Why stressed over 920-324 exam? Download 920-324 exam VCE | | Inicio RADIONAVES

Pass4sure 920-324 PDF and exam simulator are MUST HAVE for test prep It contains braindumps and practice test for new course contents - Pass4sure - - Inicio RADIONAVES

Pass4sure 920-324 dumps | Killexams.com 920-324 existent questions | http://www.radionaves.com/

920-324 Communication Server (CS) Rls. 4.0 Database Administrator

Study usher Prepared by Killexams.com Nortel Dumps Experts


Killexams.com 920-324 Dumps and existent Questions

100% existent Questions - Exam Pass Guarantee with tall Marks - Just Memorize the Answers



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

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

hints & tricks to certify 920-324 exam with unreasonable scores.
It ended up being a frail department of expertise to plot. I required a e-book which could kingdom query and respond and i without a doubt allude it. killexams.com Questions & answers are singularly in permeate of every final one in outright credits. a whole lot obliged killexams.com for giving nice conclusion. I had endeavored the exam 920-324 exam for 3 years continuously but couldnt gain it to passing score. I understood my hole in information the subject of creating a session room.


i am very satisfied with 920-324 exam manual.
Passing the 920-324 exam changed into simply not viable for me as I couldnt manipulate my preparation time rightly. Left with only 10 days to go, I referred the exam by way of killexams.com and it made my life smooth. subjects hold beenpresented nicely and was dealt nicely within the check. I scored a gorgeous 959. thanks killexams. i was hopeless however killexams.com given me hope and helped for passing when i was hopeless that i cant grow to live an IT licensed; my pal instructed me approximately you; I tried your on-line education gear for my 920-324 exam and become capable of accumulate a 91 bring about exam. I own thanks to killexams.


Get unreasonable rankings in diminutive time for education.
Passing the 920-324 exam was pretty tough for me until i used to live added with the question & solution via killexams. Some of the topics seemed very hard to me. Attempted lots to test the books, however failed as time was brief. Eventually, the promote off helped me apprehend the subjects and wrap up my instruction in 10 days time. Exquisite guide, killexams. My heartfelt manner to you.


it's miles splendid to hold 920-324 dumps.
920-324 exam became certainly difficult for me as i was no longer getting enough time for the coaching. finding no manner out, I took mitigate from the dump. I too took mitigate from professional Certification guide. The sell off was top notch. It handled outright the topics in an smooth and pleasant manner. could accumulate via most of them with diminutive effort. responded outright the query in only eighty one minutes and were given 97 mark. Felt virtually glad. thank you a lot to killexams.com for their valuable steering.


Great source of worthy 920-324 brain dumps, accurate answers.
I was about to give up exam 920-324 because I wasnt confident in whether I would pass or not. With just a week remaining I decided to switch to killexams.com QA for my exam preparation. Never thought that the topics that I had always Run away from would live so much fun to study; its facile and short way of getting to the points made my preparation lot easier. outright thanks to killexams.com QA, I never thought I would pass my exam but I did pass with flying colors.


save your time and money, examine these 920-324 and ensnare the exam.
Im opemarks into an IT organization and consequently I hardly ever find out any time to build together for 920-324 exam. Therefore, I stand up to an spotless discontinuance of killexams.com dumps. To my marvel it labored fondness wonders for me. I ought to resolve outright of the questions in least feasible time than provided. The questions seem to live pretty facile with improbable reference guide. I secured 939 marks which become without a doubt a wonderful wonder for me. Outstanding thanks to killexams!


Get those s and Go to vacations to build together.
Im impressed to leer the feedback that 920-324 braindump is up to date. The modifications are very unusual and that i did no longerassume to discover them everywhere. I simply took my first 920-324 exam so this one may live the next step. Gonna order quickly.


Take a smart move, obtain these 920-324 questions and answers.
This is to recount that I passed 920-324 exam the break day. This killexams.com questions solutions and exam simulator changed into very useful, and that i dont assume i might hold accomplished it without it, with simplest every week of steerage. The 920-324 questions are real, and this is exactly what I noticed within the check center. Moreover, this prep corresponds with outright the key problems of the 920-324 exam, so i used to live truly organized for a few questions that hold been barely different from what killexams.com provided, but on the equal problem live counted. But, I passed 920-324 and tickled approximately it.


Do you know the fastest manner to clear 920-324 examination? i hold were given it.
I dont feel lonely a mid exams any longer in light of the fact that I hold a magnificent study accomplice as this killexams.com dumps. I am exceptionally appreciative to the educators here for being so decent and well disposed and helping me in clearing my extremely exam 920-324. I solved outright questions in exam. This very direction was given to me amid my exams and it didnt gain a inequity whether it was day or night, outright my questions were replied.


got no hassle! 3 days training of 920-324 existent exam questions is required.
nicely, I did it and that i cant trust it. I can too want to in no way hold passed the 920-324 with out your help. My score became so immoderate i used to live amazed at my overall performance. Its simply due to you. Thank you very an entire lot!!!


Nortel Communication Server (CS) Rls.

Microsoft and Nortel gain Unified Communications obtainable to organizations outright over the state | killexams.com existent Questions and Pass4sure dumps

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

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

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

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

At NXTcomm08, Microsoft and Nortel will exhibit the hosted unified communications respond and parade its cost in bettering traffic agility. NXTcomm08 attendees can attain additional info by using journeying the Microsoft booths SL5916 and SL5923 and the Nortel booth SL3516. more information will too live found at http://www.microsoft.com/serviceproviders/nxtcomm08.

About Nortel

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

About Microsoft

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

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


Nortel Launches unusual VoIP Softswitch | killexams.com existent Questions and Pass4sure dumps

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

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

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

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

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

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

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


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

Nortel

NYSE : NTTSX : NT

Nortel

March 05, 2007 09:02 ET

CEO Mike Zafirovski Outlines Nortel UC vision at VoiceCon 2007

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

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

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

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

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

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

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

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

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

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

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

About Nortel

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

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

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


While it is very hard task to pick liable certification questions / answers resources with respect to review, reputation and validity because people accumulate ripoff due to choosing wrong service. Killexams.com gain it sure to serve its clients best to its resources with respect to exam dumps update and validity. Most of other's ripoff report complaint clients further to us for the brain dumps and pass their exams happily and easily. They never compromise on their review, reputation and property because killexams review, killexams reputation and killexams client self-confidence is primary to us. Specially they ensnare custody of killexams.com review, killexams.com reputation, killexams.com ripoff report complaint, killexams.com trust, killexams.com validity, killexams.com report and killexams.com scam. If you remark any wrong report posted by their competitors with the cognomen killexams ripoff report complaint internet, killexams.com ripoff report, killexams.com scam, killexams.com complaint or something fondness this, just hold in mind that there are always depraved people damaging reputation of safe services due to their benefits. There are thousands of satisfied customers that pass their exams using killexams.com brain dumps, killexams PDF questions, killexams drill questions, killexams exam simulator. Visit Killexams.com, their sample questions and sample brain dumps, their exam simulator and you will definitely know that killexams.com is the best brain dumps site.

Back to Braindumps Menu


000-399 test prep | 000-M50 existent questions | AHIMA-CCS drill test | 70-543-CSharp pdf download | 000-235 cram | M2150-768 questions answers | C2170-051 brain dumps | 000-875 braindumps | 920-132 free pdf download | 156-915-65 existent questions | M2065-659 dumps questions | ST0-066 study guide | M2010-720 drill test | 000-349 cheat sheets | 2VB-602 mock exam | M2040-671 questions and answers | 00M-227 dump | COG-605 drill questions | 920-259 dumps | A4040-124 drill questions |


Murder your 920-324 exam at first attempt!
killexams.com Nortel Certification keep publications are setup by means of IT experts. Lots of students had been complaining that there are too many questions in such a lot of drill assessments and exam guides, and they are just worn-out to hold enough money any more. Seeing killexams.com professionals work out this comprehensive version at the very time as nonetheless assure that every one the understanding is blanketed after deep studies and analysis.

Inside seeing the existent braindumps of the brain dumps at killexams.com you will gladden to know that every actual test is available here. For the IT professionals, they hold provided almost outright exam question with explanations and reference where applicable. they hold an approach to build it straightforward for their shoppers to hold certification test with the assist of killexams.com confirmed and sincere to goodness braindumps. For an excellent destiny in its space, their brain dumps are the satisfactory choice. killexams.com Discount Coupons and Promo Codes are as under; WC2017 : 60% Discount Coupon for outright exams on web site PROF17 : 10% Discount Coupon for Orders over $69 DEAL17 : 15% Discount Coupon for Orders over $99 SEPSPECIAL : 10% Special Discount Coupon for outright Orders A high-quality dumps making will live a basic piece that creates it honest for you to require Nortel certifications. In any case, 920-324 braindumps PDF offers agreement for candidates. The IT declaration will live a very primary robust enterprise if one does not discover actual route as obvious drill test. Thus, they hold got actual and updated dumps for the composition of certification test. At killexams.com, they provide completely verified Nortel 920-324 actual Questions and Answers that are simply needed for Passing 920-324 exam, and to induce certified with the assistance of 920-324 braindumps. they hold an approach to nearly assist people improve their understanding to memorize the and certify. It is a wonderful preference to spice up your profession as an expert within the business. Click http://killexams.com/pass4sure/exam-detail/920-324

High property 920-324 products: they hold their experts Team to ensure their Nortel 920-324 exam questions are always the latest. They are outright very intimate with the exams and testing center.

How they hold Nortel 920-324 exams updated?: they hold their special ways to know the latest exams information on Nortel 920-324. Sometimes they contact their partners who are very intimate with the testing headquarters or sometimes their customers will email us the most recent feedback, or they got the latest feedback from their dumps market. Once they find the Nortel 920-324 exams changed then they update them ASAP.

Money back guarantee?: if you really fail this 920-324 Communication Server (CS) Rls. 4.0 Database Administrator and don’t want to wait for the update then they can give you complete refund. But you should send your score report to us so that they can hold a check. They will give you complete refund immediately during their working time after they accumulate the Nortel 920-324 score report from you.

Nortel 920-324 Communication Server (CS) Rls. 4.0 Database Administrator Product Demo?: they hold both PDF version and Software version. You can check their software page to remark how it looks like.

killexams.com Huge Discount Coupons and Promo Codes are as under;
WC2017 : 60% Discount Coupon for outright exams on website
PROF17 : 10% Discount Coupon for Orders greater than $69
DEAL17 : 15% Discount Coupon for Orders greater than $99
DECSPECIAL : 10% Special Discount Coupon for outright Orders


When will I accumulate my 920-324 material after I pay?: Generally, After successful payment your username/password are sent at your email address within 5 min. But if there is any retard in bank side for payment authorization, then it takes diminutive longer.

