睡眠呼吸暫停麻醉醫(yī)師應知道些什么雙語

睡眠呼吸暫停麻醉醫(yī)師應知道些什么雙語第一頁，共三十三頁，2022年，8月28日OSAisadiseasecharacterizedbyrecurrentepisodiccessationofbreathinglasting≥10sduringsleep睡眠時呼吸停止≥10秒，反復發(fā)作。Thereisexaggerateddepressionofpharyngealmuscletoneduringsleepandanesthesia,resultinginacyclicalpatternofpartialorcompleteupperairwayobstructionwithimpairedrespiration.睡眠和麻醉過程中咽肌失去張力，導致部分或完全的上氣道梗阻氣道Thismanifestsasrepeatednocturnalarousalsandincreasedsympatheticoutput,daytimehypersomnolence,memoryloss,andexecutiveandpsychomotordysfunction.反復的夜間覺醒和交感神經(jīng)興奮，白天嗜睡，記憶力減退，以及行為和精神運動功能障礙。

Itsestimatedprevalenceare1in4malesand1in10femalesformildOSA，and1in9malesand1in20femalesformoderateOSA.預計的發(fā)生率為：輕度OSA男性4人中有1人，女性10人中有1人；中等OSA男性9人中有1人，女性20人中有1人。第二頁，共三十三頁，2022年，8月28日OSADiagnosticCriteria

Anovernightpolysomnographyorsleepstudy.TheAHIdefinedastheaveragenumberofabnormalbreathingeventsperhourofsleep,isusedtodeterminethepresenceofandtheseverityofOSA.AHI被定義為每小時睡眠的呼吸異常事件的平均數(shù)量，是用于確定是否存在OSA及嚴重程度。Anapneiceventreferstocessationofairflowfor10s,whilehypopneaoccurswithreducedairflowwithdesaturation≥4%呼吸暫停事件：氣流停止10s，而血氧至少下降4%.TheAmericanAcademyofSleepMedicine(AASM)diagnosticcriteriaforOSArequireseitheranAHI≥15,orAHI≥5withsymptoms,suchasdaytimesleepiness,loudsnoring,orobservedobstructionduringsleep如白天嗜睡，鼾聲如雷，或觀察的到的梗阻睡眠TheCanadianThoracicSocietyguidelinesforthediagnosisofOSAspecifiesthepresenceofanAHI≥5onpolysomnography,andeitherof(1)daytimesleepinessor(2)atleast2othersymptomsofOSA(e.g.chokingorgaspingduringsleep,recurrentawakenings,unrefreshingsleep,daytimefatigue).多導睡眠圖提示AHI≥5，及（1）白天嗜睡或（2）至少2個其他OSA的癥狀如睡眠中有窒息或喘息，經(jīng)常醒來，不能恢復精神的睡眠，白天疲勞。OSAseverityismildforAHI≥5to15,moderateforAHI15to30,andsevereforAHI>30.

第三頁，共三十三頁，2022年，8月28日ComorbiditiesAssociatedwithOSA

OSA的合并癥OSAisassociatedwithmultiplecomorbiditiessuchasmyocardialischemia,heartfailure,hypertension,arrhythmias,cerebrovasculardisease,metabolicsyndrome,insulinresistance,gastroesophagealreflux,andobesity.心肌缺血，心臟衰竭，高血壓，心律失常，腦血管疾病，代謝綜合征，胰島素抵抗，胃食管反流，肥胖Variouspathophysiological,demographicandlifestylefactorsalsopredisposetoOSA.Theseincludeanatomicalabnormalitieswhichcauseamechanicalreductioninairwaylumendiameter(e.g.craniofacialdeformities,macroglossia,retrognathia),endocrinediseases(e.g.Cushingdisease,hypothyroidism),connectivetissuediseases(e.g.MarfanSyndrome),malegender,ageabove50years,neckcircumference>40cm,andlifestylefactorsofsmokingandalcoholconsumption.各種病理生理，人口結(jié)構(gòu)和生活方式等因素與OSA有關(guān).包括導致機械降低氣道管腔直徑的解剖異常（如顱面畸形，巨舌，下頜后縮），內(nèi)分泌疾病（如皮質(zhì)醇增多癥，甲狀腺功能減退），結(jié)締組織?。ㄈ珩R凡氏綜合癥），男性，年齡50歲以上，頸圍>40公分和吸煙、飲酒的生活方式因素第四頁，共三十三頁，2022年，8月28日PostoperativeComplicationsinPatientswithOSA

