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1、The Adult Patient With Morbid Obesity and/or Obstructive Sleep Apnea For Ambulatory Surgery,Girish P. Joshi, MB BS, MD, FFARCSI 协和规培：石磊,病态肥胖及阻塞性睡眠呼吸暂停病人的门诊手术麻醉（一）,.,Introduction,Morbidly obese（病态肥胖） have an increased risk of Co- morbidities(并存病，Table 1), and therefore pose considerable challenges to
2、 the anesthesiologist (Table 2). One of the major co-morbidities associated with obesity includes obstructive sleep apnea (阻塞性睡眠呼吸暂停，OSA), reported in 60-70% of morbidly obese.,简介,Introduction,Table 1: Co-morbidities（并存病） Associated With Obesity（肥胖） Respiratory（呼吸系统）: Restrictive pulmonary disease（限
3、制性肺疾病）, obstructive sleep apnea（阻塞性睡眠呼吸暂停）, asthma（哮喘）, Pulmonary hypertension（肺动脉高压） Cardiac（心血管）: Systemic hypertension（系统性高血压）, coronary artery disease（冠状动脉心脏病）, dysrhythmias（心律失常）, Cardiomyopathy（心肌病）, CHF（慢性心衰） Neurologic（神经系统）: Stroke（中风） Renal（泌尿系统）: Renal dysfunction（肾功能不全） Metabolic（内分泌）: M
4、etabolic syndrome（代谢症候群）, type 2 diabetes mellitus（2型糖尿病）, hypothyroidism（甲低）,Introduction,Table 2: Challenges in the patients with morbid obesity(病态肥胖) and/or OSA （阻塞性呼吸暂停综合征）undergoing ambulatory surgery（门诊手 术）. Intra-operative（手术中）: Difficult/failed mask ventilation（面罩通气） and/or tracheal intubati
5、on （气管插管） Difficulty in ventilation and/or maintaining adequate oxygen saturation（维持足够氧饱和度） Diffculty in positioning Exacerbation of cardiac co-morbidities（心血管并存病加重）: hypertension（高血压）, arrhythmias（心律失常）,myocardial ischemia（心肌缺血）and infarction（梗塞）, pulmonary hypertension（肺动脉高压）, heart failure（心衰）,In
6、troduction,Immediate postoperative（术后即刻）: Delayed extubation（拔管延迟） Obstruction and/or desaturation after extubation（拔管后梗阻） Post-obstructive pulmonary edema（梗阻后肺水肿） Need for tracheal reintubation（再插管） Exacerbation of cardiac comorbidities（心血管并存病加重） Cerebrovascular disorders (e.g., stroke)（脑血管疾病） Post
7、operative delirium（术后谵妄） Prolonged PACU stay（恢复室逗留时间延长） Delayed discharge home（住院时间延长）,Introduction,Post-discharge（出院后）: Readmission after discharge （出院后再入院） Hypoxic brain death and death（缺氧性脑死亡和死亡）,Selection of Adult Patients Morbidly Obesity and/or OSA For Ambulatory Surgery (病态肥胖及阻塞性睡眠呼吸暂停病人的选择),
8、A recent systematic review revealed that BMI alone might not influence perioperative complications or unplanned admissions （BMI指数并不单独 影响围术期并发症). Therefore, BMI should not be considered the sole patient selection criterion for ambulatory surgery(BMI不应作为独立的选择标准). Overall, the patient selection for amb
9、ulatory surgery should depend upon the severity of co-morbidities, the surgical procedure, and the anesthetic technique（取决于并存病严重程度、手术过程、麻醉技术）.,Selection of Adult Patients Morbidly Obesity and/or OSA For Ambulatory Surgery,Overall, patients with inadequately treated co-morbid conditions（未经 充分治疗的并存病状况
10、）are not suitable for ambulatory surgery（不适合 门诊手术）. Also, it is imperative that all surgical patients are evaluated for presence of OSA, preoperatively（术前对OSA评估）. Patients with known diagnosis of moderate-to-severe OSA（确诊中重度 的OSA） and optimized comorbid conditions（并存病处在最佳状况）can be considered for amb
11、ulatory surgery, if they are able to use the CPAP device in the postoperative period （术后使用持续正压通气）.,Selection of Adult Patients Morbidly Obesity and/or OSA For Ambulatory Surgery,Patients with presumed diagnosis of OSA and optimized comorbid conditions（疑似OSA和最佳并存病状况） can be considered for ambulatory
12、surgery, if postoperative pain can be managed predominantly with non-opioid Analgesic Techniques（由非阿片类术后镇痛）. In addition, the ability of the facility to manage these patients should also be taken into consideration （同时考虑应用设备的能力）.,Preoperative Considerations,Morbidly obese patients (BMI 40 kg/m2) suf
13、fer from numerous chronic medical conditions (许多慢性医疗症状，Table 1). Because OSA is undiagnosed in an estimated 60-70% of patients（大约 60-70%未确诊）, screening for OSA should be part of routine preoperative evaluation（筛查OSA应作为常规术前评估）. The STOP-BANG screening tool is a user-friendly questionnaire（STOP- BANG是
14、一个病人易掌握的调查问卷） that could be included in routine preoperative evaluation to identify unrecognized OSA (Table 3). Two recent studies have validated（证实） the STOP-BANG questionnaire and found that a higher STOP-BANG score identified patients with high probability of moderate/severe OSA（高分提示中重度OSA的可能）,术前
15、注意事项,Preoperative Considerations,Table 3: STOP-BANG Scoring System S = Snoring（打鼾）. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? T = Tiredness（疲劳）. Do you often feel tired, fatigued, or sleepy during daytime（白天欲睡）? O = Observed Apnea（观察到的呼吸暂停）. Has anyon
16、e observed you stop breathing during your sleep? P = Pressure（高血压）. Do you or are you being treated for high blood pressure? B = BMI 35 kg/m2 A = Age 50 years N = Neck circumference 40 cm G = Male Gender High risk of OSA: 3 or more questions answered yes Moderate-to-severe OSA: 6 or more questions answered yes,Preoperative Testing,The American college of Cardiology (ACC) and American Heart Association (AHA) recommended that ECG be obtained in patients with at least one risk factor
