250-403 exam Dumps Source : Administration of Symantec(TM)(R) Management Platform 7.1
Test Code : 250-403
Test title : Administration of Symantec(TM)(R) Management Platform 7.1
Vendor title : Symantec
: 174 true Questions
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Addition of Janice Chaffin Expands Board to Eight individuals
FREMONT, Calif., Nov. 08, 2018 (GLOBE NEWSWIRE) -- Electronics For Imaging, Inc. (Nasdaq: EFII), an international chief in consumer-focused digital printing innovation, nowadays announced the appointment of Janice Chaffin to its Board of directors.
Ms. Chaffin is an skilled know-how trade government, specializing in strategic marketing and international operations. She has held several senior executive positions with Symantec organisation, including serving as neighborhood president of its consumer trade unit from 2007 to 2013. Ms. Chaffin additionally serves on the boards of directors of Nasdaq-traded corporations Synopsys, Inc. and PTC Inc. She is an Advisory Council member for Illuminate Ventures and a member of the Board of guests for the UCLA Anderson faculty of administration. up to now she served on the boards of Informatica supplier and overseas game technology, together with the working Committee of privately held Ancestry.com.
Gill Cogan, Chairman of EFI’s Board of administrators, commented, “along with her confirmed expertise in international advertising, method, trade construction, R&D management and product building, Janice is an excellent addition to the EFI board.”
“i am excited in regards to the alternatives forward for EFI, and that i appear forward to contributing to the enterprise’s increase and strategic path,” talked about Ms. Chaffin.
Commenting on the appointment, EFI CEO bill Muir stated, “Janice is a confirmed leader and innovator within the application and hardware industries. They appear to subsist forward to taking odds of her talents as they continue to develop their business.”
ahead of leading Symantec's buyer trade unit, Ms. Chaffin served because the company's executive vice president and chief advertising officer from 2006 to 2007, and as senior vice chairman and chief advertising officer from 2003 to 2006. earlier than becoming a member of Symantec, Ms. Chaffin worked for greater than twenty years at Hewlett-Packard company in numerous administration and advertising management positions. Ms. Chaffin graduated summa cum laude from the institution of California, San Diego, with a Bachelor of Arts diploma in Political Science, and earned a master of company Administration from the school of California, los angeles, where she turned into an Edward W. Carter Fellow.
About EFIEFI™ is a worldwide know-how business, based mostly in Silicon Valley, and is main the worldwide transformation from analog to digital imaging. we are captivated with fueling customer success with items that boost competitiveness and raise productiveness. To achieve this, they enhance leap forward applied sciences for the manufacturing of signage, packaging, textiles, ceramic tiles, and personalized documents, with a wide array of printers, inks, digital entrance ends, and a complete enterprise and construction workflow suite that transforms and streamlines the total production manner. (www.efi.com)
Investor RelationsJoAnn HorneMarket highway Partnersir@efi.com415-445-3233
Fremont, California, u.s.
Nation states, cybercriminals and unscrupulous competitors are everything vying to hook elegant assistance from prostrate groups. records loss prevention (DLP) products assist companies tender protection to sensitive suggestions through keeping it at ease. These DLP products determine information at leisure on file servers or in the cloud, records in action throughout networks and information in utilize on endpoint devices.
records loss prevention tools can subsist create either as portion of standalone committed DLP suites for commercial enterprise-huge coverage, or are integrated into different protection items, similar to endpoint security materiel and community utility gateways.
this article examines three DLP utilization scenarios -- and the common issues linked to them -- to more suitable champion readers do the rectify resolution when purchasing DLP items.
In these eventualities, the cybersecurity groups -- working with region count specialists from departments that process elegant counsel and trade compliance specialists -- hold identified the records paths, communications protocols and statistics codecs of sensitive advice. particular enterprise technique managers and compliance experts hold categorized this counsel based on the company's facts classification policy, and the legal fork and compliance workforce labored collectively on e-discovery considerations, renovation of proof, and monitoring provider and trade affiliate compliance.
the primary situation examines how a standalone DLP suite could subsist used; the 2nd, how a DLP suite and security tools with built-in DLP aspects may subsist employed; and the terminal one, how assorted security materiel with built-in DLP points might possibly subsist used to obtain the same influence.The standalone DLP situation
A regional clinical core has a erudition core containing sufferers' personally identifiable information (PII) and protected health guidance (PHI), The PII and PHI is shared with health insurance suppliers and is accessible to healthcare gurus at workstations, cell-records carts and capsules. consumer billing is dealt with via a 3rd-birthday party seller.
The scientific middle at present makes utilize of Symantec Endpoint coverage with encryption lead from Symantec Encryption for e mail encryption on windows and Macintosh OSX hosts. The logs from the endpoint insurance policy and DLP servers pass to the Splunk SIEM equipment.
The Symantec DLP Suite presents coverage for records at use, information in transit and statistics in storage (key elements to the success of any DLP product) and, importantly, integrates well with the deployed Symantec Encryption products. for instance, Symantec Endpoint avoid analyzes statistics earlier than it's transferred to detachable media, and might immediately encrypt elegant assistance because it is stored on the removable media.
statistics in transit is addressed by using Symantec community computer screen with companion modules Symantec network evade for internet and Symantec network steer clear of for electronic mail.
sensitive statistics on endpoints is covered by means of an agent containing both Endpoint stay away from for statistics in use, and Symantec records Loss Prevention Endpoint ascertain for information at rest. These modules are enabled by means of licensing. Endpoint preclude is used to video parade and cease sensitive advice from being copied to removable media enjoy CD-R/DVD-R and USB contraptions. it is additionally configured to steer clear of facts from being printed, faxed, or copied into reminiscence to paste to one other document. sensitive facts is prevented from leaving the endpoint via network protocols enjoy FTP, SMTP and IM.