920-324 | 920-324 | 920-324 | 920-324 | 920-324 | 920-324


Killexams 9L0-625 existent questions | Killexams HP2-B85 existent questions | Killexams HP3-045 questions and answers | Killexams MB2-184 exam questions | Killexams JN0-311 braindumps | Killexams 000-382 drill questions | Killexams EX0-100 bootcamp | Killexams A2040-410 drill test | Killexams 000-834 cheat sheets | Killexams 000-019 free pdf download | Killexams 922-072 free pdf | Killexams LOT-928 study guide | Killexams VCS-352 existent questions | Killexams CRCM examcollection | Killexams 300-101 drill exam | Killexams 7693X drill test | Killexams 70-569-VB exam prep | Killexams 000-085 questions and answers | Killexams HP5-B05D brain dumps | Killexams 9L0-508 pdf download |


Exam Simulator : Pass4sure 920-324 Exam Simulator

View Complete list of Killexams.com Brain dumps


Killexams 000-317 braindumps | Killexams 000-101 VCE | Killexams 922-095 mock exam | Killexams 156-315-76 existent questions | Killexams C2180-181 bootcamp | Killexams UM0-200 questions and answers | Killexams 132-S-916.2 cheat sheets | Killexams 156-115.77 existent questions | Killexams HPE2-T22 drill test | Killexams HP0-A113 examcollection | Killexams 00M-645 test prep | Killexams HPE0-S48 braindumps | Killexams 250-255 drill Test | Killexams 70-354 free pdf | Killexams 1Z0-932 exam prep | Killexams 1Z0-102 study guide | Killexams E20-005 drill test | Killexams HP2-E21 brain dumps | Killexams 4A0-106 study guide | Killexams 300-135 brain dumps |


Communication Server (CS) Rls. 4.0 Database Administrator

Pass 4 sure 920-324 dumps | Killexams.com 920-324 existent questions | http://www.radionaves.com/

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

The purpose of the Society of Anesthesia and Sleep Medicine (SASM) Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on the available scientific evidence. In light of a paucity of well-designed, high-quality studies in this perioperative field, a large piece of the present recommendations was developed by experts in the realm taking into account published evidence in the literature and utilizing consensus processes, including the grading of the level 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 live suitable for outright clinical settings and patients. Thus, its consideration requires an assessment of appropriateness by clinicians on an individualized basis. Among many factors, the existence of institutional protocols, individual patient-related conditions, the invasiveness of an intervention, and the availability of resources need to live considered. The present drill guideline is not intended to define standards or limn absolute requirements for patient care. Adherence to this guideline cannot guarantee successful outcomes but rather should aid health custody professionals and institutions to formulate plans for improved management of patients with OSA. The present recommendations reflect the current state of erudition and its interpretation by a group of experts in the realm at the time of publication. fitful reevaluations of the literature will live needed, and novel scientific evidence should live considered between updates. Deviations from this guideline in the practical setting may live justifiable, and such deviations should not live interpreted as a basis for negligence claims.

OSA is a common and frequently undiagnosed disorder defined by the repeated collapse of the upper airway with resultant blood oxygen desaturation events during sleep.1,2 OSA has been associated with adverse long-term health outcomes and has been linked to increased perioperative complication risk.3–5 Indeed, a comprehensive review of the literature performed by a task compel appointed by SASM revealed substantial risk for adverse events, especially pulmonary complications, to live 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 live made to appropriately identify patients with OSA, with the goal to raise awareness among providers, mitigate risk, and improve 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 lack of evidence-based drill 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 large amount of related literature in this arena, this study focuses only on intraoperative patient care. Postoperative custody issues are not considered and may live the subject of future projects.

What Other Guidelines and Reviews Are Available?

Previous OSA-related drill 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 task compel on best drill recommendations for the anesthetic perioperative custody and stitch management in weight loss surgery.14

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

This guideline was developed to provide evidence-based recommendations for the intraoperative management of patients with OSA. Therefore, a heedful examination of the current literature using a systematic review approach with a focus on airway management, commonly used anesthesia-related drugs and agents, and anesthetic techniques in this patient population was conducted. The task compel 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 lack of evidence in this context, statements were made referring to patients with OSA as a universal group. Nevertheless, phenotypic subcategorization may allow the evolution of individual risk profiling in the future.

Aims

The train 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 spend of anesthetic medications, making it difficult to single out specific factors that potentially drive the adverse outcome. lack of preoperative polysomnography data within publications represents a further challenge, making it difficult to include information of the impact of disease severity. Ethical considerations in study designs regarding the randomization of patients with known OSA were additional obstacles in this context. Furthermore, the task compel recognizes that there is a tendency to underreport medical complications, rendering it difficult to establish the just perioperative risk.16 Presenting the current available evidence and its limitations should raise awareness regarding the need 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 impact of individual anesthesia-related drugs and agents in the custody 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 sufficient published evidence, the task compel 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 lack of evidence on which to foundation recommendations for these specific populations.

GUIDELINE TASK FORCE

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

METHODS Research Questions

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

Literature Search Strategy

With the mitigate 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 outright 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 spend in Patients With OSA, http://links.lww.com/AA/C376; Supplemental Digital Content 5, Search Strategy NMBA, http://links.lww.com/AA/C377.

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

Study Selection

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

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

Exclusion Criteria.

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

Level of Evidence and Recommendations

The Oxford level of Evidence (Oxford LOE) tool was utilized to evaluate the property of evidence of individual studies.18 Grading the strength of recommendations and property of the underlying evidence enhances the usefulness of clinical drill guidelines.19 Therefore, the approach according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system20,21 was utilized with regard to the carcass 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 include study methodology, consistency and precision of results, and directness of evidence.19 These levels were assigned to the carcass of evidence of each respective recommendation within their focus zone and reflect the self-confidence in estimates of the just effect.21 When affecting from evidence to recommendations, the GRADE approach focuses on 4 factors: poise between capitalize and harm, assurance of evidence, values and preferences, and resource considerations.22 The strength of recommendation is separated into strong and weak and defines the extent to which one can live confident that the desirable consequences outweigh its undesirable consequences (Table 2).23

In-person SASM Intraoperative Guideline Task compel meetings took state 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 state throughout this time period. introductory results and implications of findings were presented and discussed at the 2017 SASM annual meeting in Boston, MA.

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

    Rationale

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

    Association Between OSA and Difficult Airway Management

    After applying the designated search strategy and removing duplicates, 4806 references were screened for title and/or abstract. After reviewing 25 full-text articles, 16 studies were identified as reporting on the association between difficult airway management and OSA, while 9 studies were excluded.40–47 A detailed 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 need 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 impact 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 impact 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. detailed data, analysis, and results on the association between OSA and difficult airway will live reported in a separate systematic review with meta-analysis by the SASM airway focus group (members listed in acknowledgments).

    One prospective controlled study34 reported on the spend of the LMA Unique® (Teleflex Incorporated, Morrisville, NC), and an additional retrospective investigation27 reported on a separate unspecified supraglottic airway device. No significant association was found 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, found 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 define 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 shape of failure to reintubate in the postoperative period.49 erudition about the association between OSA and difficult airway may improve perioperative airway management and abate airway-related complications.

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

    2. INTRAOPERATIVE MEDICATION spend IN PATIENTS WITH OSA

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

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

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

    Rationale.

    NMBAs are commonly used to optimize intubation conditions and provide surgical relaxation for various procedures. However, residual neuromuscular blockade has been reported to occur in ≤64% of patients in postanesthesia custody units.57 The spend 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 live at higher risk for postoperative respiratory complications due to the adverse effects of postoperative residual neuromuscular blockade compared to patients without OSA. Moreover, it is uncertain whether the type of reversal agent impacts the risk of postoperative complications in patients with OSA. Patients with suspected61 or confirmed50,63,64 OSA hold been shown to live 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 spend 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 enlarge vulnerability to the effects of residual neuromuscular blockade on the upper airway and pharyngeal function.

    Our literature search yielded 5 studies that were heterogeneous in terms of study design, types of surgery, and types of respiratory complications.65–69 Many studies were excluded because OSA diagnosis or spend 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 spend of NMBA compared to patients without OSA. Although the level of evidence was limited (Oxford LOE 2–3), the studies suggest that patients with OSA who received NMBA may live at increased risk of effects of residual neuromuscular blockade, postoperative respiratory failure, and hypoxemia.65–67 The results of their review are consistent with previous studies showing that patients with OSA are at higher risk of postoperative respiratory failure and hypoxemia than patients without OSA.6,61,70,71 Even partial residual neuromuscular blockade that does not educe respiratory symptoms can impair upper airway dilator muscle function.72 Minimizing the spend and dose of NMBA, monitoring the level of neuromuscular blockade, and complete reversal of NMBA before extubation may live particularly primary 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 abate the incidence of residual paralysis compared to the anticholinesterase inhibitor, neostigmine.74 A recent Cochrane review of 41 studies comparing sugammadex with neostigmine concluded that patients receiving sugammadex versus neostigmine had 40% fewer composite adverse events (bradycardia, postoperative nausea and vomiting, and residual neuromuscular blockade).75 Patients receiving sugammadex had less desaturation and need for transitory oxygen supplementation; however, the OSA status was not reported in these reviews, limiting its value to assess its differential outcome in this subpopulation.74,75

    There are limited studies comparing the impact 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) found 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 inequity 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 inequity in clinical outcomes.69

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

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

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

    Rationale.

