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920-324 exam Dumps Source : Communication Server (CS) Rls. 4.0 Database Administrator

Test Code : 920-324
Test designation : Communication Server (CS) Rls. 4.0 Database Administrator
Vendor designation : Nortel
: 58 real Questions

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Nortel Communication Server (CS) Rls.

Microsoft and Nortel invent Unified Communications obtainable to organizations full over the location | killexams.com real Questions and Pass4sure dumps

LAS VEGAS — June sixteen, 2008 — today at NXTcomm08, Microsoft Corp. and Nortel announced a totally hosted provider solution that grants a unified communications journey to minuscule and midsize companies (SMBs), extending benefits prior to now attainable simplest to gigantic agencies. The hosted respond is in response to the Nortel Communications Server 2000 (CS 2000), a web Protocol multimedia softswitch, and the Microsoft respond for Hosted Messaging and Collaboration version four.5 (HMC 4.5), which contains hosted models of Microsoft office Communications Server 2007 and Microsoft alternate Server 2007. Nortel is providing the primary integration with HMC four.5 to assist control actual-time communications and convey a unified messaging adventure. in addition, to uphold carriers simplify and quicken up deployment, Nortel’s global features portfolio gives a comprehensive suite of integration and conclusion-person functions to comprehensive the end-to-end answer.

via combining the service-grade CS 2000 with HMC four.5, service providers can proffer SMBs new, potent unified communications that coalesce precise-time communications, reminiscent of voice, with Microsoft’s collaboration features, equivalent to click on-to-name, click on-to-conference, missed muster electronic mail messages, mobility and telephony presence. These features full work seamlessly with the Microsoft office portfolio and the Microsoft office Communicator client to bring a unique experience to the discontinuance user. This current solution additionally makes it feasible for SMBs to improvement from unified communications with no necessity to buy, set up, manipulate and retain additional network infrastructure and sophisticated in-condo techniques, enabling them to retailer operational charges and raise productivity.

“Unified communications is a strategic purchase that, up until nowadays, has been leveraged basically by using the tremendous business,” spoke of Ruchi Prasad, vice chairman and regular supervisor of the innovative Communications Alliance at Nortel. “This better joint Microsoft and Nortel solution makes unified communications attainable to groups of full sizes. For carrier providers, this solution presents current salary opportunities and the ability to expand their addressable market and carry better-value application and service bundles to their valued clientele.”

“we're presently seeing powerful activity within the hosted unified communications respond among their provider issuer valued clientele,” observed Steve Zimba, managing director, international Telecom business, Microsoft. “The entirely hosted unified communications solution offers alternatives for expanded profits and helps provider providers convey the linked work vogue to SMBs, proposing the means to speak almost each time, any location and on any gadget.”

At NXTcomm08, Microsoft and Nortel will exhibit the hosted unified communications respond and array its expense in bettering business agility. NXTcomm08 attendees can attain additional info by using journeying the Microsoft booths SL5916 and SL5923 and the Nortel booth SL3516. more information will also breathe institute at http://www.microsoft.com/serviceproviders/nxtcomm08.

About Nortel

Nortel is a recognized leader in supplying communications capabilities that invent the pledge of company Made elementary a verisimilitude for their valued clientele. Their next-generation applied sciences, for both service issuer and commercial enterprise networks, guide multimedia and business-important purposes. Nortel’s applied sciences are designed to assist dispose of nowadays’s limitations to efficiency, pace and efficiency through simplifying networks and connecting americans to the suggestions they want, once they necessity it. Nortel does business in additional than one hundred fifty international locations full over the world. For extra assistance, consult with Nortel on the net at www.nortel.com. For the newest Nortel news, discuss with www.nortel.com/information.

About Microsoft

founded in 1975, Microsoft (Nasdaq “MSFT”) is the international chief in software, services and options that uphold people and companies know their full talents.

note to editors: in case you are interested in viewing more information on Microsoft, tickle visit the Microsoft net web page at http://www.microsoft.com/presspass on Microsoft’s corporate information pages. net links, cell numbers and titles had been remedy at time of publication, but can also on the grounds that fill changed. For further guidance, journalists and analysts may additionally contact Microsoft’s speedy Response group or different confiscate contacts listed at http://www.microsoft.com/presspass/contactpr.mspx.


Nortel Launches current VoIP Softswitch | killexams.com real Questions and Pass4sure dumps

Communications technology issuer, Nortel, has announced the Nortel communique Server 1500 (CS 1500), a second era VoIP softswitch as a pass to enable minuscule and medium-sized wireline service suppliers to satisfy transforming into subscriber demand for aboriginal and lengthy-distance voice and next generation features.

The CS 1500 core manage, gateways and operations, administration and renovation interfaces are full housed in a sole chassis answer. carrier providers can install the swap for end-office (class 5) and access Tandem (category four) purposes to change an existing switch or as an addition to the community.

The enjoyable thing concerning the VoIP softswitch is that it permits carrier suppliers to leverage their latest funding and infrastructure via providing compatibility with legacy networks. The change presents full latitude of legacy community interfaces and regulatory necessities, including E-911 and CALEA.

Making the announcement, Alan Stoddard, GM, service Multimedia Networks, Nortel noted, “Nortel is leveraging its VoIP leadership to serve carrier suppliers seamlessly evolve their networks to a brand current economical packet infrastructure in a position to supplying the advanced communications functions, subscribers are disturbing.”

The product is complemented through a suite of Nortel global capabilities for CS 1500 to serve the complete community lifecycle, together with engineering and setting up, security assessment, integration and acceptance, assisted on-web page or far flung community operations, and on-going renovation.

in keeping with Bettina Tratz-Ryan, research Director, Gartner, “VoIP is an expected and virtually required development of full communique networks, and the focal point is on now not best how to invent it felicitous within an evolving network and repair atmosphere, but also how to invent it ecocnomic. To this end, carrier providers are turning to softswitch architecture emigrate their networks to IP and carry scalable, multimedia functions to discontinuance users that generate current revenues from day one.”

The CS 1500 is scheduled for container trials dawn fourth quarter 2006 and time-honored availability in chosen global markets throughout the primary quarter of 2007.


Nortel Builds on its Unified Communications vision, solutions Portfolio | killexams.com real Questions and Pass4sure dumps

Nortel

NYSE : NTTSX : NT

Nortel

March 05, 2007 09:02 ET

CEO Mike Zafirovski Outlines Nortel UC vision at VoiceCon 2007

ORLANDO, FLORIDA--(CCNMatthews - March 5, 2007) - At VoiceCon Spring 2007 this week, Nortel(1) (TSX:NT)(NYSE:NT) is outlining its vision for unified communications (UC) and unveiling current options designed to supply agencies with essential and official the perquisite pass to carry voice, video and records over IP and permit superior unified communications.

Nortel President and CEO Mike Zafirovski could breathe a keynote speaker on Tuesday, and will focus on how unified communications options and converged purposes are poised to transform enterprise communications.

"Unified communications essentially changes the style corporations speak, simplifying the deluge of communications with a single, seamless interface," observed Zafirovski. "Nortel and their companions are working to create a UC experience that makes people more productive and responsive, with a wealthy communications event within the office or on the go."

Nortel's unified communications imaginative and prescient focuses on featuring options that align to the enterprise atmosphere the business uses these days. These solutions permit clients to event streamlined communications within their business application whereas leveraging their current IT investments - really UC your means.

As a allotment of its expanding unified communications portfolio, Nortel is introducing a number of current solutions that deliver a richer set of UC outfit whereas making unavoidable the resiliency of the communications community.

Nortel's cornerstone IP Telephony solution, the verbal exchange Server (CS) 1000 will bring current capabilities and enhancements to extra better this main VoIP platform. a current liberate of CS 1000 will deliver more suitable reliability and redundancy, improved network and voice designation safety and current E911 capabilities, full aimed toward making unavoidable organizations can depend on their network for crucial communications needs. through planned interoperability with Microsoft workplace Communications Server 2007, this current release will deliver unified communications capabilities as a allotment of the creative Communications Alliance roadmap.

the brand current CS a thousand architecture will extend its guide for open requisites, with serve for an open working outfit and start on business off-the-shelf (COTS) hardware from IBM and other suppliers, to better deployment flexibility and manageability of the community. stout simplification of the portfolio features and pricing bundles will invent it less difficult for partners and resellers to quote and promote. This current free up is deliberate for availability in 2Q07.

additionally nowadays Nortel announced the universal availability of a brand current unencumber of the award-profitable Multimedia conversation Server (MCS) 5100. This current release improves productivity by means of featuring clients with tight integration of telephony and multimedia applications within IBM Lotus Notes. It also features a couple of colossal enhancements, including greater and simplified collaboration capabilities that allow a full ambit of voice, video, conferencing, email, IM and presence capabilities at the click of a mouse, along with more desirable mobility capabilities that deliver a moneyed communications experience for cell worker's. the brand current MCS 5100 free up also introduces aid for brand current SIP-primarily based IP telephones improving usability and suppleness and improves the overall protection, reliability, manageability and scalability of the core platform, which now operates on IBM servers with a Linux working gadget.

Nortel is also introducing Unified Messaging (UM) 2000, a function-prosperous, provider-grade respond supporting up to a million clients that allows for voicemail, fax and electronic mail to breathe accessed together through everyday electronic mail functions and integrates with Microsoft's active listing®. UM 2000 is necessities-based so that it could operate in a multivendor voice community, and is focused to international organisations as well as carriers that proffer their customers unified messaging options.

To serve enterprises installation UC-optimized networks, Nortel is additionally unveiling converged records networking enhancements to its North American advertising campaigns, which build on the a hit IPT 1-2-three campaign launched remaining yr. These crusade enhancements consist of associate equipment, concentrated demand era activities, pre-engineered information programs, and non-compulsory features that invent it simpler and more low cost for approved channel companions to install a LAN that supports clients' VoIP and UC wants.

These information packages and functions can breathe quoted starting in April 2007 and involve alternatives to enable the entire deployment of verve over Ethernet, VoIP-Optimized at ease Routing for WAN entry, and WLAN for mobility and not obligatory renovation, setting up and technical uphold functions. Nortel's North American campaign also contains promotion and incentive courses purchasable nowadays through approved Nortel channel partners for firms who are customizing their community for unified communications.

About Nortel

Nortel is a identified chief in delivering communications capabilities that invent the pledge of company Made elementary a verisimilitude for their valued clientele. Their subsequent-generation applied sciences, for each provider company and commercial enterprise networks, aid multimedia and company-vital purposes. Nortel's technologies are designed to uphold rep rid of cutting-edge boundaries to efficiency, velocity and efficiency by using simplifying networks and connecting americans to the recommendation they need, once they necessity it. Nortel does business in additional than one hundred fifty international locations everywhere. For extra counsel, talk over with Nortel on the internet at www.nortel.com. For the newest Nortel news, hunt recommendation from www.nortel.com/information.

certain statements during this press unencumber can also involve words corresponding to "might", "expects", "may additionally", "anticipates", "believes", "intends", "estimates", "pursuits", "envisions", "seeks" and other equivalent language and are considered forward-looking statements or guidance under relevant securities legislations. These statements are in keeping with Nortel's current expectations, estimates, forecasts and projections about the working environment, economies and markets wherein Nortel operates. These statements are zone to essential assumptions, dangers and uncertainties, which can breathe intricate to prophesy and the precise outcome could breathe materially distinctive. additional, actual outcomes or routine might vary materially from those reflected in forward-looking statements because of perquisite here(i) hazards and uncertainties regarding Nortel's restatements and related concerns including: Nortel's most concurrent restatement and two previous restatements of its fiscal statements and related hobbies; the poverty-stricken influence on Nortel and NNL of their most fresh restatement and lengthen in submitting their monetary statements and linked sporadic reviews; legal judgments, fines, penalties or settlements, or any gigantic regulatory fines or different penalties or sanctions, related to the continuing regulatory and crook investigations of Nortel within the U.S. and Canada; any giant pending civil litigation movements now not encompassed by pass of Nortel's proposed category motion contract; any tremendous cash expense and/or stout dilution of Nortel's current equity positions as a consequence of the approval of its proposed category action contract; any unsuccessful remediation of Nortel's fabric weaknesses in internal manipulate over monetary reporting leading to an want of ability to file Nortel's results of operations and monetary circumstance accurately and in a timely manner; the time required to implement Nortel's remedial measures; Nortel's want of ability to entry, in its latest kind, its shelf registration filed with the USA Securities and trade commission (SEC), and Nortel's below funding grade credit rating and any additional opposed repercussion on its credit rating due to Nortel's restatements of its economic statements; any hostile fill an outcome on on Nortel's enterprise and market fee of its publicly traded securities arising from carrying on with terrible publicity related to Nortel's restatements; Nortel's abilities inability to attract or continue the personnel integral to obtain its company pursuits; any infraction through Nortel of the continued listing requirements of the NYSE or TSX inflicting the NYSE and/or the TSX to commence suspension or delisting approaches;(ii) hazards and uncertainties regarding Nortel's enterprise including: each year and quarterly fluctuations of Nortel's working consequences; decreased demand and pricing pressures for its items because of international economic situations, significant competition, aggressive pricing practice, cautious capital spending with the aid of consumers, improved industry consolidation, swiftly altering technologies, evolving industry standards, everyday current product introductions and brief product life cycles, and different trends and industry characteristics affecting the telecommunications business; the sufficiency of recently announced restructuring movements, together with the potential for greater actual expenses to breathe incurred in reference to these restructuring movements compared to the estimated fees of such movements and the skill to obtain the centered suffuse rate reductions and discounts of Nortel's unfunded pension legal responsibility deficit; any fabric and adverse impacts on Nortel's efficiency if its expectations involving market demand for particular products demonstrate to breathe incorrect or because of unavoidable limitations in its efforts to extend internationally; any reduction in Nortel's working effects and any linked volatility out there expense of its publicly traded securities arising from any decline in its indelicate margin, or fluctuations in outlandish currency trade rates; any negative developments linked to Nortel's provide constrict and constrict manufacturing agreements together with as a result of the usage of a sole service provider for key optical networking solutions accessories, and any defects or errors in Nortel's present or deliberate items; any negative influence to Nortel of its failure to obtain its company transformation goal; extra valuation allowances for full or a portion of its deferred tax property; Nortel's failure to give protection to its intellectual property rights, or any adversarial judgments or settlements arising out of disputes involving intellectual property; adjustments in law of the cyber web and/or different facets of the industry; Nortel's failure to effectively duty or combine its strategic acquisitions, or failure to consummate or breathe triumphant with its strategic alliances; any negative repercussion of Nortel's failure to evolve accurately its economic and managerial manage and reporting programs and methods, control and develop its company, or create a superb possibility administration approach; and(iii) hazards and uncertainties concerning Nortel's liquidity, financing preparations and capital including: the fill an outcome on of Nortel's most fresh restatement and two outdated restatements of its financial statements; any inability of Nortel to manipulate cash movement fluctuations to fund working capital necessities or obtain its business targets in a well timed manner or reap additional sources of funding; immoderate stages of debt, boundaries on Nortel capitalizing on enterprise opportunities on account of aid facility covenants, or on acquiring further secured debt pursuant to the provisions of indentures governing unavoidable of Nortel's public debt considerations and the provisions of its serve facility; any enlarge of limited cash requirements for Nortel whether it is unable to restful alternative guide for obligations arising from positive universal route business actions, or any inability of Nortel's subsidiaries to give it with ample funding; any negative outcome to Nortel of the necessity to invent bigger described advantage plans contributions in the future or publicity to client credit score dangers or inability of shoppers to satisfy fee obligations beneath consumer financing preparations; any poverty-stricken fill an outcome on on Nortel's capacity to invent future acquisitions, raise capital, subject debt and continue employees coming up from stock rate volatility and further declines in the market cost of Nortel's publicly traded securities, or the proportion consolidation leading to a lessen total market capitalization or adverse outcome on the liquidity of Nortel's accustomed shares. For additional info with respect to unavoidable of these and different elements, espy Nortel's Annual record on Form10-okay/A, Quarterly experiences on kindhearted 10-Q and other securities filings with the SEC. except otherwise required with the aid of applicable securities legal guidelines, Nortel disclaims any end or duty to update or revise any ahead-looking statements, even if as a result of current information, future movements or in any other case.