The scientific middle moreover created policies to cease facts from being despatched to cloud file-sharing sites and companionable media sites. The agent pop-up characteristic is enabled to notify the user of a DLP policy violation, and as a result give a boost to protection awareness working towards. To address data at leisure on endpoints, the Endpoint find module scans file storage on workstations and laptops. it's configured to each drag unauthorized sensitive assistance to a safer network quarantine place, and generate a DLP incident alert for extra motion by artery of the cybersecurity cadaver of workers.
facts at relaxation for community-based statistics storage is dealt with via the licensed modules of network find and network protect. The scientific core has configured network ascertain to always scan file servers, network access storage and databases for sensitive counsel, and then (in accordance with policy) uses community protect to immediately copy, relocate or quarantine uncovered confidential information.
mobile contraptions corresponding to iPhones and iPads are addressed by using information Loss Prevention for cell. This product uses a digital inner most network (VPN) connection known as VPN on exact in the course of the clinical middle's mobile device administration (MDM) product to contact its Symantec DLP servers, and hence invoke DLP coverage. mobile evade for web is used to celebrate and cache personal facts detected in HTML site visitors. Symantec cell e mail video parade is configured to tune exclusive assistance when it is downloaded from the clinical core's network to the indigenous e-mail client on supported Apple iOS contraptions.
The facts Loss Prevention facts perception commercial enterprise product gives the scientific middle with file usage and possession evaluation that can subsist used with the aid of a lot of departmental teams liable for safeguarding elegant information. counsel from data perception is shared by artery of a self-service portal with additional info provided by custom Splunk dashboards which are created by means of the medical core's cybersecurity crew.The blended DLP condition of affairs
A medical health insurance company has a crucial workplace with regional income workplaces and outlying container workplaces. insurance applicants' PII and PHI are collected with the aid of coverage agents at the outlying places of work and despatched to the domestic workplace to determine coverage eligibility. insurance agent PII, akin to employment records and opinions, are handled at the regional earnings office and kept on the domestic office file servers.
The domestic workplace processes customer funds and reimburses fitness suppliers for client healthcare claims. furthermore, it compiles agent fee stories, investigates consumer claim fraud, handles worker personnel concerns, and addresses customer grievances. The felony fork handles complaints, by former shoppers and former agents; client billing is dealt with by a 3rd-party vendor.
The trade begun using a few McAfee products administered through McAfee ePolicy Orchestrator (ePO). These included VirusScan commercial enterprise, materiel control and finished facts insurance draw for records encryption. desultory log statistics from ePO is at present exported to the enterprise's SIEM product, trade protection supervisor.
The enterprise uses ePO to manage guidelines for and to divide McAfee DLP Endpoint to its windows and Mac hosts. It opted to construct upon built-in DLP points create in its endpoint protection suite's McAfee gadget manage for portable facts contraptions. the utilize of the adventure won from this product, it selected to add licenses for McAfee DLP Endpoint for desktop and mobile contraptions.
This DLP product addresses sensitive facts in utilize through utility control and monitoring records circulation to portable storage media and portable storage contraptions. The DLP endpoint brokers, meanwhile, are used to video parade and quarantine information in utilize everything the artery through the enterprise. Working with complete records insurance policy, the agents are in a position to encrypt elegant tips when it's copied to moveable storage media.
information loss prevention tools can subsist create both as portion of standalone committed DLP suites for commercial enterprise-large insurance, or are integrated into other safety items, such as endpoint protection tools and community utility gateways.
The company uses DLP parade screen, a standalone DLP product to parade screen information in transit over the business's inner networks. sensitive data passing to external networks is filtered by using McAfee DLP avoid, an inline DLP product meant to dam sensitive tips from leaving the enterprise over lots of protocols such as FTP, IM, SMTP and HTTP/HTTPS.
McAfee's DLP find file scanners address statistics at rest. they're used at the domestic workplace to monitor and quarantine sensitive statistics at its data middle. everything movements are correlated and challenging hobbies are reviewed as a minimum daily by means of the cybersecurity crew. fitful reports are prepared for the records owners, so company methods can moreover subsist monitored and adjusted as fundamental.
the usage of the DLP supervisor, customized detection and correlation rules attend the trade protect its highbrow property, manufacturing operations and conform to exchange laws. The cybersecurity and compliance specialist displays routine said by trade protection manager's SIEM indicators. fitful reports from the SIEM and DLP manager are prepared for the data house owners so trade tactics can subsist monitored and adjusted as integral.
DLP manager, DLP parade screen, DLP find and DLP withhold away from are used by artery of the trade on the McAfee DLP 5500 appliance and in virtual computing device configurations.
meanwhile, integrated DLP points in Sophos' UTM and subsequent-gen firewall home equipment, along with the McAfee DLP endpoint agents, are in utilize on the regional and outlying places of work to parade screen and quarantine information and communications that achieve not meet compliance instructions. Outbound webmail and cloud-based file-sharing functions are blocked in any respect perimeters.
company cellular gadgets are managed through McAfee enterprise Mobility administration. File sharing with authorized parties is carried out through a at ease file sharing product determined at the domestic workplace. assurance agents utilize terminal server-primarily based functions to procedure coverage applications and service latest valued clientele from company-offered tablets. The enterprise is investigating virtual desktop environments and embedded working programs hosts to replace time-honored PCs whose difficult drives can moreover unintentionally hold PII or PHI in temporary files.The blended built-in DLP situation
A tiny but growing technology company has developed a number of creative products applying both actual and firmware components. It continues a headquarters, a modest manufacturing facility specializing in only-in-time manufacturing, a research and construction campus, and places of work located in the a ways East for negotiation with a variety of digital suppliers. in preference to having a valuable campus, the dispersed nature of the enterprise presents some communications and collaboration challenges.
The business's records crown jewels involve its intellectual property in the figure of engineering files, diagrams, standards, firmware source code and product assembly guidance. supporting documents consist of enterprise lists, materials inventories, contractual agreements, software versioning, analysis databases and notes. Collaboration is robotically carried out via net conferencing.
