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Featured Articles: Original Clinical Research Report

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey

Berezin, Linor BSc*; Nagappa, Mahesh MD; Wong, Jean MD*,‡; Clivatti, Jefferson MD§; Singh, Mandeep MD*; Auckley, Dennis MD; Charchaflieh, Jean G. MD; Jonsson Fagerlund, Malin MD, PhD#,**; Gali, Bhargavi MD††; Joshi, Girish P. MD‡‡; Overdyk, Frank J. MD§§; Margarson, Michael MD∥∥; Mokhlesi, Babak MD, MSc¶¶; Moon, Tiffany MD‡‡; Ramachandran, Satya K. MD##; Ryan, Clodagh M. MD***; Schumann, Roman MD†††,‡‡‡; Weingarten, Toby N. MD§§§; Won, Christine H.J. MD, MSc∥∥∥,¶¶¶; Chung, Frances MD*

Author Information
doi: 10.1213/ANE.0000000000005446

Abstract

KEY POINTS

  • Question: Which sleep medicine topics are most important to include in anesthesia residency training?
  • Findings: High-priority sleep medicine topics include the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea.
  • Meaning: We identify important topics in sleep medicine based on the consensus of numerous experts in the field which may aid in developing anesthesiology residency curricula.

Sleep disorders affect up to 25% of the general population and are prevalent in surgical patients.1,2 Understanding the perioperative management of surgical patients with these disorders is particularly relevant to the safe practice of perioperative medicine. Patients with sleep-disordered breathing such as obstructive sleep apnea (OSA), central sleep apnea, and sleep-related hypoventilation are at an increased risk of perioperative adverse events such as postoperative cardiopulmonary complications, intensive care unit transfers, and death.3–5 In adults undergoing major noncardiac surgery, unrecognized severe OSA was significantly associated with increased risk of 30-day postoperative vascular complications.4 Higher risk of major adverse cardiac or cerebrovascular events were found in patients with OSA when compared to non-OSA patients following cardiac surgery.6 In patients with OSA undergoing surgery, death and brain damage were more likely to occur with unwitnessed events, no supplemental oxygen, lack of respiratory monitoring, and coadministration of opioids and sedatives.5 Despite the potential impact of sleep-disordered breathing to the practice of anesthesia, the core topics of sleep medicine that should be included in anesthesia residency curricula have not been well-defined.

Although there exists mounting evidence of increased morbidity and mortality associated with OSA, 60% of anesthesiologists and 92% of surgeons fail to identify patients with undiagnosed OSA presenting for surgery, perhaps due to an inadequate training in sleep medicine.2 A survey of anesthesiologists revealed poor use of OSA screening tools, uncertainty regarding the use of postoperative monitoring, and frequent lack of institutional policy guidance.7 We postulate that certain topics in sleep medicine should be essential components in the anesthesia residency curriculum in an effort to improve patient safety and residency education.8

Program directors face many challenges when designing residency curricula. The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Anesthesiology do not list the specific content required to achieve the competencies required for the practice of anesthesiology.9 In addition, the American Board of Anesthesiology (ABA) initial certification content outline makes a brief mention of sleep medicine–related content and focuses solely on sleep apnea.10 The lack of actionable guidelines and objective topics may make it difficult for program directors to develop effective residency curricula. The objective of this study is to determine the core topics of sleep medicine which can assist in the development of anesthesia training curricula. To do this, we sought the expertise and opinions of a panel of experts in the fields of anesthesia and sleep medicine and used a modified Delphi method to achieve consensus.

METHODS

Study Design and Modified Delphi Technique Survey

This study was approved by the University Health Network institutional review board in Toronto, Canada (20-5321). We conducted a prospective cross-sectional survey based on the Delphi technique, which is a reliable method to obtain consensus from a panel of experts. The Delphi technique uses multiple anonymous iterations of an opinion survey and has been used successfully to determine curriculum content in different medical specialties.11–15 Each iteration modifies the survey to incorporate feedback from the previous round and is resent to the respondents, until consensus emerges. It has the additional advantage of avoiding the influence of dominant individuals or group pressure for conformity.15 The requirement for written informed consent was waived by the institutional review board.

