Paul Liszewski, CRNA, DNP
Welcome to the first blog entry for the newly updated Allegheny Anesthetists website. I am Paul Liszewski, CRNA and DNP. In addition to working as a staff anesthetist for more than 15 years, I am a self-professed anesthesia nerd and evidence-based practice enthusiast. My blog entries will revolve around anesthesia issues, in a longer form than the posts that I have been contributing to on the Allegheny Anesthetist Facebook page. My other interests include running, indie rock music, and all the major Pittsburgh professional and college sports. In this inaugural blog, I would like to discuss an example of fast-tracking the process of utilizing new research study results in everyday anesthetic practice.
Now to the Elbow Sign. As nurse anesthetists, we have the unique ability to hasten the normally prolonged time frame from the discovery of meaningful research study results and its application to clinical practice. The average delay from new research evidence to implementation into practice has been estimated to be 17 years (from Institute for Healthcare Improvement). Clinicians like CRNAs can lead the charge in accelerating this process by staying current with newly published research studies, understanding their relevance to anesthetic practice and incorporating the information into the clinical setting.
For example, the article “The Utility of the Elbow Sign in the Diagnosis of OSA” was published in the March 2014 edition of the Journal Chest. The article described a straightforward prospective questionnaire study that was conducted on patients referred to a sleep disorder clinic for a diagnostic polysomnogram (PSG). These were patients with symptoms that pointed to a high suspicion for OSA due to the fact that they were scheduled for PSG. The subjects were asked if their bed partner ever poked or elbowed them because they were snoring or stopped breathing. The study authors concluded an affirmative response to being elbowed/poked for snoring and apneic spells improved the pre-SPG prediction of OSA, and in particular, that the group of male subjects with a BMI of 31 or higher and a positive elbow sign had a 96% correlation to obstructive sleep apnea (OSA) diagnosed by PSG.
This correlation is similar to the efficacy of the STOP-BANG questionnaire to determine patients at high risk for OSA. While the PSG is the gold standard for diagnosing OSA, limited availability and long waiting lists have contributed to the fact that most people with OSA remain undiagnosed and susceptible to additional risks undergoing an anesthetic. Use of the STOP- BANG questionnaire and the elbow sign query are nearly as accurate as a PSG to diagnose OSA, and are practical tools to screen undiagnosed patients for OSA in the pre-anesthetic interview.
When I conduct a pre-anesthesia interview with a patient who is at high risk for OSA based on body habitus or history & physical, and that same patient denies snoring or apnea during sleep, I often turn to a patient’s spouse during such an interview and ask them if the patient (their bed partner) snores or stops breathing at night. Even prior to my question ,it’s not unusual for the spouse to be seen vigorously nodding their head “yes” to the snoring question directed to the patient. Based on this new research, I feel that I can more confidently determine the OSA status for my at-risk patient, or perhaps I can say that adding the elbow sign query to my interview process will add more “STOP-BANG” for the buck.