Cutaneous angioleiomyoma of the auricle: a painless variant of a painful tumour

Cutaneous angioleiomyomas (ALMs) are uncommon benign tumours of the skin which derive from the smooth muscle layer of dermal blood vessels. They usually present as tender nodules in the fifth or sixth decade of life, predominantly in the legs of females. These tumours rarely present on the head and neck, especially the ear. Head and neck ALMs differ from their more common leg counterparts in that they are painless. Additionally, they do not manifest with a female predominance. Herein, a new case of a painless auricular ALM in a 63-year-old man is reported.

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Genitalia self-mutilation commanded by hallucinations: a psychointensive case of Klingsor syndrome

Description 

One of the world's rarest cases recorded up to date stands a case of hallucination influenced genitalia self-mutilation (GSM). There are just 13 cases recorded on PubMed till date. What and who is Klingsor? It was derived from the name of a character in Parsifal (a German opera) who had engaged in the act of self-castration for gaining entry into the prestige brotherhood of the Knights of the Holy Grail. In one of the first recorded cases in 1990, the author argued that the term 'Klingsor' be applied to all cases of GSM to patients of psychotic illness and not just religious conflicts.1 Some literatures call this syndrome as Skoptic syndrome.

Various surveys done by psychologists found psychosis beneath the cases of men carrying out autocastration. One of the most famous cases documented of Thomas Corbett, the man behind the assassination of John Wilkes Booth and...

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Primary intratracheal schwannoma resected during bronchoscopy using argon plasma coagulation

A 63-year-old man presented with intermittent, progressively worsening dyspnoea associated with cough and blood-tinged sputum. Initial work-up showed left axis deviation on ECG, chest X-ray with an elevated left hemidiaphragm and a non-contrast CT chest that showed a multilobulated mass in the proximal trachea. Bronchoscopy showed a whitish-appearing lesion, which was then sampled and partially resected with pathology showing a schwannoma with no malignant cells. He felt partial relief post procedure; however, he presented a month later with similar symptoms of dyspnoea and a repeat CT scan showed enlargement of the mass in the same location. The patient underwent another flexible bronchoscopy and resection with argon plasma coagulation (APC)/electrocautery snare. APC/electrocautery is an effective interventional bronchoscopy technique that can be used to resect endoluminal lesions or extraluminal lesions that have infiltrated into the airway using flexible/rigid bronchoscopy. It is more cost-effective, safe, works well with vascular lesions and achieves excellent haemostasis as compared with Nd:YAG lasers.

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A rare cause of ascites in a renal transplant recipient

Thirty-five-year-old man, underwent renal transplantation 4 years back and was doing well. He now presented with complaints of ascites with engorged neck veins and dyspnoea on exertion for last 6 months. Examination showed elevated jugular venous pressure with two prominent descents, high pitched diastolic heart sound (pericardial knock). Echocardiography showed characteristic features of thickened pericardium, septal bounce, expiratory flow reversal in hepatic veins and phasic variation of mitral inflow, suggestive of constrictive pericarditis. The patient was started on empirical antitubercular therapy and diuretics. The patient symptomatically improved, but in view of persisting constrictive physiology he was planned for pericardiectomy.

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Dental management of a patient with 22q11.2 deletion syndrome (22q11.2DS)

22q11.2 deletion syndrome (22q11.2DS) is one of the most common microdeletion syndromes, with an incidence of approximately 1/2000–1/4000 live births; it is thought to be mainly attributable to a de novo deletion. The clinical phenotype of this syndrome is highly variable. Certain craniofacial and oral features are common to most patients with 22q11.2DS, including a high prevalence of dental caries; abnormalities of tooth shape, eruption and number; and enamel defects such as hypomineralisation and hypoplasia. This report focuses on the dental features and management of an 8-year-old boy with 22q11.2DS. Dental treatments were carried out under general anaesthesia. In summary, facial dysmorphism and common dental manifestations are typically noticeable in patients with this syndrome. Therefore, dentists need to be aware of the dental features of this condition in order to refer them to the adequate specialists. Cooperation among and experience with different specialties are mandatory to improve quality of life for patients with 22q11.2DS.