    While opioids are highly effectual in treating moderate to severe 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 usher safe opioid drill in this population is limited.76

    Nevertheless, despite limitations with respect to the property of evidence suggesting an adverse impact of acute opioid administration in OSA, current literature indicates that a heightened concern regarding opioid spend in this population may live 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 impact of systemic opioid spend in OSA were identified. While the majority demonstrated an association between opioid spend and adverse perioperative outcomes in OSA,61,77–89 this was not confirmed by all.66,90,91 It should live notable that, particularly among observational analyses, there is notable heterogeneity with regard to the modality of OSA assessment, ranging from the gold standard of polysomnography to identification by screening questionnaires or patient history. Furthermore, potential selection jaundice should live considered in these studies. In recent publications, a comparison of postoperative complications among patients with and without OSA within the very 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 impact of opioid dose enlarge within patients with OSA demonstrated an associated enlarge in the odds for gastrointestinal complications, prolonged length of stay, and increased hospital cost, while no further enlarge in risk for pulmonary complications was observed, possibly due to increased levels of monitoring afforded to this population.88 A higher incidence of postoperative complications in OSA versus non-OSA in this context was too found by Blake et al77 and Esclamado et al,80 while the latter conducted their study in upper airway surgery, a procedure with a potentially inherent influence on respiratory outcome.80

    Chung et al79 demonstrated an opioid dose-dependent postoperative worsening of sleep-disordered breathing associated with the severity of OSA (expressed by AHI), although this outcome may hold been fairly small. manful 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 episode 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 live established as an independent risk factor.66,85 However, a factor potentially causing an underestimation of a viable deleterious outcome of OSA was the postoperative spend 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 spend 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 regard 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 live notable that opioid reduction may abate respiratory depression and related complications in the universal population as well.92 Using a nonvalidated OSA prediction instrument, Blake et al95 showed that central apneas and respiratory events were related to the dose of morphine administered postoperatively. However, differences in the episode of respiratory complications between patients with standard morphine patient-controlled analgesia and an opioid-sparing regimen could not live established.95

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

    In summary, limited literature suggests that patients with OSA may live at increased risk for opioid-related respiratory adverse events. However, high-quality evidence to support 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 stitch 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 primary 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 primary 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 stitch in subjects suffering from OSA, 1 study found that patients with OSA and comorbid temporomandibular joint disorder experienced hypoalgesia to pressure-related pain,109 while another reported a significant enlarge in stitch threshold after restoring sleep continuity with the application of CPAP therapy.110 In contrast, the third investigation found 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 confirmed pain, a retrospective analysis of prospectively collected data from the Cleveland Family Study showed that confirmed intermittent hypoxia was associated with more frequent confirmed stitch complaints, even after adjusting for the potentially hyperalgesic outcome of sleep fragmentation and systemic inflammation.112

    Despite the primary goal to focus on the adult patient population in this guideline, a significant amount of evidence originates from the pediatric population and deserves mention here particularly because they note contradictory findings to those found 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 very population did not corroborate these findings.115,116 In the first study, African American children versus Caucasian children with OSA presented with more stitch 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 too demonstrated a higher incidence of opioid-related respiratory complications.116

    In adults, 1 retrospective analysis found 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 spend in universal surgical patients with OSA.118 A more detailed and comprehensive summary of evidence on the potential impact of acute opioid analgesia in OSA is provided in a separate systematic review by the SASM opioids focus group (members listed in the acknowledgments).

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

    Rationale.

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

    Propofol is the most commonly used agent for DISE.119,120 A summary of findings from 5 studies120–124 is shown in Supplemental Digital Content, Table A4, http://links.lww.com/AA/C373 (Oxford LOE: 2–4). Both carcass mass index (BMI) and severity of OSA correlated with a greater likelihood of a patient having multiple sites of airway collapse and a higher possibility of circumferential and total airway obstruction during DISE.119,125 The goal of propofol administration for DISE is to produce 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 live 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 Uncertainty regarding dosing scalar adjustments that may live required in patients with obesity, as well as the concomitant spend of depressant drugs with synergistic effects (midazolam,131 ketamine,132,133 dexmedetomidine,134 opioids135), further add to the need for heightened vigilance when using propofol for patients with OSA. Propofol has a relatively steep dose-response curve compared to other sedatives/hypnotics, thus underscoring the significance of heedful 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, manful gender, American Society of Anesthesiologists physical status ≥III, initial dose of propofol, and increased age were found to live independent risk factors for hypoxemic incidents. Airway interventions were common in patients receiving propofol, although indications for airway intervention were left to the discretion of the anesthesia provider. Whether precautionary or subsequent to an obstructed airway, apneic, or desaturation episode, such airway interventions were undoubtedly done to prevent or mitigate a sedation-related adverse event. The spend of capnography was associated with a decreased incidence of hypoxic events compared to standard monitoring lonely during sedation with propofol144 in patients with OSA.140

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

    Rationale.

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

    This renders the term of emergence and recovery from anesthesia of 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 live associated with a faster recovery from anesthesia and improved postoperative respiratory control in 2 RCTs.154,155 However, sevoflurane was found to live 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 inequity with regard 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 spend of propofol impaired pulmonary office and SpO2 to a greater degree than desflurane,157 while another could not corroborate these differences.156 Thus, current evidence indicates that sevoflurane and desflurane might live 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 favorable 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 custody unit stay, and hospital length of stay when compared to isoflurane within a long-acting regimen. This analysis emphasized the colorable capitalize of generally utilizing short-acting medications with regard to outright anesthetic drug classes, including opioids and NMBA, among patients at higher perioperative risk.65 The majority of studies, however, focused on the comparative effectiveness between sevoflurane and desflurane,161,163,165,167 demonstrating improved anesthesia recovery with desflurane (Oxford LOE: 2).162,164,166,168,169,174 Notably, limitations inherent to the nature of these comparisons can prevent the detection of differences. For instance, Eger and Shafer175 showed that differences in postoperative wake-up times among anesthetics were minimal at lower anesthetic concentrations,175 while the duration of anesthesia176 and BMI present primary 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 small clinical trial by Juvin et al170 too compared desflurane, isoflurane, and propofol together in 1 analysis. Both Liu et al171 and Juvin et al170 established desflurane as the most favorable 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 cognomen 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 too been observed in the universal population.177–180

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

    These properties, in turn, imply earlier achievement of baseline respiratory office with potentially better protection against aspiration and improved oxygenation.183 This has too 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 serious hypoxemia,184 thus suggesting a capitalize associated with early and rapid recovery of dynamic airway control and alertness.171

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

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

    In summary, the available evidence supports the spend of desflurane and sevoflurane in patients with obesity (Oxford LOE: 2). Given the strong 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 live made.

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

    Rationale.

    The literature is scarce with regard 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 spend in patients with OSA, but data are insufficient to draw any hard 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, import >0.5 mg/kg boluses and 100 µg/kg/h infusions.193

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

    Furthermore, Drummond196 studied the outcome of ketamine versus midazolam on upper airway function. Interestingly, they found 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 live increased after administration of tall and low doses of ketamine in rats.197 Upper airway dilator muscle activity plays an primary role in patients who are at risk of upper airway obstruction. Despite the lack of data on ketamine in the patient population with OSA, available information suggests that these patients could capitalize from potentially favorable respiratory effects over other sedatives. hard conclusions, however, cannot live drawn at this time.

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

    Rationale.

    Although the literature is immature on the topic of differential effects of intravenous benzodiazepine sedation in patients with OSA compared to those without OSA, studies suggest that the spend 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 spend 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 safe option to study obstructive events in patients with OSA.102,105

    Interestingly, Sadaoka et al209 found 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 spend 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. outright patients with OSA had desaturation events after 2 mg of midazolam, but no one at all 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 vigorous 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
  • 2.7.1 Question: Are patients with OSA at increased risk for adverse events from the spend of α-2 agonists?
  • 2.7.1 Recommendation: There is a lack of evidence to assess adverse effects of α-2 agonists in the OSA population.
  • Level of evidence: Low; Grade of recommendation: No recommendation

    Rationale.

    Dexmedetomidine and clonidine are centrally acting α-2 agonists with sedative, analgesic, and sympatholytic properties. Dexmedetomidine, in particular, has been suggested to antecedent minimal respiratory depression. Because OSA is associated with an increased risk of adverse postoperative pulmonary events,6 the potentially favorable respiratory profile and analgesic-sparing effects theoretically gain α-2 agonists appealing for this population. When assessing the risk of adverse events with the spend 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 spend of α-2 agonists to either placebo or other medications. The carcass of literature is limited by a small total number of subjects, incongruous results, lack 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 spend of dexmedetomidine to propofol in DISE as summarized in Supplemental Digital Content, Table A10, http://links.lww.com/AA/C373 (propofol in DISE has too been discussed in Section 2.3). In a series by Capasso et al,123 patients receiving propofol had a significantly increased likelihood of complete tongue 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 abate in respiratory rate and lower SpO2 with propofol compared to dexmedetomidine.124,221 In the study by Cho et al,220 weigh in 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 weigh in arterial pressure (MAP) but lower weigh in 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. weigh in 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 yield 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 live due to drug outcome rather than reflective of the natural sleep state. Consequently, additional investigation is necessary to ascertain the optimal sedative in DISE.

    Other Procedures.

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

    Two studies reported respiratory outcomes during sedation procedures. In a descriptive series of 20 patients at 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 spend resulted in lower desaturation incidence, higher SpO2 at most time points, and lower rates of airway obstruction.223

    Data are limited regarding respiratory effects of dexmedetomidine in the postoperative recovery period. A descriptive series of bariatric patients reported adequate saturations with supplemental oxygen without the need for CPAP.224 Studies with quantitative data suggest that intraoperative spend of dexmedetomidine may not touch 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 severe and less frequent cough during extubation and less respiratory depression compared to the propofol group.226 Finally, in a retrospective review comparing patients undergoing airway reconstruction surgery who received dexmedetomidine versus those who did not, neither group required interventions for airway compromise.227

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

    The hemodynamic effects of α-2 agonists were assessed according to varied outcome measures, including vital sign measurements, categorical descriptors, and need 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 inequity to controls was observed in 2 other studies.231,232 Chawla et al227 reported transient loading dose hypertension followed by “titratable, controlled hypotension, and bradycardia.” Three studies223,227,231 demonstrated less frequent spend 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 need for phenylephrine support in patients receiving dexmedetomidine.231 In studies reporting the need 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 too characterized outcomes according to categorical variables and found 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 outright 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 inequity compared to control patients,231 and another showed increased time to extubation.93 One series described prolonged drowsiness with dexmedetomidine,134 while another study showed no inequity in sedation score compared to control patients.93 discontinuance points related to postoperative nausea/vomiting were examined in 1 observational study225 and 3 RCTs.93,226,231

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

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

    Rationale

    A wide sweep of literature and earlier guidelines hold favored the spend of regional anesthesia techniques and multimodal analgesic approaches among patients with OSA despite diminutive scientific evidence to support 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 regard to comparative effectiveness between universal and regional anesthesia specifically in patients with OSA, 6 observational studies were identified.61,235–239 A summary of evidence is provided in Supplemental Digital Content, Table A12, http://links.lww.com/AA/C373. Overall, studies indicated that the utilization of regional as opposed to universal anesthesia would improve postoperative outcome.79,235–239 The largest population-based analysis included >30,000 patients with OSA from >400 US hospitals undergoing joint arthroplasty procedures.235 Adjusted risk of numerous major complications was significantly lower in patients with OSA who received neuraxial anesthesia versus universal anesthesia. Furthermore, the addition of neuraxial to universal anesthesia versus the spend of universal anesthesia lonely was associated with improved outcome profiles. Additionally, the utilization of peripheral nerve blocks was associated with decreased odds for mechanical ventilation, censorious custody admissions, and prolonged hospital length of stay.235

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

    Given the necessity of airway manipulation under universal anesthesia, other challenges inherent to OSA should live considered as well. The higher risk for a difficult airway in OSA has been discussed in Section 1. However, challenges with regard to airway complications in patients with OSA emerge to too 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 live driven by upper airway obstruction.240,241 Recently, Ramachandran et al61 showed that OSA was an independent predictor of respiratory complications and unplanned intubation after universal anesthesia.