(1)Nortel, the Nortel brand and the Globemark are logos of Nortel Networks.


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Communication Server (CS) Rls. 4.0 Database Administrator

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Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea | killexams.com real questions and Pass4sure dumps

The purpose of the Society of Anesthesia and Sleep Medicine (SASM) Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on the available scientific evidence. In light of a paucity of well-designed, high-quality studies in this perioperative field, a large allotment of the present recommendations was developed by experts in the bailiwick taking into account published evidence in the literature and utilizing consensus processes, including the grading of the even of evidence. At times, when specific information on patients with OSA was not available in the literature, evidence in highly correlated patient populations, specifically those with obesity, was considered if appropriate. When this was the case, it is explicitly stated in various parts of this document.

The guideline presented may not breathe suitable for full clinical settings and patients. Thus, its consideration requires an assessment of appropriateness by clinicians on an individualized basis. Among many factors, the existence of institutional protocols, individual patient-related conditions, the invasiveness of an intervention, and the availability of resources necessity to breathe considered. The present rehearse guideline is not intended to define standards or portray absolute requirements for patient care. Adherence to this guideline cannot guarantee successful outcomes but rather should aid health keeping professionals and institutions to formulate plans for improved management of patients with OSA. The present recommendations reflect the current situation of lore and its interpretation by a group of experts in the bailiwick at the time of publication. sporadic reevaluations of the literature will breathe needed, and novel scientific evidence should breathe considered between updates. Deviations from this guideline in the practical setting may breathe justifiable, and such deviations should not breathe interpreted as a basis for negligence claims.

OSA is a common and frequently undiagnosed disorder defined by the repeated collapse of the upper airway with resultant blood oxygen desaturation events during sleep.1,2 OSA has been associated with adverse long-term health outcomes and has been linked to increased perioperative complication risk.3–5 Indeed, a comprehensive review of the literature performed by a task force appointed by SASM revealed substantial risk for adverse events, especially pulmonary complications, to breathe associated with OSA in the perioperative period.6 Based on the elevated risk for perioperative complications, the recently published SASM Guideline on Preoperative Screening and Assessment of Adults With Obstructive Sleep Apnea recommends that attempts should breathe made to appropriately identify patients with OSA, with the goal to raise awareness among providers, mitigate risk, and better outcomes.7 While recommendations for preoperative screening and assessment of patients with OSA and their optimal preparation for surgery are now available, there is a paucity of evidence-based guidance for the intraoperative management of this patient population. Thus, there remains a want of evidence-based rehearse recommendations regarding techniques for airway management, selection of anesthetic agents, and drugs, as well as selection of anesthetic technique.

This document is derived from results of an extensive consensus process based on a systematic literature search, review, and analysis performed by experts in the field. It is a follow-up to the previously published SASM Guideline on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea.7 Given the large amount of related literature in this arena, this study focuses only on intraoperative patient care. Postoperative keeping issues are not considered and may breathe the subject of future projects.

What Other Guidelines and Reviews Are Available?

Previous OSA-related rehearse guidelines8–12 fill been published by the American Society of Anesthesiologists,8,9 the Society for Ambulatory Anesthesia,10 the American Academy of Sleep Medicine,11 the SASM,7 the International Bariatric Consensus Guideline Group,13 and the task force on best rehearse recommendations for the anesthetic perioperative keeping and smart management in weight loss surgery.14

Why Was This Guideline Developed and How Does It vary From Existing Guidelines?

This guideline was developed to provide evidence-based recommendations for the intraoperative management of patients with OSA. Therefore, a watchful examination of the current literature using a systematic review approach with a focus on airway management, commonly used anesthesia-related drugs and agents, and anesthetic techniques in this patient population was conducted. The task force recognizes that there has been recent progress in attempts to subcategorize patients with OSA according to anatomic predisposition, arousal thresholds, muscle responsiveness, and ventilatory control characteristics.15 However, given the want of evidence in this context, statements were made referring to patients with OSA as a universal group. Nevertheless, phenotypic subcategorization may allow the development of individual risk profiling in the future.

Aims

The even of this guideline was to present recommendations based on the best current evidence. Clinical research as it relates to best perioperative practices in OSA is burdened by numerous difficulties. The intraoperative setting involves a army of concurrent interventions and employ of anesthetic medications, making it difficult to sole out specific factors that potentially drive the adverse outcome. want of preoperative polysomnography data within publications represents a further challenge, making it difficult to involve information of the repercussion of disease severity. Ethical considerations in study designs regarding the randomization of patients with known OSA were additional obstacles in this context. Furthermore, the task force recognizes that there is a tendency to underreport medical complications, rendering it difficult to establish the accurate perioperative risk.16 Presenting the current available evidence and its limitations should raise awareness regarding the necessity for high-quality studies in the future.

Specific aims were to: (1) evaluate considerations of difficult airway management in patients with OSA, (2) assess the repercussion of individual anesthesia-related drugs and agents in the keeping of patients with OSA, and (3) evaluate best anesthetic techniques in this patient population. To achieve these aims, a question-driven approach was sought.

In areas lacking enough published evidence, the task force sought to establish expert consensus while considering related literature. Patients affected by sleep-disordered breathing unrelated to OSA, including hypoventilation syndromes, sporadic breathing, and central apnea unrelated to OSA, were not considered in this project. This decision was made a priori to reduce the influence of heterogeneity in their assessment given the want of evidence on which to groundwork recommendations for these specific populations.

GUIDELINE task FORCE

The task force was comprised of 14 members of SASM, an international society devoted to advancing the keeping for clinical problems shared by anesthesiology and sleep medicine clinicians. Given that this project included only intraoperative aspects, the task force included 12 anesthesiologists and 2 anesthesiology research fellows. Members of the task force partake expertise on the topic of sleep-disordered breathing in the perioperative setting and included practitioners from both academic and nonacademic settings from various parts of the United States, Canada, and Europe.

METHODS Research Questions

A systematic review of the literature addressing the intraoperative management of patients with OSA was conducted after search terms were developed by the task force. Three groups were established, each focusing on one of the focus areas (Table 1). Group 1 investigated whether patients with OSA are at increased risk for difficult airway management. Group 2 investigated the repercussion of various anesthesia-related drugs and agents used in the intraoperative keeping of patients with OSA. Group 3 evaluated the outcome of anesthesia technique in patients with OSA. Leaders and group members are listed in the acknowledgments section of the article.

Literature Search Strategy

With the serve of a research librarian, a literature search was performed for each group, including publications from 1946 to September 2016. Databases searched included (1) Medline, (2) ePub Ahead of Print/Medline In-process, (3) Embase, (4) Cochrane Central Register of Controlled Trials, (5) Cochrane Database of Systematic Reviews, (6) PubMed-NOT-Medline, and (7) ClinicalTrials.Gov. The search focused on studies of adult individuals (≥18 years of age) and published in English. Continued literature surveillance was done through January 2018.

Excerpt of the Controlled Vocabulary Terms and Key Words Included in the Systematic Search.

Group 1: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “airway,” “intubation,” “extubation,” “airway management,” “airway obstruction,” “airway extubation,” “intubation, intratracheal,” “intubation.mp,” “laryngeal masks,” “respiration, artificial,” “positive pressure respiration,” “respiratory mechanics,” “continuous positive airway pressure,” “supine position,” “apap.mp,” “bipap.mp,” “cpap.mp,” “facemask,” “ventilat.mp,” “patient positioning,” “difficult mask ventilation,” “supraglottic airway devices,” and “surgical airway.”

Group 2: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “postoperative period,” “complications or outcome,” “perioperative care,” “perioperative complications,” “intraoperative complications,” “postoperative complications,” “outcome,” “risk,” “morbidity,” “mortality and death,” “anesthesia,” “anesthetics,” “anesthetics, intravenous,” “inhalational anesthesia,” “volatile anesthesia,” “anesthetics local,” “analgesia, opioid,” “hypnotics and sedatives,” “adverse effects,” “intravenous regional anesthesia,” “sedation,” “sedatives,” “short acting,” “nonsteroid of nonsteroid or nasaids,” “opioid,” “complication,” “muscle relaxant,” “rocuronium, atracurium,” “cis-atracurium,” “vecuronium,” “mivacurium,” “suxamethonium or succinylcholine,” “rapacuronium,” “pancuronium,” “skeletal muscle relaxant,” “neuromuscular reversal agents,” “sugammadex,” “residual neuromuscular block,” “drug effects,” “adverse effects,” “adverse drug reactions,” “abnormalities drug induced,” “adverse drug events,” “adverse drug reactions reporting systems,” “morbidity,” and “mortality.”

Group 3: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “postoperative period,” “complications or outcome,” “perioperative care,” “perioperative complications,” “intraoperative complications,” “postoperative complications,” “outcome,” “risk,” “morbidity,” “mortality and death,” “anesthesia, epidural,” “anesthesia, spinal,” “anesthesia, general,” “major conduction anesthesia,” “treatment outcome,” “treatment failure,” “mortality,” “outcome,” “peripheral nerve blocks,” “nerve blocks,” “anesthesia regional,” “anesthesia technique,” “sedation,” “sedative medication,” “deep sedation,” “secure airway,” “airway,” “multimodal analgesia,” “balanced anesthesia,” “opioid sparing,” and “opioids.”

Full search strategies in Medline for full groups are reported in the Supplemental Digital Content 1, SASM Guideline Intraoperative OSA Appendix, http://links.lww.com/AA/C373; Supplemental Digital Content 2, Search Anesthesia Technique, http://links.lww.com/AA/C374; Supplemental Digital Content 3, Search Difficult Airway and OSA, http://links.lww.com/AA/C375; Supplemental Digital Content 4, Search Intraoperative Medication employ in Patients With OSA, http://links.lww.com/AA/C376; Supplemental Digital Content 5, Search Strategy NMBA, http://links.lww.com/AA/C377.

Furthermore, particular reviews addressing difficult airway, anesthesia-related drugs and agents, specifically those involving neuromuscular blocking agents (NMBAs) and opioids, were conducted and summarized in sever systematic reviews by the respective SASM focus groups (members listed in the acknowledgments) to partake the evidence gathered and expand the scope of the present guideline.

Study Selection

In the respective groups, ≥2 reviewers assessed titles and abstracts for eligibility by using the standardized format of the Covidence platform.17 This step was followed by a full-text review and data extraction. Furthermore, a citation search by a manual review of references from primary or review articles was performed to compile additional relevant results. Any disagreements were resolved by consensus among reviewers or by consulting with the respective SASM groups via face-to-face meetings, teleconferences, or email communications. Study designs considered included randomized controlled trials (RCTs), prospective and retrospective observational studies, case series, systematic reviews, and meta-analyses. Within this literature, the presence or risk for OSA was based on polysomnography, screening questionnaires, clinical assessment, chart diagnosis, medical history, or International Classification of Diseases (ICD)-9 codes from administrative or billing records, while studies reported on at least 1 outcome of interest. Existing guidelines were cross-checked for completeness of references.

Data extracted from these studies included type of study, demographic data, comorbidities, procedure type, anesthesia-related interventions and medications, adverse events, as well as other clinically well-known outcomes and effects.

Exclusion Criteria.

Exclusion criteria were: nonhuman studies, non-English language, review articles, sole case reports, studies reporting on the chronic employ of medications commonly used intraoperatively such as chronic opioid medication, and studies without outcome reporting. For group 3, studies not directly comparing anesthesia modalities were also excluded.

Level of Evidence and Recommendations

The Oxford even of Evidence (Oxford LOE) implement was utilized to evaluate the attribute of evidence of individual studies.18 Grading the power of recommendations and attribute of the underlying evidence enhances the usefulness of clinical rehearse guidelines.19 Therefore, the approach according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system20,21 was utilized with esteem to the carcass of evidence and the development of guideline recommendations.22 As specified by GRADE, the attribute of evidence is classified into high, moderate, low, and very low levels, according to factors that involve study methodology, consistency and precision of results, and directness of evidence.19 These levels were assigned to the carcass of evidence of each respective recommendation within their focus zone and reflect the self-confidence in estimates of the accurate effect.21 When pathetic from evidence to recommendations, the GRADE approach focuses on 4 factors: equipoise between benefit and harm, certainty of evidence, values and preferences, and resource considerations.22 The power of recommendation is separated into stout and frail and defines the extent to which one can breathe confident that the desirable consequences outweigh its undesirable consequences (Table 2).23

In-person SASM Intraoperative Guideline task force meetings took location at special sessions during the SASM annual meetings in Chicago, IL (2016), and Boston, MA (2017), as well as the International Anesthesia Research Society annual meeting in Washington, DC (2017). Furthermore, multiple teleconferences and electronic communications took location throughout this time period. preparatory results and implications of findings were presented and discussed at the 2017 SASM annual meeting in Boston, MA.

1. DIFFICULT AIRWAY AND OSA
  • 1.1. Question: Are patients with OSA at increased risk for difficult airway management and conclude special precautions necessity to breathe taken?
  • 1.1. Recommendation: Known or suspected OSA should breathe considered an independent risk factor for difficult intubation, difficult mask ventilation, or a combination of both. Adequate difficult airway management precautions should breathe taken.
  • Level of evidence: Moderate; Grade of recommendation: Strong

    Rationale

    The perception of OSA as an well-known risk factor for difficult airway management is widely held among anesthesiologists and intensive keeping physicians. In the absence of RCTs, several prospective and retrospective controlled studies fill supported this assumption.24–39

    Association Between OSA and Difficult Airway Management

    After applying the designated search strategy and removing duplicates, 4806 references were screened for title and/or abstract. After reviewing 25 full-text articles, 16 studies were identified as reporting on the association between difficult airway management and OSA, while 9 studies were excluded.40–47 A particular summary of associations between OSA and various difficult airway management components is provided in Supplemental Digital Content, Table A1, http://links.lww.com/AA/C373.

    Among the included studies, 5 were retrospective24,25,27,35,36 and 11 were prospective controlled studies.26,28–34,37–39 Ten studies confirmed OSA by overnight polysomnography24,25,27,29,35 or electronic database entries,28,30,31,34,37 3 used the STOP-Bang screening questionnaire,33,38,39 2 identified patients by clinical diagnosis,26,36 and 1 used both polysomnography and the STOP-Bang questionnaire.32

    In total, 266,603 patients were included in 16 studies. Of those patients, 32,052 had OSA (identified by polysomnography, electronic database, chart or clinical diagnoses, and STOP-Bang questionnaires) and 234,551 did not. In summary, 12 studies reported on difficult intubation,24–29,31–33,35,38,39 6 on difficult mask ventilation,28,30,31,36,38,39 2 on both difficult intubation and mask ventilation,28,37 and 2 on failed supraglottic airway.27,34 Several studies reported >1 difficult airway outcome. No study was available on the necessity for a surgical airway (Supplemental Digital Content, Table A1, http://links.lww.com/AA/C373).

    Concerning difficult intubation and OSA, 7 of 12 studies showed positive associations.24,25,28,33,35,38,39 Of 6 studies, 5 demonstrated a significant repercussion of OSA on difficult mask ventilation.28,30,36,38,39 In the 2 studies that reported on combined difficult intubation and mask ventilation, both demonstrated a significant repercussion of OSA.28,37 Although 5 studies assessing difficult intubation26,27,29,31,32 and 1 study evaluating difficult mask ventilation31 did not find a significant association with OSA, the overall estimates showed a positive association between OSA and difficult airway. This finding suggests that patients with OSA are at increased risk of difficult airway management compared to patients without OSA. particular data, analysis, and results on the association between OSA and difficult airway will breathe reported in a sever systematic review with meta-analysis by the SASM airway focus group (members listed in acknowledgments).

    One prospective controlled study34 reported on the employ of the LMA Unique® (Teleflex Incorporated, Morrisville, NC), and an additional retrospective investigation27 reported on a sever unspecified supraglottic airway device. No significant association was institute between OSA and failed supraglottic devices.