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Mid-ventricular takotsubo cardiomyopathy triggered by major depressive disorder after abortion

Description 

A 28-year-old gravida 7 para 5 woman presented from an outlying facility with non-radiating, crushing, severe left-sided chest pain. She was initially treated for a non-ST elevation myocardial infarction with ECG evidence of T wave inversions in leads II, III, aVF, V5, V6 and an abnormal troponin level at 0.56 ng/mL. Accordingly, left heart catheterisation was performed emergently and revealed normal coronary arteries without any obstruction (figure 1). Left ventriculography showed mid-ventricular hypokinesis with hyperdynamic apical and basal wall contraction, consistent with a mid-ventricular takotsubo cardiomyopathy (TCM) (video 1). The ejection fraction was estimated at 30%–35%.

Figure 1

Coronary angiogram showing normal coronary arteries. (A) Left anterior oblique 30 view. (B) Right anterior oblique 10 cranial 40 view. (C) Left anterior oblique 45 caudal 25 view.

Video 1

Left ventriculogram.

Medical history was significant for an elective abortion...

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A case of young diabetes and parasuicide

Wolfram syndrome is a rare monogenic cause of juvenile onset diabetes mellitus. It is a non-autoimmune, insulin-deficient state with concurrent or consequent optic atrophy. Here we depict the case of a 16-year-old young girl afflicted with this condition, who presented with parasuicide on a background of depressive disorder. The aetiology of this presentation was attributable to multiple physical ailments and a genetic predisposition conferred by the disease-causing mutation for which she tested positive. She was managed with intensive insulin therapy and specific psychotherapy. Her case highlights the importance of recognising and addressing these comorbidities associated with Wolfram syndrome, so as to curtail disastrous consequences.

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Subperiosteal haematoma of the orbit secondary to frontal sinusitis

Reported is the case of a 79-year-old woman initially diagnosed with periorbital abscess on the background of a recent upper respiratory tract infection. Unexpectedly, intraoperative findings were that of a haematoma rather than an abscess. Subperiosteal orbital haematoma (SOH) is an extremely rare complication of rhinosinusitis. In contrast to the more common periorbital abscess, it is seldom listed as a complication of sinusitis. A review of reported cases suggests an older patient demographic are affected by SOH in contrast to periorbital abscess which typically affects paediatric patients. Given current demographic trends toward an older patient population with multiple comorbidities, failure to consider SOH as a differential will have important implications on preoperative workup, perioperative care and final outcome for patients. We present this case as a reminder of a rare but important complication of a common disease.

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Custom 3D-printed finger proximal phalanx as salvage of limb function after aggressive recurrence of giant cell tumour

Giant cell tumours (GCT) of the finger phalanges are extremely rare but have a high rate of recurrence. This report details the case of a GCT of the proximal phalanx of the fourth finger in a 64-year-old man. The patient was initially subjected to systemic neoadjuvant denosumab treatment, and subsequent aggressive curettage, sparing of the articular joints, local cryotherapy and autologous intercalary fibular bone graft. Finger function after surgery was considered satisfactory, despite limited proximal interphalangeal (PIP) joint motion. Aggressive local GCT recurrence was noted at the 32-month follow-up, with entire articular and diaphyseal phalangeal destruction. The patient refused amputation and, after analysing several reconstruction options, he was treated by entire en bloc resection and reconstruction employing a 3D-printed custom titanium implant. At the 24-month follow-up, the patient is free of disease and pain, and has a stable finger, good metacarpal–phalangeal joint motion, fusion of the PIP joint, a good Musculoskeletal Tumour Society score, and functional ability.

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Suspicious breast pseudocalcifications

Description 

We present a follow-up case of an invasive right ductal breast carcinoma in a 72-year-old woman.