Its strategic plans and modern product documentation would subsist of particular activity to rivals.
in this condition of affairs, the cybersecurity consultants and business-technique consultants hold accomplished their homework, with additional work performed by the company's compliance specialist and its lawyers on exotic traffic in arms regulations, Export Administration laws concerns, and monitoring third-party contractor and enterprise compliance.
It has opted to construct upon integrated DLP features present in its style Micro Inc.'s endpoint security application for desktops and AirWatch enterprise cell materiel management to tackle statistics in utilize and in transit on enterprise and worker BYOD mobile instruments. Its cybersecurity cadaver of workers has additionally created customized DLP guidelines for its Sourcefire IDS/IPS sensors observed on the headquarters, R&D campus and manufacturing plant. Proofpoint electronic mail gateway and its DLP coverage facets hold been elevated to the trade privateness suite to cache or encrypt e mail with elegant counsel at the perimeters of the main sites.
Websense TRITON items for the HTTP security gateway and mobile net insurance policy are used to cover internet traffic for records in transit at the perimeters and on cellular devices. Websense TRITON cell protection is used to give protection to cellular gadget net classes and ensure enterprise web filtering is applied continuously throughout everything systems.
Code green Networks CI-appliance DLP file scanners are latest at the enterprise headquarters, R&D campus and manufacturing plant to exploit data at leisure present in SAN installations, administrative file servers, net servers, databases, SharePoint servers, research wikis and cloud components. The associate Code eco-friendly content Inspection Agent examines endpoints at faraway websites as directed via the CI-equipment.
customized detection and correlation guidelines within the LogRhythm SIEM assist give protection to its highbrow property, manufacturing operations and comply with trade laws. The cybersecurity and compliance professional computer screen activities suggested by LogRhythm SIEM signals. fitful studies from the SIEM are prepared for the information house owners so trade procedures can moreover subsist monitored and adjusted as integral.
The enterprise makes utilize of trend Micro AV products with licenses for integrated records Loss Prevention. everything vogue Micro products are centrally managed the utilize of fashion Micro exploit supervisor. statistics at relaxation on enterprise home windows and Mac desktops and laptops are addressed the utilize of OfficeScan. The integrated DLP facets in ScanMail Suite assist to establish elegant tips in the trade mail store, and manage incoming and outgoing email, thus addressing insider collaboration scenarios.
Airwatch by using VMware addresses the company's MDM needs and gives a multifarious DLP administration strategy, using cellular app protection alternate options and container alternatives for securing company supplies and featuring employee privacy on worker-supplied mobile instruments. Containers and information in transit are encrypted the usage of FIPS-compliant AES-256 encryption. Airwatch application whitelists and blacklists ensure cell instruments don't appear to subsist getting used to skip company DLP guidelines. whereas Airwatch snug content Collaboration ensures documents cleared for company partners can moreover subsist securely shared from mobile devices with out exposing additional info.Which DLP products are birthright for you?
The previous eventualities illustrated how DLP items could subsist employed, first the usage of a DLP trade product, then a DLP trade admit augmented via safety items with integrated points, and finally a totally integrated solution capitalizing on safety items that could both subsist tailored to a DLP role, or which already hold DLP points.
In everything eventualities, they regarded cellular devices in addition to stationary computing infrastructures. They even in-built the natural tenor to count on present DLP product lines well general to a company. Their selection of DLP products achieve not constitute endorsements however simply expose how they -- and an identical DLP items --could subsist utilized in given eventualities.
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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 great portion of the present recommendations was developed by experts in the territory taking into account published evidence in the literature and utilizing consensus processes, including the grading of the plane 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 subsist suitable for everything clinical settings and patients. Thus, its consideration requires an assessment of appropriateness by clinicians on an individualized basis. Among many factors, the actuality of institutional protocols, individual patient-related conditions, the invasiveness of an intervention, and the availability of resources exigency to subsist considered. The present exercise guideline is not intended to define standards or picture absolute requirements for patient care. Adherence to this guideline cannot guarantee successful outcomes but rather should aid health faith professionals and institutions to formulate plans for improved management of patients with OSA. The present recommendations reflect the current condition of erudition and its interpretation by a group of experts in the territory at the time of publication. fitful reevaluations of the literature will subsist needed, and novel scientific evidence should subsist considered between updates. Deviations from this guideline in the practical setting may subsist justifiable, and such deviations should not subsist 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 stint oblige appointed by SASM revealed substantial risk for adverse events, especially pulmonary complications, to subsist 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 subsist made to appropriately identify patients with OSA, with the goal to raise awareness among providers, mitigate risk, and ameliorate 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 exigency of evidence-based exercise recommendations regarding techniques for airway management, selection of anesthetic agents, and drugs, as well as preference 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 great amount of related literature in this arena, this study focuses only on intraoperative patient care. Postoperative faith issues are not considered and may subsist the subject of future projects.What Other Guidelines and Reviews Are Available?
Previous OSA-related exercise guidelines8–12 hold 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 stint oblige on best exercise recommendations for the anesthetic perioperative faith and throe management in weight loss surgery.14Why Was This Guideline Developed and How Does It disagree From Existing Guidelines?
This guideline was developed to provide evidence-based recommendations for the intraoperative management of patients with OSA. Therefore, a observant 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 stint oblige 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 exigency of evidence in this context, statements were made referring to patients with OSA as a general group. Nevertheless, phenotypic subcategorization may allow the evolution of individual risk profiling in the future.Aims
The direct 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 legion of concurrent interventions and utilize of anesthetic medications, making it difficult to single out specific factors that potentially drive the adverse outcome. exigency 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 stint oblige recognizes that there is a tenor to underreport medical complications, rendering it difficult to establish the dependable perioperative risk.16 Presenting the current available evidence and its limitations should raise awareness regarding the exigency 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 faith 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 stint oblige sought to establish expert consensus while considering related literature. Patients affected by sleep-disordered breathing unrelated to OSA, including hypoventilation syndromes, fitful breathing, and central apnea unrelated to OSA, were not considered in this project. This determination was made a priori to reduce the influence of heterogeneity in their assessment given the exigency of evidence on which to foundation recommendations for these specific populations.GUIDELINE stint FORCE
The stint oblige was comprised of 14 members of SASM, an international society devoted to advancing the faith for clinical problems shared by anesthesiology and sleep medicine clinicians. Given that this project included only intraoperative aspects, the stint oblige included 12 anesthesiologists and 2 anesthesiology research fellows. Members of the stint oblige participate 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 stint 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 faith of patients with OSA. Group 3 evaluated the consequence 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 attend 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 everything 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 utilize 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 divide systematic reviews by the respective SASM focus groups (members listed in the acknowledgments) to participate 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 kind of study, demographic data, comorbidities, procedure type, anesthesia-related interventions and medications, adverse events, as well as other clinically notable outcomes and effects.Exclusion Criteria.