OSA患者術(shù)后并發(fā)癥ChronicuntreatedOSAleadstomultisystemicadverseconsequencesandisanindependentriskfactorforincreasedall-causemortalityinthegeneralpopulation.慢性未經(jīng)治療的OSA可導致多系統(tǒng)的不良后果，也是普通人死亡率增加的獨立危險因素。TheanatomicalinherentcollapsibilityoftheairwayandthesystemiceffectsofthediseasealsoplacethesurgicalOSApatientsatincreasedriskofseriouscomplications.OSA患者氣道解剖結(jié)構(gòu)的改變和疾病的全身影響也增加其手術(shù)的嚴重并發(fā)癥的風險。Memtsoudisetalfounda2XhigherriskofpulmonarycomplicationsinOSApatientsafternon-cardiacsurgeryvsnon-OSA.在非心臟手術(shù)中，與非OSA相比OSA患者肺部并發(fā)癥的風險更高一倍。Inbariatricsurgicalpatients,thepresenceofOSAwasfoundtobeanindependentriskfactorforadversepostoperativeevents.Flinketalreporteda53%incidenceofpostoperativedeliriuminOSApatientsvs20%innon-OSApatients.在減肥手術(shù)患者中，OSA是術(shù)后不良事件的獨立危險因素。弗林克等人報道了53%的OSA患者和20%非OSA患者術(shù)后譫妄的發(fā)生率。第五頁，共三十三頁，2022年，8月28日AmetaanalysisbyKawetalshowedthatthepresenceofOSAincreasedtheoddsofpostoperativecardiaceventsincludingmyocardialinfarction,cardiacarrestandarrhythmias(OR2.1),respiratoryfailure(OR2.4),desaturation(OR2.3),ICUtransfers(OR2.8),andreintubations(OR2.1).OSA的存在增加了術(shù)后心臟事件However,arecentstudyfoundthatneitheranOSAdiagnosisnorsuspectedOSAwasassociatedwithincreased30-dayor1-yearpostoperativemortality.Also,Mokhlesietalexaminatedlargenationallyrepresentativecohortsinelectiveorthopedic,prostate,abdominalandCVsurgeryin1millionpatientsand90,000patientsundergoingbariatricsurgery.Bothstudiesshowedincreasedcomplicationsbutnotanincreaseinmortality.OSA除了增加死亡率也增加術(shù)后并發(fā)癥。GiventhebodyofevidenceassociatingadiagnosisofOSAwithadverseperioperativeoutcomes,precautionsshouldbetakenperioperativelytoreducecomplicationsinthisvulnerablegroupofpatients.鑒于OSA的診斷與圍手術(shù)期不良事件的相關(guān)性，應采取預防措施，減少這一弱勢群體患者的圍手術(shù)期的并發(fā)癥第六頁，共三十三頁，2022年，8月28日PreoperativeEvaluationofthePatientwithDiagnosedOSA