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

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

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

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

    The SASM task compel 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: brand 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 fondness 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, unusual York, NY; Bridget Jivanelli, Kim Barrett Memorial Library, Hospital for Special Surgery, unusual York, NY; Eva E. Mörwald, MD, Department of Anesthesiology, Perioperative Medicine and Intensive custody 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 stitch Management, Beth Israel Deaconess Medical Center, Boston, MA; Sarah M. Weinstein, BA, Department of Anesthesiology, Hospital for Special Surgery, unusual York, NY.

    DISCLOSURES

    Name: Stavros G. Memtsoudis, MD, PhD.

    Contribution: This author helped design the study, conduct the study, analyze 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 stitch 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 one at all of these relations influenced the conduct of the present study.

    Name: Crispiana Cozowicz, MD.

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

    Conflicts of Interest: None.

    Name: Mahesh Nagappa, MD.

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

    Conflicts of Interest: None.

    Name: Jean Wong, MD, FRCPC.

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

    Conflicts of Interest: None.

    Name: Anthony G. Doufas, MD, PhD.

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

    Conflicts of Interest: None.

    Name: Meltem Yilmaz, MD.

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

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

    Name: brand H. Stein, MD.

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

    Conflicts of Interest: None.

    Name: Megan L. Krajewski, MD.

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

    Conflicts of Interest: None.

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

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

    Conflicts of Interest: None.

    Name: Lukas Pichler, MD.

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

    Conflicts of Interest: None.

    Name: Satya Krishna Ramachandran, MD.

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

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

    Name: Frances Chung, MBBS, FRCPC.

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

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

    This manuscript was handled by: David Hillman, MD.