    Prevalence of OSA in Patients With Difficult Intubation

    Two studies elucidated the association between OSA and difficult intubation in a reverse manner by investigating the rate of OSA among patients with difficult intubation. In a retrospective study, Hiremath et al,24 using an apnea-hypopnea index (AHI) ≥10 as a cutoff, institute that 53% of patients with difficult airway had OSA. This finding was confirmed by a prospective controlled study by Chung et al.29 using an AHI ≥5 as a cutoff for OSA diagnosis. Patients who were determined to fill a difficult airway were referred for polysomnography after surgery, and 66% were shown to fill OSA.

    Kim and Lee35 showed that patients with an AHI ≥40 had a significantly higher prevalence of difficult intubation. For patients with OSA with AHIs ≤40, 40–70, and ≥70, the incidence of difficult intubation was 3.3%, 19.3%, and 27.6%, respectively.35 Anatomical skeletal and soft tissue changes may contribute to a difficult airway in OSA. However, these observations are “hypothesis-generating” rather than “hypothesis-proving” findings. The shared anatomical abnormalities interpret the positive association between difficult airway and OSA.

    A number of studies evaluated the association of difficult airway management with OSA using the STOP-Bang questionnaire to identify patients at towering risk of OSA.32,33,38,39 The sensitivity and specificity of the STOP-Bang questionnaire can vary according to the prevalence and severity of OSA.48 This variation can create false-positive and false-negative cases in both OSA and non-OSA groups, leading to potential misclassification bias.

    One of the contributing factors for adverse respiratory events in patients with OSA is the increased risk of difficult airway management, such as difficult intubation, difficult mask ventilation, or both. In a recent report, there were 7 litigation cases where OSA was associated with either death or anoxic brain injury due to difficult airway management in the configuration of failure to reintubate in the postoperative period.49 lore about the association between OSA and difficult airway may better perioperative airway management and abate airway-related complications.

    In view of ethical considerations, it is difficult to achieve RCTs in patients with OSA to determine its associations with difficult airway management. As a result, only observational prospective and retrospective studies are available in the literature. The discontinuance estimates of these studies argue that there is an increased risk of difficult airway management in patients with OSA. Due to the large number of trials and large patient numbers, the overall attribute of the carcass of evidence was considered to breathe qualify using the GRADE approach20,21 and the Oxford LOE.18

    2. INTRAOPERATIVE MEDICATION employ IN PATIENTS WITH OSA

    A large carcass of literature supports the notion that the effects of surgery and anesthesia pose unique hazards to patients with OSA.5,50,51 Anesthetic agents and analgesic drugs interact with consciousness, sleep, and ventilatory drive,52,53 and thus they deserve consideration when caring for patients with OSA. In addition, upper airway and pulmonary physiology, including upper airway dilator muscle activity, are impacted by pharmacological and mechanical elements (airway manipulation) of anesthesia with feasible increased detriment in OSA.54–56 The following section discusses questions related to the effects of various agents and drugs commonly utilized intraoperatively in patients with OSA.

    2.1 Neuromuscular Blocking Agents
  • 2.1.1 Question: Are patients with OSA at increased risk for postoperative respiratory complications from the employ of NMBAs?
  • 2.1.1 Recommendation: Patients with OSA who received NMBAs may breathe at increased risk of effects of postoperative residual neuromuscular blockade, hypoxemia, or respiratory failure.
  • Level of evidence: Low; Grade of recommendation: Weak

  • 2.1.2 Question: Does the selection of neuromuscular blocking reversal agent repercussion the risk of postoperative respiratory complications in patients with OSA?
  • 2.1.2 Recommendation: Currently, there is insufficient evidence to imply the preference of any neuromuscular blocking reversal agent to reduce the risks of postoperative respiratory complications in patients with OSA.
  • Level of evidence: Low; Grade of recommendation: No recommendation

    Rationale.

    NMBAs are commonly used to optimize intubation conditions and provide surgical relaxation for various procedures. However, residual neuromuscular blockade has been reported to occur in ≤64% of patients in postanesthesia keeping units.57 The employ of NMBAs and residual neuromuscular blockade has been associated with significant postoperative respiratory complications such as hypoxemia,58 upper airway obstruction,58 and pneumonia.59 towering doses of NMBA given during abdominal surgery were associated with an increased risk of 30-day readmission, increased length of hospital stay, and increased hospital cost.60 A retrospective review of a single-center database showed that patients who required tracheal intubation within the first 3 days after surgery had a significantly higher frequency of NMBA administration and reversal with neostigmine.61 Residual neuromuscular blockade may persist despite the administration of neostigmine reversal, especially when neuromuscular monitoring is not utilized.62

    It is unclear whether patients with OSA may breathe at higher risk for postoperative respiratory complications due to the adverse effects of postoperative residual neuromuscular blockade compared to patients without OSA. Moreover, it is uncertain whether the type of reversal agent impacts the risk of postoperative complications in patients with OSA. Patients with suspected61 or confirmed50,63,64 OSA fill been shown to breathe at increased risk for early postoperative respiratory complications, including emergent intubation,63,64 mechanical ventilation,63,64 noninvasive ventilation,63,64 respiratory failure,50 desaturation,6,50 and pneumonia.64 The employ of NMBA was not described in these studies.6,50,63,64 Many patients with OSA are obese and fill anatomical risk factors that may enlarge vulnerability to the effects of residual neuromuscular blockade on the upper airway and pharyngeal function.

    Our literature search yielded 5 studies that were heterogeneous in terms of study design, types of surgery, and types of respiratory complications.65–69 Many studies were excluded because OSA diagnosis or employ of NMBA was not described.

    One RCT11 and 2 observational studies66,67 were included to address the question of whether patients with OSA are at a higher risk for postoperative respiratory complications from the employ of NMBA compared to patients without OSA. Although the even of evidence was limited (Oxford LOE 2–3), the studies imply that patients with OSA who received NMBA may breathe at increased risk of effects of residual neuromuscular blockade, postoperative respiratory failure, and hypoxemia.65–67 The results of their review are consistent with previous studies showing that patients with OSA are at higher risk of postoperative respiratory failure and hypoxemia than patients without OSA.6,61,70,71 Even partial residual neuromuscular blockade that does not educe respiratory symptoms can impair upper airway dilator muscle function.72 Minimizing the employ and dose of NMBA, monitoring the even of neuromuscular blockade, and complete reversal of NMBA before extubation may breathe particularly well-known for patients with OSA.9

    While not considering OSA status, reversal of NMBA with sugammadex, a cyclodextrin used to reverse rocuronium,73 has been shown to abate the incidence of residual paralysis compared to the anticholinesterase inhibitor, neostigmine.74 A recent Cochrane review of 41 studies comparing sugammadex with neostigmine concluded that patients receiving sugammadex versus neostigmine had 40% fewer composite adverse events (bradycardia, postoperative nausea and vomiting, and residual neuromuscular blockade).75 Patients receiving sugammadex had less desaturation and necessity for transitory oxygen supplementation; however, the OSA status was not reported in these reviews, limiting its value to assess its differential outcome in this subpopulation.74,75

    There are limited studies comparing the repercussion of different neuromuscular blocking reversal agents on postoperative respiratory complications in patients with OSA. They identified 1 RCT68 and 1 observational study69 that compared sugammadex to neostigmine. In the 2 studies, 209 patients with OSA and 185 patients without OSA were included.68,69 The RCT (n = 74) institute that patients receiving sugammadex versus neostigmine had less postoperative respiratory complications (desaturation, hypoxemia, apnea, airway manipulation, airway usage, reintubation, continuous positive airway pressure [CPAP] therapy, and invasive mechanical ventilation).68 There was no variation in airway obstruction. The observational study (n = 320) compared sugammadex to a historical cohort of patients who received neostigmine reversal for laparoscopic bariatric surgeries. Patients with OSA who received sugammadex versus neostigmine had less postoperative chest radiographic changes (atelectasis, pleural effusions), 6.9% vs 16.3% (odds ratio [OR], 0.36; 95% CI, 0.18–0.8),69 but there were no differences in postoperative mechanical ventilation or hospital length of stay. Although both studies showed a reduction in some postoperative respiratory complications, the evidence is limited because the number of patients included in the RCT (Oxford LOE: 2) was small,68 and the observational study (Oxford LOE: 3) reported no variation in clinical outcomes.69

    Currently, there is insufficient evidence to recommend the employ of sugammadex over neostigmine to reduce the risk of postoperative respiratory complications in patients with OSA. More trials with larger sample sizes are needed in this patient population.

    2.2 Opioids
  • 2.2.1 Question: Are patients with OSA at increased risk for opioid-related respiratory events?
  • 2.2.1 Recommendation: Patients with OSA may breathe at increased risk for adverse respiratory events from the employ of opioid medications.
  • Level of evidence: Low; Grade of recommendation: Weak

  • 2.2.2 Question: Is smart perception and opioid potency altered in patients with OSA?
  • 2.2.2 Recommendation: The possibility of altered smart perception in patients with OSA should breathe considered.
  • Level of evidence: Low; Grade of recommendation: Weak

    Rationale.

    While opioids are highly efficient in treating qualify to austere pain, their intrinsic capacity to repress ventilatory drive demands caution in OSA. Despite consensus among perioperative physicians to restrict or avoid opioids in OSA,9 the presence of robust, high-quality scientific evidence to demonstrate the merit of heightened concern and guide safe opioid rehearse in this population is limited.76

    Nevertheless, despite limitations with respect to the attribute of evidence suggesting an adverse repercussion of acute opioid administration in OSA, current literature indicates that a heightened concern regarding opioid employ in this population may breathe justified. A summary of evidence is provided in Supplemental Digital Content, Table A2, http://links.lww.com/AA/C373.

    Specifically, 17 observational studies exploring the repercussion of systemic opioid employ in OSA were identified. While the majority demonstrated an association between opioid employ and adverse perioperative outcomes in OSA,61,77–89 this was not confirmed by all.66,90,91 It should breathe preeminent that, particularly among observational analyses, there is notable heterogeneity with esteem to the modality of OSA assessment, ranging from the gold yardstick of polysomnography to identification by screening questionnaires or patient history. Furthermore, potential selection prejudice should breathe considered in these studies. In recent publications, a comparison of postoperative complications among patients with and without OSA within the identical study cohort revealed that the incidence of postoperative pulmonary (2.49% vs 1.83%), cardiac (2.81% vs 0.23%), gastrointestinal (0.45% vs 0.33%), renal (3.47% vs 1.83%), and thromboembolic (0.41% vs 0.33%) complications was higher in patients with OSA at similar opioid dose levels.88,92 Additional analysis of the repercussion of opioid dose enlarge within patients with OSA demonstrated an associated enlarge in the odds for gastrointestinal complications, prolonged length of stay, and increased hospital cost, while no further enlarge in risk for pulmonary complications was observed, possibly due to increased levels of monitoring afforded to this population.88 A higher incidence of postoperative complications in OSA versus non-OSA in this context was also institute by Blake et al77 and Esclamado et al,80 while the latter conducted their study in upper airway surgery, a procedure with a potentially inherent influence on respiratory outcome.80

    Chung et al79 demonstrated an opioid dose-dependent postoperative worsening of sleep-disordered breathing associated with the severity of OSA (expressed by AHI), although this outcome may fill been fairly small. manlike patients with OSA had a significantly higher central apnea index on postoperative night 1 versus female patients with OSA. In this context, numerous other observational studies took a different approach by investigating the incident of critical, life-threatening respiratory events, such as respiratory failure and naloxone requirement and identifying drivers for these complications.61,81–84,86,87 Moreover, a recent systematic review reported that the majority of surgical patients with OSA experiencing perioperative death or near-death events received a morphine equivalent dose of <10 mg/d.89 Subramani et al89 suggested that a dose-response pattern with increased odds for complications at increasing opioid dose levels (ORs of 1.0, 1.5, and 3.0 at opioid doses of <10, 10–25, and >25 mg; P for trend <.005) exists.

    In contrast, others66,85 who restricted their focus to patients with obesity, a population of towering OSA prevalence,2 demonstrated that, although postoperative respiratory complications in the context of opioid analgesia were common, surprisingly, OSA could not breathe established as an independent risk factor.66,85 However, a factor potentially causing an underestimation of a feasible deleterious outcome of OSA was the postoperative employ of positive airway pressure therapy among patients with OSA.85 Moreover, a proof of concept analysis by Wang et al91 suggested that the experimental oral administration of 30 mg controlled-release morphine in 10 volunteers outside the surgical setting paradoxically improved oxygenation through modulating chemoreflexes.91 In summary, evidence from observational analyses suggests that opioid employ in the presence of OSA presents a risk factor for postoperative captious respiratory events (Oxford LOE 3–4).61,79,81–84,86,87,89

    With esteem to evidence from RCTs, 6 such studies were identified (Oxford LOE 2).93–98 In a volunteer study, Bernards et al94 directly demonstrated that opioid administration during sleep increased the number of central apneas, leading to decreased saturation levels in patients with OSA versus those without OSA.94 Abdelmageed et al93 demonstrated that opioid dose reduction significantly reduced the incidence of central apneas and respiratory events in patients with OSA.93 While interesting, it must breathe preeminent that opioid reduction may abate respiratory depression and related complications in the universal population as well.92 Using a nonvalidated OSA prediction instrument, Blake et al95 showed that central apneas and respiratory events were related to the dose of morphine administered postoperatively. However, differences in the incident of respiratory complications between patients with yardstick morphine patient-controlled analgesia and an opioid-sparing regimen could not breathe established.95

    Other studies explored the safety of neuraxial opioid administration in patients with OSA.99–102 In a systematic review, Orlov et al99 institute that the incidence of major cardiorespiratory complications after neuraxial opioid administrations was 4.1% among patients with OSA. However, the authors also emphasized that significant limitations in the attribute of evidence and persistent underreporting of adverse events prevented an accurate and robust assessment of accurate perioperative risk.16,99 A prospective study in patients having a cesarean delivery with intrathecal morphine administration demonstrated that OSA and obesity were associated with approximately a 2-fold enlarge in risk for desaturation.100 However, another observational analysis of 990 patients undergoing orthopedic surgery with intrathecal morphine could not find an association between OSA and adverse pulmonary events.101

    In summary, limited literature suggests that patients with OSA may breathe at increased risk for opioid-related respiratory adverse events. However, high-quality evidence to uphold and prove this notion is largely lacking (Oxford LOE 2–4).

    Pain and Opioid Analgesia in OSA.

    A systematic evaluation of opioid-related respiratory effects in OSA requires focused attention on closely related issues such as smart perception and pharmacology of opioid analgesia. A summary of evidence is provided in Supplemental Digital Content, Table A3, http://links.lww.com/AA/C373 (Oxford LOE 3). Characterizing these relationships is well-known because the dose of opioids that is required to treat pain, as well as the sensitivity to these medications, directly influence the likelihood of opioid-induced respiratory depression.

    Disturbed sleep continuity and intermittent hypoxia are 2 well-known features of OSA. Studies in humans fill repeatedly demonstrated that fragmented103,104 or chronically curtailed sleep87,105 and insomnia,106 a condition highly comorbid with OSA,107 are associated with heightened sensitivity to pain.108

    Among 3 identified studies examining the response to experimental smart in subjects suffering from OSA, 1 study institute that patients with OSA and comorbid temporomandibular joint disorder experienced hypoalgesia to pressure-related pain,109 while another reported a significant enlarge in smart threshold after restoring sleep continuity with the application of CPAP therapy.110 In contrast, the third investigation institute no association between wake-after-sleep-onset or nocturnal nadir blood oxygen saturation (SpO2) polysomnographic parameters and threshold/tolerance to thermal pain.111

    In the context of chronic pain, a retrospective analysis of prospectively collected data from the Cleveland Family Study showed that chronic intermittent hypoxia was associated with more frequent chronic smart complaints, even after adjusting for the potentially hyperalgesic outcome of sleep fragmentation and systemic inflammation.112

    Despite the primary goal to focus on the adult patient population in this guideline, a significant amount of evidence originates from the pediatric population and deserves mention here particularly because they demonstrate contradictory findings to those institute among adults. In children undergoing adenotonsillectomy for treatment of OSA, 2 case–control studies, 1 retrospective113 and 1 prospective,114 showed that patients with a preoperative nocturnal nadir SpO2 <85% required half the dose of morphine to treat postoperative pain, versus those with a nadir SpO2 ≥85%. Two prospective case–control studies in the identical population did not substantiate these findings.115,116 In the first study, African American children versus Caucasian children with OSA presented with more smart requiring a higher dose of morphine for postoperative analgesia.115 The second study showed that children with OSA (respiratory disturbance index >5) required more morphine for postoperative analgesia, but they also demonstrated a higher incidence of opioid-related respiratory complications.116

    In adults, 1 retrospective analysis institute that bariatric patients with nocturnal hypoxemia (expressed as percentage of total sleep time spent at oxygen saturation [SaO2] <90%) required less opioids for postoperative analgesia,117 whereas another prospective study did not detect any association between preoperative nocturnal hypoxemia and postoperative opioid employ in universal surgical patients with OSA.118 A more particular and comprehensive summary of evidence on the potential repercussion of acute opioid analgesia in OSA is provided in a sever systematic review by the SASM opioids focus group (members listed in the acknowledgments).