OSA患者的術(shù)前評估Athoroughhistoryandphysicalexaminationareessential.FocusedquestionsregardingOSAsymptomsshouldbeasked.PolysomnographyresultsshouldbereviewedtoconfirmthediagnosisofOSAandevaluatetheseverityofthedisease.PatientswithlongstandingOSAmaymanifestamyriadofsignsandsymptomssuggestingthedevelopmentofsystemiccomplications,suchashypoxemia,hypercarbia,polycythemiaandcorpulmonale.徹底的病史和體格檢查是必不可少的。與OSA癥狀相關(guān)的問題應被詢問到。多導睡眠監(jiān)測結(jié)果應進行復習以確認OSA的診斷和評估疾病的嚴重程度。在長期的OSA患者會表現(xiàn)出各種的體征和癥狀，提示系統(tǒng)性并發(fā)癥的發(fā)展，如缺氧，高碳酸血癥，紅細胞增多癥和肺心病。第七頁，共三十三頁，2022年，8月28日Thepatientshouldalsobeassessedforsignificantcomorbiditiesincludingmorbidobesity,uncontrolledhypertension,arrhythmias,cerebrovasculardisease,heartfailureandmetabolicsyndrome.Obesityhypoventilatonsyndromeoccursin0.15-0.3ofthegeneralpopulation.PulmonaryarterialhypertensionisafairlycommonlongtermcomplicationofOSA,occurringin15-20%ofpatients.Itssignificanceliesinthefactthatcertainphysiologicalderangementsmayraisepulmonaryarterypressuresfurtherandshouldbeavoidedintraoperatively.應評估重要的合并癥包括病態(tài)肥胖，未控制的高血壓，心律失常，腦血管疾病，心臟衰竭，代謝綜合征。肥胖低通氣綜合征發(fā)生在普通人群中的0.15-0.3。肺動脈高壓是OSA相當常見的長期并發(fā)癥，發(fā)生率達15-20％。其意義在于某些生理紊亂可提高肺動脈壓力，術(shù)中應進一步避免。TheAmericanCollegeofChestPhysiciansdoesnotrecommendroutineevaluationforpulmonaryarterialhypertensioninpatientswithknownOSA.However,shouldtherebeanticipatedintraoperativetriggersforacuteelevationsinpulmonaryarterialpressures,forexample,highrisksurgicalproceduresoflongduration,apreoperativetransthoracicechocardiographymaybeconsidered.美國胸科醫(yī)師不建議常規(guī)評估已知的OSA患者肺動脈高壓。然而，如果有預期的術(shù)中的觸發(fā)在肺動脈壓力急性升高的因素，例如，持續(xù)時間長的高風險的外科手術(shù)，可考慮做術(shù)前經(jīng)胸超聲心動圖檢查以評估肺動脈高壓。第八頁，共三十三頁，2022年，8月28日

SimplebedsideinvestigationsmaybeperformedinthepreoperativeclinictoscreenforOSArelatedcomplications.Intheabsenceofotherattributablecausesforhypoxemia,abaselineoximetryreadingof≤94%onroomairsuggestsseverelongstandingOSA,andmaybearedflagsignalingpostoperativeadverseoutcome術(shù)前進行的簡單的床頭調(diào)查可能篩查出OSA相關(guān)的并發(fā)癥。沒有其他原因引起低氧血癥，室內(nèi)空氣下血氧≤94％，表明存在嚴重的長期的OSA，并可能是標志著術(shù)后不良事件的紅色信號第九頁，共三十三頁，2022年，8月28日ThecomplianceofOSApatientstosuchtreatmentshouldbeevaluated.Thepatient’supdatedPAP(Positiveairwaypressure)therapysettingsshouldbeobtained.Reassessmentbyasleepmedicinephysicianmaybeindicatedinpatientswhohavedefaultedfollowup,havebeennon-complianttotreatment,havehadrecentexacerbationofsymptoms,orhaveundergoneupperairwaysurgerytorelieveOSAsymptoms.PatientswhodefaultPAPuseshouldbeadvisedtoresumetherapy.OSA患者的治療依從性應評估.病人的最新PAP治療的設置應該得到的。通過睡眠醫(yī)師的重新評估可表明：誰放棄治療，誰不按規(guī)定治療，誰近期癥狀加重，誰進行了上氣道手術(shù)來緩解OSA癥狀。放棄PAP治療的患者應建議其恢復治療。第十頁，共三十三頁，2022年，8月28日Interestingly,thereistodateinsufficientevidencetoproveconclusivelythebenefitofPAPtherapyinthepreoperativesetting;andthedurationoftherapyrequiredtoeffectivelyreduceperioperativeriskshasnotbeendelineated.有趣的是，迄今沒有足夠的證據(jù)證明在術(shù)前PAP治療的獲益；以及有效地減少圍手術(shù)期的風險，治療所需的時間尚未確定。