Our study consisted of 2 iterations. The initial topic list used in our survey was generated by content experts and based on various sleep medicine resources, including the chapter on “Sleep medicine” by Zaremba et al16 from “Miller’s Anesthesia,” Bolden and Strohl,17 the table of contents of the book “Principles and Practice of Sleep Medicine,” fifth edition, by Kryger et al18; The International Classification of Sleep Disorders – Third Edition (ICSD-3) from the American Academy of Sleep Medicine (AASM),19 as well as guidelines and publications from the Society of Anesthesia and Sleep Medicine (SASM).3,20,21

The questionnaires were designed using SurveyGizmo (Louisville, CO), a commercial online survey technology. The first survey was a 17-item questionnaire requesting demographic information of participants and feedback on the initial list of curriculum topics through 5-point Likert scale rankings, as well as open response questions inviting additional topic suggestions. In the second round of the survey, L.B. and F.C. incorporated all of the feedback received, and the process was repeated with all of the new topics identified in the previous iteration. The survey questions are provided in the Supplemental Digital Content, Material, http://links.lww.com/AA/D407.

Participant Selection and Sample Size Rationale

Prominent experts in the fields of sleep medicine and anesthesia in North America and Europe were identified on the basis of their publication record in the field in the past 5–10 years. We also invited key opinion leaders, educational experts, and members of SASM, a group founded with the aim to strengthen the link between sleep physicians and anesthesiologists, and to encourage the training of anesthesiologists in sleep medicine to extend their reach as perioperative physicians.3,20,21 While the optimal panel size of a Delphi survey is unknown, it is suggested that a reasonable result can be obtained with panels of 10–15 individuals.15,22

Data Collection

An invitation letter and link to the survey was sent to the e-mail addresses of 58 experts identified based on our criteria in the fields of sleep medicine and anesthesia, identified as described above. The survey remained open for 3 weeks, with a reminder e-mail sent after 2 weeks. The novel topics from this initial survey were identified and used to develop a second survey for the next round of agreement building, which was sent to those who completed the first round. Data were collected for 3 additional weeks. The survey links were active for a period of 2 months between August and September 2020. Participants were blinded to the type and level of agreement required for any topic to be selected.

Statistical Analysis

The level of agreement used to define consensus as reported in the health care literature is often chosen arbitrarily and ranges from 60% to 80%.14,23,24 For our initiative, consensus or agreement for inclusion as a core topic was defined as ≥80% of the experts selecting either “agree” or “strongly agree” on the 5-point Likert scale for a given topic. Any topic achieving consensus was considered to be a high-priority topic for inclusion in anesthesia residency education, and any topic with a low level of agreement (<80% of experts selecting “agree” or “strongly agree”) was not included as a core topic.

All analyses were conducted using SPSS 24.0 (IBM Corporation, Armonk, NY). Demographic variables were summarized with descriptive statistical methods and presented as percentages. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages of participants selecting “agree” and “strongly agree.” In addition, a mean agreement score (weighted average of ratings on the 5-point Likert scale, whereby strongly disagree, disagree, neutral, agree, and strongly agree were given weightings of 1, 2, 3, 4, and 5, respectively) was calculated for each suggested topic to represent the distribution and level of agreement among participants. A weighted mean with standard deviation (SD) was calculated for the mean agreement score.

RESULTS

A total of 33 of the 58 experts who were invited to participate in the survey responded to the initial survey, representing a 57% response rate. Of these participants, 28 (85%) completed the second round of the survey. Demographic characteristics of the respondents are outlined in Table 1.