Exclusion criteria were: nonhuman studies, non-English language, review articles, single case reports, studies reporting on the inveterate utilize of medications commonly used intraoperatively such as inveterate opioid medication, and studies without outcome reporting. For group 3, studies not directly comparing anesthesia modalities were moreover excluded.Level of Evidence and Recommendations
The Oxford plane of Evidence (Oxford LOE) implement was utilized to evaluate the property of evidence of individual studies.18 Grading the energy of recommendations and property of the underlying evidence enhances the usefulness of clinical exercise guidelines.19 Therefore, the approach according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system20,21 was utilized with respect to the cadaver of evidence and the evolution of guideline recommendations.22 As specified by GRADE, the property 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 cadaver of evidence of each respective recommendation within their focus region and reflect the assurance in estimates of the dependable effect.21 When piteous from evidence to recommendations, the GRADE approach focuses on 4 factors: equilibrium between profit and harm, certainty of evidence, values and preferences, and resource considerations.22 The energy of recommendation is separated into stout and infirm and defines the extent to which one can subsist confident that the desirable consequences outweigh its undesirable consequences (Table 2).23
In-person SASM Intraoperative Guideline stint oblige meetings took situation 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 situation throughout this time period. preliminary results and implications of findings were presented and discussed at the 2017 SASM annual meeting in Boston, MA.1. DIFFICULT AIRWAY AND OSA
Level of evidence: Moderate; Grade of recommendation: StrongRationale
The perception of OSA as an notable risk factor for difficult airway management is widely held among anesthesiologists and intensive faith physicians. In the absence of RCTs, several prospective and retrospective controlled studies hold supported this assumption.24–39Association 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 exigency 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 subsist reported in a divide systematic review with meta-analysis by the SASM airway focus group (members listed in acknowledgments).
One prospective controlled study34 reported on the utilize of the LMA Unique® (Teleflex Incorporated, Morrisville, NC), and an additional retrospective investigation27 reported on a divide unspecified supraglottic airway device. No significant association was create 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 transpose 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, create 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 hold a difficult airway were referred for polysomnography after surgery, and 66% were shown to hold 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 clarify 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 tall 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 figure of failure to reintubate in the postoperative period.49 erudition about the association between OSA and difficult airway may ameliorate perioperative airway management and lessen 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 cease estimates of these studies argue that there is an increased risk of difficult airway management in patients with OSA. Due to the great number of trials and great patient numbers, the overall property of the cadaver of evidence was considered to subsist temper using the GRADE approach20,21 and the Oxford LOE.182. INTRAOPERATIVE MEDICATION utilize IN PATIENTS WITH OSA
A great cadaver 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
Level of evidence: Low; Grade of recommendation: Weak
Level of evidence: Low; Grade of recommendation: No recommendationRationale.
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 faith units.57 The utilize 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 tall 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 subsist 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 kind of reversal agent impacts the risk of postoperative complications in patients with OSA. Patients with suspected61 or confirmed50,63,64 OSA hold been shown to subsist 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 utilize of NMBA was not described in these studies.6,50,63,64 Many patients with OSA are obese and hold anatomical risk factors that may increase 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 utilize 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 utilize of NMBA compared to patients without OSA. Although the plane of evidence was limited (Oxford LOE 2–3), the studies insinuate that patients with OSA who received NMBA may subsist 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 evoke respiratory symptoms can impair upper airway dilator muscle function.72 Minimizing the utilize and dose of NMBA, monitoring the plane of neuromuscular blockade, and complete reversal of NMBA before extubation may subsist particularly notable for patients with OSA.9
While not considering OSA status, reversal of NMBA with sugammadex, a cyclodextrin used to transpose rocuronium,73 has been shown to lessen 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 exigency for transitory oxygen supplementation; however, the OSA status was not reported in these reviews, limiting its value to assess its differential consequence 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) create 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 disagreement 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 disagreement in clinical outcomes.69
Currently, there is insufficient evidence to recommend the utilize 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
Level of evidence: Low; Grade of recommendation: Weak
Level of evidence: Low; Grade of recommendation: WeakRationale.