ArecentstudyshowedthatthepreoperativepatientsidentifiedtohaveOSAandtreatedwithCPAPhavelongtermhealthbenefitsintermsofimprovedsnoring,sleepquality,daytimesleepinessandreductionofmedicationsforcomorbidites.However,adherencetoprescribedCPAPtherapyduringtheperioperativeperiodwasextremelylow.最近的一項研究表明，術(shù)前確診為OSA并進行CPAP治療在長期改善打鼾，睡眠質(zhì)量，白天嗜睡和減少合并癥的用藥有意義。然而，在圍手術(shù)期遵守規(guī)定給予CPAP治療者非常少。第十一頁，共三十三頁，2022年，8月28日CurrentguidelinesrecommendthatpatientswithmoderateorsevereOSAalreadyonPAPtherapyshouldcontinuePAPusepriortosurgery.目前的指南建議中度或重度OSA已經(jīng)進行PAP治療者應該繼續(xù)治療至手術(shù)前。

Theanesthesiateamshouldbeinformedearlytoallowforadvancedintraoperativemanagementplanningandriskmitigation.麻醉團隊應被提前告知以便制定更好的術(shù)中管理計劃降低手術(shù)風險

MildOSAmaynotbeasignificantdiseaseentityforpatientsundergoingsurgeryandanesthesia.輕度OSA患者不是暫停手術(shù)和麻醉的實質(zhì)疾病。FromthepublishedresultsoftheBusseltonHealthCohortStudy,mildOSAwasnotanindependentriskfactorforhighermortalityinthegeneralpopulation.輕度的OSA不是增加普通人群死亡率的獨立危險因素。

BasedonexpertopinionandsymptomatologyofOSApatients,preoperativePAPusemaynotbeindicatedinpatientswithmildOSA.PAP不是輕度OSA患者治療的指征。第十二頁，共三十三頁，2022年，8月28日MethodsforPerioperativeScreeningforOSA

對OSA的圍手術(shù)期的篩選方法PSG多導睡眠監(jiān)測金標準昂貴questionnaire-basedmethodstheEpworthSleepinessScale,theBerlinQuestionnaire,theASAchecklist,theSleepApneaClinicalScore,theP-SAPscoreandtheSTOP-Bangquestionnaire.

第十三頁，共三十三頁，2022年，8月28日第十四頁，共三十三頁，2022年，8月28日Table1:ObstructiveSleepApneaScreeningQuestionnaire–STOP-BangSnoring:Doyousnoreloudly(louderthantalkingorloudenoughtobeheardthroughcloseddoors)?YesNoTired:Doyouoftenfeeltired,fatigued,orsleepyduringdaytime?YesNoObserved:Hasanyoneobservedyoustopbreathingduringyoursleep?YesNoBloodPressure:Doyouhaveorareyoubeingtreatedforhighbloodpressure?YesNoBMI:BMImorethan35kg/m2?YesNoAge:Ageover50yearsold?YesNoNeckcircumference:Neckcircumferencegreaterthan40cm?YesNoGender:Male?YesNoLowriskofOSA:Yes0-2AtriskofOSA:Yes3ormorequestionsHighriskofOSA:Yes5-8第十五頁，共三十三頁，2022年，8月28日PatientswithSTOP-Bangscores0-2maybeconsideredlowrisk,3-4intermediaterisk,and5-8highriskofOSA.Apnea/hypopneaduringsleepcanleadtointermittenthypercapniaandresultinserumbicarbonateretention.TheadditionofserumbicarbonateleveltotheSTOP-Bangquestionnairemayimproveitsspecificity.TheSTOP-BangquestionnaireisusefulinthepreoperativesettingtopredictOSAseverity,triagepatientsforfurtherconfirmatorytesting,andexcludethosewithoutdisease。得分0-2可能是低風險，3-4中間風險，和5-8OSA的高危人群。睡眠時呼吸暫停/低通氣可導致間歇性高碳酸血癥，導致血清碳酸氫鹽潴留。增加血清碳酸氫鹽水平，以STOP-Bang調(diào)查問卷可提高術(shù)前OSA診斷的特異性，STOP-Bang問卷有利于評估OSA的嚴重程度，篩選出一些病人作進一步確定性測試，并排除那些沒有OSA的病人。第十六頁，共三十三頁，2022年，8月28日PreoperativeEvaluationofthePatientwithSuspectedOSA

