What’s New in the Patient Safety World

June 2013

Anesthesia Choice for TJR in Sleep Apnea Patients



We’ve done a whole host of columns on the risks of surgery in patients with obstructive sleep apnea (OSA), recognized or unrecognized (see the list at the end of today’s column). A couple key principles in managing such patients are to (1) use multimodality analgesic techniques so that post-op use of opioids can be minimized and (2) minimize the use of other drugs that might promote airway collapse or suppress respiration. Choice of anesthesia for such patients has always been an item for discussion but there has been no consensus and most such discussions are based on theoretical considerations, “expert” opinions, and anecdotal case reports rather than being evidence-based.


Now researchers from The Hospital for Special Surgery have demonstrated that choice of anesthesia does make a difference in outcomes (Memtsoudis 2013). They found that using regional anesthesia instead of general anesthesia in patients with sleep apnea undergoing total joint replacement decreased major complications by 17%. They analyzed data from approximately 400 hospitals in the United States who submit data to a large administrative database (Premier Inc) and looked at the types of anesthesia used in over 30,000 sleep apnea patients undergoing primary hip or knee arthroplasty. Approximately 11% of cases were performed under neuraxial, 15% under combined neuraxial and general, and 74% under general anesthesia. Major complication rates for those 3 types of anesthesia were 16.0%, 17.2%, and 18.1%, respectively. After adjustment, the risk of major complications for those undergoing surgery under neuraxial or combined neuraxial-general anesthesia was 17% lower than those undergoing general anesthesia.


Though this was a retrospective study rather than a randomized controlled trial it does provide at least some evidence that regional anesthesia may be preferable in this patient population, at least for major joint replacement surgery. Whether regional or neuraxial techniques have fewer major complications in other types of surgery in patients with OSA needs to be addressed in further studies.




Our prior columns on obstructive sleep apnea in the perioperative period:


Patient Safety Tips of the Week:

June 10, 2008              “Monitoring the Postoperative COPD Patient”

August 18, 2009           “Obstructive Sleep Apnea in the Perioperative Period”

August 17, 2010           “Preoperative Consultation – Time to Change”

July 13, 2010               “Postoperative Opioid-Induced Respiratory Depression”

February 22, 2011       “Rethinking Alarms”

November 22, 2011     “Perioperative Management of Sleep Apnea Disappointing”

May 22, 2012              “Update on Preoperative Screening for Sleep Apnea”

February 12, 2013       “CDPH: Lessons Learned from PCA Incident”

February 19, 2013       “Practical Postoperative Pain Management”

March 26, 2013           “Failure to Recognize Sleep Apnea Before Surgery”


What’s New in the Patient Safety World columns:

July 2010                     “Obstructive Sleep Apnea in the General Inpatient Population”

November 2010           “More on Preoperative Screening for Obstructive Sleep Apnea”

March 2012                 “Postoperative Complications with Obstructive Sleep Apnea”








Memtsoudis SG, Stundner O, Rasul R, et al. Sleep Apnea and Total Joint Arthroplasty under Various Types of Anesthesia: A Population-Based Study of Perioperative Outcomes. Regional Anesthesia & Pain Medicine.2013; POST AUTHOR CORRECTIONS, published online ahead of print 3 April 2013

doi: 10.1097/AAP.0b013e31828d0173






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