    2.3 Propofol
  • 2.3.1 Question: Are patients with OSA at increased risk for adverse events from the employ of propofol for procedural sedation?
  • 2.3.1 Recommendation: Patients with OSA may breathe at increased risk for adverse respiratory events from the employ of propofol for procedural sedation.
  • Level of evidence: Moderate; Grade of recommendation: Strong

    Rationale.

    The literature discussed for the purpose of the recommendation reflects evidence of import for patients receiving propofol for sedation in a procedural setting, that is, drug-induced sleep endoscopy (DISE), gastroenterological endoscopy, or dentistry. The employ of propofol to induce universal anesthesia purposefully suppresses respiratory activity and was thus deferred in this section.

    Propofol is the most commonly used agent for DISE.119,120 A summary of findings from 5 studies120–124 is shown in Supplemental Digital Content, Table A4, http://links.lww.com/AA/C373 (Oxford LOE: 2–4). Both carcass mass index (BMI) and severity of OSA correlated with a greater likelihood of a patient having multiple sites of airway collapse and a higher possibility of circumferential and total airway obstruction during DISE.119,125 The goal of propofol administration for DISE is to bow a sleep-like loss of consciousness and muscle relaxation to precipitate pharyngeal narrowing and collapse in vulnerable individuals. To avoid the problem of profound relaxation or central apnea, it has been suggested that initial dosing for DISE breathe judiciously titrated.120,126

    Attempts fill been made to formulate a mathematical equation to model the pharmacokinetics for propofol in patients with obesity (Supplemental Digital Content, Table A5, http://links.lww.com/AA/C373).127–130 dubiety regarding dosing scalar adjustments that may breathe required in patients with obesity, as well as the concomitant employ of depressant drugs with synergistic effects (midazolam,131 ketamine,132,133 dexmedetomidine,134 opioids135), further add to the necessity for heightened vigilance when using propofol for patients with OSA. Propofol has a relatively steep dose-response curve compared to other sedatives/hypnotics, thus underscoring the import of watchful titration.131,136,137 Adverse effects are not uncommon in patients with OSA undergoing procedures with propofol sedation. A summary of findings from 5 studies138–143 is shown in Supplemental Digital Content, Table A6, http://links.lww.com/AA/C373. OSA, increased BMI, manlike gender, American Society of Anesthesiologists physical status ≥III, initial dose of propofol, and increased age were institute to breathe independent risk factors for hypoxemic incidents. Airway interventions were common in patients receiving propofol, although indications for airway intervention were left to the discretion of the anesthesia provider. Whether precautionary or subsequent to an obstructed airway, apneic, or desaturation episode, such airway interventions were undoubtedly done to prevent or mitigate a sedation-related adverse event. The employ of capnography was associated with a decreased incidence of hypoxic events compared to yardstick monitoring lonely during sedation with propofol144 in patients with OSA.140

    2.4 Inhalational Agents
  • 2.4.1 Question: Are patients with OSA at increased risk for residual effects of inhalational anesthetic agents?
  • 2.4.1 Recommendation: There is a want of evidence to assess residual effects of inhalational anesthetic agents in the population with OSA.
  • Level of evidence: Moderate; Grade of recommendation: No recommendation

    Rationale.

    There is a want of scientific literature to guide best intraoperative practices in OSA regarding the preferred technique among various inhalational agents and intravenous propofol for the maintenance of anesthesia. Nevertheless, a significant amount of evidence has been published on the universal population and patients with obesity.145 Evidence from the population with obesity may merit consideration in this context, given the immediate association to OSA,146 reflected in the substantial OSA prevalence of ≤90% in manlike bariatric patients.147,148 Notably, there is significant overlap between obesity and OSA with esteem to challenges in universal anesthesia because of altered cardiorespiratory physiology, including decreased functional residual capacity, upper airway obstruction, and the propensity to hypoxemia in perioperative settings.149,150

    This renders the term of emergence and recovery from anesthesia of towering concern regarding the risk for detrimental outcomes.56,146

    In this context, 25 studies were identified that compared the efficacy and recovery profile among the most common inhalational agents and intravenous propofol.65,151–174 A summary of evidence is provided in Supplemental Digital Content, Tables A7 and A8, http://links.lww.com/AA/C373. Comparing propofol and isoflurane, propofol was suggested to breathe associated with a faster recovery from anesthesia and improved postoperative respiratory control in 2 RCTs.154,155 However, sevoflurane was institute to breathe superior to propofol in 2 RCTs due to faster anesthesia recovery and improved hemodynamic stability.152,153 In addition, recently Fassbender et al151 reported no variation with esteem to postoperative obstructive and hypoxemic events between the 2 anesthetic agents when combined with remifentanil. Furthermore, comparing propofol and desflurane, 1 study demonstrated that the employ of propofol impaired pulmonary duty and SpO2 to a greater degree than desflurane,157 while another could not substantiate these differences.156 Thus, current evidence indicates that sevoflurane and desflurane might breathe superior to intravenous propofol in terms of anesthesia recovery in patients with obesity (Oxford LOE: 2).

    Similarly, 4 RCTs conducted in the population with obesity supported the notion that sevoflurane was associated with auspicious features compared to isoflurane.65,158–160 In particular, Sudré et al65 demonstrated that sevoflurane embedded in a short-acting anesthetic regimen comprised of remifentanil, rocuronium, and ropivacaine improved emergence from anesthesia and reduced respiratory complications, postoperative anesthesia keeping unit stay, and hospital length of abide when compared to isoflurane within a long-acting regimen. This analysis emphasized the colorable benefit of generally utilizing short-acting medications with esteem to full anesthetic drug classes, including opioids and NMBA, among patients at higher perioperative risk.65 The majority of studies, however, focused on the comparative effectiveness between sevoflurane and desflurane,161,163,165,167 demonstrating improved anesthesia recovery with desflurane (Oxford LOE: 2).162,164,166,168,169,174 Notably, limitations inherent to the nature of these comparisons can prevent the detection of differences. For instance, Eger and Shafer175 showed that differences in postoperative wake-up times among anesthetics were minimal at lower anesthetic concentrations,175 while the duration of anesthesia176 and BMI present well-known covariates.174

    Summarizing the evidence, a well-designed systematic review by Liu et al171 provided a comprehensive comparison with quantitative analysis of immediate postoperative recovery after desflurane, isoflurane, sevoflurane, and intravenous propofol anesthesia in patients with obesity. In addition, a rather minuscule clinical affliction by Juvin et al170 also compared desflurane, isoflurane, and propofol together in 1 analysis. Both Liu et al171 and Juvin et al170 established desflurane as the most auspicious anesthetic agent because of its superior postoperative recovery profile. Specifically, it was observed that patients who received desflurane anesthesia required less time to respond to commands, eye opening, hand squeezing, tracheal extubation, and designation stating. Moreover, desflurane reduced sedation levels171 and conferred higher postoperative SpO2.170,171

    It appears, therefore, that postoperative recovery might occur faster and with improved hemodynamic stability after anesthesia with desflurane followed by sevoflurane (Supplemental Digital Content, Table A7, http://links.lww.com/AA/C373), and these findings fill also been observed in the universal population.177–180

    Consistently, desflurane and sevoflurane feature low blood-gas partition coefficients,171 conferring greater intraoperative control of anesthesia depth, as well as rapid and consistent postoperative emergence and recovery.161,181,182

    These properties, in turn, imply earlier achievement of baseline respiratory duty with potentially better protection against aspiration and improved oxygenation.183 This has also been supported by the observation of decreases in hypoxemia in clinical trials.170,171 Both obesity and OSA predispose patients to higher risk of postoperative upper airway obstruction and sedate hypoxemia,184 thus suggesting a benefit associated with early and rapid recovery of active airway control and alertness.171

    Another intervention, possibly promoting increased safety in OSA, is the intraoperative monitoring of anesthesia depth. This has been suggested by Ibraheim et al172 and Freo et al,173 who demonstrated that monitoring for titration of levels of inhalational agents reduced the required anesthetic dosage and improved the postanesthetic recovery in patients with obesity.

    Furthermore, Katznelson et al185 suggested that recovery time after universal anesthesia in patients with and without obesity can breathe accelerated using either isocapnic or hypercapnic hyperpnea.185

    In summary, the available evidence supports the employ of desflurane and sevoflurane in patients with obesity (Oxford LOE: 2). Given the stout association between obesity and OSA, and the benefits of accelerating and improving postoperative anesthesia recovery, these outcomes are desirable and may apply to patients with OSA as well. However, except for 2 RCTs,151,154 no studies specifically in OSA are available, and thus no specific recommendations can breathe made.

    2.5 Ketamine
  • 2.5.1 Question: Are patients with OSA at increased risk for adverse events from the employ of ketamine?
  • 2.5.1 Recommendation: There is a want of evidence to assess residual effects of ketamine in the population with OSA.
  • Level of evidence: Very low; Grade of recommendation: No recommendation

    Rationale.

    The literature is scarce with esteem to complications associated with ketamine in patients with OSA.

    Ketamine has mostly been studied with respect to its potent analgesic effects as a sedative and hypnotic and, more recently, to reduce opioid use.186–188 There are only a few studies involving ketamine employ in patients with OSA, but data are insufficient to draw any firm conclusions.189,190

    Adverse effects of ketamine, such as neuropsychiatric effects, signs of increased sympathetic system activation (hypertension and tachycardia), and hypersalivation, are well documented in patients without OSA.191,192 Although patients with OSA are not specifically studied, these adverse events most likely translate to increased risk in this patient population as well. Adverse events are mostly seen in patients who received towering doses, signification >0.5 mg/kg boluses and 100 µg/kg/h infusions.193

    Ketamine has been shown to fill some beneficial effects. Studies demonstrated that ketamine, when combined with other sedative medications, mostly propofol, may abate respiratory-related adverse effects.194,195 One such prospective observational study looking at sedation-related risk factors (airway obstruction, hypoventilation, and desaturation) for procedural sedation institute ketamine to breathe a protective factor.195 De Oliveira et al194 reported that ketamine decreased duration and severity of hypercapnia in patients undergoing breast surgery under deep sedation.

    Furthermore, Drummond196 studied the outcome of ketamine versus midazolam on upper airway function. Interestingly, they institute decreased upper airway muscle activity in the midazolam group, which resulted in airway obstruction, whereas no change in muscle activity was observed in the ketamine group. In another study, genioglossus muscle activity, tidal volume, and respiratory rate fill been shown to breathe increased after administration of towering and low doses of ketamine in rats.197 Upper airway dilator muscle activity plays an well-known role in patients who are at risk of upper airway obstruction. Despite the want of data on ketamine in the patient population with OSA, available information suggests that these patients could benefit from potentially auspicious respiratory effects over other sedatives. firm conclusions, however, cannot breathe drawn at this time.

    2.6 Benzodiazepines
  • 2.6.1 Question: Are patients with OSA at increased risk for adverse events from intravenous benzodiazepine sedation?
  • 2.6.1 Recommendation: Patients with OSA may breathe at increased risk for adverse respiratory events from intravenous benzodiazepine sedation. Intravenous benzodiazepine sedation should breathe used with caution.
  • Level of evidence: Moderate; Grade of recommendation: Weak

    Rationale.

    Although the literature is immature on the topic of differential effects of intravenous benzodiazepine sedation in patients with OSA compared to those without OSA, studies imply that the employ of intravenous benzodiazepines is associated with airway compromise in patients with OSA. Intravenous benzodiazepine sedation is routinely used to induce airway collapse for diagnostic purposes in OSA.

    Much of the literature revolves around the employ of intravenous benzodiazepines for DISE in a diagnostic context to examine locations and patterns of obstruction in patients with OSA.119,198–210 Midazolam is the most commonly used intravenous benzodiazepine for DISE. In 7 studies,199,200,202,205,207,208,210 the majority of patients had multilevel obstruction, especially those with higher AHI. Two studies evaluated sleep staging during midazolam-induced sleep. The first showed that patients spent the most time in nonrapid eye movement sleep stage N1 and N2 but not in stage N3 and rapid eye movement (REM) sleep.198 The second reported that patients reached N2 sleep without further deepening of sleep stage.201 Because most obstructive events occur in N1 and N2 sleep, DISE with intravenous midazolam is considered a much option to study obstructive events in patients with OSA.102,105

    Interestingly, Sadaoka et al209 institute that patients with OSA had oxygen desaturation and apneas during DISE with intravenous diazepam more frequently than simple snorers.

    Another category of studies described the employ of intravenous benzodiazepines for sleep imaging.211–214 Thus, a retrospective analysis by Lee et al213 compared 53 patients with OSA to 10 simple snorers. full patients with OSA had desaturation events after 2 mg of midazolam, but nobody in the simple snorers group had such events.213

    We identified 5 studies evaluating intravenous benzodiazepines in the context of other endoscopic or surgical procedures.215–219 Midazolam was used either lonely or in combination with fentanyl. One study did not specify which benzodiazepines were used.218 Three studies215,216,219 compared outcomes between patients with and without OSA. In a retrospective cohort study by Adler et al,215 215 patients undergoing routine endoscopy were randomized to 4 groups: patients with OSA undergoing endoscopy with propofol or midazolam + fentanyl and patients without OSA undergoing endoscopy with propofol or midazolam + fentanyl. A comparison of patients with and without OSA receiving midazolam and fentanyl showed that desaturation events and other complications were not significantly different.215 Notably, doses of midazolam and fentanyl needed for colonoscopy were slightly lower in patients with OSA, although the procedure time was moderately longer.

    Cha et al216 published a prospective study that compared cardiopulmonary complications during routine esophagogastroduodenoscopy under sedation with midazolam between 31 patients with OSA and 65 wholesome controls. Patients with OSA received a higher dose of midazolam than patients without OSA, but cardiopulmonary complications were not increased in patients with OSA.

    Mador et al219 conducted a prospective study in 904 patients undergoing endoscopy to investigate whether OSA, assessed by the Berlin questionnaire, increases the risk of complications during sedation with midazolam and fentanyl. Major complications were observed in 3.25% of patients with low risk for OSA and in 1.9% of patients with towering risk for OSA (OR, 0.6; 95% CI, 0.26–1.46; P = .21). Minor complications were observed in 10.56% of patients with low OSA risk and 10.63% of patients with towering OSA risk (OR, 1.01; 95% CI, 0.65–1.56; P = 1.0), suggesting that OSA was not associated with increased risk for cardiopulmonary complications during endoscopy under sedation with midazolam and fentanyl in this analysis.

    In conclusion, 5 studies directly compared outcomes between patients with and without OSA after intravenous benzodiazepine sedation in the context of anesthesia.209,213,215,216,219 However, only 2 studies209,213 were able to establish a higher risk for respiratory complications in patients with OSA (Oxford LOE: 3). A summary of evidence is provided in Supplemental Digital Content, Table A9, http://links.lww.com/AA/C373.

    2.7 α-2 Agonists
  • 2.7.1 Question: Are patients with OSA at increased risk for adverse events from the employ of α-2 agonists?
  • 2.7.1 Recommendation: There is a want of evidence to assess adverse effects of α-2 agonists in the OSA population.
  • Level of evidence: Low; Grade of recommendation: No recommendation

    Rationale.