While opioids are highly efficacious in treating temper to stern pain, their intrinsic capacity to suppress 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 lead safe opioid exercise in this population is limited.76
Nevertheless, despite limitations with respect to the property of evidence suggesting an adverse repercussion of acute opioid administration in OSA, current literature indicates that a heightened concern regarding opioid utilize in this population may subsist 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 utilize in OSA were identified. While the majority demonstrated an association between opioid utilize and adverse perioperative outcomes in OSA,61,77–89 this was not confirmed by all.66,90,91 It should subsist notable that, particularly among observational analyses, there is notable heterogeneity with respect to the modality of OSA assessment, ranging from the gold standard of polysomnography to identification by screening questionnaires or patient history. Furthermore, potential selection bias should subsist considered in these studies. In recent publications, a comparison of postoperative complications among patients with and without OSA within the same 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 increase within patients with OSA demonstrated an associated increase in the odds for gastrointestinal complications, prolonged length of stay, and increased hospital cost, while no further increase 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 moreover create 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 consequence may hold been fairly small. mannish 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 occurrence 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 tall OSA prevalence,2 demonstrated that, although postoperative respiratory complications in the context of opioid analgesia were common, surprisingly, OSA could not subsist established as an independent risk factor.66,85 However, a factor potentially causing an underestimation of a feasible deleterious consequence of OSA was the postoperative utilize 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 utilize in the presence of OSA presents a risk factor for postoperative censorious respiratory events (Oxford LOE 3–4).61,79,81–84,86,87,89
With respect 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 subsist notable that opioid reduction may lessen respiratory depression and related complications in the general 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 occurrence of respiratory complications between patients with standard morphine patient-controlled analgesia and an opioid-sparing regimen could not subsist established.95
Other studies explored the safety of neuraxial opioid administration in patients with OSA.99–102 In a systematic review, Orlov et al99 create that the incidence of major cardiorespiratory complications after neuraxial opioid administrations was 4.1% among patients with OSA. However, the authors moreover emphasized that significant limitations in the property of evidence and persistent underreporting of adverse events prevented an accurate and robust assessment of dependable 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 increase 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 subsist at increased risk for opioid-related respiratory adverse events. However, high-quality evidence to champion 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 throe 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 notable 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 notable features of OSA. Studies in humans hold 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 throe in subjects suffering from OSA, 1 study create that patients with OSA and comorbid temporomandibular joint disorder experienced hypoalgesia to pressure-related pain,109 while another reported a significant increase in throe threshold after restoring sleep continuity with the application of CPAP therapy.110 In contrast, the third investigation create 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 inveterate pain, a retrospective analysis of prospectively collected data from the Cleveland Family Study showed that inveterate intermittent hypoxia was associated with more frequent inveterate throe complaints, even after adjusting for the potentially hyperalgesic consequence 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 expose contradictory findings to those create 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 same population did not authenticate these findings.115,116 In the first study, African American children versus Caucasian children with OSA presented with more throe 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 moreover demonstrated a higher incidence of opioid-related respiratory complications.116
In adults, 1 retrospective analysis create 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 utilize in general 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 divide systematic review by the SASM opioids focus group (members listed in the acknowledgments).2.3 Propofol
Level of evidence: Moderate; Grade of recommendation: StrongRationale.
The literature discussed for the purpose of the recommendation reflects evidence of importance for patients receiving propofol for sedation in a procedural setting, that is, drug-induced sleep endoscopy (DISE), gastroenterological endoscopy, or dentistry. The utilize of propofol to induce general 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 cadaver 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 relent 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 subsist judiciously titrated.120,126
Attempts hold 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 doubt regarding dosing scalar adjustments that may subsist required in patients with obesity, as well as the concomitant utilize of depressant drugs with synergistic effects (midazolam,131 ketamine,132,133 dexmedetomidine,134 opioids135), further add to the exigency for heightened vigilance when using propofol for patients with OSA. Propofol has a relatively sheer dose-response curve compared to other sedatives/hypnotics, thus underscoring the importance of observant 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, mannish gender, American Society of Anesthesiologists physical status ≥III, initial dose of propofol, and increased age were create to subsist 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 preclude or mitigate a sedation-related adverse event. The utilize of capnography was associated with a decreased incidence of hypoxic events compared to standard monitoring lonely during sedation with propofol144 in patients with OSA.1402.4 Inhalational Agents
Level of evidence: Moderate; Grade of recommendation: No recommendationRationale.
There is a exigency of scientific literature to lead 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 general population and patients with obesity.145 Evidence from the population with obesity may merit consideration in this context, given the nigh association to OSA,146 reflected in the substantial OSA prevalence of ≤90% in mannish bariatric patients.147,148 Notably, there is significant overlap between obesity and OSA with respect to challenges in general 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 period of emergence and recovery from anesthesia of tall 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 subsist associated with a faster recovery from anesthesia and improved postoperative respiratory control in 2 RCTs.154,155 However, sevoflurane was create to subsist 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 disagreement with respect 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 utilize of propofol impaired pulmonary duty and SpO2 to a greater degree than desflurane,157 while another could not authenticate these differences.156 Thus, current evidence indicates that sevoflurane and desflurane might subsist 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 propitious 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 faith unit stay, and hospital length of stay when compared to isoflurane within a long-acting regimen. This analysis emphasized the colorable profit of generally utilizing short-acting medications with respect to everything 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 preclude 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 notable 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 tiny clinical affliction by Juvin et al170 moreover compared desflurane, isoflurane, and propofol together in 1 analysis. Both Liu et al171 and Juvin et al170 established desflurane as the most propitious 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 title 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 hold moreover been observed in the general 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 moreover 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 solemn hypoxemia,184 thus suggesting a profit associated with early and rapid recovery of energetic 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 general anesthesia in patients with and without obesity can subsist accelerated using either isocapnic or hypercapnic hyperpnea.185
In summary, the available evidence supports the utilize 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 subsist made.2.5 Ketamine
Level of evidence: Very low; Grade of recommendation: No recommendationRationale.
The literature is scarce with respect 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 utilize in patients with OSA, but data are insufficient to draw any solid 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 tall doses, meaning >0.5 mg/kg boluses and 100 µg/kg/h infusions.193
Ketamine has been shown to hold some profitable effects. Studies demonstrated that ketamine, when combined with other sedative medications, mostly propofol, may lessen 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 create ketamine to subsist a protective factor.195 De Oliveira et al194 reported that ketamine decreased duration and severity of hypercapnia in patients undergoing breast surgery under abysmal sedation.
Furthermore, Drummond196 studied the consequence of ketamine versus midazolam on upper airway function. Interestingly, they create 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 hold been shown to subsist increased after administration of tall and low doses of ketamine in rats.197 Upper airway dilator muscle activity plays an notable role in patients who are at risk of upper airway obstruction. Despite the exigency of data on ketamine in the patient population with OSA, available information suggests that these patients could profit from potentially propitious respiratory effects over other sedatives. solid conclusions, however, cannot subsist drawn at this time.2.6 Benzodiazepines
Level of evidence: Moderate; Grade of recommendation: WeakRationale.