A follow-up mammography study (figure 1) performed 1 year after right lumpectomy (wide local excision) shows postsurgical changes in the right breast and reveals 'de novo' coarse/amorphous microcalcifications in the left breast axis. Some of these calcifications show radiolucent centre, and can only be depicted in the craniocaudal mammographic images, raising concern for hypothetic cutaneous location, although presenting suspicious features.

Figure 1

Mammographic images showing postlumpectomy (wide local excision) changes in the right upper outer quadrant and coarse and amorphous calcifications in the left breast. Blue square shows the magnification of the calcifications, revealing some calcifications with radiolucent centre.

Cancer biomarkers and clinical status were unremarkable.

An ultrasound (US) evaluation was further advised. The patient was told not to apply any cream, lotion or deodorant on...

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Severe pulmonary hypertension associated with hepatic arteriovenous malformation in a patient with hereditary haemorrhagic telangiectasia

We report a case of 46-year-old Asian woman with a history of recurrent epistaxis who presented with dyspnoea on exertion. Physical examination revealed mucocutaneous telangiectasias and signs of heart failure. Further evaluation showed huge hepatic arteriovenous malformation and severe pulmonary hypertension. This case demonstrates an uncommon manifestation of hereditary haemorrhagic telangiectasia presented with severe pulmonary hypertension.

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Primary peritoneal hepatoid adenocarcinoma: a diagnostic and therapeutic conundrum in patients with gastrointestinal bleeding

Description 

A 50-year-old man with a history of iron-deficiency anaemia and fatty liver disease presented to the emergency department complaining of black tarry stools with associated weakness and shortness of breath for 1 week. At presentation, contrast-enhanced CT revealed multiple hypervascular masses in the abdomen and pelvis with the largest lesion located in the right lower quadrant, abutting the right psoas muscle (figure 1). Laboratory evaluation demonstrated a haemoglobin level of 5.5 g/dL (normal, 13.5–17.5 g/dL). Upper endoscopy showed a mass, which was making an extrinsic impression into the stomach (figure 2). Colonoscopy was unremarkable for abnormalities. Endoscopic ultrasound-guided fine-needle aspiration (FNA) of the lesion adjacent to the stomach was performed using a 22-gauge needle (Expect Slimline; Boston Scientific, Natick, Massachusetts, USA). The FNA was positive for metastatic carcinoma with hepatic features. Furthermore, capsule endoscopy identified blood clots surrounding the multiple, small intestinal masses. These lesions were...

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Endogenous bacterial endophthalmitis and subretinal abscess complicating diabetic ketoacidosis

Description 

A 26-year-old Lithuanian man with type 1 diabetes, diagnosed at aged 14, presented to the emergency department with shortness of breath as well as left flank pain. The patient was taking a basal-bolus (Actrapid/Lantus) regimen of insulin and had no other medical conditions. The patient was found to be in diabetic ketoacidosis (blood glucose level 21 mmol/L, pH 7.10) and diagnosed with chest sepsis based on bilateral consolidation on a chest X-ray. The patient was admitted to the high dependency unit and treated empirically with intravenous flucloxacillin and ceftriaxone. Blood cultures grew a fully sensitive Staphylococcus aureus. The patient's flank pain failed to improve and on day 3 of admission CT of the abdomen and pelvis demonstrated a left 4.9 cm intermedius muscle abscess (figure 1). There were additional small focal collections in the left psoas, right psoas and right erector spinae muscle. Radiologically guided aspiration of the left intermedius...

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MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.

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Significant bleeding from Meckel’s diverticulum after blunt abdominal trauma: a case report

Meckel's diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have report...

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The effect of anesthetic technique on µ-opioid receptor expression and immune cell infiltration in breast cancer

Abstract

Background

Clinical histological studies demonstrate that the distribution of natural killer (NK) cells, other immune cells and μ-opioid receptors (MOR) within cancer tissue can predict cancer prognosis. No clinical study has evaluated whether anesthetic technique influences immune cell and MOR expression within human breast cancer.

