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Correspondence  |   September 2014
Read the Fine Print: Updated Sleep Apnea Guidelines and Risk Stratification
Author Affiliations & Notes
  • Kenneth P. Rothfield, M.D., M.B.A.
    Saint Agnes Hospital, Baltimore, Maryland. kprothfield@aol.com
  • (Accepted for publication June 3, 2014.)
    (Accepted for publication June 3, 2014.)×
Article Information
Correspondence
Correspondence   |   September 2014
Read the Fine Print: Updated Sleep Apnea Guidelines and Risk Stratification
Anesthesiology 09 2014, Vol.121, 665-666. doi:10.1097/ALN.0000000000000355
Anesthesiology 09 2014, Vol.121, 665-666. doi:10.1097/ALN.0000000000000355
To the Editor:
The recent update of the report “Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea” by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea did not provide any new recommendations.1  Like its predecessor, the updated version includes “table 2,” a scoring system for perioperative risk for obstructive sleep apnea. This table allows the reader to assign a numerical score for severity of sleep apnea, invasiveness of surgery and anesthesia, and requirement for postoperative opioids. The overall score yields an estimate of perioperative risk. By its very design, the scoring system appears scientific and precise.
A footnote to the table states: “This example, which has not been clinically validated, is meant only as a guide, and clinical judgment should be used to assess the risk of an individual patient.” Many readers may miss this subtle point, and confuse the table with a reliable means for stratifying risk for postoperative respiratory complications, as well as the need for postoperative respiratory monitoring. Risk stratification for opioid-induced respiratory depression is by no means an exact science, and failure to rescue remains a significant source of human suffering and healthcare expense. The Anesthesia Patient Safety Foundation recognizes this fact, and has stated “…risk stratification for increased postoperative electronic monitoring would potentially miss a large population of patients that is at increased risk for opioid-induced respiratory depression.”2  Not surprisingly, the Anesthesia Patient Safety Foundation has advocated for continuous respiratory monitoring for all postoperative patients receiving parenteral opioids.
By all means, practice guidelines should help providers make sound clinical decisions when solid scientific evidence is lacking. The inclusion of an untested numerical risk assessment scale, however, has no place in such a document, even if there is a disclaimer in the fine print.
Competing Interests
The author declares no competing interests.
Kenneth P. Rothfield, M.D., M.B.A., Saint Agnes Hospital, Baltimore, Maryland. kprothfield@aol.com
References
American Society of Anesthesiologists, 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. (2014). 120 268–86 [Article] [PubMed]
Weinger, M, Lee, L No patient shall be harmed by opioid-induced respiratory depression.. Anesth Patient Saf Found Newslett. (2011). 26 21–8