疑似OSA患者的術(shù)前評估InpatientssuspectedofOSA,athoroughclinicalexaminationshouldbeperformedwithemphasisonpertinentsymptomsandsignsofOSA.在疑似OSA患者的，徹底的臨床檢查應著重于與OSA相關(guān)的癥狀和體征Thesubsequentmanagementisdeterminedbytheurgencyofsurgery.后續(xù)的處理取決于手術(shù)的緊迫性Wherenon-urgentelectivesurgeryisplanned,thedecisionforfurtherevaluationrestson(1)theriskofsurgery,and(2)thepresenceofothersignificantcomorbiditiessuggestiveofchronicOSA,suchasuncontrolledhypertension,heartfailure,arrhythmias,pulmonaryhypertension,cerebrovasculardisease,morbidobesityandmetabolicsyndrome.計劃非緊急的擇期手術(shù)時，作出進一步評價這一決定取決于（1）手術(shù)的風險，（2）OSA其他明顯并發(fā)癥的存在ForpatientswithSTOP-Bangscore5-8,scheduledformajorelectivesurgery,andhavecomorbiddisease(s)associatedwithlongstandingOSA,apreoperativeassessmentbythesleepphysicianandapolysomnographyshouldbeconsideredfordiagnosisandtreatment患者STOP-Bang得分5-8，進行重大手術(shù)，長期的OSA相關(guān)的合并癥，術(shù)前評估應考慮進行多導睡眠檢查和睡眠醫(yī)師協(xié)助診斷和治療第十七頁，共三十三頁，2022年，8月28日Sometimes,majorelectivesurgerymayhavetobedeferredtoallowadequateevaluationandoptimizationofsuspectedsevereOSA.有時大的擇期手術(shù)可能被推遲，以便進行足夠的術(shù)前評估及疑似嚴重OSA患者的身體的優(yōu)化。Wesuggestthatpatientsscoredashighriskbutwithoutsignificantcomorbiditiesbeconsideredforfurtherevaluationwithportablemonitoringdevices,orproceedwithsurgerywithapresumeddiagnosisofmoderateOSAandwithperioperativeOSAprecautions.Thesepatientscanbereferredaftersurgery我們建議高危但無明顯合并癥患者可以使用便攜式設備進一步評估，或?qū)σ伤浦械瘸潭鹊腛SA患者繼續(xù)進行手術(shù)，但圍手術(shù)期采取針對OSA的預防措施。這些病人可以監(jiān)測直到術(shù)后第十八頁，共三十三頁，2022年，8月28日PortablePolysomnographyandOvernightOximetry

