Patients. (2014). Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology, 120(2), 268-286.