    REFERENCES 1. Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the universal population: the HypnoLaus study. Lancet Respir Med. 2015;3:310–318. 2. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177:1006–1014. 3. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–1053. 4. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353:2034–2041. 5. Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg. 2011;112:113–121. 6. Opperer M, Cozowicz C, Bugada D, et al. does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the Society of Anesthesia and Sleep Medicine Task compel on Preoperative Preparation of Patients With Sleep-Disordered Breathing. Anesth Analg. 2016;122:1321–1334. 7. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of anesthesia and sleep medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123:452–473. 8. unbecoming JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task compel on Perioperative Management. drill guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task compel on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104:1081–1093. 9. unbecoming JB, Apfelbaum JL, Caplan RA, et al. drill guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task compel on Perioperative Management of Patients With Obstructive Sleep Apnea. Anesthesiology. 2014;120:268–286. 10. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115:1060–1068. 11. Meoli AL, Rosen CL, Kristo D, et al; Clinical drill Review Committee; American Academy of Sleep Medicine. Upper airway management of the adult patient with obstructive sleep apnea in the perioperative period–avoiding complications. Sleep. 2003;26:1060–1065. 12. Seet E, Chung F. Management of sleep apnea in adults: functional algorithms for the perioperative period: continuing professional development. Can J Anaesth. 2010;57:849–864. 13. de Raaff CAL, Gorter-Stam MAW, de Vries N, et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis. 2017;13:1095–1109. 14. Schumann R, Jones SB, Cooper B, et al. Update on best drill recommendations for anesthetic perioperative custody and stitch management in weight loss surgery, 2004-2007. Obesity (Silver Spring). 2009;17:889–894. 15. Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea: identification of novel therapeutic targets. Am J Respir Crit custody Med. 2013;188:996–1004. 16. Leape LL. Reporting of adverse events. N Engl J Med. 2002;347:1633–1638. 17. Innovation VH. Covidence systematic review software. Melbourne, Australia. 19. Schünemann HJ, Jaeschke R, Cook DJ, et al; ATS Documents evolution and Implementation Committee. An official ATS statement: grading the property of evidence and strength of recommendations in ATS guidelines and recommendations. Am J Respir Crit custody Med. 2006;174:605–614. 20. Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: an emerging consensus on rating property of evidence and strength of recommendations. BMJ. 2008;336:924–926. 21. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the property of evidence. J Clin Epidemiol. 2011;64:401–406. 22. Neumann I, Santesso N, Akl EA, et al. A usher for health professionals to interpret and spend recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016;72:45–55. 23. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66:719–725. 24. Hiremath AS, Hillman DR, James AL, Noffsinger WJ, Platt PR, Singer SL. Relationship between difficult tracheal intubation and obstructive sleep apnoea. Br J Anaesth. 1998;80:606–611. 25. Siyam MA, Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg. 2002;95:1098–1102. 26. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–736. 27. Sabers C, Plevak DJ, Schroeder DR, Warner DO. The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery. Anesth Analg. 2003;96:1328–1335. 28. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105:885–891. 29. Chung F, Yegneswaran B, Herrera F, Shenderey A, Shapiro CM. Patients with difficult intubation may need referral to sleep clinics. Anesth Analg. 2008;107:915–920. 30. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110:891–897. 31. Shah PN, Sundaram V. Incidence and predictors of difficult mask ventilation and intubation. J Anaesthesiol Clin Pharmacol. 2012;28:451–455. 32. Toshniwal G, McKelvey GM, Wang H. STOP-Bang and prediction of difficult airway in obese patients. J Clin Anesth. 2014;26:360–367. 33. Acar HV, Yarkan Uysal H, Kaya A, Ceyhan A, Dikmen B. Does the STOP-Bang, an obstructive sleep apnea screening tool, predict difficult intubation? Eur Rev Med Pharmacol Sci. 2014;18:1869–1874. 34. Ramachandran SK, Mathis MR, Tremper KK, Shanks AM, Kheterpal S. Predictors and clinical outcomes from failed Laryngeal Mask Airway Unique™: a study of 15,795 patients. Anesthesiology. 2012;116:1217–1226. 35. Kim JA, Lee JJ. Preoperative predictors of difficult intubation in patients with obstructive sleep apnea syndrome. Can J Anaesth. 2006;53:393–397. 36. Cattano D, Killoran P, Cai C, Katsiampoura AD, Corso RM, Hagberg CA. Difficult mask ventilation in universal surgical population: observation of risk factors and predictors. F1000Res. 2014;3:1–9. 37. Kheterpal S, Healy D, Aziz MF, et al; Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119:1360–1369. 38. Gokay P, Tastan S, Orhan ME. Is there a inequity between the STOP-BANG and the Berlin Obstructive Sleep Apnoea Syndrome questionnaires for determining respiratory complications during the perioperative period? J Clin Nurs. 2016;25:1238–1252. 39. Corso RM, Petrini F, Buccioli M, et al. Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery. Minerva Anestesiol. 2014;80:877–884. 40. Aceto P, Perilli V, Modesti C, Ciocchetti P, Vitale F, Sollazzi L. Airway management in obese patients. Surg Obes Relat Dis. 2013;9:809–815. 41. Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiol Clin North America. 2002;20:789–811. 42. Biro P, Bloch KE. Case reports patient with obstructive sleep and difficult airway access. 1995;180:417–421. 43. Corso RM, Cattano D, Buccioli M, Carretta E, Maitan S. Post analysis simulated correlation of the El-Ganzouri airway rigor score with difficult airway. Braz J Anesthesiol. 2016;66:298–303. 44. Hukins C. Mallampati class is not useful in the clinical assessment of sleep clinic patients. J Clin Sleep Med. 2010;6:545–549. 45. Kim MK, Park SW, Lee JW. Randomized comparison of the Pentax AirWay Scope and Macintosh laryngoscope for tracheal intubation in patients with obstructive sleep apnoea. Br J Anaesth. 2013;111:662–666. 46. Neligan PJ, Porter S, Max B, Malhotra G, Greenblatt EP, Ochroch EA. Obstructive sleep apnea is not a risk factor for difficult intubation in morbidly obese patients. Anesth Analg. 2009;109:1182–1186. 47. Cattano D, Katsiampoura A, Corso RM, Killoran P, Cai C, Hagberg CA. Predictive factors for difficult mask ventilation in the obese surgical population. F1000Research. 2014:1–11. 48. Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang Questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One. 2015;10:e0143697. 49. Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature. Anesth Analg. 2016;122:145–151. 50. Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth. 2012;109:897–906. 51. Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth. 2014;26:591–600. 52. Ankichetty S, Wong J, Chung F. A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea. J Anaesthesiol Clin Pharmacol. 2011;27:447–458. 53. Hillman DR, Chung F. Anaesthetic management of sleep-disordered breathing in adults. Respirology. 2017;22:230–239. 54. McNicholas WT, Ryan S. Obstructive sleep apnoea syndrome: translating science to clinical practice. Respirology. 2006;11:136–144. 55. Ciscar MA, Juan G, Martínez V, et al. Magnetic resonance imaging of the pharynx in OSA patients and vigorous subjects. Eur Respir J. 2001;17:79–86. 56. Ehsan Z, Mahmoud M, Shott SR, Amin RS, Ishman SL. The effects of anesthesia and opioids on the upper airway: a systematic review. Laryngoscope. 2016;126:270–284. 57. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. piece I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111:120–128. 58. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and censorious respiratory events in the postanesthesia custody unit. Anesth Analg. 2008;107:130–137. 59. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM. Nondepolarizing neuromuscular blocking agents, reversal, and risk of postoperative pneumonia. Anesthesiology. 2016;125:647–655. 60. Thevathasan T, Shih SL, Safavi KC, et al. Association between intraoperative non-depolarising neuromuscular blocking agent dose and 30-day readmission after abdominal surgery. Br J Anaesth. 2017;119:595–605. 61. Ramachandran SK, Pandit J, Devine S, Thompson A, Shanks A. Postoperative respiratory complications in patients at risk for obstructive sleep apnea: a single-institution cohort study. Anesth Analg. 2017;125:272–279. 62. Fuchs-Buder T, Nemes R, Schmartz D. Residual neuromuscular blockade: management and impact on postoperative pulmonary outcome. Curr Opin Anaesthesiol. 2016;29:662–667. 63. Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample. Obes Surg. 2013;23:1842–1851. 64. Memtsoudis SG, Stundner O, Rasul R, et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg. 2014;118:407–418. 65. Sudré EC, de Batista PR, Castiglia YM. Longer immediate recovery time after anesthesia increases risk of respiratory complications after laparotomy for bariatric surgery: a randomized clinical trial and a cohort study. Obes Surg. 2015;25:2205–2212. 66. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107:138–143. 67. Pereira H, Xará D, Mendonça J, Santos A, Abelha FJ. Patients with a tall risk for obstructive sleep apnea syndrome: postoperative respiratory complications. Rev Port Pneumol. 2013;19:144–151. 68. Ünal DY, Baran İ, Mutlu M, Ural G, Akkaya T, Özlü O. Comparison of sugammadex versus neostigmine costs and respiratory complications in patients with obstructive sleep apnoea. Turk J Anaesthesiol Reanim. 2015;43:387–395. 69. Llauradó S, Sabaté A, Ferreres E, Camprubí I, Cabrera A. Postoperative respiratory outcomes in laparoscopic bariatric surgery: comparison of a prospective group of patients whose neuromuscular blockade was reverted with sugammadex and a historical one reverted with neostigmine. Rev Esp Anestesiol Reanim. 2014;61:565–570. 70. Dowidar AE-RM, Basuni AS, EL-kalla RS, Eid GM. Influence of severity of obstructive sleep apnea on postoperative pulmonary complications in patients undergoing gastroplasty. Tanta Med J. 2016;44:58. 71. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth. 2009;56:819–828. 72. Eikermann M, Vogt FM, Herbstreit F, et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit custody Med. 2007;175:9–15. 73. Abrishami A, Ho J, Wong J, Yin L, Chung F. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Database Syst Rev. 2009:Cd007362. 74. Abad-Gurumeta A, Ripollés-Melchor J, Casans-Francés R, et al; Evidence Anaesthesia Review Group. A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade. Anaesthesia. 2015;70:1441–1452. 75. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8:CD012763. 76. Doufas A. Obstructive sleep apnea, pain, and opioid analgesia in the postoperative patient. Curr Anesthesiol Rep. 2014;4:1–9. 77. Blake DW, Chia PH, Donnan G, Williams DL. Preoperative assessment for obstructive sleep apnoea and the prediction of postoperative respiratory obstruction and hypoxaemia. Anaesth Intensive Care. 2008;36:379–384. 78. Bolden N, Smith CE, Auckley D, Makarski J, Avula R. Perioperative complications during spend of an obstructive sleep apnea protocol following surgery and anesthesia. Anesth Analg. 2007;105:1869–1870. 79. Chung F, Liao P, Elsaid H, Shapiro CM, Kang W. Factors associated with postoperative exacerbation of sleep-disordered breathing. Anesthesiology. 2014;120:299–311. 80. Esclamado RM, Glenn MG, McCulloch TM, Cummings CW. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope. 1989;99:1125–1129. 81. Etches RC. Respiratory depression associated with patient-controlled analgesia: a review of eight cases. Can J Anaesth. 1994;41:125–132. 82. Lee LA, Caplan RA, Stephens LS, et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122:659–665. 83. Melamed R, Boland LL, Normington JP, et al. Postoperative respiratory failure necessitating transfer to the intensive custody unit in orthopedic surgery patients: risk factors, costs, and outcomes. Perioper Med (Lond). 2016;5:19. 84. Ramachandran SK, Haider N, Saran KA, et al. Life-threatening censorious respiratory events: a retrospective study of postoperative patients found unresponsive during analgesic therapy. J Clin Anesth. 2011;23:207–213. 85. Weingarten TN, Hawkins NM, Beam WB, et al. Factors associated with prolonged anesthesia recovery following laparoscopic bariatric surgery: a retrospective analysis. Obes Surg. 2015;25:1024–1030. 86. Weingarten TN, Herasevich V, McGlinch MC, et al. Predictors of delayed postoperative respiratory depression assessed from naloxone administration. Anesth Analg. 2015;121:422–429. 87. Weingarten TN, Chong EY, Schroeder DR, Sprung J. Predictors and outcomes following naloxone administration during side I anesthesia recovery. J Anesth. 2016;30:116–122. 88. Mörwald EE, Olson A, Cozowicz C, Poeran J, Mazumdar M, Memtsoudis SG. Association of opioid prescription and perioperative complications in obstructive sleep apnea patients undergoing total joint arthroplasties. Sleep Breath. 2018;22:115–121. 89. Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of censorious complications. Br J Anaesth. 2017;119:885–899. 