便攜式多導睡眠圖和夜間血氧飽和度儀Thelevel2portablepolysomnographyhasbeenshowntohaveadiagnosticaccuracysimilartostandardpolysomnography,whilenocturnaloximetryisbothsensitiveandspecificfordetectingOSAinSTOP-Bangpositivesurgicalpatients.2級的便攜式多導睡眠圖已被證明與標準多導睡眠診斷有一致的準確性，而夜間血氧飽和度在STOP-Bang陽性的手術(shù)患者中鑒別出OSA有一定的敏感和特異性TheoxygendesaturationindexderivedfromnocturnaloximetrycorrelateswellwiththeAHIobtainedfrompolysomnography.Furthermore,patientswithmeanpreoperativeovernightSpO2<93%orODI>28.5events/hareathigherriskforpostoperativeadverseevents.夜間血氧飽和度儀所得到的氧飽和度指數(shù)與多導睡眠監(jiān)測獲得的AHI很好的相關(guān)性?；颊咝g(shù)前平均血氧飽和度過夜<93％或ODI>28.5次/h在手術(shù)后不良事件發(fā)生的風險較高。第十九頁，共三十三頁，2022年，8月28日ThePortableMonitoringTaskForceoftheAmericanAcademyofSleepMedicine(AASM)suggeststhatportabledevicesmaybeconsideredwhenthereishighpretestlikelihoodformoderatetosevereOSAwithoutothersubstantialcomorbidities.AASM建議在中度至重度OSA沒有其他實質(zhì)性合并癥的患者考慮使用便攜式設備。TheCanadianThoracicSociety2011updateonthediagnosisandtreatmentofsleepdisorderedbreathingrecommendedthatlevel2,3and4portablemonitoringdevicesincludingnocturnaloximetrymaybeusedasconfirmatorytestsforthediagnosisofOSA,providedthatproperstandardsforconductingthetestandinterpretationofresultsaremet.CTS提出如果正確地進行測試并對結(jié)果進行解釋，那么2級，3和4的便攜式監(jiān)測設備包括夜間血氧飽和度可作為診斷為OSA的確認測試。第二十頁，共三十三頁，2022年，8月28日IntraoperativeRiskReductionStrategiesforOSAPatientsOSA患者圍手術(shù)期預防和減少風險措施AnestheticConcernPrinciplesofManagementPremedication術(shù)前用藥PremedicationAvoidsedatingpremedication避免術(shù)前用藥術(shù)前鎮(zhèn)靜ConsiderAlpha-2adrenergicagonists(clonidine,dexmedetomidine)考慮α-2腎上腺素受體激動劑（可樂定，右美托咪）Potentialdifficultairway(difficultmaskventilationandtrachealintubation)潛在的困難氣道（困難的面罩通氣和氣管插管）OptimalpositioningHeadelevatedlaryngoscopypositionifpatientobese最佳位置肥胖病人頭部墊高喉鏡的位置Adequatepreoxygenation充分預吸氧ConsiderCPAPpreoxygenation考慮CPAP預吸氧Two-handedtripleairwaymaneuvers(見注）雙手三氣道操作法Anticipatedifficultairway.Personnelfamiliarwithaspecificdifficultairwayalgorithm預見困難氣道。熟悉特殊困難氣道的處理流程注：1slightneckextension;2elevationofthemandible3mouthopening第二十一頁，共三十三頁，2022年，8月28日Gastroesophagealrefluxdisease胃食管反流病

Considerprotonpumpinhibitors,antacids,rapidsequenceinductionwithcricoidpressure考慮質(zhì)子泵抑制劑，抗酸劑，快速誘導并環(huán)狀軟骨壓迫

Opioid-relatedrespiratorydepression阿片類藥物相關(guān)的呼吸抑制Minimizeopioiduse減少阿片類藥物的使用Useofshort-actingagents(remifentanil)使用短效藥物（瑞芬太尼）Multimodalapproachtoanalgesia(NSAIDs,acetaminophen,tramadol,ketamine,gabapentin,pregabalin,dexmedetomidine,clonidine,Dexamethasone,melatonin)多模式鎮(zhèn)痛（NSAIDs，對乙酰氨基酚