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 insinuate that the utilize 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 utilize 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 suited option to study obstructive events in patients with OSA.102,105
Interestingly, Sadaoka et al209 create 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 utilize 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. everything patients with OSA had desaturation events after 2 mg of midazolam, but no portion 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 sound 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 tall 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 tall 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
Level of evidence: Low; Grade of recommendation: No recommendationRationale.
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 propitious respiratory profile and analgesic-sparing effects theoretically do α-2 agonists appealing for this population. When assessing the risk of adverse events with the utilize 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 utilize of α-2 agonists to either placebo or other medications. The cadaver of literature is limited by a tiny total number of subjects, discordant results, exigency 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 utilize of dexmedetomidine to propofol in DISE as summarized in Supplemental Digital Content, Table A10, http://links.lww.com/AA/C373 (propofol in DISE has moreover been discussed in Section 2.3). In a succession by Capasso et al,123 patients receiving propofol had a significantly increased likelihood of complete tongue foundation 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 lessen in respiratory rate and lower SpO2 with propofol compared to dexmedetomidine.124,221 In the study by Cho et al,220 stand for 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 stand for arterial pressure (MAP) but lower stand for 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. stand for 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 relent 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 subsist due to drug consequence 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 succession of 20 patients at tall 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 utilize 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 succession of bariatric patients reported adequate saturations with supplemental oxygen without the exigency for CPAP.224 Studies with quantitative data insinuate that intraoperative utilize of dexmedetomidine may not move the respiratory rate in bariatric patients225 and when compared to placebo may hold a better recovery profile in individuals undergoing uvuloplasty.93 In another group of patients receiving postoperative sedation after uvulopalatopharyngoplasty, the dexmedetomidine group experienced less stern 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 consequence 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 disagree 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 disagree between groups.
The hemodynamic effects of α-2 agonists were assessed according to varied outcome measures, including vital sign measurements, categorical descriptors, and exigency 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 disagreement to controls was observed in 2 other studies.231,232 Chawla et al227 reported evanescent loading dose hypertension followed by “titratable, controlled hypotension, and bradycardia.” Three studies223,227,231 demonstrated less frequent utilize 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 exigency for phenylephrine champion in patients receiving dexmedetomidine.231 In studies reporting the exigency 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 moreover characterized outcomes according to categorical variables and create 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 everything 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 disagreement compared to control patients,231 and another showed increased time to extubation.93 One succession described prolonged drowsiness with dexmedetomidine,134 while another study showed no disagreement in sedation score compared to control patients.93 cease 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 consequence 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 subsist observed, the clinical repercussion of these findings remains unknown.3. ANESTHESIA TECHNIQUE
Level of evidence: Moderate; Grade of recommendation: StrongRationale
A wide gain of literature and earlier guidelines hold favored the utilize of regional anesthesia techniques and multimodal analgesic approaches among patients with OSA despite shrimp scientific evidence to champion 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 respect to comparative effectiveness between general 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 general anesthesia would ameliorate 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 general anesthesia. Furthermore, the addition of neuraxial to general anesthesia versus the utilize of general anesthesia lonely was associated with improved outcome profiles. Additionally, the utilization of peripheral nerve blocks was associated with decreased odds for mechanical ventilation, censorious faith admissions, and prolonged hospital length of stay.235
Subsequent studies236,239 confirmed the previous findings, while 1 suggested benefits with respect 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 general 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 general anesthesia may move postoperative sleep architecture and sleep-disordered breathing in OSA.
Given the necessity of airway manipulation under general anesthesia, other challenges inherent to OSA should subsist considered as well. The higher risk for a difficult airway in OSA has been discussed in Section 1. However, challenges with respect to airway complications in patients with OSA display to moreover 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 subsist 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 general anesthesia.
Another potential hazard associated with the utilize of general anesthesia is the frequent exigency for neuromuscular blockade. As described in Section 2.1, studies insinuate that patients with OSA who received NMDA may subsist at increased risk for effects of residual neuromuscular blockade and respiratory failure compared to the general population.67,242 Therefore, the utilize of regional anesthesia may tender advantages by virtue of avoiding upper airway effects, although the potential for the exigency to transform to general anesthesia should always subsist considered.
Neural stimulation appears to subsist essential in initiating the surgical catabolic stress response,243,244 and regional anesthesia utilizing local anesthetics seems to reliably cache this effect.245 Given the evidence suggesting potential OSA-related alterations in throe perception and opioid potency due to intermittent hypoxia and sleep fragmentation, as discussed in Section 2.2, regional anesthesia confers benefits by providing efficacious throe relief while reducing opioid requirement,246,247 a key factor to respect in patients with OSA.112,248
In summary, despite the exigency of high-quality RCTs, some evidence suggests a higher risk of complications with general compared to regional anesthesia in patients with OSA (Oxford LOE 2–4). Thus, regional anesthesia should subsist considered by anesthesiologists whenever feasible.RECOMMENDATIONS: EXECUTIVE SUMMARY
The SASM stint oblige 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: impress 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 enjoy 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, modern York, NY; Bridget Jivanelli, Kim Barrett Memorial Library, Hospital for Special Surgery, modern York, NY; Eva E. Mörwald, MD, Department of Anesthesiology, Perioperative Medicine and Intensive faith 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, censorious Care, and throe Management, Beth Israel Deaconess Medical Center, Boston, MA; Sarah M. Weinstein, BA, Department of Anesthesiology, Hospital for Special Surgery, modern York, NY.DISCLOSURES
Name: Stavros G. Memtsoudis, MD, PhD.
Contribution: This author helped design the study, conduct the study, anatomize 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 throe 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. no portion of these relations influenced the conduct of the present study.
Name: Crispiana Cozowicz, MD.
Contribution: This author helped design the study, conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Mahesh Nagappa, MD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Jean Wong, MD, FRCPC.