Methods

Excised preoperative biopsies and intraoperative breast cancer specimens from 20 patients randomly chosen from patients previously enrolled in an ongoing, prospective, randomized trial (NCT00418457) investigating the effect of anesthetic technique on long-term breast cancer outcome were immunohistochemically stained and microscopically examined by two independent investigators, masked to randomization, to quantify MOR and immune cell infiltration: CD56, CD57 (NK cells), CD4 (T helper cells), CD8 (cytotoxic T cells) and CD68 (macrophages). Patients had been randomized to receive either a propofol–paravertebral anesthetic with continuing analgesia (PPA, n = 10) or balanced general anesthetic with opioid analgesia (GA, n = 10).

Results

There were no differences between the groups in staining intensity in preoperative biopsy specimens. Expression intensity values (median 25–75%) for MOR in intraoperative resected biopsy were higher in GA 8.5 (3–17) versus PPA 1 (0–10), p = 0.04. The numbers of MOR-positive cells were also higher in GA patients. Expression and absolute numbers of CD56, CD57, CD4 and CD68 were similar in resected tumor in both groups.

Conclusion

General anesthesia with opioid analgesia increased resected tumor MOR expression compared with propofol–paravertebral anesthetic technique, but the anesthetic technique did not significantly influence the expression of immune cell markers.

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Understanding Conflict Management Styles in Anesthesiology Residents

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios. METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%–99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores. RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1–Q3 = 27–87) and accommodating (69th, Q1–Q3 = 30–94) styles, and the lowest scores for competing (32nd, Q1–Q3 = 10–57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1–Q3 = 14–16; counterpart: 16, Q1–Q3 = 15–16) and problem solving (self: 17, Q1–Q3 = 16–18; counterpart: 16, Q1–Q3 = 16–17), and lower scores for forcing (self: 13, Q1–Q3 = 10–15; counterpart: 13, Q1–Q3 = 13–15) and avoiding (self: 14, Q1–Q3 = 10–16; counterpart: 14.5, Q1–Q3 = 11–16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05). CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one's dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations.

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Preventing Adverse Events in Cataract Surgery

No abstract available

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Maternal Hemorrhage—Regional Versus General Anesthesia: Does It Really Matter?

No abstract available

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Beyond the “E” in OSCE

No abstract available

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Optimal Organization of Acute Pain Services: At the Confluence of Semantics, Logistics, and Economics

No abstract available

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Natural Born Survivors?

No abstract available

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Sevoflurane Protects Hepatocytes From Ischemic Injury by Reducing Reactive Oxygen Species Signaling of Hepatic Stellate Cells: Translational Findings Based on a Clinical Trial

BACKGROUND: Randomized controlled trials (RCTs) data demonstrate that sevoflurane postconditioning improves clinical outcomes of liver resection with inflow occlusion, presumably due to hepatocyte protection from ischemic injury. However, mechanisms remain unclear. This study examines liver biopsy samples obtained in an RCT of sevoflurane postconditioning to test the hypothesis that sevoflurane attenuates hepatocyte apoptosis. METHODS: Messenger ribonucleic acid (mRNA) of pro- and antiapoptotic regulators Bax and B-cell lymphoma 2 (Bcl2) was examined in hepatic biopsies obtained during the RCT. Hepatic stellate cells (HSCs) and hepatocytes were exposed to hypoxia/reoxygenation (H/R) in vitro to evaluate the effect of sevoflurane postconditioning on apoptosis. The role of HSC as a potential apoptosis trigger in hepatocytes through the production of reactive oxygen species induced by H/R was explored by transferring supernatants from H/R-exposed HSC to hepatocytes as target cells. RESULTS: In patients of the RCT, the Bax/Bcl2 mRNA ratio in liver tissue was markedly decreased in the sevoflurane arm (25% ± 21% reduction; P = .001). In vitro, H/R increased reactive oxygen species production in HSC by 33% ± 16% (P = .025), while it was abolished in the presence of sevoflurane (P