，曲馬多，氯胺酮，加巴噴丁，普瑞巴林，右美托咪定，可樂定，地塞米松，褪黑激素）Considerlocalandregionalanesthesiawhereappropriate適當?shù)目紤]局部和區(qū)域麻醉第二十二頁，共三十三頁，2022年，8月28日Carry-oversedationeffectsfromlonger-actingintravenousandvolatileanestheticagents長效的靜脈麻醉藥物和揮發(fā)性麻醉藥的遺留效應Useofpropofol/remifentanilformaintenanceofanesthesia丙泊酚/瑞芬太尼進行麻醉維持Useofinsolublepotentanestheticagents(desflurane)利用不溶性的強效麻醉劑（地氟醚）Useofregionalblocksasasoleanesthetictechnique利用區(qū)域阻滯為唯一的麻醉技術(shù)Excessivesedationinmonitoredanestheticcare監(jiān)測麻醉時的過度鎮(zhèn)靜Useofintraoperativecapnographyformonitoringofventilation術(shù)中應監(jiān)測PetCO2了解通氣的情況Post-extubationairwayobstruction拔管后氣道阻塞verifyfullreversalofneuromuscularblockade肌松作用完全拮抗extubateonlywhenfullyconsciousandcooperative意識清楚、合作Non-supinepostureforextubationandrecovery非仰臥姿勢拔管和復蘇準備ResumeuseofPAPdeviceaftersurgery手術(shù)后恢復使用PAP設備第二十三頁，共三十三頁，2022年，8月28日PostoperativeDispositionofKnownandSuspectedOSAPatientsafterGeneralAnesthesiaThepostoperativedispositionoftheOSApatientwilldependonthreemaincomponents:theinvasivenessofthesurgery,theseverityofOSA,andtherequirementforpostoperativeopioids.OSA患者的術(shù)后處置將取決于三個主要組成部分：手術(shù)的級別，OSA的嚴重程度，及術(shù)后阿片類藥物需求Thefinaldecisionregardingthelevelofmonitoringisdeterminedbytheattendinganesthesiologist,takingintoaccountallpatient-related,logisticalandcircumstantialfactors.對于監(jiān)測水平，最終的決定由麻醉醫(yī)師決定，應考慮到病人相關(guān)癥狀，經(jīng)濟和環(huán)境因素。第二十四頁，共三十三頁，2022年，8月28日AllpatientswithknownorsuspectedOSAwhohadreceivedgeneralanesthesiashouldhaveextendedmonitoringinPACUwithcontinuousoximetry.所有曾接受全身麻醉的已知或懷疑OSA患者在PACU中應繼續(xù)血氧飽和度監(jiān)測Therearecurrentlynoevidence-basedguidelinesaddressingtheoptimallengthofmonitoringrequiredinPACU.沒有明確的循證指南指導PACU的最佳監(jiān)測時間TheASAguidelines,whichwerebasedonexpertopinion,recommendedprolongedobservationfor7hoursinPACUifrespiratoryeventssuchasapneaorairwayobstructionoccur.ASA指南推薦若呼吸事件如呼吸暫?；驓獾雷枞霈F(xiàn)，PACU觀察延長至7小時。

Suchrecommendationsaredifficulttoadhereto,especiallyinthecontextofcommunityhospitals.WeproposeextendedPACUobservationforanadditional30-60minutesinaquietenvironmentafterthemodifiedAldretecriteriafordischargehasbeenmet.這些建議是很難堅持的，尤其是在社區(qū)醫(yī)院。我們建議如果患者能滿足改良Aldrete出院的評分標準，那么僅需額外的30-60分鐘PACU觀察時間。第二十五頁，共三十三頁，2022年，8月28日第二十六頁，共三十三頁，2022年，8月28日TheoccurrenceofrecurrentrespiratoryeventsinPACUisanotherindicationforcontinuouspostoperativemonitoring.在PACU中復發(fā)的呼吸事件是繼續(xù)術(shù)后監(jiān)測的另一個指征。PACUrespiratoryeventsare:(1)episodesofapnea≥10seconds,(2)bradypnea<8breaths/min,(3)pain-sedationmismatch,or(4)repeatedO2desaturation<90%.Anyoftheaboveeventsoccurringrepeatedlyinseparate30-minuteintervalsmaybeconsideredrecurrentPACUrespiratoryevents.PACU呼吸事件：（1）暫?！?0秒發(fā)作，（2）呼吸徐緩＜8次／分，（3）疼痛鎮(zhèn)靜不匹配，或（4）重復血氧＜90%。上述事件重復出現(xiàn)在單獨的30分鐘的時間間隔，可以認為復發(fā)的PACU呼吸事件PatientswithsuspectedOSAandwhodeveloprecurrentPACUrespiratoryeventsareatincreasedriskofpostoperativerespiratorycomplications.增加術(shù)后氣道并發(fā)癥的風險Continuousmonitoringwithoximetryinaunitwithreadyaccesstomedicalinterventionisadvocated.ThesewouldincludeICU,stepdownunits,orthesurgicalwardequippedwithremotetelemetryandoximetrymonitoring.ThesepatientsmayrequirepostoperativePAPtherapy.提倡在重癥監(jiān)護病房，二級病房（手術(shù)暫留區(qū)）或外科病房連續(xù)監(jiān)測血氧飽和度以便隨時獲得醫(yī)療干預。這些患者可能需要手術(shù)后PAP治療第二十七頁，共三十三頁，2022年，8月28日OneshouldconsiderdischargingapatientwithknownOSAtoamonitoredenvironmentifthepatienthassevereOSA,isnon-complianttoPAPtherapy,orhasrecurrentPACUrespiratoryevents.如果病人有嚴重的OSA，而沒有進行規(guī)范的PAP治療，或有復發(fā)的PACU呼吸事件,應該考慮其監(jiān)控環(huán)境Monitoringwithcontinuousoximetryisrecommendedwithparenteralopioidsduetopossibledruginducedrespiratorydepression.腸外阿片類藥物可能引起呼吸抑制，推薦連續(xù)血氧飽和度監(jiān)測