    Dexmedetomidine and clonidine are centrally acting α-2 agonists with sedative, analgesic, and sympatholytic properties. Dexmedetomidine, in particular, has been suggested to occasions minimal respiratory depression. Because OSA is associated with an increased risk of adverse postoperative pulmonary events,6 the potentially auspicious respiratory profile and analgesic-sparing effects theoretically invent α-2 agonists appealing for this population. When assessing the risk of adverse events with the employ of α-2 agonists, no eligible studies compared patients with OSA to patients without OSA. The majority of studies focused on OSA or bariatric populations, comparing the employ of α-2 agonists to either placebo or other medications. The carcass of literature is limited by a minuscule total number of subjects, discordant results, want of uniformity in outcomes, and low adverse event rates. Although many studies demonstrate statistical differences in hemodynamic parameters with α-2 agonists, the translation into clinically meaningful outcome differences is not supported at this time.

    Four studies123,124,220,221 compared the employ of dexmedetomidine to propofol in DISE as summarized in Supplemental Digital Content, Table A10, http://links.lww.com/AA/C373 (propofol in DISE has also been discussed in Section 2.3). In a series by Capasso et al,123 patients receiving propofol had a significantly increased likelihood of complete tongue groundwork obstruction versus partial or no obstruction compared to those receiving dexmedetomidine. The 2 other studies that examined aspects of airway obstruction did not demonstrate significant differences between the dexmedetomidine and comparison groups.220,221

    Three DISE studies measured intraprocedural respiratory and hemodynamic parameters. Two studies demonstrated a abate in respiratory rate and lower SpO2 with propofol compared to dexmedetomidine.124,221 In the study by Cho et al,220 imply SpO2 of the dexmedetomidine-remifentanil and propofol groups did not differ; however, it was significantly lower in the propofol-remifentanil group.220 This study showed no hemodynamic differences, a finding shared by Kuyrukluyildiz et al.124 Conversely, Yoon et al221 observed similar imply arterial pressure (MAP) but lower imply heart rate (HR) with dexmedetomidine and no episodes of clinically significant bradycardia. Kuyrukluyildiz et al124 measured postprocedure outcomes, finding significantly lower MAP and HR with dexmedetomidine. imply SpO2 and respiratory rate were higher with dexmedetomidine, although only 1 patient receiving propofol required additional oxygen supplementation.124

    These 4 studies were examined in a systematic review, which concluded that dexmedetomidine appeared to bow a more stable cardiopulmonary profile, while propofol offered a faster onset, a shorter half-life, and potentially a greater degree of airway obstruction.222 The authors emphasized that neither propofol nor dexmedetomidine has been validated in replicating the obstruction that occurs during sleep. The obstructive patterns could breathe due to drug outcome rather than reflective of the natural sleep state. Consequently, additional investigation is necessary to ascertain the optimal sedative in DISE.

    Other Procedures.

    For studies involving procedures other than DISE, adverse events were characterized according to respiratory effects, hemodynamic effects, and recovery profile (Supplemental Digital Content, Table A11, http://links.lww.com/AA/C373).

    Two studies reported respiratory outcomes during sedation procedures. In a descriptive series of 20 patients at towering risk of OSA, 13 required interventions for airway obstruction and 2 for desaturation during endoscopy with combined dexmedetomidine–propofol sedation.134 An RCT in upper respiratory procedures demonstrated that, compared to propofol target-controlled infusion, dexmedetomidine employ resulted in lower desaturation incidence, higher SpO2 at most time points, and lower rates of airway obstruction.223

    Data are limited regarding respiratory effects of dexmedetomidine in the postoperative recovery period. A descriptive series of bariatric patients reported adequate saturations with supplemental oxygen without the necessity for CPAP.224 Studies with quantitative data imply that intraoperative employ of dexmedetomidine may not influence the respiratory rate in bariatric patients225 and when compared to placebo may fill a better recovery profile in individuals undergoing uvuloplasty.93 In another group of patients receiving postoperative sedation after uvulopalatopharyngoplasty, the dexmedetomidine group experienced less austere and less frequent cough during extubation and less respiratory depression compared to the propofol group.226 Finally, in a retrospective review comparing patients undergoing airway reconstruction surgery who received dexmedetomidine versus those who did not, neither group required interventions for airway compromise.227

    Two studies examined the outcome of clonidine on respiratory parameters and sleep in patients with OSA.228,229 In an RCT of 8 patients, clonidine compared to placebo suppressed the amount of time in REM sleep and decreased apnea duration during REM while not affecting overall AHI.228 Minimum SpO2 levels were higher in the clonidine group (86% ± 1.5% vs 84% ± 1.0%), reaching statistical but arguably not clinical significance. Pawlik et al229 performed an RCT in patients with OSA undergoing ear, nose, and throat surgery, with patients receiving either oral clonidine or placebo the night before and 2 hours before surgery. AHI in the night of surgery did not vary from baseline or between the 2 treatment groups. In both groups, the desaturation index decreased on the preoperative night, the day of the operation, and the postoperative night compared to their respective baseline measurements but did not vary between groups.

    The hemodynamic effects of α-2 agonists were assessed according to varied outcome measures, including vital badge measurements, categorical descriptors, and necessity for rescue medications. Intraoperatively, 3 studies demonstrated significantly lower MAPs with α-2 agonists,229–231 while 1 study showed no difference.232 Heart rate was significantly lower with dexmedetomidine in 3 studies,223,229,230 while no variation to controls was observed in 2 other studies.231,232 Chawla et al227 reported ephemeral loading dose hypertension followed by “titratable, controlled hypotension, and bradycardia.” Three studies223,227,231 demonstrated less frequent employ of rescue antihypertensives or β blockers among α-2 agonist groups intraoperatively; 1 study showed this postoperatively.229 Furthermore, 1 study demonstrated a greater incidence of necessity for phenylephrine uphold in patients receiving dexmedetomidine.231 In studies reporting the necessity for atropine and/or ephedrine, the overall incidence was low, and no differences were reported between treatment groups.223,229 Among studies that measured postoperative hemodynamics, there was inconsistency as to whether MAP was decreased with α-2 agonists229–231 or similar to that of the control patients.93,225 Xu et al226 also characterized outcomes according to categorical variables and institute a decreased incidence of hypertension and tachycardia, as well as an increased incidence of bradycardia in the dexmedetomidine-treated group; the frequency of hypotension did not differ.

    The potential role of α-2 agonists in modulating the sympathetic response is of clinical interest. Four studies226,229,231,233 examined the effects of α-2 agonists on hemodynamics at points of stimulation, such as intubation, incision, and extubation. Only 1 study compared the measurements of each group to their respective baseline values,226 while full compared the measurements between treatment groups. Blood pressure and HR in the α-2 agonist groups were either lower than or similar to their control groups. Another group observed less frequent spikes in MAP and HR in clonidine-treated patients, but this was not statistically significant.234

    The effects of α-2 agonists on recovery profile varied. Three studies demonstrated shorter time to extubation with α-2 agonists,226,230,234 1 showed no variation compared to control patients,231 and another showed increased time to extubation.93 One series described prolonged drowsiness with dexmedetomidine,134 while another study showed no variation in sedation score compared to control patients.93 discontinuance points related to postoperative nausea/vomiting were examined in 1 observational study225 and 3 RCTs.93,226,231

    In summary, the literature on the differential outcome of α-2-agonists in patients with and without OSA is limited and results are nonuniform (Oxford LOE: 2–4). While a trend in statistical outcomes for some cardiorespiratory parameters may breathe observed, the clinical repercussion of these findings remains unknown.

    3. ANESTHESIA TECHNIQUE
  • 3.1 Question: Should regional anesthesia breathe preferred over universal anesthesia in patients with OSA?
  • 3.1 Recommendation: When applicable, regional anesthesia is preferable over universal anesthesia in patients with OSA.
  • Level of evidence: Moderate; Grade of recommendation: Strong

    Rationale

    A wide ambit of literature and earlier guidelines fill favored the employ of regional anesthesia techniques and multimodal analgesic approaches among patients with OSA despite diminutive scientific evidence to uphold this practice.8,9 To address this matter, a systematic literature search was performed to summarize evidence on preferable anesthesia techniques in patients with OSA.

    Anesthesia Technique as a Modifier of Postoperative Outcome.

    With esteem to comparative effectiveness between universal and regional anesthesia specifically in patients with OSA, 6 observational studies were identified.61,235–239 A summary of evidence is provided in Supplemental Digital Content, Table A12, http://links.lww.com/AA/C373. Overall, studies indicated that the utilization of regional as opposed to universal anesthesia would better postoperative outcome.79,235–239 The largest population-based analysis included >30,000 patients with OSA from >400 US hospitals undergoing joint arthroplasty procedures.235 Adjusted risk of numerous major complications was significantly lower in patients with OSA who received neuraxial anesthesia versus universal anesthesia. Furthermore, the addition of neuraxial to universal anesthesia versus the employ of universal anesthesia lonely was associated with improved outcome profiles. Additionally, the utilization of peripheral nerve blocks was associated with decreased odds for mechanical ventilation, captious keeping admissions, and prolonged hospital length of stay.235

    Subsequent studies236,239 confirmed the previous findings, while 1 suggested benefits with esteem to mortality.239 Notably, in a prospective analysis investigating drivers of postoperative worsening of sleep-disordered breathing, Chung et al79 demonstrated that the utilization of universal anesthesia was associated with an increased central apnea index postoperatively, while 72-hour total opioid dose was a driver of increased AHI. This finding suggests that the residual effects of universal anesthesia may influence postoperative sleep architecture and sleep-disordered breathing in OSA.

    Given the necessity of airway manipulation under universal anesthesia, other challenges inherent to OSA should breathe considered as well. The higher risk for a difficult airway in OSA has been discussed in Section 1. However, challenges with esteem to airway complications in patients with OSA issue to also extend to the time for emergence from anesthesia and the immediate postoperative period, potentially leading to the requirement of emergent airway interventions.240,241 Thus, consistent with the underlying pathogenesis of OSA, perioperative complications in these patients may breathe driven by upper airway obstruction.240,241 Recently, Ramachandran et al61 showed that OSA was an independent predictor of respiratory complications and unplanned intubation after universal anesthesia.

    Another potential hazard associated with the employ of universal anesthesia is the frequent necessity for neuromuscular blockade. As described in Section 2.1, studies imply that patients with OSA who received NMDA may breathe at increased risk for effects of residual neuromuscular blockade and respiratory failure compared to the universal population.67,242 Therefore, the employ of regional anesthesia may proffer advantages by virtue of avoiding upper airway effects, although the potential for the necessity to transmogrify to universal anesthesia should always breathe considered.

    Neural stimulation appears to breathe essential in initiating the surgical catabolic stress response,243,244 and regional anesthesia utilizing local anesthetics seems to reliably screen this effect.245 Given the evidence suggesting potential OSA-related alterations in smart perception and opioid potency due to intermittent hypoxia and sleep fragmentation, as discussed in Section 2.2, regional anesthesia confers benefits by providing efficient smart relief while reducing opioid requirement,246,247 a key factor to deem in patients with OSA.112,248

    In summary, despite the want of high-quality RCTs, some evidence suggests a higher risk of complications with universal compared to regional anesthesia in patients with OSA (Oxford LOE 2–4). Thus, regional anesthesia should breathe considered by anesthesiologists whenever feasible.

    RECOMMENDATIONS: EXECUTIVE SUMMARY
  • Patients with OSA should breathe considered at increased risk for difficult airway challenges compared to patients without OSA. This particularly applies to difficult intubation, difficult mask ventilation, or both. Data on the placement of supraglottic airway devices are scarce, but available evidence does not imply a variation between patients with and without OSA. Adequate difficult airway management precautions should breathe taken in patients with OSA.
  • Anesthetic and analgesic drugs can interact with or repercussion consciousness, sleep, upper airway anatomy and physiology, arousal responses, muscle activation, and ventilatory drive, potentially increasing perioperative risk in patients with OSA.
  • In patients with OSA, the utilization of NMBA may treat an increased risk for the effects of residual neuromuscular blockade, postoperative respiratory failure, or hypoxemia. Residual neuromuscular blockade could breathe a driver of the higher incidence of respiratory complications in OSA. While neuromuscular blocking reversal agents can abate postoperative residual paralysis and respiratory complications, current evidence does not favor any specific neuromuscular reversal agent with esteem to outcome.
  • Given the respiratory depressant effects of opioids, patients with OSA may breathe at increased risk for respiratory complications from the employ of these analgesic drugs. Furthermore, chronic intermittent hypoxia and habitual sleep fragmentation may enlarge smart perception and augment opioid potency in OSA. These factors should breathe considered when administering opioids to patients with OSA.
  • Patients with OSA receiving propofol for procedural sedation may breathe at increased risk for respiratory compromise and hypoxemic events. In the absence of certainty regarding dosing and scalar adjustments to concomitant employ of other drugs and potential concurrent obesity, the utilization of propofol sedation in OSA requires a heightened even of vigilance as well as watchful monitoring and titration to achieve desired effects.
  • There is a want of evidence on residual effects and anesthesia recovery profiles of inhalational agents and intravenous propofol specifically for the population with OSA. However, evidence in patients with obesity, a population with a towering prevalence of OSA, indicates a potential superiority of sevoflurane and desflurane compared to intravenous propofol with esteem to emergence and recovery from anesthesia. Comparing sevoflurane and desflurane, the latter has been associated with improved anesthesia recovery in patients with obesity.
  • Evidence on the repercussion of ketamine specifically in OSA is largely lacking; however, adverse events such as psychiatric effects, sympathetic system activation, and hypersalivation, as usually observed in the universal population during utilization of towering doses, likely translate to OSA as well. Notably, however, emerging evidence indicates a potentially auspicious repercussion of ketamine over other sedatives with esteem to preservation of upper airway and ventilatory function.
  • Despite the scarcity of data on the comparative effectiveness of intravenous benzodiazepine sedation among patients with and without OSA, intravenous benzodiazepines are known to and are purposefully utilized to induce upper airway collapse for diagnostic purposes of OSA. Thus, the procedure of intravenous benzodiazepine sedation may breathe associated with airway compromise in OSA.
  • The potentially auspicious respiratory profile and analgesic-sparing effects of α-2 agonists may render these drugs beneficial to the population with OSA. However, current literature on the outcome of α-2 agonists in patients with OSA is limited and provides heterogeneous results. Thus, despite the detection of trends in statistical outcomes for some cardiorespiratory parameters, the clinical relevance of these findings remains unclear.
  • Evidence on the comparative effectiveness of universal versus regional anesthesia in the context of OSA is sparse. Nevertheless, the limited evidence in patients with OSA indicates a higher risk of complications with universal compared to regional anesthesia. When feasible, regional anesthesia may treat advantages such as avoidance of upper airway effects and neuromuscular blockade, efficient smart management, reduced opioid consumption, and efficient suppression of the systemic stress response. These features may breathe of benefit to patients with OSA. Given these findings and in the absence of evidence suggesting a handicap of regional anesthesia, the utilization of these techniques should breathe considered preferable over universal anesthesia whenever feasible. A summary of evidence is provided in Supplemental Digital Content, Table A9, http://links.lww.com/AA/C373.
  • ACKNOWLEDGMENTS

    The SASM task force is divided into 9 groups addressing the questions surrounding (1) airway, (2) neuromuscular blocking agents, (3) opioids, (4) propofol, (5) inhalational agents, (6) benzodiazepines, (7) ketamine, (8) α-2 agonists, and (9) anesthesia technique. The leaders of the respective groups and its individual members were: (1) Difficult airway in OSA: Mahesh Nagappa (Leader), David T. Wong, Frances Chung, Satya Krishna Ramachandran; (2) NMBAs: Jean Wong (Leader), Frances Chung, Mandeep Singh; (3) Opioids: Crispiana Cozowicz (Leader), Anthony G. Doufas, Frances Chung, Stavros G. Memtsoudis; (4) Propofol: imprint H. Stein (Leader), Frances Chung; (5) Inhalational agents: Girish P. Joshi (Leader), Crispiana Cozowicz, Stavros G. Memtsoudis; (6) Ketamine: Meltem Yilmaz (Leader); (7) Benzodiazepines: Stavros G. Memtsoudis (Leader), Lukas Pichler, Crispiana Cozowicz; (8) α 2-agonists: Megan L. Krajewski (Leader), Satya Krishna Ramachandran, Crispiana Cozowicz; and (9) Anesthesia technique: Stavros G. Memtsoudis (Leader), Crispiana Cozowicz. They would relish to express special thanks to the following participants in alphabetical order for their significant contribution in the systematic literature search and data analysis process: Marina Englesakis, Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; Rie Goto, Kim Barrett Memorial Library, Hospital for Special Surgery, current York, NY; Bridget Jivanelli, Kim Barrett Memorial Library, Hospital for Special Surgery, current York, NY; Eva E. Mörwald, MD, Department of Anesthesiology, Perioperative Medicine and Intensive keeping Medicine, Paracelsus Medical University, Salzburg, Austria; Khawaja Rashid Hafeez, MBBS, FCPS, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Arvind Tuteja, MBBS, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Vwaire Urhuru, MD, Department of Anesthesia, captious Care, and smart Management, Beth Israel Deaconess Medical Center, Boston, MA; Sarah M. Weinstein, BA, Department of Anesthesiology, Hospital for Special Surgery, current York, NY.

