HSC Section 3 - Trauma, Critical Care and Sleep Medicine

from 1.0 V down to 0.5 V and below, as appropriate. Once proper tongue movement has been visualized, or, where necessary, palpated, the IPG is anchored in place to the pectoralis fascia with two permanent sutures secured to the small hole in the left upper corner of the IPG. It is rec- ommended that the anchoring sutures be placed with a loose sling so as to avoid excess tension on the chest wall, which can create patient discomfort during movement. Closure/Dressings The three incisions are then closed in multiple layers, and Steri-Strips are applied. Wound drainage is not neces- sary and is discouraged due to risk of infection. Following wound closure, it is recommended to apply pressure dress- ings to the two chest wounds. This is accomplished by placement of bulky gauze or fluff dressings with elastic tape overlain (Medipore or Hypafix). The pressure dress- ings and sling may be removed at 48 hours. SPECIAL CONSIDERATIONS IN UPPER AIRWAY STIMULATION SURGERY Postoperative Care Upon arrival to the recovery room an anteroposterior chest x-ray and lateral neck x-ray are obtained to docu- ment the position of the IPG and the leads and to rule out an ipsilateral pneumothorax. Ideally, the chest x-ray incorporates the upper neck as well as the lung fields to allow visualization of the entire implant. Because this is not standard for x-ray technicians, special instructions are necessary to facilitate the appropriate images. Patients are discharged to home and given instruc- tions to limit right arm movement and heavy lifting for 2 to 3 weeks. Wound care instructions are provided, with a follow-up arranged within 1 week for evaluation of all wounds and suture removal. Patients are explicitly advised that the device remains inactive and should not expect to feel any stimulation. Given the complexity of follow-up care and events that will take place in the postoperative period, pre- printed instructions that include detailed information, including a timeline, are recommended. Management of Device-Related Infections Although the exact incidence of UAS device–related infection is unknown, there is established risk of infection with any surgical implant. Comparing literature on car- diac device infections, there is wide variability reported in the literature, with an incidence between 0.8 to 5.7%. Pre- vention resides in meticulous sterile technique in conjunc- tion with perioperative use of antibiotics. Approximately 60 minutes before incision, a first generation cephalosporin should be administered and can be repeated for extended cases based on the half-life of the antibiotic. In patients with known cephalosporin allergy, intravenous vancomycin or clindamycin can be utilized. 15,16

Routine administration of postoperative antibiotics is not recommended and is in concordance with guide- lines that exist with other surgical implants. 17 Special circumstances and surgeon judgment may dictate use of postoperative antibiotics.

CONCLUSION UAS therapy offers an alternative to continuous positive airway pressure in patients with moderate to severe OSA. This update provides highlights of hypoglos- sal nerve anatomy, which are essential to determine the optimal site for stimulation cuff placement. The detailed step-by-step updates of the implant procedure help standardize the operative techniques for consistent ther- apy outcomes. Finally, we offer several postoperative care and device-related infection management considera- tions to reduce surgery-related complications. BIBLIOGRAPHY 1. Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining pheno- typic causes of obstructive sleep apnea. Identification of novel therapeu- tic targets. Am J Respir Crit Care Med 2013;188:996–1004. 2. Safiruddin F, Vanderveken OM, de Vries N, et al. Effect of upper-airway stimulation for obstructive sleep apnoea on airway dimensions. Eur Respir J 2015;45:129–138. 3. Van de Heyning PH, Badr MS, Baskin JZ, et al. Implanted upper airway stimulation device for obstructive sleep apnea. Laryngoscope 2012;122: 1626–1633. 4. Strollo PJ, Soose RJ, Maurer JT, et al.; STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139– 149. 5. Woodson BT, Soose RJ, Maurer JT, et al.; STAR Trial Investigators. Randomized controlled withdrawal study of upper airway stimulation on OSA: short- and long-term effect. Otolaryngol Head Neck Surg 2014; 151:880–887. 6. Soose RJ, Woodson BT, Gillespie MB, et al.; STAR Trial Group. Upper air- way stimulation for obstructive sleep apnea: self-reported outcomes at 24 months. J Clin Sleep Med 2016;12:43–48. 7. Woodson BT, Soose RJ, Gillespie MB, et al.; STAR Trial Investigators. Three-year outcomes of cranial nerve stimulation for obstructive sleep apnea: the STAR trial. Otolaryngol Head Neck Surg 2016;154:181–188. 8. Schwartz AR, Bennett ML, Smith PL, et al. Therapeutic electrical stimula- tion of the hypoglossal nerve in obstructive sleep apnea. Arch Otolaryn- gol Head Neck Surg 2001;127:1216–1223. 9. Oliven A, O’Hearn DJ, Boudewyns A, et al, Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol 2003;95:2023–2029. 10. Heiser C, Maurer JT, Steffen A. Functional outcome of tongue motions with selective hypoglossal nerve stimulation in patients with obstructive sleep apnea. Sleep Breath 2016;20:553–560. 11. Mu L, Sanders I. Human tongue neuroanatomy: nerve supply and motor endplates. Clin Anat 2010;23:777–791. 12. Sanders I, Mu L. A three-dimensional atlas of human tongue muscles. Anat Rec 2013;296:1102–1114. 13. Bassiri Gharb BB, Tadisina KK, Rampazzo A, et al, Microsurgical anat- omy of the terminal hypoglossal nerve relevant for neurostimulation in obstructive sleep apnea. Neuromodulation 2015;18:721–728. 14. Heiser C, Hofauer B, Lozier L, et al. Nerve monitoring-guided selective hypoglossal nerve stimulation in obstructive sleep apnea patients. Laryngoscope 2016; Epub ahead of print. 15. Eggimann P, Waldvogel F. Pacemaker and defibrillator infection. In: Wald- vogel FA, Bisno AL, eds. Infections Associated With Indwelling Medical Devices Washington, DC: American Society for Microbiology Press; 2000:247. 16. Baddour L, Cha YM, Wilson W. Infections of cardiovascular implantable electronic devices. N Engl J Med 2012;367:842–849. 17. de Olivera JC, Martinelli M, Nishioka SA, et al. Efficacy of antibiotic pro- phylaxis before the implantation of pacemakers and cardioverter-defib- rillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol 2009;2:29–34.

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