PatientswithmoderateOSAwhorequirehighdoseoralopioidsshouldbemanagedinasurgicalwardwithcontinuousoximetryregardlessofthenumberofPACUrespiratoryevents.無論PACU呼吸事件的數(shù)目多少，需要大劑量口服阿片類藥物治的中度OSA患者應在外科病房進行連續(xù)血氧飽和度的監(jiān)測。第二十八頁，共三十三頁，2022年，8月28日KnownOSApatientsalreadyonPAPdevicesshouldcontinuePAPtherapypostoperatively，maymitigatetheriskofpostoperativecomplications.已知的已使用PAP設備的OSA患者術(shù)后應繼續(xù)PAP治療，可以減輕術(shù)后并發(fā)癥的風險Amultimodalapproachtoanalgesiashouldbeemployedtominimizetheuseofopioidspostoperatively.應用多模式鎮(zhèn)痛減少術(shù)后阿片類藥物的使用。Ifpostoperativeparenteralopioidsarenecessary,considerationshouldbemadefortheuseofpatientcontrolledanalgesiawithnobasalinfusionandastricthourlydoselimit,asthismayhelpreducethetotalamountofopioidused.如果術(shù)后的腸外阿片類藥物是必要的，應考慮使用PCA，但不使用基礎輸注量并嚴格限制每小時劑量，這可能有助于減少阿片類藥物使用的總量。OSApatientsmayhaveanupregulationofthecentralopioidreceptorssecondarytorecurrenthypoxemia,andarethereforemoresusceptibletotherespiratorydepressanteffectsofopioids.Assuch,theymaybenefitfromsupplementaloxygenwhileonparenteralopioids.OSA患者反復低氧血癥后可能繼發(fā)中樞阿片受體上調(diào)，更容易受到阿片類藥物的呼吸抑制作用。因此，腸外阿片類藥物使用時患者應進行吸氧。第二十九頁，共三十三頁，2022年，8月28日AnesthesiologistsshouldconsiderthefactorsandeventsassociatedwithhigherriskofcomplicationsfromOSA,diagnosticfollow-upandpossiblesleepmedicineconsult.麻醉醫(yī)師需關(guān)注OSA患者并發(fā)癥的高危因素和事件，跟進診斷和睡眠專科醫(yī)師會診Fortheperioperativemanagement,itisimportanttoeducatesurgeons,nurses,patients,andtheirfamily.Pharmacyinvolvementtopreventmultipledrugswithpotentialtocausesedationandlimitingtheupperdoseofopioidsisessential.Nursetrainingindetectingrespiratorydepressionandinrapidadministrationofnaloxonewillpreventmortalityandmorbidity.對于圍手術(shù)期管理，外科醫(yī)生，護士，患者和他們的家屬共同學習認知是很重要的。藥店參與，在避免多種鎮(zhèn)靜藥物使用和控制阿片類藥物的劑量上是必不可少的。訓練護士發(fā)現(xiàn)呼吸抑制和納洛酮快速給藥可以防止死亡率和發(fā)病率。第三十頁，共三十三頁，2022年，8月28日PreoperativeAHI,malegenderand72hopioiddosewerepositivelyassociatedwithpostoperativeAHI.術(shù)前的AHI，男性及72h內(nèi)的阿片