90. Madani M. Effectiveness of Stadol NS (butorphanol tartrate) with ibuprofen in the treatment of stitch after laser-assisted uvulopalatopharyngoplasty. J Oral Maxillofac Surg. 2000;58:27–31. 91. Wang D, Somogyi AA, Yee BJ, et al. The effects of a single mild dose of morphine on chemoreflexes and breathing in obstructive sleep apnea. Respir Physiol Neurobiol. 2013;185:526–532. 92. Cozowicz C, Olson A, Poeran J, et al. Opioid prescription levels and postoperative outcomes in orthopedic surgery. Pain. 2017;158:2422–2430. 93. Abdelmageed WM, Elquesny KM, Shabana RI, Abushama HM, Nassar AM. Analgesic properties of a dexmedetomidine infusion after uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Saudi J Anaesth. 2011;5:150–156. 94. Bernards CM, Knowlton SL, Schmidt DF, et al. Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology. 2009;110:41–49. 95. Blake DW, Yew CY, Donnan GB, Williams DL. Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesth Intensive Care. 2009;37:720–725. 96. Huang HC, Lee LA, Fang TJ, Li HY, Lo CC, Wu JH. Transnasal butorphanol for stitch relief after uvulopalatopharyngoplasty: a hospital-based, randomized study. Chang Gung Med J. 2009;32:390–399. 97. Lee LA, Wang PC, Chen NH, et al. Alleviation of wound stitch after surgeries for obstructive sleep apnea. Laryngoscope. 2007;117:1689–1694. 98. Yang L, Sun DF, Wu Y, Han J, Liu RC, Wang LJ. Intranasal administration of butorphanol benefits aged patients undergoing H-uvulopalatopharyngoplasty: a randomized trial. BMC Anesthesiol. 2015;15:20. 99. Orlov D, Ankichetty S, Chung F, Brull R. Cardiorespiratory complications of neuraxial opioids in patients with obstructive sleep apnea: a systematic review. J Clin Anesth. 2013;25:591–599. 100. Ladha KS, Kato R, Tsen LC, Bateman BT, Okutomi T. A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150μg. Int J Obstet Anesth. 2017;32:48–53. 101. Thompson MJ, Clinger BN, Simonds RM, Hochheimer CJ, Lahaye LA, Golladay GJ. Probability of undiagnosed obstructive sleep apnea does not correlate with adverse pulmonary events nor length of stay in hip and knee arthroplasty using intrathecal opioid. J Arthroplasty. 2017;32:2676–2679. 102. Zotou A, Siampalioti A, Tagari P, Paridis L, Kalfarentzos F, Filos KS. Does epidural morphine loading in addition to thoracic epidural analgesia capitalize the postoperative management of morbidly obese patients undergoing open bariatric surgery? A pilot study. Obes Surg. 2014;24:2099–2108. 103. Roehrs T, Hyde M, Blaisdell B, Greenwald M, Roth T. Sleep loss and REM sleep loss are hyperalgesic. Sleep. 2006;29:145–151. 104. Smith MT, Edwards RR, McCann UD, Haythornthwaite JA. The effects of sleep deprivation on stitch inhibition and spontaneous stitch in women. Sleep. 2007;30:494–505. 105. Roehrs TA, Harris E, Randall S, Roth T. stitch sensitivity and recovery from mild confirmed sleep loss. Sleep. 2012;35:1667–1672. 106. Haack M, Scott-Sutherland J, Santangelo G, Simpson NS, Sethna N, Mullington JM. stitch sensitivity and modulation in primary insomnia. Eur J Pain. 2012;16:522–533. 107. Luyster FS, Buysse DJ, Strollo PJ Jr.. Comorbid insomnia and obstructive sleep apnea: challenges for clinical drill and research. J Clin Sleep Med. 2010;6:196–204. 108. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14:1539–1552. 109. Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory stitch sensitivity in temporomandibular joint disorder. Sleep. 2009;32:779–790. 110. Khalid I, Roehrs TA, Hudgel DW, Roth T. Continuous positive airway pressure in severe obstructive sleep apnea reduces stitch sensitivity. Sleep. 2011;34:1687–1691. 111. Doufas AG, Tian L, Padrez KA, et al. Experimental stitch and opioid analgesia in volunteers at tall risk for obstructive sleep apnea. PLoS One. 2013;8:e54807. 112. Doufas AG, Tian L, Davies MF, Warby SC. Nocturnal intermittent hypoxia is independently associated with stitch in subjects suffering from sleep-disordered breathing. Anesthesiology. 2013;119:1149–1162. 113. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology. 2004;100:806–810. 114. Brown KA, Laferrière A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology. 2006;105:665–669. 115. Sadhasivam S, Chidambaran V, Ngamprasertwong P, et al. Race and unequal burden of perioperative stitch and opioid related adverse effects in children. Pediatrics. 2012;129:832–838. 116. Sanders JC, King MA, Mitchell RB, Kelly JP. Perioperative complications of adenotonsillectomy in children with obstructive sleep apnea syndrome. Anesth Analg. 2006;103:1115–1121. 117. Turan A, You J, Egan C, et al. confirmed intermittent hypoxia is independently associated with reduced postoperative opioid consumption in bariatric patients suffering from sleep-disordered breathing. PLoS One. 2015;10:e0127809. 118. Chung F, Liao P, Yegneswaran B, Shapiro CM, Kang W. Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea. Anesthesiology. 2014;120:287–298. 119. Vanderveken OM, Maurer JT, Hohenhorst W, et al. Evaluation of drug-induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea. J Clin Sleep Med. 2013;9:433–438. 120. De Vito A, Agnoletti V, Berrettini S, et al. Drug-induced sleep endoscopy: conventional versus target controlled infusion techniques: a randomized controlled study. Eur Arch Otorhinolaryngol. 2011;268:457–462. 121. Rabelo FA, Küpper DS, Sander HH, Fernandes RM, Valera FC. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls. Laryngoscope. 2013;123:2300–2305. 122. Dotan Y, Pillar G, Tov N, et al. Dissociation of electromyogram and mechanical response in sleep apnoea during propofol anaesthesia. Eur Respir J. 2013;41:74–84. 123. Capasso R, Rosa T, Tsou DY, et al. Variable findings for drug-induced sleep endoscopy in obstructive sleep apnea with propofol versus dexmedetomidine. Otolaryngol Head Neck Surg. 2016;154:765–770. 124. Kuyrukluyildiz U, Binici O, Onk D, et al. Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome. Int J Clin Exp Med. 2015;8:5691–5698. 125. Blumen M, Bequignon E, Chabolle F. Drug-induced sleep endoscopy: a unusual gold standard for evaluating OSAS? piece II: results. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134:109–115. 126. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18:453–465. 127. Cortínez LI, Anderson BJ, Penna A, et al. Influence of obesity on propofol pharmacokinetics: derivation of a pharmacokinetic model. Br J Anaesth. 2010;105:448–456. 128. Servin F, Farinotti R, Haberer JP, Desmonts JM. Propofol infusion for maintenance of anesthesia in morbidly obese patients receiving nitrous oxide: a clinical and pharmacokinetic study. Anesthesiology. 1993;78:657–665. 129. La Colla L, Albertin A, La Colla G, et al. No adjustment vs adjustment formula as input weight for propofol target-controlled infusion in morbidly obese patients. Eur J Anaesthesiol. 2009;26:362–369. 130. Dong D, Peng X, Liu J, Qian H, Li J, Wu B. Morbid obesity alters both pharmacokinetics and pharmacodynamics of propofol: dosing recommendation for anesthesia induction. Drug Metab Dispos. 2016;44:1579–1583. 131. Short TG, Chui PT. Propofol and midazolam act synergistically in combination. Br J Anaesth. 1991;67:539–545. 132. Thomas MC, Jennett-Reznek AM, Patanwala AE. Combination of ketamine and propofol versus either agent lonely for procedural sedation in the emergency department. Am J Health Syst Pharm. 2011;68:2248–2256. 133. Bojak I, Day HC, Liley DT. Ketamine, propofol, and the EEG: a neural realm analysis of HCN1-mediated interactions. Front Comput Neurosci. 2013;7:22. 134. Hannallah M, Rasmussen M, Carroll J, Charabaty A, Palese C, Haddad N. Evaluation of dexmedetomidine/propofol anesthesia during upper gastrointestinal endoscopy in patients with tall probability of having obstructive sleep apnea. Anaesth stitch Intensive Care. 2013;173. 135. Vuyk J. Pharmacokinetic and pharmacodynamic interactions between opioids and propofol. J Clin Anesth. 1997;9:23S–26S. 136. Sneyd JR, Rigby-Jones AE. unusual drugs and technologies, intravenous anaesthesia is on the toddle (again). Br J Anaesth. 2010;105:246–254. 137. Colao J, Rodriguez-Correa D. Rapidly metabolized anesthetics: novel alternative agents for procedural sedation. J Anesth Clin Res. 2016;7:11. 138. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc. 2014;79:436–444. 139. Coté GA, Hovis RM, Ansstas MA, et al. Incidence of sedation-related complications with propofol spend during advanced endoscopic procedures. Clin Gastroenterol Hepatol. 2010;8:137–142. 140. Friedrich-Rust M, Welte M, Welte C, et al. Capnographic monitoring of propofol-based sedation during colonoscopy. Endoscopy. 2014;46:236–244. 141. Nagels AJ, Bridgman JB, Bell SE, Chrisp DJ. Propofol-remifentanil TCI sedation for oral surgery. N Z Dent J. 2014;110:85–89. 142. Mador MJ, Abo Khamis M, Nag N, Mreyoud A, Jallu S, Mehboob S. Does sleep apnea enlarge the risk of cardiorespiratory complications during endoscopy procedures? Sleep Breath. 2011;15:393–401. 143. McVay T, Fang JC, Taylor L, et al. Safety analysis of bariatric patients undergoing outpatient upper endoscopy with non-anesthesia administered propofol sedation. Obes Surg. 2017;27:1501–1507. 144. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does discontinuance tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol abate the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010;55:258–264. 145. Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98:632–641. 146. Benumof JL. Obesity, sleep apnea, the airway and anesthesia. Curr Opin Anaesthesiol. 2004;17:21–30. 147. Peromaa-Haavisto P, Tuomilehto H, Kössi J, et al. Prevalence of obstructive sleep apnoea among patients admitted for bariatric surgery: a prospective multicentre trial. Obes Surg. 2016;26:1384–1390. 148. Duarte RL, Magalhães-da-Silveira FJ. Factors predictive of obstructive sleep apnea in patients undergoing pre-operative evaluation for bariatric surgery and referred to a sleep laboratory for polysomnography. J Bras Pneumol. 2015;41:440–448. 149. Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth. 2000;85:91–108. 150. Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. censorious respiratory events in the postanesthesia custody unit: patient, surgical, and anesthetic factors. Anesthesiology. 1994;81:410–418. 151. Fassbender P, Bürgener S, Haddad A, Silvanus MT, Peters J. Perioperative incidence of airway obstructive and hypoxemic events in patients with confirmed or suspected sleep apnea: a prospective, randomized pilot study comparing propofol/remifentanil and sevoflurane/remifentanil anesthesia. BMC Anesthesiol. 2018;18:14. 152. Salihoglu Z, Karaca S, Kose Y, Zengin K, Taskin M. Total intravenous anesthesia versus single breath technique and anesthesia maintenance with sevoflurane for bariatric operations. Obes Surg. 2001;11:496–501. 153. Siampalioti A, Karavias D, Zotou A, Kalfarentzos F, Filos K. Anesthesia management for the super obese: is sevoflurane superior to propofol as a sole anesthetic agent? A double-blind randomized controlled trial. Eur Rev Med Pharmacol Sci. 2015;19:2493–2500. 154. Hendolin H, Kansanen M, Koski E, Nuutinen J. Propofol-nitrous oxide versus thiopentone-isoflurane-nitrous oxide anaesthesia for uvulopalatopharyngoplasty in patients with sleep apnea. Acta Anaesthesiol Scand. 1994;38:694–698. 155. Pizzirani E, Pigato P, Favretti F, et al. The post-anaesthetic recovery in obesity surgery: comparison between two anaesthetic techniques. Obes Surg. 1992;2:91–94. 156. Tanaka P, Goodman S, Sommer BR, Maloney W, Huddleston J, Lemmens HJ. The outcome of desflurane versus propofol anesthesia on postoperative delirium in superannuated obese patients undergoing total knee replacement: a randomized, controlled, double-blinded clinical trial. J Clin Anesth. 2017;39:17–22. 157. Zoremba M, Dette F, Hunecke T, Eberhart L, Braunecker S, Wulf H. A comparison of desflurane versus propofol: the effects on early postoperative lung office in overweight patients. Anesth Analg. 2011;113:63–69. 158. Sollazzi L, Perilli V, Modesti C, et al. Volatile anesthesia in bariatric surgery. Obes Surg. 2001;11:623–626. 159. Torri G, Casati A, Albertin A, et al. Randomized comparison of isoflurane and sevoflurane for laparoscopic gastric banding in morbidly obese patients. J Clin Anesth. 2001;13:565–570. 160. Torri G, Casati A, Comotti L, Bignami E, Santorsola R, Scarioni M. Wash-in and wash-out curves of sevoflurane and isoflurane in morbidly obese patients. Minerva Anestesiol. 2002;68:523–527. 161. Arain SR, Barth CD, Shankar H, Ebert TJ. preference of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane. J Clin Anesth. 2005;17:413–419. 162. De Baerdemaeker LE, Struys MM, Jacobs S, et al. Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an “inhalation bolus” technique. Br J Anaesth. 2003;91:638–650. 163. De Baerdemaeker LE, Jacobs S, Den Blauwen NM, et al. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obes Surg. 2006;16:728–733. 164. Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G; PINOCCHIO Study Group. Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial. J Neurosurg Anesthesiol. 2009;21:207–213. 165. Ozdogan HK, Cetinkunar S, Karateke F, Cetinalp S, Celik M, Ozyazici S. The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy. J Clin Anesth. 2016;35:441–445. 166. Strum EM, Szenohradszki J, Kaufman WA, Anthone GJ, Manz IL, Lumb PD. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesth Analg. 2004;99:1848–1853. 167. Vallejo MC, Sah N, Phelps AL, O’Donnell J, Romeo RC. Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients. J Clin Anesth. 2007;19:3–8. 168. La Colla L, Albertin A, La Colla G, Mangano A. Faster wash-out and recovery for desflurane vs sevoflurane in morbidly obese patients when no premedication is used. Br J Anaesth. 