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A silent threat: The prevalence of undiagnosed obstructive sleep apnea among gynecologic oncology patients
Abstracts / Gynecologic Oncology 130 (2013) e1–e169
comorbidities were recorded: hypertension (49%), malignancy (44%), smoking (26.8%), diabetes (22.3%), hypothyroidism (17.4%), coronary artery disease (9.7%), chronic obstructive pulmonary disease (4%), synchronous hernia repair (3.3%), warfarin/clopidogrel use (7.2%), and colostomy formation (2%). Postoperative complications included: wound infection (9.2%), pelvic abscess (4.1%), incisional seroma (2.3%), venous thromboembolic event (1.8%), and fascial dehiscence (0.2%). 66 patients (9%) had a wound separation (N3 mm in width/ depth). Diabetes (P b 0.0001), hypertension (P = 0.007), hernia repair (P = 0.004), warfarin use (P = 0.04), and colostomy formation (P = 0.05) were significantly associated with wound separation. A logistic covariate model was created for wound separation. It incorporated BMI, diabetes, smoking, and medical comorbidities. Diabetes had a relative risk of 1.9 (95% CI, 1.03-3.4; P = 0.04) for wound separation. BMI was significantly associated with wound separation (P b 0.0001). As a woman’s BMI increased, so did the odds of having a wound separation as compared to women with a BMI b30. BMI 30-40 had an odds ratio (OR) of 2.22 (95% CI, 0.99-5.04; P = 0.11); BMI 40-50 had an OR of 6.14 (95% CI, 2.64-14.29; P = 0.0029); and BMI N50 had an OR of 7.15 (95% CI, 2.79- 18.28; P = 0.0021). Conclusions: Diabetes and BMI significantly increase the risk of wound separation. doi:10.1016/j.ygyno.2013.04.205
147 A silent threat: The prevalence of undiagnosed obstructive sleep apnea among gynecologic oncology patients M. Courtney-Brooks1, M. Barrett2, L. Cantrell2. 1University of Virginia, Charlottesville, VA, 2University of Virginia Health System, Charlottesville, VA. Objective: Patients with obstructive sleep apnea (OSA) are at increased risk for life-threatening breathing irregularities, perioperative complications, and postoperative mortality. Due to the high prevalence of undiagnosed OSA, an institutional screening initiative was enacted for all patients preparing to undergo surgery. All preoperative patients are screened using a Modified STOP BANG Questionnaire. For those patients scoring ≥3 points, providers consider completion of a sleep study before surgery. The objective of this study was to estimate the prevalence of undiagnosed OSA among gynecologic oncology patients. Methods: All gynecologic oncology surgical patients initially seen as outpatients between January 31 and August 31, 2012, were included. Data abstracted from the electronic medical record included demographic data, past medical history, documentation of either known OSA or a completed Modified STOP BANG Questionnaire for those without a known diagnosis of OSA, and results of sleep studies. Results: A total of 316 women met inclusion criteria. Nineteen (6%) women had the diagnosis of OSA at time of presentation. Of the 297 women with no diagnosis of OSA, 278 (94%) were screened using the Modified STOP BANG Questionnaire and 57 (20%) scored ≥3 points. Of these, 21 completed a sleep study and 20 were diagnosed with OSA. The prevalence of undiagnosed OSA was at least 7.2% among gynecologic oncology patients. Sixty women had a BMI ≥40, and 11 (18%) of these women with class III obesity had the diagnosis of OSA before presentation. Of the 49 women with class III obesity who had no diagnosis of OSA, 47 were screened using the Modified STOP BANG Questionnaire and 28 (60%) had a score ≥3 points. Eleven women completed a sleep study and 10 were diagnosed with OSA. The prevalence of undiagnosed OSA among gynecologic oncology patients with class III obesity was at least 20%. Conclusions: Screening for undiagnosed OSA is accepted and feasible in a busy surgical clinic setting. The rates of undiagnosed OSA are high among gynecologic oncology patients, particularly in the super obese category. This is likely an underestimate because fewer than
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half the patients with scores ≥3 actually completed a sleep study and the vast majority of patients who had a sleep study were diagnosed with OSA. Due to the increased perioperative morbidity and mortality associated with undiagnosed OSA, universal screening among gynecologic oncology patients should be considered. doi:10.1016/j.ygyno.2013.04.206