    DISCLOSURES

    Name: Stavros G. Memtsoudis, MD, PhD.

    Contribution: This author helped design the study, conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: S. G. Memtsoudis is a director on the boards of the American Society of Regional Anesthesia and smart Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a 1-time consultant for Sandoz Inc and the holder of US Patent Multicatheter Infusion System US-2017-0361063. He is the owner of SGM Consulting, LLC, and co-owner of FC Monmouth, LLC. nobody of these relations influenced the conduct of the present study.

    Name: Crispiana Cozowicz, MD.

    Contribution: This author helped design the study, conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Mahesh Nagappa, MD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Jean Wong, MD, FRCPC.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: J. Wong has received research grants from Acacia Pharma.

    Name: Girish P. Joshi, MBBS, MD, FFARCSI.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: G. P. Joshi received an honorarium from Baxter Pharmaceuticals, Mallinckrodt Pharmaceuticals, Merck Pharmaceuticals, and Pacira Pharmaceuticals.

    Name: David T. Wong, MD, FRCPC.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Anthony G. Doufas, MD, PhD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Meltem Yilmaz, MD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: M. Yilmaz serves on the advisory board of VitaHEAT Medical.

    Name: imprint H. Stein, MD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Megan L. Krajewski, MD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Mandeep Singh, MBBS, MD, MSc, FRCPC.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: None.

    Name: Lukas Pichler, MD.

    Contribution: This author helped resolve the data and write the manuscript.

    Conflicts of Interest: None.

    Name: Satya Krishna Ramachandran, MD.

    Contribution: This author helped conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: S. K. Ramachandran funded research from Merck, sharp & Dohme, current Jersey.

    Name: Frances Chung, MBBS, FRCPC.

    Contribution: This author helped design the study, conduct the study, resolve the data, and write the manuscript.

    Conflicts of Interest: F. Chung received research grants from Ontario Ministry of Health and Long-Term keeping Innovation Fund, University Health Network Foundation, ResMed Foundation, Acacia Pharma, and Medtronics Inc STOP-Bang tool: proprietary to University Health Network, royalties from Up-To-Date.

    This manuscript was handled by: David Hillman, MD.

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Pharmacokinetic and pharmacodynamic interactions between opioids and propofol. J Clin Anesth. 1997;9:23S–26S. 136. Sneyd JR, Rigby-Jones AE. current drugs and technologies, intravenous anaesthesia is on the wobble (again). Br J Anaesth. 2010;105:246–254. 137. Colao J, Rodriguez-Correa D. Rapidly metabolized anesthetics: novel alternative agents for procedural sedation. J Anesth Clin Res. 2016;7:11. 138. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system prognosticate cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc. 2014;79:436–444. 139. Coté GA, Hovis RM, Ansstas MA, et al. Incidence of sedation-related complications with propofol employ during advanced endoscopic procedures. Clin Gastroenterol Hepatol. 2010;8:137–142. 140. Friedrich-Rust M, Welte M, Welte C, et al. Capnographic monitoring of propofol-based sedation during colonoscopy. Endoscopy. 2014;46:236–244. 141. 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Ibraheim O, Alshaer A, Mazen K, et al. outcome of bispectral index (BIS) monitoring on postoperative recovery and sevoflurane consumption among morbidly obese patients undergoing laparoscopic gastric banding. Middle East J Anaesthesiol. 2008;19:819–830. 173. Freo U, Carron M, Innocente F, Foletto M, Nitti D, Ori C. Effects of A-line Autoregression Index (AAI) monitoring on recovery after sevoflurane anesthesia for bariatric surgery. Obes Surg. 2011;21:850–857. 174. McKay RE, Malhotra A, Cakmakkaya OS, Hall KT, McKay WR, Apfel CC. outcome of increased carcass mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. Br J Anaesth. 2010;104:175–182. 175. Eger EI 2nd, Shafer S. The complexity of recovery from anesthesia. J Clin Anesth. 2005;17:411–412. 176. Ebert TJ, Robinson BJ, Uhrich TD, Mackenthun A, Pichotta PJ. Recovery from sevoflurane anesthesia: a comparison to isoflurane and propofol anesthesia. 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Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW. Anesthetic considerations for bariatric surgery. Anesth Analg. 2002;95:1793–1805. 183. Eger EI 2nd.. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001;93:947–953. 184. Juvin P, Marmuse JP, Delerme S, et al. Post-operative course after conventional or laparoscopic gastroplasty in morbidly obese patients. Eur J Anaesthesiol. 1999;16:400–403. 185. Katznelson R, Naughton F, Friedman Z, et al. Increased lung clearance of isoflurane shortens emergence in obesity: a prospective randomized-controlled trial. Acta Anaesthesiol Scand. 2011;55:995–1001. 186. De Kock M, Lavand’homme P, Waterloos H. Balanced analgesia” in the perioperative period: is there a location for ketamine? Pain. 2001;92:373–380. 187. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev. 2006:CD004603. 188. 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Intravenous sub-anesthetic ketamine for perioperative analgesia. J Anaesthesiol Clin Pharmacol. 2016;32:160–167. 194. De Oliveira GS Jr, Fitzgerald PC, Hansen N, Ahmad S, McCarthy RJ. The outcome of ketamine on hypoventilation during deep sedation with midazolam and propofol: a randomised, double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2014;31:654–662. 195. Taylor DM, Bell A, Holdgate A, et al. Risk factors for sedation-related events during procedural sedation in the emergency department. Emerg Med Australas. 2011;23:466–473. 196. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663–667. 197. Eikermann M, Grosse-Sundrup M, Zaremba S, et al. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116:35–46. 198. Abdullah VJ, Lee DL, Ha SC, van Hasselt CA. Sleep endoscopy with midazolam: sedation even evaluation with bispectral analysis. Otolaryngol Head Neck Surg. 2013;148:331–337. 199. Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008;265:1397–1402. 200. Bachar G, Nageris B, Feinmesser R, et al. Novel grading system for quantifying upper-airway obstruction on sleep endoscopy. Lung. 2012;190:313–318. 201. Carrasco Llatas M, Agostini Porras G, Cuesta González MT, et al. Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography. Eur Arch Otorhinolaryngol. 2014;271:181–187. 202. De Corsa E, Fiorita A, Rizzotto G, et al. The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: their personal experience. Acta Otorhinolaryngol Ital. 2013;33:405–413. 203. Gregório MG, Jacomelli M, Figueiredo AC, Cahali MB, Pedreira WL Jr, Lorenzi Filho G. Evaluation of airway obstruction by nasopharyngoscopy: comparison of the Müller maneuver versus induced sleep. Braz J Otorhinolaryngol. 2007;73:618–622. 204. Hamans E, Meeus O, Boudewyns A, Saldien V, Verbraecken J, Van de Heyning P. Outcome of sleep endoscopy in obstructive sleep apnoea: the Antwerp experience. B-ENT. 2010;6:97–103. 205. Hessel NS, de Vries N. Diagnostic work-up of socially unacceptable snoring: II. Sleep endoscopy. Eur Arch Otorhinolaryngol. 2002;259:158–161. 206. Iwanaga K, Hasegawa K, Shibata N, et al. Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep. Acta Oto laryngol Suppl. 2003;550:36–40. 207. Koo SK, Choi JW, Myung NS, Lee HJ, Kim YJ, Kim YJ. Analysis of obstruction site in obstructive sleep apnea syndrome patients by drug induced sleep endoscopy. Am J Otolaryngol. 2013;34:626–630. 208. Ravesloot MJ, de Vries N. 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    Raspberry Pi and Windows 10 IoT Core: A Huge Letdown | killexams.com real questions and Pass4sure dumps

    Last Spring, Microsoft unveiled their procedure for Windows and the Internet of Things. It starts with the Raspberry Pi and Windows 10 IoT Core – a stripped down system with Windows API calls running on an ARM architecture. Yes, Microsoft is finally pathetic away from the desktop, edifice a platform for a billion Internet of Things things, or filling the gap left by tens of thousands of POS terminals and ATMs running XP being taken offline. Either one is accurate.

    Earlier this week, Microsoft announced the first public release of Windows 10 IoT Core. This is the review, but here’s the takeaway: run. elope as relish a shimmer as you can away from Windows IoT. It’s not worth your time unless you fill a burning desire to write apps for Windows, and even then you could conclude a better job with less worry with any Linux distro.

    When Windows 10 IoT was first announced, there was much hope for a Windows RT-like experience. Being able to elope real Windows applications on a Raspberry Pi would breathe a killer feature, and putting Skype on a Pi would imply real Jetsons-style video phones appearing in short order.

    Windows 10 IoT core isn’t so much an operating system, as it is a device that will elope apps written with Windows APIs: there is no shell. If you want to control dozens or hundreds of devices, each running a program written in Visual Basic, JavaScript, C#, or Python, this is for you.

    devicemanagerThe majority of interaction with Windows 10 IoT Core is over the web. After booting and pointing a browser to the Pi, you’re presented with a rather complete web-based interface. Here, you can check out what devices are connected to the Pi, gape at the running processes, and elope current apps. assume of this feature as a web-based Windows control panel.

    While Windows 10 IoT uses the HDMI output on the Pi, this is merely informational, the video output capabilities of the Pi reserved for application-specific displays – digital signage, POS terminals and ATMs are where Windows 10 IoT Core excels. For general-purpose computing, you’re better off looking elsewhere.

    Installing

    Officially, the only pass to install Windows 10 IoT Core is with a computer running Windows 10. There are a few ways around this is with the ffu2img project on GitHub. This Python script takes the special Microsoft .FFU image file format and turns it into an .IMG file that can breathe used with dd under *nix and Win32DiskImager on Windows.

    Yes, Windows 10 is free for everyone with a relatively modern Windows box, but since the only requirement for running Windows 10 IoT core is putting an image on an SD card and monitoring a swarm of IoT Core devices, there is no judgement why this OS can’t breathe supplied in an .IMG file.

    After putting the image on an SD card, installing Windows 10 IoT Core is as simple as any other Raspi distro: shove the card in the Pi, connect an Ethernet cable, and give it some power. No, you don’t necessity a keyboard or mouse; there’s very diminutive you can actually conclude with the Pi. In fact, the only thing that is displayed through the Pi’s HDMI port is a screen giving you the IP address and what USB devices are attached.

    PiWinThe totality of the Windows 10 IoT Core experience

    You conclude rep a few options for language and network settings, and there are a few tutorials and examples – connecting to Visual Studio and blinking an LED – but that’s it. The groundwork user experience of Windows 10 IoT Core is just network information, a device name, and a picture of a Raspberry Pi.

    There are a few shortcomings of the Windows 10 IoT core for the Raspberry Pi. Officially, the only supported WiFi module is the official Raspberry Pi WiFi module with a BCM43143 chipset. By far, the most celebrated WiFi module used for the Raspberry Pi (and something you should always carry around in your go-bag) is the Edimax EW-7811Un, a tiny WiFi module that uses a Realtek chipset. Odds are, if you fill a Raspberry Pi 2, that WiFi module you picked up won’t work. Common sense would ordain that you could install the Windows driver for the Realtek chipset, but this is not the case; no Windows driver will ever work with Windows 10 IoT core. Even devices from the Raspberry Pi foundation, relish the Raspberry Pi camera, are not supported by IoT core

    If you’ve ever wanted clearer evidence the Windows 10 IoT core is not meant to breathe an extensible system relish every other Linux-based sole board computer, you necessity only gape a diminutive deeper. Digital audio is completely ignored, and pins 8 and 10 – normally reserved for a 3.3V UART on every other Raspberry Pi distribution – are reserved pins. Microsoft managed to invent a sole board computer without a hardware UART.

    Fortunately, some of these problems are temporary. A representative from the Windows On Devices team told us more WiFi dongles will breathe supported in the future; the only driver they were able to bring up in time is the official dongle from the Raspberry Pi foundation. A similar situation of engineering tradeoffs is the judgement for the want of UART support.

    Who is this for, exactly?

    The concept that Microsoft would outcome out a non-operating system without uphold for the de facto yardstick WiFi adapter, a hardware UART, or drivers for the majority of peripherals is one thing. Selling this to the ‘maker movement’ strains credulity. There is another explanation.

    CorewatcherThe Windows 10 IoT Core Watcher, the remote admin app for multitudes of Pis.

    Let’s fade over once again what Windows 10 IoT Core actually is. By design, you can write programs in Visual Studio and upload them to one or many devices running IoT core. These programs can fill a familiar-looking GUI, and are actually pretty smooth to build given 20+ years of Windows framework development. This is not a device for makers, this is a device for point of sale terminals and ATMs. Windows XP – the operating system that is still deployed on a frighting number of ATMs – is going away soon, and this is Microsoft’s attempt to reclaim their partake of that market. IoT Core isn’t for you, it isn’t for me, and it isn’t for the 9-year-old that wants to wink an LED. This is an OS for companies that necessity to replace thousands of systems still running XP Embedded and necessity Windows APIs in kiosks and terminals.

    Save your SD card

    For anyone with a Raspberry Pi 2 and an SD card, the only investment you’ll invent in trying out Windows 10 IoT Core is your time. It’s not worth it.

    While Windows 10 IoT Core is much for any company that has a lot of Visual Basic and other engineering debt, it’s not meant for hackers, makers, or anyone edifice something new. For that, there are dozens of choices if you want an Internet-connected box that can breathe programmed and updated remotely. The Cloud9 IDE for the Pi and BeagleBone allow you to write code on sole board computers without forcing you to install Visual Studio, and Linux is king for managing dozens or hundreds of boxes over the Internet.

    This is not an OS that replaces everything out there. A Linux system will almost always fill better hardware support, and this is especially accurate on embedded devices. Windows 10 IoT Core is a beginning, and should breathe viewed as such. It’s there for those who want it, but for everyone else any one of a dozen Linux distributions will breathe better.


    The Charter on Professionalism for Health keeping Organizations | killexams.com real questions and Pass4sure dumps

    Professionalism may not breathe enough to drive the profound and far-reaching changes needed in the health keeping system, but without it, the health keeping enterprise is lost.

    — Lesser et al1

    The concept of professionalism for health keeping providers and organizations can proffer guidance for decision making in a fiscally difficult, rapidly changing, and ethically challenging environment. Professionalism is based on a specific set of principles and commitments that provide an orientation to the thoughts and actions of a given profession. These principles for physicians were enunciated in the Physician Charter on Medical Professionalism 13 years ago.2 That charter has been widely accepted by physicians, but its repercussion on the attribute of health keeping and patient experience is increasingly recognized as intertwined with the professionalism of health keeping organizations.1,3

    Indeed, structural factors in the health keeping system may impede physicians from animate up to the charter.4 Health keeping is now a three-trillion-dollar industry,5 with an estimated one-third of full spending being deemed “systematic waste,” including unnecessary and possibly harmful care.6 Hospitals and health keeping systems are focused necessarily on their own financial health during a time of major reform in keeping delivery and payment models; but at the identical time, they can ensure the primacy of their missions, ethical and efficient operations, and patient and provider welfare. Professional ideology recognizes a towering priority for useful and needed work and its gregarious benefits. It does not avoid economic rewards. It simply requires that these rewards breathe acquired with confiscate attention to professional service and gregarious responsibility.