2007;99:353–358. 169. Kaur A, Jain AK, Sehgal R, Sood J. Hemodynamics and early recovery characteristics of desflurane versus sevoflurane in bariatric surgery. J Anaesthesiol Clin Pharmacol. 2013;29:36–40. 170. Juvin P, Vadam C, Malek L, Dupont H, Marmuse JP, Desmonts JM. Postoperative recovery after desflurane, propofol, or isoflurane anesthesia among morbidly obese patients: a prospective, randomized study. Anesth Analg. 2000;91:714–719. 171. Liu FL, Cherng YG, Chen SY, et al. Postoperative recovery after anesthesia in morbidly obese patients: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2015;62:907–917. 172. Ibraheim O, Alshaer A, Mazen K, et al. outcome of bispectral index (BIS) monitoring on postoperative recovery and sevoflurane consumption among morbidly obese patients undergoing laparoscopic gastric banding. Middle East J Anaesthesiol. 2008;19:819–830. 173. Freo U, Carron M, Innocente F, Foletto M, Nitti D, Ori C. Effects of A-line Autoregression Index (AAI) monitoring on recovery after sevoflurane anesthesia for bariatric surgery. Obes Surg. 2011;21:850–857. 174. McKay RE, Malhotra A, Cakmakkaya OS, Hall KT, McKay WR, Apfel CC. outcome of increased carcass mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. Br J Anaesth. 2010;104:175–182. 175. Eger EI 2nd, Shafer S. The complexity of recovery from anesthesia. J Clin Anesth. 2005;17:411–412. 176. Ebert TJ, Robinson BJ, Uhrich TD, Mackenthun A, Pichotta PJ. Recovery from sevoflurane anesthesia: a comparison to isoflurane and propofol anesthesia. Anesthesiology. 1998;89:1524–1531. 177. Dexter F, Tinker JH. Comparisons between desflurane and isoflurane or propofol on time to following commands and time to discharge: a meta-analysis. Anesthesiology. 1995;83:77–82. 178. Macario A, Dexter F, Lubarsky D. Meta-analysis of trials comparing postoperative recovery after anesthesia with sevoflurane or desflurane. Am J Health Syst Pharm. 2005;62:63–68. 179. Dexter F, Bayman EO, Epstein RH. Statistical modeling of unprejudiced and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane. Anesth Analg. 2010;110:570–580. 180. Agoliati A, Dexter F, Lok J, et al. Meta-analysis of unprejudiced and variability of time to extubation comparing isoflurane with desflurane or isoflurane with sevoflurane. Anesth Analg. 2010;110:1433–1439. 181. Yasuda N, Lockhart SH, Eger EI 2nd, et al. Comparison of kinetics of sevoflurane and isoflurane in humans. Anesth Analg. 1991;72:316–324. 182. Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW. Anesthetic considerations for bariatric surgery. Anesth Analg. 2002;95:1793–1805. 183. Eger EI 2nd.. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001;93:947–953. 184. Juvin P, Marmuse JP, Delerme S, et al. Post-operative course after conventional or laparoscopic gastroplasty in morbidly obese patients. Eur J Anaesthesiol. 1999;16:400–403. 185. Katznelson R, Naughton F, Friedman Z, et al. Increased lung clearance of isoflurane shortens emergence in obesity: a prospective randomized-controlled trial. Acta Anaesthesiol Scand. 2011;55:995–1001. 186. De Kock M, Lavand’homme P, Waterloos H. Balanced analgesia” in the perioperative period: is there a state for ketamine? Pain. 2001;92:373–380. 187. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev. 2006:CD004603. 188. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth. 2011;58:911–923. 189. Luscri N, Tobias JD. Monitored anesthesia custody with a combination of ketamine and dexmedetomidine during magnetic resonance imaging in three children with trisomy 21 and obstructive sleep apnea. Paediatr Anaesth. 2006;16:782–786. 190. Cheng X, Huang Y, Zhao Q, Gu E. Comparison of the effects of dexmedetomidine-ketamine and sevoflurane-sufentanil anesthesia in children with obstructive sleep apnea after uvulopalatopharyngoplasty: an observational study. J Anaesthesiol Clin Pharmacol. 2014;30:31–35. 191. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26:985–1028. 192. Melendez E, Bachur R. Serious adverse events during procedural sedation with ketamine. Pediatr Emerg Care. 2009;25:325–328. 193. Gorlin AW, Rosenfeld DM, Ramakrishna H. Intravenous sub-anesthetic ketamine for perioperative analgesia. J Anaesthesiol Clin Pharmacol. 2016;32:160–167. 194. De Oliveira GS Jr, Fitzgerald PC, Hansen N, Ahmad S, McCarthy RJ. The outcome of ketamine on hypoventilation during deep sedation with midazolam and propofol: a randomised, double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2014;31:654–662. 195. Taylor DM, Bell A, Holdgate A, et al. Risk factors for sedation-related events during procedural sedation in the emergency department. Emerg Med Australas. 2011;23:466–473. 196. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663–667. 197. Eikermann M, Grosse-Sundrup M, Zaremba S, et al. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116:35–46. 198. Abdullah VJ, Lee DL, Ha SC, van Hasselt CA. Sleep endoscopy with midazolam: sedation level evaluation with bispectral analysis. Otolaryngol Head Neck Surg. 2013;148:331–337. 199. Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008;265:1397–1402. 200. Bachar G, Nageris B, Feinmesser R, et al. Novel grading system for quantifying upper-airway obstruction on sleep endoscopy. Lung. 2012;190:313–318. 201. Carrasco Llatas M, Agostini Porras G, Cuesta González MT, et al. Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography. Eur Arch Otorhinolaryngol. 2014;271:181–187. 202. De Corsa E, Fiorita A, Rizzotto G, et al. The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: their personal experience. Acta Otorhinolaryngol Ital. 2013;33:405–413. 203. Gregório MG, Jacomelli M, Figueiredo AC, Cahali MB, Pedreira WL Jr, Lorenzi Filho G. Evaluation of airway obstruction by nasopharyngoscopy: comparison of the Müller maneuver versus induced sleep. Braz J Otorhinolaryngol. 2007;73:618–622. 204. Hamans E, Meeus O, Boudewyns A, Saldien V, Verbraecken J, Van de Heyning P. Outcome of sleep endoscopy in obstructive sleep apnoea: the Antwerp experience. B-ENT. 2010;6:97–103. 205. Hessel NS, de Vries N. Diagnostic work-up of socially unacceptable snoring: II. Sleep endoscopy. Eur Arch Otorhinolaryngol. 2002;259:158–161. 206. Iwanaga K, Hasegawa K, Shibata N, et al. Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep. Acta Oto laryngol Suppl. 2003;550:36–40. 207. Koo SK, Choi JW, Myung NS, Lee HJ, Kim YJ, Kim YJ. Analysis of obstruction site in obstructive sleep apnea syndrome patients by drug induced sleep endoscopy. Am J Otolaryngol. 2013;34:626–630. 208. Ravesloot MJ, de Vries N. One hundred consecutive patients undergoing drug-induced sleep endoscopy: results and evaluation. Laryngoscope. 2011;121:2710–2716. 209. Sadaoka T, Kakitsuba N, Fujiwara Y, Kanai R, Takahashi H. The value of sleep nasendoscopy in the evaluation of patients with suspected sleep-related breathing disorders. Clin Otolaryngol Allied Sci. 1996;21:485–489. 210. Vroegop AV, Vanderveken OM, Boudewyns AN, et al. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope. 2014;124:797–802. 211. Choi JK, Hur YK, Lee JM, Clark GT. Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109:712–719. 212. Hillarp B, Nylander G, Rosén I, Wickström O. Videoradiography of patients with habitual snoring and/or sleep apnea: technical description and presentation of videoradiographic results during sleep concerning episode of apnea, type of apnea, and site of obstruction. Acta Radiol. 1996;37:307–314. 213. Lee CH, Mo JH, Kim BJ, et al. Evaluation of soft palate changes using sleep videofluoroscopy in patients with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2009;135:168–172. 214. Lee CH, Hong SL, Rhee CS, Kim SW, Kim JW. Analysis of upper airway obstruction by sleep videofluoroscopy in obstructive sleep apnea: a large population-based study. Laryngoscope. 2012;122:237–241. 215. Adler DG, Kawa C, Hilden K, Fang J. Nurse-administered propofol sedation is safe for patients with obstructive sleep apnea undergoing routine endoscopy: a pilot study. Dig Dis Sci. 2011;56:2666–2671. 216. Cha JM, Jeun JW, Pack KM, et al. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol. 2013;19:4745–4751. 217. Cillo JE Jr, Finn R. Hemodynamics and oxygen saturation during intravenous sedation for office-based laser-assisted uvuloplasty. J Oral Maxillofac Surg. 2005;63:752–755. 218. Madan AK, Tichansky DS, Isom J, Minard G, Bee TK. Monitored anesthesia custody with propofol versus surgeon-monitored sedation with benzodiazepines and narcotics for preoperative endoscopy in the morbidly obese. Obes Surg. 2008;18:545–548. 219. Mador MJ, Nadler J, Mreyoud A, et al. execute patients at risk of sleep apnea hold an increased risk of cardio-respiratory complications during endoscopy procedures? Sleep Breath. 2012;16:609–615. 220. Cho JS, Soh S, Kim EJ, et al. Comparison of three sedation regimens for drug-induced sleep endoscopy. Sleep Breath. 2015;19:711–717. 221. Yoon BW, Hong JM, Hong SL, Koo SK, Roh HJ, Cho KS. A comparison of dexmedetomidine versus propofol during drug-induced sleep endoscopy in sleep apnea patients. Laryngoscope. 2016;126:763–767. 222. Chang ET, Certal V, Song SA, et al. Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review. Sleep Breath. 2017;21:727–735. 223. Ma XX, Fang XM, Hou TN. Comparison of the effectiveness of dexmedetomidine versus propofol target-controlled infusion for sedation during coblation-assisted upper airway procedure. Chin Med J (Engl). 2012;125:869–873. 224. Bamgbade OA, Alfa JA. Dexmedetomidine anaesthesia for patients with obstructive sleep apnoea undergoing bariatric surgery. Eur J Anaesthesiol. 2009;26:176–177. 225. Dholakia C, Beverstein G, Garren M, Nemergut C, Boncyk J, Gould JC. The impact of perioperative dexmedetomidine infusion on postoperative narcotic spend and duration of stay after laparoscopic bariatric surgery. J Gastrointest Surg. 2007;11:1556–1559. 226. Xu J, Jin C, Cui X, Jin Z. Comparison of dexmedetomidine versus propofol for sedation after uvulopalatopharyngoplasty. Med Sci Monit. 2015;21:2125–2133. 227. Chawla S, Robinson S, Norton A, Esterman A, Taneerananon T. Peri-operative spend of dexmedetomidine in airway reconstruction surgery for obstructive sleep apnoea. J Laryngol Otol. 2010;124:67–72. 228. Issa FG. outcome of clonidine in obstructive sleep apnea. Am Rev Respir Dis. 1992;145:435–439. 229. Pawlik MT, Hansen E, Waldhauser D, Selig C, Kuehnel TS. Clonidine premedication in patients with sleep apnea syndrome: a randomized, double-blind, placebo-controlled study. Anesth Analg. 2005;101:1374–1380. 230. Feld JM, Hoffman WE, Stechert MM, Hoffman IW, Ananda RC. Fentanyl or dexmedetomidine combined with desflurane for bariatric surgery. J Clin Anesth. 2006;18:24–28. 231. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the outcome on recovery outcome variables. Anesth Analg. 2008;106:1741–1748. 232. Feld J, Hoffman WE, Paisansathan C, Park H, Ananda RC. Autonomic activity during dexmedetomidine or fentanyl infusion with desflurane anesthesia. J Clin Anesth. 2007;19:30–36. 233. Jayaraman L, Sinha A, Punhani D. A comparative study to evaluate the outcome of intranasal dexmedetomidine versus oral alprazolam as a premedication agent in morbidly obese patients undergoing bariatric surgery. J Anaesthesiol Clin Pharmacol. 2013;29:179–182. 234. Sollazzi L, Modesti C, Vitale F, et al. Preinductive spend of clonidine and ketamine improves recovery and reduces postoperative stitch after bariatric surgery. Surg Obes Relat Dis. 2009;5:67–71. 235. Memtsoudis SG, Stundner O, Rasul R, et al. Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes. Reg Anesth stitch Med. 2013;38:274–281. 236. Ambrosii T, Şandru S, Belîi A. The prevalence of perioperative complications in patients with and without obstructive sleep apnoea: a prospective cohort study. Rom J Anaesth Intensive Care. 2016;23:103–110. 237. Liu DY, Cai XL, Liu HY. [Obstructive sleep apnea hypopnea syndrome: surgical complications and strategy for avoidance]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2009;44:555–560. 238. Liu SS, Chisholm MF, Ngeow J, et al. Postoperative hypoxemia in orthopedic patients with obstructive sleep apnea. HSS J. 2011;7:2–8. 239. Naqvi SY, Rabiei AH, Maltenfort MG, et al. Perioperative complications in patients with sleep apnea undergoing total joint arthroplasty. J Arthroplasty. 2017;32:2680–2683. 240. Biddle C. Comparative aspects of the airway during universal anesthesia in obese sufferers of sleep apnea and matched normals. Adv Pract Nurs Q. 1996;2:14–19. 241. Loube DI, Erman MK, Reed W. Perioperative complications in obstructive sleep apnea patients. Sleep Breath. 1997;2:3–10. 242. Xará D, Mendonça J, Pereira H, Santos A, Abelha FJ. Adverse respiratory events after universal anesthesia in patients at tall risk of obstructive sleep apnea syndrome. Braz J Anesthesiol. 2015;65:359–366. 243. Kehlet H. The stress response to surgery: release mechanisms and the modifying outcome of stitch relief. Acta Chir Scand Suppl. 1989;550:22–28. 244. Kehlet H. Manipulation of the metabolic response in clinical practice. World J Surg. 2000;24:690–695. 245. O’Neill J, Helwig E. Postoperative management of the physiological effects of spinal anesthesia. J Perianesth Nurs. 2016;31:330–339. 246. Meng T, Zhong Z, Meng L. impact of spinal anaesthesia vs universal anaesthesia on peri-operative outcome in lumbar spine surgery: a systematic review and meta-analysis of randomised, controlled trials. Anaesthesia. 2017;72:391–401. 247. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–2402. 248. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol. 2016;29:134–140.