148 Postoperative pain control in the gynecologic laparotomy patient: A prospective, randomized comparison of acetaminophen with narcotics vs. ketorolac with narcotics J. Rakowski, C. Jeppson, J. James, S. Ahmad, G. BigsbyIV, G. Ghurani, R. Holloway, J. KendrickIV. Florida Hospital Cancer Institute, Orlando, FL. Objective: To determine which non-narcotic analgesic, acetaminophen or ketorolac, provides better postoperative pain control when combined with an opioid patient-controlled analgesic (PCA) pump, with attention to clinically important differences in ileus, narcotic requirement, length of hospitalization, and postoperative blood loss. Methods: A prospective, randomized comparison trial of 2 different postoperative pain regimens for patients undergoing laparotomy for benign or cancerous gynecologic conditions. In addition to a standard opioid PCA, patients received either acetaminophen 1 g every 6 hours or ketorolac 15 mg every 6 hours from postoperative day 1 to 3. A hydromorphone hydrochloride PCA was used for those with allergies or adverse reactions to morphine sulfate. Patients were excluded for renal insufficiency, active peptic ulcer disease, recent gastrointestinal hemorrhage, allergy to acetaminophen or ketorolac, asthma, warfarin or therapeutic enoxaparin use, liver disease/impaired function, or significant postoperative bleeding. Abstracted data included quantification of pain via visual acuity pain scales (VAS), volume of narcotic PCA used, liver enzymes, daily hemoglobin (HB), urine output, blood transfusions, return of flatus, and length of hospitalization. Results: Fifty-nine patients have been studied to date, with 29 in the ketorolac (K) group and 30 in the acetaminophen (A) group. The groups were equally matched for gynecologic cancer staging procedures (33% K vs. 34% A). VAS pain levels (3.6 K, vs. 3.7 A) and morphine PCA use (85.86 mg K vs. 92.91 mg A) showed no difference statistically. Hydromorphone hydrochloride PCA use was less by ketorolac patients than their acetaminophen counterparts (18.37 mg K vs. 43.75 mg A, P = 0.026). Postoperative blood loss revealed a significant difference in HB drop between the 2 groups (2.96 g K vs. 2.04 g A, P = 0.008), but this did not translate into an increased rate of blood transfusion (30% K vs. 31% A). Daily urine output was similar between the groups (1,998 mL K vs. 2,450 mL A). Return of flatus (2.79 days K vs. 3.87 days A, P = 0.002) and length of hospitalization (4.48 days K vs. 5.53 days A, P = 0.059) were both improved in the ketorolac group. Conclusions: Ketorolac and acetaminophen provide similar postoperative analgesia through VAS pain scales. Adding ketorolac to the standard opioid regimen leads to less dependence on PCA narcotics, faster return of bowel function, and a shorter hospital stay. Ketorolac patients did not show any clinically significant postoperative bleeding. doi:10.1016/j.ygyno.2013.04.207
149 A single institution review of continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients M. Courtney-Brooks, C. Tanner Kurtz, E. Pelkofski, J. Nakayama, L. Duska. University of Virginia Health System, Charlottesville, VA.
comorbidities were recorded: hypertension (49%), malignancy (44%), smoking (26.8%), diabetes (22.3%), hypothyroidism (17.4%), coronary artery disease (9.7%), chronic obstructive pulmonary disease (4%), synchronous hernia repair (3.3%), warfarin/clopidogrel use (7.2%), and colostomy formation (2%). Postoperative complications included: wound infection (9.2%), pelvic abscess (4.1%), incisional seroma (2.3%), venous thromboembolic event (1.8%), and fascial dehiscence (0.2%). 66 patients (9%) had a wound separation (N3 mm in width/ depth). Diabetes (P b 0.0001), hypertension (P = 0.007), hernia repair (P = 0.004), warfarin use (P = 0.04), and colostomy formation (P = 0.05) were significantly associated with wound separation. A logistic covariate model was created for wound separation. It incorporated BMI, diabetes, smoking, and medical comorbidities. Diabetes had a relative risk of 1.9 (95% CI, 1.03-3.4; P = 0.04) for wound separation. BMI was significantly associated with wound separation (P b 0.0001). As a woman’s BMI increased, so did the odds of having a wound separation as compared to women with a BMI b30. BMI 30-40 had an odds ratio (OR) of 2.22 (95% CI, 0.99-5.04; P = 0.11); BMI 40-50 had an OR of 6.14 (95% CI, 2.64-14.29; P = 0.0029); and BMI N50 had an OR of 7.15 (95% CI, 2.79- 18.28; P = 0.0021). Conclusions: Diabetes and BMI significantly increase the risk of wound separation. doi:10.1016/j.ygyno.2013.04.205
147 A silent threat: The prevalence of undiagnosed obstructive sleep apnea among gynecologic oncology patients M. Courtney-Brooks1, M. Barrett2, L. Cantrell2. 1University of Virginia, Charlottesville, VA, 2University of Virginia Health System, Charlottesville, VA. Objective: Patients with obstructive sleep apnea (OSA) are at increased risk for life-threatening breathing irregularities, perioperative complications, and postoperative mortality. Due to the high prevalence of undiagnosed OSA, an institutional screening initiative was enacted for all patients preparing to undergo surgery. All preoperative patients are screened using a Modified STOP BANG Questionnaire. For those patients scoring ≥3 points, providers consider completion of a sleep study before surgery. The objective of this study was to estimate the prevalence of undiagnosed OSA among gynecologic oncology patients. Methods: All gynecologic oncology surgical patients