    Health keeping systems increasingly ordain the practices of health keeping professionals, for better or worse, as an increasing number of physicians are employed by hospitals and hospital systems.7 As such, health keeping organizations fill an opening to positively and negatively influence the behavior of their employees and affiliated physicians. Most members of the health keeping team are motivated to conclude the perquisite thing. There are, however, many opportunities for health keeping providers and organizations to engage in activities that are not in concordance with the principles of medical professionalism.

    This Perspective includes a Charter on Professionalism for Health keeping Organizations (referred to as the “Charter”; espy Appendix 1) with the even of stimulating health keeping leaders, health professionals, policy stakeholders, and society to evaluate their current and preferred ways of operating, to ensure best practices in providing health keeping and improving health. They also narrate the identification and resolution of a number of issues that arose during the creation of the Charter. These involve the rationale for a charter for organizational professionalism; the charter process, goals, domains, and obstacles; and finally, what they hope the Charter will accomplish. Their Perspective is offered by a subset of the Charter authors to provide its gregarious context. It represents the ideas of the authors, not their institutions or the organizations that sponsored the Charter project.

    Why a Charter on Organizational Professionalism?

    A charter is a reflection of values and can breathe efficient in bringing about positive changes in a target audience. Evidence indicates that such a document can stimulate conversation and affirmation of the stated values. For example, since its publication in 2002, the Physician Charter on Medical Professionalism has been endorsed by over 130 organizations,8 and the number of related professionalism articles has quadrupled to over 600 annually.9 A charter or mission statement that incorporates social, ethical, or societal goals can also positively influence organizational success. Kanter’s10 research on financially successful companies revealed that an expressed commitment to gregarious responsibility creates a buffer against uncertainty, evokes positive emotions, and stimulates motivation among employees. Along similar lines, Paine11 argues that companies reap financial rewards when their programs feature such elements as community involvement and ethics. These views are supported by the growing list of companies seeking B company certification, which attests to a company’s commitment to society and the environment.12 Additionally, Nielsen’s 2014 survey of 30,000 consumers institute that 55% of respondents were willing to pay extra for products and services provided by companies committed to positive gregarious and environmental issues.13

    For these reasons and others discussed later in this article, members of the health keeping professions, patients, and representatives from hospitals and health keeping systems fill collaborated to create a charter that outlines behaviors that uphold an organizational culture of professionalism. The Charter on Professionalism for Health keeping Organizations is aspirational, supports a learning health system, and places the patient first. It seeks to ensure that the concept of fiduciary responsibility of health keeping organizations is broadened to involve not only the financial health of the organizations but also the health of the patients, the well-being of the organizations’ employees, and a responsibility to the community.

    Charter Process

    The Organizational Professionalism Charter Project was funded by grants from the Commonwealth Fund, the American Board of Internal Medicine Foundation, North Shore Long Island Jewish Health System, the Federation of American Hospitals, and the American Hospital Association. The authors of the original organizational professionalism publication3 and representatives of the grantors formed a Steering Committee to direct the project. The Steering Committee nominated individuals for the Writing Group who were approved by consensus and created the Charter. These writers represented a variety of disciplines, points of view, and stakeholders in health care. They included nurses, health system leaders, medical ethicists, and consumer advocates. Although some participants felt that they were to portray the organization that nominated them, the Charter was not subject to approval by any grantor or organization. Over a term of almost two years, the Writing Group met twice in person, first to decide what domains were well-known to address and that it would invent decisions by consensus, and then to procedure the writing of the Charter. The Writing Group refined the document by conference calls and e-mail. As might breathe expected from such a diverse group, compromise was well-known for the final Charter to breathe approved by consensus. The issues that required the most vigorous discussions were whether health keeping is a “right,” whether to stipulate a specific percentage of margin that a health keeping organization ought to recur to the community, and the responsibility of health keeping organizations to address the gregarious determinants of health.

    Charter Goals

    The purpose of the Charter is to narrate professionalism behaviors to which for-profit and not-for-profit hospitals and hospital systems may aspire. As the work unfolded, the Writing Group recognized that the principles were relevant to any health keeping organization. This article describes the evidence-based rationales for the behaviors of hospitals and hospital systems implied by these principles.

    No organization can fully embody full of these behaviors. However, if they partake the values elaborated in the Charter’s preamble, they may identify activities described in the subsequent domain sections that align with their strategic initiatives. They proffer evidence that implementing these behaviors would better health keeping as well as the experience of working or being cared for within health keeping organizations. Engaging outside partners—the community, government, and other organizations—creates the potential to influence population health, because partnerships among these are essential for addressing the gregarious determinants of health.

    At times, different sections of the Charter will imply competing actions. For example, touchstones of the Charter are to prioritize the health of individual patients and to better the health of the community. However, being a steward of limited resources may contest with optimizing the health of each individual patient. Organizations may ethically rob different actions based on their different missions and cultural values.14 Transparent discussions that involve patients and local communities will themselves fill gregarious benefit, because they may serve health keeping organizations pick paths that reflect both organizational and local values. However, when ethical dilemmas arise from conflicts between an organization’s self-interest and those of the community or patient, the community or patient interest takes precedence. While this premise of the Charter may look controversial, it is central to its content, consistent with the seminal Physician Charter on Medical Professionalism,2 and the source of its greatest potential gregarious benefit.

    Charter Domains

    The discussion in the following domain sections provides the rationale and evidence to uphold the commitments requested in the Charter.

    Patient partnerships

    In 2001, the IOM report Crossing the attribute Chasm: A current Health System for the 21st Century created a sense of urgency for reinventing a health keeping system built around six aims for improvement considered essential for better meeting patient-family needs.15 Among these six aims is patient-centered care, defined as “providing keeping that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide full clinical decisions.”15 It requires collaboration among health keeping teams and efficient partnerships with patients, families, and other caregivers.16,17 Successful navigation from the traditional “doctor knows best” approach to one that engages patients and families to participate in their keeping and decision making is contingent on a culture of organizational leadership that values multidirectional collaboration and communication.17

    The foundational characteristics of this vision for health keeping transformation are well aligned with the precepts of professionalism. Over time, organizations that integrate person-centric principles can experience greater patient trust and loyalty and teams that duty in a more coordinated manner.18 efficient assignation with patients and families can fill a measurable repercussion on organizational improvement and has been cited as having the greatest potential for sustaining long-term system-wide transformation.19 Health systems and organizations that intentionally invite patients and families to participate in rounds, committees, and advisory panels and to partake their stories in the boardroom fill accelerated improvements in the attribute of keeping they provide.20

    In the eventual decade, many factors fill influenced the expectation that patients and families rob an active role in decisions that repercussion their health and health care,21 and studies demonstrate that this rehearse benefits full involved.22–24

    Executive leadership is essential for achieving the cultural transformation needed to uphold genuine partnerships with patients and families throughout their organizations.25 Leadership that is engaged and provides the resources needed to sustain strategies for patient-family input is captious for successful adoption of these practices. Organizations and systems that uphold patient partnerships as an integrated core value will exemplify professionalism and stand apart from others.20

    This domain is aligned with Medicare’s adoption of measures of patient experience measures as an well-known ingredient of value, and thus payment. Although the exact measures of patient experience and assignation remain controversial, the expectation of patient- and family-centeredness as a core value of health keeping organizations is here to stay.26

    Organizational culture

    Successful transformation of health keeping systems will likely depend more on the gregarious capital of organizations than their financial capital.27 While many professional entities provide guidelines for the behavior of individuals within their disciplines, it is the responsibility of leadership to narrate a health keeping organization’s desired culture, articulate its rationale, and create the structures that uphold it and ensure accountability. With this guidance, organizational culture is cocreated by patients, nonemployed workers, employees, and leadership. trust in leadership requires that management behavior breathe consistent with the organizational mission, professional values, and expectations of employees.28 That trust in turn empowers individuals to propagate consonant behaviors into the various units where they work. Organizational culture is thus viewed as a involved adaptive system composed of interrelated microcultures.

    There is increasing evidence of relationships between the culture of senior management,29 organizational culture,30 and the performance of health keeping organizations. Organizational leadership style influences both physician31 and nurse satisfaction and burnout.32 Although physician burnout has not been consistently tied to the attribute of care,33 nurse burnout has.34 Physician well-being is correlated with lower rates of turnover and can breathe improved through focused organizational interventions.35 A Rand study on physician well-being concluded that “the identical considerations that apply outside medicine—for example, honest treatment; responsive leadership; attention to work quantity, content, and pace—can serve as targets for policymakers and health delivery systems that hunt to better physician professional satisfaction.”36 Achieving the “triple aim” may indeed require incorporating “care of the provider” into a “quadruple aim.”37 A healing environment can best breathe achieved when full those in the organization are afforded the identical value and respect that clinicians aspire to give to patients. This requires soliciting, respecting, and incorporating the perspectives of employees.

    High-value, cost-conscious rehearse also depends on interprofessional collaboration.38 Validated measures of team cohesion fill been developed,39 and numerous studies demonstrate that better teamwork is correlated with better patient outcomes, patient satisfaction, organizational efficiency, patient engagement, and worker satisfaction.40 Studies are dawn to emerge that test whether interventions to better teamwork also better clinical outcomes, though more research is needed.41,42

    Community partnerships

    Traditional clinical services account for only 10% to 20% of a population’s health, and genetics account for 20% to 30%.43,44 Spurred by well-articulated missions to create wholesome communities, model health keeping organizations fill sought to address the remaining 50% to 70%—the so-called gregarious determinants of health—in moneyed strategic partnerships with the communities they serve.45 The health of the U.S. population has improved significantly during the eventual century; however, many high-risk communities fill not shared in the gains achieved by traditional health promotion strategies. There is growing recognition that promoting the health of populations requires a systems approach to understanding and addressing the gregarious and environmental factors that can protect or undermine health.46

    As awareness of the import of addressing “health” as a broader construct has grown, so too has awareness of the import of health keeping organizations joining together—in full partnership with each other and the communities they serve—to define barriers to health and health care, design interventions, maximize the value of investments, and implement current strategies together to better a community’s health.47 Partnerships of this type require skill, collaboration, and a even of trust that has not previously existed among most health keeping organizations and the communities they serve. Still, several notable examples fill emerged.48 The Affordable keeping Act includes the requirement that nonprofit health keeping organizations demonstrate their “community benefit” beyond the accustomed charity keeping to involve community health assessments, planning, implementation, and evaluation.49 The expectation is that health keeping organizations will provide “a wide ambit of services and activities that focus on improving health status and attribute of life in local communities.”50

    In tandem with the mission to create wholesome communities, model health keeping organizations recognize that shifts in public policy toward population and outcomes-based reimbursement invent effectively addressing the gregarious determinants of health mission captious to fiscal sustainability in a post-fee-for-service future.51,52 In this way, the long-term health of model health keeping organizations and the communities they serve are inextricably intertwined and must breathe addressed in real partnerships where this reality is embraced by all.

    Operations and business practices

    In recent years, a vision for a health keeping system that continuously learns and improves has evolved.53,54 Efforts to enhance ethical behavior in health keeping organizations result in best operational and business practices and in real benefits for patients.55 Furthermore, Tsai and colleagues56 institute that hospitals that rank towering on the employ of efficient management practices provide a higher attribute of keeping than lower-ranking hospitals, and hospital management’s employ of such practices is associated with a high-performing board of trustees.

    Paine57 argues that increasingly, companies are launching ethics programs, values initiatives, and community involvement activities premised on management’s credence that “ethics pays.” In health care, this concept goes well beyond the economic value of branding and includes efforts at cost control, service attribute improvement, patient and staff safety, risk management, innovation, reputation, loyalty, and satisfaction for both patients and providers.

    Bart and Tabone58 institute an well-known relationship between nonprofit hospital leadership satisfaction with mission statement and their organization’s performance. Their primary finding was that leaders conclude in fact discriminate and differentiate in the wording of mission statements, which in turn influences organizational behavior and performance. Of distinct import is a commitment to service quality, patient welfare, and satisfaction. Components typically not included in the mission are financial goals and competitive strategies. Ethical guidance in the configuration of mission statements are valuable tools for health systems to employ to better organizational performance and enlarge employee motivation.59

    Holy Cross Hospital System (HCHS) of South Bend, Indiana, provides an instance of a successful organizational program to ensure that HCHS’s organizational structure and performance were value based and mission driven.60 HCHS developed 11 mission standards, created opportunities for ownership, and fostered personal responsibility within the system to ensure the fulfillment of its mission. This process of mission discernment is expanded on by Gallagher and Goodstein54 and represents an ethically grounded and practical process to ensure the moral integrity of an organization. The key operational values of the HCHS mission statement were faith, service, excellence, empowerment, and stewardship. The core values that drove the discussion and development of its mission were gregarious justice and human dignity. financial and legal issues were considered, but this was proportionate to core service commitments to the poverty-stricken and vulnerable. As a result of sound moral grounding through its mission statement, HCHS was able to clarify choices among competing goals for the organization and find compromise for stakeholders both internal and external to the organization.

    At the Harvard Vanguard Kenmore Medical Associates practice, where previous attribute improvement efforts had been associated with deteriorating morale, leadership implemented specific relationship-centered practices which defused pent-up arouse and frustration in the staff, decreased isolation, built teamwork, and facilitated significant attribute improvement.61 They created an environment in which each clinician and staff person was treated with dignity, involved in identifying and solving quality-of-care issues, and incorporated into a systematic approach to continuous improvement. This facilitated the adoption of process improvement techniques pioneered by Toyota Production Systems, while at the identical time improving morale.

    Ethics guidance that is formalized in codes and organizational mission statements promotes ethical discourse and deliberation around institutional integrity and responsibility, and influences organizational behavior in meeting those goals.

    Charter Obstacles

    The Charter is aspirational; it is meant to narrate the behavior of a “model organization.” Many of its challenges are cultural, requiring both organizational leaders and employees to alter their historical views of their organizations and their roles within them. Traditionally, health keeping institutions fill been hierarchical and physician focused. And despite recent financial, structural, and operational changes, health keeping institutions fill not fundamentally altered the relationship between leadership and employees. Some individuals may breathe challenged by the more dynamic, open dialogue between leadership and the full spectrum of professions, employed nonprofessionals, and patients as described in the Charter. In addition, the Charter reminds full those individuals to focus on the ultimate goal of medicine, healing the patient. While the pace of work can invent each task look an discontinuance in itself, mindfulness of the larger institutional mission and each individual’s role within it can impart a sense of purpose to every job and signification to each activity.

    Another challenge is altering the gregarious determinants of health. The ecology of these determinants is involved and not fully understood. Nor is any gregarious structure in a position to influence full the influences on these determinants. The Charter does not imply that health keeping organizations are solely liable for improving the gregarious determinants of health but, rather, suggests that they hunt strategic partnerships with other organizations, government, and local communities, consistent with their means and their unique missions, in order to better the health of the community.

    What They Want to Accomplish

    This Charter complements existing treatises on professionalism, creating a document directed at health organizations and systems rather than a group of individuals. The Charter defines the professional competencies and behaviors that organizations can leverage to create an environment that promotes professional behavior throughout the organization. Developed by administrators, physicians, nurses, and patients, the Charter is a multidisciplinary worry that melds the aspirations of full involved to provide such an outcome.

    We wish to ensure that this is a animate document similar to the Physician Charter on Medical Professionalism and will rob lessons erudite from the process employed with that charter. The task of accomplishing this will rest with a representative multidisciplinary committee. The committee will hunt opportunities to publicize the document in professional and trade journals as well as opportunities to present the Charter at professional meetings. The Charter will reside on the Web site of the Foundation for Medical Excellence (www.tfme.org). A list of health keeping systems, professional organizations, and hospitals that endorse this Charter will breathe listed. A nonmonetary annual prize will breathe awarded to the most influential rehearse resulting from such commitments. They foresee a time when the Charter could breathe incorporated into criteria for acknowledging excellence in health keeping organizations by certifying organizations. Further, they will demand for feedback so that the document can breathe modified in the future as needed to accommodate to the dynamically changing world of health keeping delivery.