Contribution: This author helped conduct the study, anatomize 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, anatomize 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, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Anthony G. Doufas, MD, PhD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Meltem Yilmaz, MD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: M. Yilmaz serves on the advisory board of VitaHEAT Medical.
Name: impress H. Stein, MD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Megan L. Krajewski, MD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Mandeep Singh, MBBS, MD, MSc, FRCPC.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: None.
Name: Lukas Pichler, MD.
Contribution: This author helped anatomize the data and write the manuscript.
Conflicts of Interest: None.
Name: Satya Krishna Ramachandran, MD.
Contribution: This author helped conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: S. K. Ramachandran funded research from Merck, sharp & Dohme, modern Jersey.
Name: Frances Chung, MBBS, FRCPC.
Contribution: This author helped design the study, conduct the study, anatomize the data, and write the manuscript.
Conflicts of Interest: F. Chung received research grants from Ontario Ministry of Health and Long-Term faith 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.
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Good morning. The role of CIO, more tightly integrated than ever into the business, is drawing from a broader pool of candidates, many of whom achieve not foster from the IT departments that bred so many of their predecessors. Eli Lilly & Co. this week named Aarti Shah, a 22-year veteran at the drug company, as its CIO.
Dr. Shah, who has a doctorate in statistics, has spent decades in the drug company in areas such as global brand evolution and advanced analytics, but not in IT, CIO Journal's Kim S. Nash reports. She will lead a 1,300-member IT organization. She says her diverse background will subsist a competitive odds for the company, because “you hold to know the trade you want to transform.”
She isn't alone. MasterCard named Ed McLaughlin to the CIO post in January, after about a decade in bill payment, franchise evolution and other areas. American Airlines Group appointed Maya Leibman to CIO in 2011, after she worked as president of the airline’s loyalty program. Says Craig Stephenson, managing director of the North American CIO exercise at executive-search solid Korn/Ferry International: “With the amount of competition out there, the CIO better know what the customer wants."
Sharing economy expert says companionable safety net must subsist revamped. “I am optimistic … But not everyone’s job will remain or grow. There will subsist some losers, no doubt about it,” says Arun Sundararajan. He sat down with CIO Journal to debate his modern book, The Sharing Economy: The cease of Employment and the ascend of Crowd-Based Capitalism.
Thieves ebb tall tech to hook cars. Police in Houston think car thieves may be using laptops to electronically red wire late model Jeep Wranglers and Cherokees, the WSJ's Jeff Bennett reports. Fiat Chrysler Automobiles NV said it is unaware of any such incidents involving its vehicles. Over the terminal two years, the auto maker, along with general Motors and Tesla Motors, hold had to alter their car electronics after learning their vehicles could subsist hacked.
Meanwhile...more connected car tech to come. Reuters reports that LG Electronics is working with Volkswagen on a platform that lets drivers connect with external devices such as home security systems. The platform will moreover include "an alerting system for drivers providing 'recommendations' based on real-time situations." In China, Alibaba and the country's largest automaker SAIC Motor demonstrated a new car running the YunOS operating system, which links with smartphones.
Old-boys' network infects cybersecurity. Just 10% of professional security employees are women, according to a study by (ISC)2, a non-profit that specializes in cyber training and certification. The FT talks with women security professionals who protest that the perception of cybersecurity as an offshoot of hacker culture, and not a multidisciplinary function, may eddy off some promising female candidates.
KKR & Co. agrees to buy trade software company Epicor Software Corp. from Apax Partners. The deal is the latest in a streak of technology company buyouts, the WSJ's Matt Jarzemsky notes. Among the recent deals, technology-focused buyout solid Thoma Bravo LLC this month agreed to buy data-analysis company Qlik Technologies for $3 billion. Vista Equity Partners in May agreed to acquire marketing software provider Marketo for $1.8 billion.
Blackberry to cease making classic smartphone. The device maker resurrected its Classic model with the physical keyboard 18 months ago, but apparently sales (and nostalgia) were not enough to withhold the product alive, Reuters reports.
Drones impede wildfire efforts. Planes and helicopters crucial to fighting wildfires in the West are being grounded as to avoid jar with tiny aircraft flown by hobbyists, the WSJ's Jennifer Calfas reports. Federal Aviation Administration rules prohibit drone operators from flying above 400 feet, and explicitly require them to withhold clear of piloted aircraft.
Fed agency says Symantec vulnerability is 'serious event.' The U.S. Department of Homeland Security's Computer Emergency Readiness Team issued an alert for a vulnerability in Symantec Corp.'s anti-virus software that lets hackers remotely control computers, Reuters reports.
Apple hopes to do organ donation easier. Owners of iPhones will soon subsist able to utilize them to sign up to subsist an organ, eye and tissue donor. Apple Inc. announced Tuesday that it teamed up with Donate Life America to build donor registration into the Health app in iOS 10, due out this fall, the WSJ's Nathan Olivarez-Giles reports. Apple said the sign-up process will tender information that will clarify to iPhone users how such donation works, and that the gross process will hook “just a few taps.”
Live, from Katmai National Park in Alaska. It's the bearcam! For the fourth season viewers can watch brown bears snag spawning salmon as it happens. Verge explains that the setup for 24/7 coverage, offered by Explore.org, was made feasible through "a tangled network of remote cameras, solar panels, microwave uplinks, and wind turbines."
It's a nice day for a... Red Hat wedding? At a recent Red Hat Summit, Paul Cormier, Red Hat executive vice president, officiated a wedding between a client and his betrothed, IDG reports. Said Mr. Cormier: "a successful marriage follows some of the same principles that I talked about in my keynote this morning: your single footprints are piteous to a combination of physical, virtual, private and public resources..."
EVERYTHING ELSE YOU exigency TO KNOW
Global oil giants investing again. gargantuan oil is taking odds of cheap drilling. Chevron, Exxon Mobil and several partners on Tuesday committed $37 billion to expand an oil project in Kazakhstan, one of the biggest investments since crude prices collapsed two years ago. They’re not alone. BP PLC terminal week gave the green light to a multibillion-dollar gas project and terminal month said it will fast-track a major discovery in Egypt. Italy’s Eni is piteous ahead on an Egypt territory as well. The world’s biggest energy companies will profit from a huge drop in drilling costs that has accompanied the oil-price fall.