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Target-Controlled Infusion: Not a One-Sized-Fits-All Answer to Drug Administration

No abstract available

https://ift.tt/2PNpYVT

I Contain Multitudes: The Microbes Within Us and a Grander View of Life

No abstract available

https://ift.tt/2xikoUH

Subspecialization … and Clinical Guidelines

No abstract available

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Special Cardiac Arrest Situations in the Perioperative Period

No abstract available

https://ift.tt/2xiXblf

An Intellectual Framework for Drug Administration Methods in Anesthesia: Three Practice Domains

No abstract available

https://ift.tt/2PKFRw2

Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0–0.0009952).

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Identifying the Best Cut-Point for a Biomarker, or Not

No abstract available

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A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before–after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0–3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0–6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0–3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6–106.3 mg MEQs) versus 144.0 mg MEQs (68.9–238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1–124.0; P 50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

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To Thine Own Self Be True: A First Step Toward Learning How Anesthesiologists Deal With Adversity in the Operating Room

No abstract available

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Propensity Score Methods: Theory and Practice for Anesthesia Research

Observational data are often readily available or less costly to obtain than conducting a randomized controlled trial. With observational data, investigators may statistically evaluate the relationship between a treatment or therapy and outcomes. However, inherent in observational data is the potential for confounding arising from the nonrandom assignment of treatment. In this statistical grand rounds, we describe the use of propensity score methods (ie, using the probability of receiving treatment given covariates) to reduce bias due to measured confounders in anesthesia and perioperative medicine research. We provide a description of the theory and background appropriate for the anesthesia researcher and describe statistical assumptions that should be assessed in the course of a research study using the propensity score. We further describe 2 propensity score methods for evaluating the association of treatment or therapy with outcomes, propensity score matching and inverse probability of treatment weighting, and compare to covariate-adjusted regression analysis. We distinguish several estimators of treatment effect available with propensity score methods, including the average treatment effect, the average treatment effect for the treated, and average treatment effect for the controls or untreated, and compare to the conditional treatment effect in covariate-adjusted regression. We highlight the relative advantages of the various methods and estimators, describe analysis assumptions and how to critically evaluate them, and demonstrate methods in an analysis of thoracic epidural analgesia and new-onset atrial arrhythmias after pulmonary resection.

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Poor Sleep, Worse Outcomes: Obstructive Sleep Apnea and Perioperative Care

No abstract available

https://ift.tt/2xkopbc

Opioids for Acute Pain Management in Patients With Obstructive Sleep Apnea: A Systematic Review

The intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with obstructive sleep apnea (OSA). The association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population. The aims of this systematic review were to summarize current evidence with respect to perioperative OIRD, changes in sleep-disordered breathing, and alterations in pain and opioid sensitivity in patients with OSA. A systematic literature search of studies published between 1946 and October 2017 was performed utilizing the following databases: Medline, ePub Ahead of Print/Medline In-process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed—NOT-Medline and ClinicalTrials.Gov. Of 4321 initial studies, 40 met the inclusion criteria. The Oxford level of evidence was assessed. Overall, high-quality evidence on the comparative impact of acute opioid analgesia in OSA versus non-OSA patients is lacking. The current body of evidence is burdened by significant limitations including risk of bias and large heterogeneity among studies with regard to OSA severity, perioperative settings, outcome definitions, and the presence or absence of various perioperative drivers. These factors complicate an accurate interpretation and robust analysis of the true complication risk. Nevertheless, there is some consistency among studies with regard to a detrimental effect of opioids in the presence of OSA. Notably, the initial 24 hours after opioid administration appear to be most critical with regard to life-threatening OIRD. Further, OSA-related increased pain perception and enhanced opioid sensitivity could predispose patients with OSA to a higher risk for OIRD without overdosing. While high-quality evidence is needed, retrospective analyses indicate that critical, life-threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.

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Society Guidelines Infographic: SASM Guideline on Intraoperative Management of OSA

No abstract available

https://ift.tt/2xr6vnh

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

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