    References 1. Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304:2732–2737. 2. American Board of Internal Medicine (ABIM) Foundation; American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Foundation; European Federation of Internal Medicine. Medical professionalism in the current millennium: A physician charter. Ann Intern Med. 2002;136:243–246. 3. Egener B, McDonald W, Rosof B, Gullen D. Perspective: Organizational professionalism: relevant competencies and behaviors. Acad Med. 2012;87:668–674. 4. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007;147:795–802. 5. Martin AB, Hartman M, Benson J, Catlin A; National Health Expenditure Accounts Team. National health spending in 2014: Faster growth driven by coverage expansion and prescription drug spending. Health Aff (Millwood). 2016;35:150–160. 6. Fineberg HV. Shattuck lecture. A successful and sustainable health system—How to rep there from here. N Engl J Med. 2012;366:1020–1027. 7. Singleton T, Miller P. The physician employment trend: What you necessity to know. Fam Pract Manag. 2015;22:11–15. 10. Kanter RM. How much companies assume differently. Harv Bus Rev. 2011;89:66–78. 11. Paine LS. Does ethics pay? Bus Ethics Q. 2000;10:319–330. 14. Tilburt JC. Addressing dual agency: Getting specific about the expectations of professionalism. Am J Bioeth. 2014;14:29–36. 15. Institute of Medicine. Crossing the attribute Chasm: A current Health System for the 21st Century. 2001.Washington, DC: National Academy Press. 17. Mechanic D. Managed keeping and the imperative for a current professional ethic. Health Aff (Millwood). 2000;19:100–111. 18. Anderson D. Competing on professionalism: Integrating patient keeping principles core values can boost performance. Trustee. 2014;67:1–4. 19. Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. 2008.2nd ed. Cambridge, MA: Institute for Healthcare Improvement. 20. Wynn JD. The transforming power of patient advisors. N C Med J. 2015;76:171–173. 21. Wolff JL, Boyd CM. A gape at person- and family-centered keeping among older adults: Results from a national survey [corrected]. J Gen Intern Med. 2015;30:1497–1504. 22. Oshima Lee E, Emanuel EJ. Shared decision making to better keeping and reduce costs. N Engl J Med. 2013;368:6–8. 23. Stacey D, Bennett CL, Barry MJ, et al. decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;10:CD001431. 24. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital keeping in the United States. N Engl J Med. 2008;359:1921–1931. 25. Taylor J, Rutherford P. The pursuit of genuine partnerships with patients and family members: The challenge and opening for executive leaders. Front Health Serv Manage. 2010;26:3–14. 27. Lee TH, Campion EW, Morrissey S, Drazen JM. Leading the transformation of healthcare delivery—The launch of NEJM Catalyst. N Engl J Med. 2015;373:2468–2469. 29. Davies HT, Mannion R, Jacobs R, Powell AE, Marshall MN. Exploring the relationship between senior management team culture and hospital performance. Med keeping Res Rev. 2007;64:46–65. 30. Jacobs R, Mannion R, Davies HT, Harrison S, Konteh F, Walshe K. The relationship between organizational culture and performance in acute hospitals. Soc Sci Med. 2013;76:115–125. 31. Shanafelt TD, Gorringe G, Menaker R, et al. repercussion of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432–440. 32. Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and attribute of care: Cross-national investigation in six countries. Res Nurs Health. 2010;33:288–298. 33. Linzer M, Manwell LB, Williams ES, et al; MEMO (Minimizing Error, Maximizing Outcome) Investigators. Working conditions in primary care: Physician reactions and keeping quality. Ann Intern Med. 2009;151:28–36, W6. 34. Spence Laschinger HK, Leiter MP. The repercussion of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. J Nurs Adm. 2006;36:259–267. 35. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary keeping physicians. JAMA. 2009;302:1284–1293. 36. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. 2013.Santa Monica, CA: RAND Corporation. 37. Bodenheimer T, Sinsky C. From triple to quadruple aim: keeping of the patient requires keeping of the provider. Ann Fam Med. 2014;12:573–576. 38. Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: A systematic review. JAMA. 2015;314:2384–2400. 39. Institute of Medicine. Measuring the repercussion of Interprofessional Education on Collaborative rehearse and Patient Outcomes. 2015.Washington, DC: National Academy Press. 40. Gittell JH. Kim C, Gretchen S. current directions for relational coordination theory. In: Oxford Handbook of Positive Organizational Scholarship. 2011: London, UK: Oxford University Press; Chapter 30. 41. Cameron K, Mora C, Leutscher T, Calarco M. Effects of positive practices on organizational effectiveness. J Appl Behav Sci. 2011;47:266–284. 42. De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation. 2013;84:1192–1196. 45. Schlesinger M, Gray B, Carrino G, et al. A broader vision for managed care, allotment 2: A typology of community benefits. Health Aff (Millwood). 1998;17:26–49. 46. Lavizzo-Mourey R. Why they necessity to build a culture of health in the United States. Acad Med. 2015;90:846–848. 47. Westfall JM, Fagnan LJ, Handley M, et al. Practice-based research is community engagement. J Am Board Fam Med. 2009;22:423–427. 52. Jacobson RM, Isham GJ, Finney Rutten LJ. Population health as a means for health keeping organizations to deliver value. Mayo Clin Proc. 2015;90:1465–1470. http://dx.doi.org/10.1016/j.mayocp.2015.07.010. Accessed November 23, 2016. 53. Institute of Medicine (IOM). Best keeping at Lower Cost: The Path to Continuously Learning Health keeping in America. 2012.Washington, DC: National Academies Press. 54. Gallagher JA, Goodstein J. Fulfilling institutional responsibilities in health care: Organizational ethics and the role of mission discernment. Bus Ethics Q. 2002;12:433–450. 55. Carter K, Dorgan S, Layton D. Why Hospital Management Matters. 2012.Washington, DC: McKinsey & Company. 56. Tsai TC, Jha AK, Gawande AA, Huckman RS, bloom N, Sadun R. Hospital board and management practices are strongly related to hospital performance on clinical attribute metrics. Health Aff (Millwood). 2015;34:1304–1311. 57. Paine LS. Does ethics pay? Bus Ethics Q. 2000;10:319–330. 58. Bart CK, Tabone JC. Mission statement content and hospital performance in the Canadian not-for-profit health keeping sector. Health keeping Manage Rev. 1999;24:18–29. 59. Forehand A. Mission and organizational performance in the healthcare industry. J Healthc Manag. 2000;45:267–277. 60. Vandenberg P, award MK. The necessity of mission integration. A system develops processes to weave values into the life of the organization. Health Prog. 1992;73:32–35. 61. Neuwirth A. Suchman A, Sluyter DJ. The Harvard Vanguard Kenmore rehearse experience: A focus on human development and relationship building. In: Leading Change in Healthcare. 2011: London, UK: Radcliffe Publishing; Chapter 12. Appendix 1 Charter on Professionalism for Health keeping Organizations Preamble

    This document is intended to articulate a set of principles and behaviors for health keeping organizations that aspire to foster professionalism, to encourage the pursuit of excellence by full employees, and to achieve outstanding health keeping with the broader community. The document is structured as a set of expectations as to how model health keeping organizations should breathe led and managed. It is aspirational and supports a health system that is dynamic and constantly trying to improve.

    A key tenet of this document is that health keeping organizations fill been gradually evolving so that the activities of model health keeping organizations should fade beyond trying to treat disease and restore health. The work of model health keeping organizations should involve health promotion, disease prevention, value-driven care, interdisciplinary collaboration, and community involvement, full within a fiscally liable environment.

    This evolution of the health keeping environment has and will continue to create challenges for full of the traditional professions that operate within health keeping organizations. As increasing numbers of the members of these professions are employed by and duty within these organizations, the organizations will fill further opportunities to profoundly influence the professional behaviors of those individuals in both positive and negative ways. Organizational behaviors conclude more than create an environment that influences the professionalism of those within it. They fill a powerful influence on the environment beyond their walls: They interact with other organizations that influence health and can directly repercussion the gregarious determinants of health in ways that individual professionals or health keeping professional membership organizations cannot.

    This Charter was created to serve meet these challenges. There are four themes or concepts that apply to full health keeping organizations’ activities. First, model health keeping organizations necessity to emphasize the primacy of obligations to patients and ensure that full members of the organization reflect this priority in their day-to-day work. Second, model health keeping organizations promote the goal of broad access to health care. Third, model health keeping organizations are much stewards of resources invested in health care. Finally, model health keeping organizations are learning organizations. The organization continually transforms itself to achieve its core mission better and to rob on current roles as the health system evolves.

    Patient Partnerships

    The primary focus of health keeping organizations is the keeping and well-being of patients. Model organizations colleague with patients to ensure a patient-centered approach that supports the health of the gross person, not just the treatment of disease.

    Commitment to engagement

    Model organizations invite active participation of patients and their formal and informal keeping partners in full relevant aspects of care. These partnerships uphold keeping that is respectful of and responsive to an individual’s priorities, goals, needs, and values. Utilizing communication strategies that engender trust, model organizations foster an outcomes-based approach to health that goes beyond delivery and receipt of health care.

    Commitment to shared decision making

    Together, patients and their keeping partners clarify and evaluate full keeping options and the best available evidence to pick a course of keeping consistent with the patient’s personal values and preferences. Organizational professionalism ensures that the culture, environment, and infrastructure uphold the communication and literacy needs of full involved in the decision-making process.

    Commitment to collaboration, continuity, and coordination

    Model organizations foster efficient team-based keeping and uphold the role of patients as members of teams. In collaboration with patients and their formal and informal keeping partners, model organizations ensure safe and efficient team transitions across settings and time to uphold a “one patient, one team” model of care.

    Commitment to measure what matters to patients

    In partnership with patients, model organizations identify outcomes of interest to patients and employ patient-reported and -generated data to monitor progress and performance on those outcomes. Model organizations establish methods to uphold their continuous learning from these data. They provide meaningful feedback to patients and their keeping partners related to these data and the learning from it.

    Organizational Culture

    Organizational culture is the set of beliefs and practices that creates the expectations, norms, and operational behaviors within an organization. Organizational culture is reflected in the well-being of patients and employees, employee retention, attribute of care, health outcomes, and elimination of medical error.

    Commitment to the well-being of individuals

    Model organizations promote the well-being of full those who are cared for or work within them. Encouraging and modeling self-reflection and humility ensures that full interactions are respectful and that employees are valued and empowered.

    Commitment to teamwork

    Best keeping happens when full members of the team, including patients, partake information and decision-making responsibility. Ensuring teamwork requires organizational structures and processes that uphold communication across staff and with patients.

    Commitment to a wholesome workplace

    Model organizations create work environments that are physically and psychologically safe and provide tools and incentives for employees to achieve wholesome lifestyles.

    Commitment to inclusion and diversity

    Model organizations incorporate the voices of employees and patients in organizational initiatives, including clinical domains. They encourage respectful attention to alternative viewpoints. Communication training for full staff emphasizes teamwork, respect, inclusiveness, and cultural sensitivity. The workforce, including leadership, reflects the diversity of patients and the community.

    Commitment to accountability

    Model organizations create a culture of trust and empowerment by articulating the mission and values of the organization, aligning policies, creating an infrastructure to promote those values, and eliminating activities that undermine professionalism. They align employee incentives with organizational values, reward success, provide supportive remediation for those who struggle to meet expectations, promote job satisfaction, and provide opportunities to learn. Model organizations encourage feedback to leadership regarding any experience and observation of activities that compromise the organization’s values. Model organizations create an environment that encourages disclosure of events or suspect processes using lore gained to prevent harm and better safety for patients and staff.

    Community Partnerships

    Model organizations collaborate with other health keeping organizations and the communities they serve to reduce health disparities related to factors such as education, income, and the environment. They focus particularly on preventable root causes of illness and access to appropriate, effective, culturally sensitive health care.

    Commitment to address the gregarious determinants of health

    Clinicians frequently encounter root causes of preventable illnesses, such as environmental toxins, nutritional deficits, unhealthy behaviors, and other preventable gregarious factors. Treating these in a clinical vacuum diminishes the organization’s full potential to better health. Therefore, it is a model organization’s ethical responsibility to serve identify, understand, and address gregarious determinants of health, and to incorporate this understanding into its work.

    Commitment to colleague with communities

    Model organizations engage in strategic partnerships with governmental entities, community organizations, and other organizations serving the community to identify and mitigate root causes of illness as well as to ensure effective, culturally confiscate care. Model health keeping organizations involve the community in organizational activities and governance, and their employees participate in community activities and governance.

    Commitment to advocate for access and high-value care

    Model organizations colleague with others to promote universal access and rational allocation of health keeping resources and to qualify incentive structures that conclude not directly lead to high-value keeping and healthier communities. They advocate with communities for regulatory reforms to better environmental conditions, mitigate barriers to health keeping access, and better gregarious services.

    Commitment to community benefit

    Model organizations and their leaders engage generously with community organizations and civic leaders to invent innovative, strategic investments that leverage improved community health.

    Operations and business Practices

    Model organizations ensure patient safety, clinical excellence, transparency, evidence-based practices, high-value care, and professional competence. They provide sensitive, respectful, compassionate, prompt, and courteous patient care.

    Commitment to safeguard the privacy of patients and their health information

    Model organizations must safeguard the privacy of patients and their health information. This is particularly well-known in the employ of electronic health records, which pose continually evolving challenges to the privacy and security of patient information.

    Commitment to ethical operations

    Ethics and compliance programs in model organizations articulate mission and values, guidelines for observing legal requirements, and standards for the highest ethical focus in addressing the health keeping needs of diverse populations. These programs require qualified senior-level executive leadership, mechanisms to set standards, evidence-based policies, comprehensive training and education, mechanisms to report violations without scare of retaliation, and approaches to monitor compliance and audit performance. Model organizations adhere to credentialing and regulatory standards in their operations, recruitment, training, education, and privileging.

    Commitment to transparent management of conflicts of interest

    Model organizations fill systems to identify and address potential conflicts of interest. When patients may breathe affected, patient welfare is given priority.

    Commitment to align incentives with values

    Model organizations routinely review their incentive systems to ensure that they are in alignment with articulated organizational values.

    Commitment to honest treatment, education, and development

    Model organizations compensate employees fairly; provide confiscate benefit packages; avoid staff shortages; and promote employee education, training, and growth.

    Commitment to high-value care

    The policies and practices of model organizations engender evidence-based keeping and treatment that are provided to every patient. Model organizations always strive for high-value, optimal clinical outcomes, aligned with the three aims of better care, wholesome populations, and reduced costs. They ensure that ordering practices for testing and treatment are evidence based and supported by standards of care.

    Commitment to innovation

    Model organizations strive to better current models of care. Creating opportunities to assist other organizations to achieve similar success is a configuration of public service. The search for and implementation of innovative approaches to management, leadership, and patient keeping are well-known indicia of organizational professionalism.

    Commitment to accounting and financial reporting standards

    Model organizations ensure that their financial statements accurately reflect the performance of the organization. They create financial control systems and internal auditing mechanisms that ensure financial integrity.

    Commitment to ensure honest and equitable access to health care

    Model organizations array expense transparency. They invent adjustments to bills for uninsured patients, so that they are not expected to pay substantially more than insured patients. They act fairly in granting “charity status” to patients who fill no colorable means of paying the cost of treatment. They demonstrate flexibility in settling patient balances that exceed the patient’s financial capabilities.

    Note: This Charter was created by the Organizational Professionalism Working Group:

    May-Lynn Andresen, RN, BSN

    Barry E. Egener, MD (Chair)

    Ezekiel Emanuel, MD, PhD

    David A. Fleming, MD, MA

    Meg E. Gaines, JD, LLM

    L. Keith Granger, BSRT

    David Gullen, MD

    Talmadge King, MD

    Wendy Levinson, MD

    Diana J. Mason, RN, PhD

    Walter J. McDonald, MD

    Sally Okun, RN, MMHS

    Tim Rice, MPH, RPh

    Bernie M. Rosof, MD

    Rosemary Stevens, PhD, MPH

    Alan Yuspeh, JD, MBA



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