    Raspberry Pi and Windows 10 IoT Core: A Huge Letdown | killexams.com existent questions and Pass4sure dumps

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

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

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

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

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

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

    Installing

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

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

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

    PiWinThe totality of the Windows 10 IoT Core experience

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

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

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

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

    Who is this for, exactly?

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

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

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

    Save your SD card

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

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

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


    The Charter on Professionalism for Health custody Organizations | killexams.com existent questions and Pass4sure dumps

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

    — Lesser et al1

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

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

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

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

    Why a Charter on Organizational Professionalism?

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

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

    Charter Process

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

    Charter Goals

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

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

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

    Charter Domains

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

    Patient partnerships

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

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

    In the final decade, many factors hold influenced the expectation that patients and families ensnare an dynamic role in decisions that impact their health and health care,21 and studies demonstrate that this drill benefits outright involved.22–24

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

    This domain is aligned with Medicare’s adoption of measures of patient taste measures as an primary component of value, and thus payment. Although the exact measures of patient taste and rendezvous remain controversial, the expectation of patient- and family-centeredness as a core value of health custody organizations is here to stay.26

    Organizational culture

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

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

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

    Community partnerships

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

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

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

    Operations and traffic practices

    In recent years, a vision for a health custody system that continuously learns and improves has evolved.53,54 Efforts to enhance ethical deportment in health custody organizations result in best operational and traffic practices and in existent benefits for patients.55 Furthermore, Tsai and colleagues56 found that hospitals that rank tall on the spend of effectual management practices provide a higher property of custody than lower-ranking hospitals, and hospital management’s spend of such practices is associated with a high-performing board of trustees.

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

    Bart and Tabone58 found an primary relationship between nonprofit hospital leadership satisfaction with mission statement and their organization’s performance. Their primary finding was that leaders execute in fact discriminate and differentiate in the wording of mission statements, which in turn influences organizational deportment and performance. Of distinct significance is a commitment to service quality, patient welfare, and satisfaction. Components typically not included in the mission are monetary goals and competitive strategies. Ethical guidance in the shape of mission statements are valuable tools for health systems to spend to improve organizational performance and enlarge employee motivation.59

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

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

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

    Charter Obstacles

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

    Another challenge is altering the social determinants of health. The ecology of these determinants is tangled and not fully understood. Nor is any social structure in a position to touch outright the influences on these determinants. The Charter does not suggest that health custody organizations are solely liable for improving the social determinants of health but, rather, suggests that they hunt strategic partnerships with other organizations, government, and local communities, consistent with their means and their unique missions, in order to improve the health of the community.

    What They Want to Accomplish

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

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

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

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

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

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

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

    Patient Partnerships

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

    Commitment to engagement

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

    Commitment to shared determination making

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

    Commitment to collaboration, continuity, and coordination

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

    Commitment to measure what matters to patients

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

    Organizational Culture

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

    Commitment to the well-being of individuals

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

    Commitment to teamwork

    Best custody happens when outright members of the team, including patients, share information and decision-making responsibility. Ensuring teamwork requires organizational structures and processes that support communication across staff and with patients.

    Commitment to a vigorous workplace

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

    Commitment to inclusion and diversity

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

    Commitment to accountability

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

    Community Partnerships

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

    Commitment to address the social determinants of health

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

    Commitment to colleague with communities

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

    Commitment to advocate for access and high-value care

    Model organizations colleague with others to promote universal access and rational allocation of health custody resources and to moderate incentive structures that execute not directly lead to high-value custody and healthier communities. They advocate with communities for regulatory reforms to improve environmental conditions, mitigate barriers to health custody access, and improve social services.

    Commitment to community benefit

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

    Operations and traffic Practices

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

    Commitment to safeguard the privacy of patients and their health information

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

    Commitment to ethical operations

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

    Commitment to transparent management of conflicts of interest

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

    Commitment to align incentives with values

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

    Commitment to just treatment, education, and development

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

    Commitment to high-value care

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

    Commitment to innovation

    Model organizations strive to improve current models of care. Creating opportunities to assist other organizations to achieve similar success is a shape of public service. The search for and implementation of innovative approaches to management, leadership, and patient custody are primary indicia of organizational professionalism.

    Commitment to accounting and monetary reporting standards

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

    Commitment to ensure just and equitable access to health care

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

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

    May-Lynn Andresen, RN, BSN

    Barry E. Egener, MD (Chair)

    Ezekiel Emanuel, MD, PhD

    David A. Fleming, MD, MA

    Meg E. Gaines, JD, LLM

    L. Keith Granger, BSRT

    David Gullen, MD

    Talmadge King, MD

    Wendy Levinson, MD

    Diana J. Mason, RN, PhD

    Walter J. McDonald, MD

    Sally Okun, RN, MMHS

    Tim Rice, MPH, RPh

    Bernie M. Rosof, MD

    Rosemary Stevens, PhD, MPH

    Alan Yuspeh, JD, MBA



    Direct Download of over 5500 Certification Exams

    3COM [8 Certification Exam(s) ]
    AccessData [1 Certification Exam(s) ]
    ACFE [1 Certification Exam(s) ]
    ACI [3 Certification Exam(s) ]
    Acme-Packet [1 Certification Exam(s) ]
    ACSM [4 Certification Exam(s) ]
    ACT [1 Certification Exam(s) ]
    Admission-Tests [13 Certification Exam(s) ]
    ADOBE [93 Certification Exam(s) ]
    AFP [1 Certification Exam(s) ]
    AICPA [2 Certification Exam(s) ]
    AIIM [1 Certification Exam(s) ]
    Alcatel-Lucent [13 Certification Exam(s) ]
    Alfresco [1 Certification Exam(s) ]
    Altiris [3 Certification Exam(s) ]
    Amazon [2 Certification Exam(s) ]
    American-College [2 Certification Exam(s) ]
    Android [4 Certification Exam(s) ]
    APA [1 Certification Exam(s) ]
    APC [2 Certification Exam(s) ]
    APICS [2 Certification Exam(s) ]
    Apple [69 Certification Exam(s) ]
    AppSense [1 Certification Exam(s) ]
    APTUSC [1 Certification Exam(s) ]
    Arizona-Education [1 Certification Exam(s) ]
    ARM [1 Certification Exam(s) ]
    Aruba [6 Certification Exam(s) ]
    ASIS [2 Certification Exam(s) ]
    ASQ [3 Certification Exam(s) ]
    ASTQB [8 Certification Exam(s) ]
    Autodesk [2 Certification Exam(s) ]
    Avaya [96 Certification Exam(s) ]
    AXELOS [1 Certification Exam(s) ]
    Axis [1 Certification Exam(s) ]
    Banking [1 Certification Exam(s) ]
    BEA [5 Certification Exam(s) ]
    BICSI [2 Certification Exam(s) ]
    BlackBerry [17 Certification Exam(s) ]
    BlueCoat [2 Certification Exam(s) ]
    Brocade [4 Certification Exam(s) ]
    Business-Objects [11 Certification Exam(s) ]
    Business-Tests [4 Certification Exam(s) ]
    CA-Technologies [21 Certification Exam(s) ]
    Certification-Board [10 Certification Exam(s) ]
    Certiport [3 Certification Exam(s) ]
    CheckPoint [41 Certification Exam(s) ]
    CIDQ [1 Certification Exam(s) ]
    CIPS [4 Certification Exam(s) ]
    Cisco [318 Certification Exam(s) ]
    Citrix [48 Certification Exam(s) ]
    CIW [18 Certification Exam(s) ]
    Cloudera [10 Certification Exam(s) ]
    Cognos [19 Certification Exam(s) ]
    College-Board [2 Certification Exam(s) ]
    CompTIA [76 Certification Exam(s) ]
    ComputerAssociates [6 Certification Exam(s) ]
    Consultant [2 Certification Exam(s) ]
    Counselor [4 Certification Exam(s) ]
    CPP-Institue [2 Certification Exam(s) ]
    CPP-Institute [1 Certification Exam(s) ]
    CSP [1 Certification Exam(s) ]
    CWNA [1 Certification Exam(s) ]
    CWNP [13 Certification Exam(s) ]
    Dassault [2 Certification Exam(s) ]
    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) ]





    References :


    Dropmark : http://killexams.dropmark.com/367904/11885406
    Wordpress : http://wp.me/p7SJ6L-1We
    Dropmark-Text : http://killexams.dropmark.com/367904/12850882
    Blogspot : http://killexamsbraindump.blogspot.com/2017/12/pass4sure-920-324-real-question-bank.html
    RSS Feed : http://feeds.feedburner.com/killexams/Jqog
    Box.net : https://app.box.com/s/79jr38ft7iqntufonp6h796j3kcdalp2






    Back to Main Page





    Killexams exams | Killexams certification | Pass4Sure questions and answers | Pass4sure | pass-guaratee | best test preparation | best training guides | examcollection | killexams | killexams review | killexams legit | kill example | kill example journalism | kill exams reviews | kill exam ripoff report | review | review quizlet | review login | review archives | review sheet | legitimate | legit | legitimacy | legitimation | legit check | legitimate program | legitimize | legitimate business | legitimate definition | legit site | legit online banking | legit website | legitimacy definition | pass 4 sure | pass for sure | p4s | pass4sure certification | pass4sure exam | IT certification | IT Exam | certification material provider | pass4sure login | pass4sure exams | pass4sure reviews | pass4sure aws | pass4sure security | pass4sure cisco | pass4sure coupon | pass4sure dumps | pass4sure cissp | pass4sure braindumps | pass4sure test | pass4sure torrent | pass4sure download | pass4surekey | pass4sure cap | pass4sure free | examsoft | examsoft login | exams | exams free | examsolutions | exams4pilots | examsoft download | exams questions | examslocal | exams practice |

    www.pass4surez.com | www.killcerts.com | www.search4exams.com | http://www.radionaves.com/