German car, parts firms derive probe. Germany’s antitrust watchdog launched a steel price-fixing investigation into six companies, including Daimler AG, BMW AG and Volkswagen AG and suppliers Robert Bosch GmbH and ZF Friedrichshafen AG. The watchdog suspects Germany’s leading car makers and two of the world’s biggest car-parts suppliers agreed on prices they would pay for steel products used in cars.
New outside CEOs often start with tinkering. When boards bring in external CEOs to foment gargantuan change, sometimes thinking tiny is better, writes Joann S. Lublin. Ron Johnson bold plans for J.C. Penney were a dud, for example. Ms. Lublin takes a leer at a trio of CEOs, at Laclede Group, Best Buy and Angie’s List Inc., who came to their respective companies and earned credibility by tapping the power of minor actions to gain associates’ champion for major transformations.
Tom Loftus contributed to this article. The Morning Download comes from the editors of CIO Journal and cues up the most notable news in trade technology every weekday morning. Send us your tips, compliments and complaints. You can derive The Morning Download emailed to you each weekday morning by clicking http://on.wsj.com/TheMorningDownloadSignup.
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DELL [9 Certification Exam(s) ]
DMI [1 Certification Exam(s) ]
DRI [1 Certification Exam(s) ]
ECCouncil [21 Certification Exam(s) ]
ECDL [1 Certification Exam(s) ]
EMC [129 Certification Exam(s) ]
Enterasys [13 Certification Exam(s) ]
Ericsson [5 Certification Exam(s) ]
ESPA [1 Certification Exam(s) ]
Esri [2 Certification Exam(s) ]
ExamExpress [15 Certification Exam(s) ]
Exin [40 Certification Exam(s) ]
ExtremeNetworks [3 Certification Exam(s) ]
F5-Networks [20 Certification Exam(s) ]
FCTC [2 Certification Exam(s) ]
Filemaker [9 Certification Exam(s) ]
Financial [36 Certification Exam(s) ]
Food [4 Certification Exam(s) ]
Fortinet [13 Certification Exam(s) ]
Foundry [6 Certification Exam(s) ]
FSMTB [1 Certification Exam(s) ]
Fujitsu [2 Certification Exam(s) ]
GAQM [9 Certification Exam(s) ]
Genesys [4 Certification Exam(s) ]
GIAC [15 Certification Exam(s) ]
Google [4 Certification Exam(s) ]
GuidanceSoftware [2 Certification Exam(s) ]
H3C [1 Certification Exam(s) ]
HDI [9 Certification Exam(s) ]
Healthcare [3 Certification Exam(s) ]
HIPAA [2 Certification Exam(s) ]
Hitachi [30 Certification Exam(s) ]
Hortonworks [4 Certification Exam(s) ]
Hospitality [2 Certification Exam(s) ]
HP [750 Certification Exam(s) ]
HR [4 Certification Exam(s) ]
HRCI [1 Certification Exam(s) ]
Huawei [21 Certification Exam(s) ]
Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1532 Certification Exam(s) ]
IBQH [1 Certification Exam(s) ]
ICAI [1 Certification Exam(s) ]
ICDL [6 Certification Exam(s) ]
IEEE [1 Certification Exam(s) ]
IELTS [1 Certification Exam(s) ]
IFPUG [1 Certification Exam(s) ]
IIA [3 Certification Exam(s) ]
IIBA [2 Certification Exam(s) ]
IISFA [1 Certification Exam(s) ]
Intel [2 Certification Exam(s) ]
IQN [1 Certification Exam(s) ]
IRS [1 Certification Exam(s) ]
ISA [1 Certification Exam(s) ]
ISACA [4 Certification Exam(s) ]
ISC2 [6 Certification Exam(s) ]
ISEB [24 Certification Exam(s) ]
Isilon [4 Certification Exam(s) ]
ISM [6 Certification Exam(s) ]
iSQI [7 Certification Exam(s) ]
ITEC [1 Certification Exam(s) ]
Juniper [64 Certification Exam(s) ]
LEED [1 Certification Exam(s) ]
Legato [5 Certification Exam(s) ]
Liferay [1 Certification Exam(s) ]
Logical-Operations [1 Certification Exam(s) ]
Lotus [66 Certification Exam(s) ]
LPI [24 Certification Exam(s) ]
LSI [3 Certification Exam(s) ]
Magento [3 Certification Exam(s) ]
Maintenance [2 Certification Exam(s) ]
McAfee [8 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [69 Certification Exam(s) ]
Microsoft [374 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [1 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
NBSTSA [1 Certification Exam(s) ]
NCEES [2 Certification Exam(s) ]
NCIDQ [1 Certification Exam(s) ]
NCLEX [2 Certification Exam(s) ]
Network-General [12 Certification Exam(s) ]
NetworkAppliance [39 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [6 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [279 Certification Exam(s) ]
P&C [2 Certification Exam(s) ]
Palo-Alto [4 Certification Exam(s) ]
PARCC [1 Certification Exam(s) ]
PayPal [1 Certification Exam(s) ]
Pegasystems [12 Certification Exam(s) ]
PEOPLECERT [4 Certification Exam(s) ]
PMI [15 Certification Exam(s) ]
Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
Prince2 [6 Certification Exam(s) ]
PRMIA [1 Certification Exam(s) ]
PsychCorp [1 Certification Exam(s) ]
PTCB [2 Certification Exam(s) ]
QAI [1 Certification Exam(s) ]
QlikView [1 Certification Exam(s) ]
Quality-Assurance [7 Certification Exam(s) ]
RACC [1 Certification Exam(s) ]
Real-Estate [1 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [8 Certification Exam(s) ]
RSA [15 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [5 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [1 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
Snia [7 Certification Exam(s) ]
SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [134 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [6 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [58 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]
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