initially seen as outpatients between January 31 and August 31, 2012, were included. Data abstracted from the electronic medical record included demographic data, past medical history, documentation of either known OSA or a completed Modified STOP BANG Questionnaire for those without a known diagnosis of OSA, and results of sleep studies. Results: A total of 316 women met inclusion criteria. Nineteen (6%) women had the diagnosis of OSA at time of presentation. Of the 297 women with no diagnosis of OSA, 278 (94%) were screened using the Modified STOP BANG Questionnaire and 57 (20%) scored ≥3 points. Of these, 21 completed a sleep study and 20 were diagnosed with OSA. The prevalence of undiagnosed OSA was at least 7.2% among gynecologic oncology patients. Sixty women had a BMI ≥40, and 11 (18%) of these women with class III obesity had the diagnosis of OSA before presentation. Of the 49 women with class III obesity who had no diagnosis of OSA, 47 were screened using the Modified STOP BANG Questionnaire and 28 (60%) had a score ≥3 points. Eleven women completed a sleep study and 10 were diagnosed with OSA. The prevalence of undiagnosed OSA among gynecologic oncology patients with class III obesity was at least 20%. Conclusions: Screening for undiagnosed OSA is accepted and feasible in a busy surgical clinic setting. The rates of undiagnosed OSA are high among gynecologic oncology patients, particularly in the super obese category. This is likely an underestimate because fewer than
e61
half the patients with scores ≥3 actually completed a sleep study and the vast majority of patients who had a sleep study were diagnosed with OSA. Due to the increased perioperative morbidity and mortality associated with undiagnosed OSA, universal screening among gynecologic oncology patients should be considered. doi:10.1016/j.ygyno.2013.04.206
148 Postoperative pain control in the gynecologic laparotomy patient: A prospective, randomized comparison of acetaminophen with narcotics vs. ketorolac with narcotics J. Rakowski, C. Jeppson, J. James, S. Ahmad, G. BigsbyIV, G. Ghurani, R. Holloway, J. KendrickIV. Florida Hospital Cancer Institute, Orlando, FL. Objective: To determine which non-narcotic analgesic, acetaminophen or ketorolac, provides better postoperative pain control when combined with an opioid patient-controlled analgesic (PCA) pump, with attention to clinically important differences in ileus, narcotic requirement, length of hospitalization, and postoperative blood loss. Methods: A prospective, randomized comparison trial of 2 different postoperative pain regimens for patients undergoing laparotomy for benign or cancerous gynecologic conditions. In addition to a standard opioid PCA, patients received either acetaminophen 1 g every 6 hours or ketorolac 15 mg every 6 hours from postoperative day 1 to 3. A hydromorphone hydrochloride PCA was used for those with allergies or adverse reactions to morphine sulfate. Patients were excluded for renal insufficiency, active peptic ulcer disease, recent gastrointestinal hemorrhage, allergy to acetaminophen or ketorolac, asthma, warfarin or therapeutic enoxaparin use, liver disease/impaired function, or significant postoperative bleeding. Abstracted data included quantification of pain via visual acuity pain scales (VAS), volume of narcotic PCA used, liver enzymes, daily hemoglobin (HB), urine output, blood transfusions, return of flatus, and length of hospitalization. Results: Fifty-nine patients have been studied to date, with 29 in the ketorolac (K) group and 30 in the acetaminophen (A) group. The groups were equally matched for gynecologic cancer staging procedures (33% K vs. 34% A). VAS pain levels (3.6 K, vs. 3.7 A) and morphine PCA use (85.86 mg K vs. 92.91 mg A) showed no difference statistically. Hydromorphone hydrochloride PCA use was less by ketorolac patients than their acetaminophen counterparts (18.37 mg K vs. 43.75 mg A, P = 0.026). Postoperative blood loss revealed a significant difference in HB drop between the 2 groups (2.96 g K vs. 2.04 g A, P = 0.008), but this did not translate into an increased rate of blood transfusion (30% K vs. 31% A). Daily urine output was similar between the groups (1,998 mL K vs. 2,450 mL A). Return of flatus (2.79 days K vs. 3.87 days A, P = 0.002) and length of hospitalization (4.48 days K vs. 5.53 days A, P = 0.059) were both improved in the ketorolac group. Conclusions: Ketorolac and acetaminophen provide similar postoperative analgesia through VAS pain scales. Adding ketorolac to the standard opioid regimen leads to less dependence on PCA narcotics, faster return of bowel function, and a shorter hospital stay. Ketorolac patients did not show any clinically significant postoperative bleeding. doi:10.1016/j.ygyno.2013.04.207
149 A single institution review of continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients M. Courtney-Brooks, C. Tanner Kurtz, E. Pelkofski, J. Nakayama, L. Duska. University of Virginia Health System, Charlottesville, VA.