Table 1. - Demographic Characteristics of Survey Respondents (n = 33)
Demographic No. of participants n (%)
Sex
 Male 18 (55)
 Female 15 (45)
Specialty
 Anesthesia 27 (82)
 Sleep medicine 6 (18)
 Dual trained 0
Years in practice
 0–10 4 (12.1)
 11–20 14 (42.4)
 21–30 8 (24.2)
 31–40 6 (18.2)
 >40 1 (3.0)
Primary practice location
 Canada 5 (15)
 United States 23 (70)
 Europe 5 (15)

The 4 topics with 100% agreement (mean agreement score = 5.0) among experts were (1) the influence of opioids and anesthetics on control of breathing and upper airway obstruction; (2) potential interactions of wake-promoting/hypnotic medications with anesthetic agents; (3) effects of sleep and anesthesia on upper airway patency; and (4) anesthetic considerations of OSA (Table 2). Other main topics achieving qualifying agreement scores between participants include (1) the effects of anesthetic drugs on respiratory control (mean [SD] agreement score = 4.97 [0.17]); (2) mechanism of action and pharmacologic effects of hypnotic medications (4.85 [0.36]); (3) mechanisms/efficacy/adverse effects of wake-promoting medications (4.70 [0.47]); (4) interaction between sleep deprivation and anesthesia (4.64 [0.49]); (5) sleep assessment questionnaires and scales (4.88 [0.33]); (6) OSA definition/epidemiology/risk factors (4.94 [0.24]); (7) OSA perioperative guidelines and management (4.94 [0.24]); and (8) perioperative management of central sleep apnea/periodic breathing (4.82 [0.39]).

Table 2. - Topics Identified to Have High Level of Agreement for Inclusion in the Sleep Medicine and Anesthesia Core Curriculum for Anesthesia Residency (n = 33)
Topic Mean agreement scorea (SD) No. of participants in agreementb (%) No. of participants who strongly agree (%)
Definition and physiology of sleep
 Sleep stages and cycle 4.48 (0.76) 30 (91) 20 (61)
 Circadian rhythms 4.12 (1.02) 27 (82) 14 (43)
 Overview of functional neuroanatomy of sleep 4.24 (1.00) 27 (82) 17 (52)
 Cardiovascular and respiratory regulation during sleep 4.70 (0.53) 32 (97) 24 (73)
Pharmacology and sleep
 Hypnotic medications: mechanisms of action and pharmacologic effects 4.85 (0.36) 33 (100) 28 (85)
 Wake-promoting medications: mechanisms, efficacy, and adverse events 4.70 (0.47) 33 (100) 23 (70)
 Potential interactions with anesthetic agents 5.00 33 (100) 33 (100)
 Influence of opioids and anesthetics on control of breathing and upper airway obstruction 5.00 33 (100) 33 (100)
Sleep physiology and anesthesia
 Similarities and differences between sleep, anesthesia, and coma 4.70 (0.53) 32 (97) 24 (73)
 EEG activity in sleep stages and anesthesia 4.36 (0.93) 28 (85) 19 (58)
 Effects of anesthetic drugs on respiratory control 4.97 (0.17) 33 (100) 32 (97)
 Effects of sleep and anesthesia on upper airway patency 5.00 33 (100) 33 (100)
 Sleep and circadian rhythm in the preoperative period 4.30 (0.77) 27 (82) 16 (49)
 Pain, analgesia, and sleep 4.85 (0.44) 32 (97) 29 (88)
 Effects of anesthesia and surgery on sleep and circadian rhythms 4.67 (0.54) 32 (97) 23 (70)
Effects of anesthesia and surgery on sleep and circadian rhythms
 Acute and chronic sleep deprivation 4.45 (0.56) 32 (97) 16 (49)
 Interaction between sleep deprivation and anesthesia 4.64 (0.49) 33 (100) 21 (64)
Methods to assess sleep
 Sleep-related history and physical examination 4.58 (0.56) 32 (97) 20 (61)
 Questionnaires and scales (STOP-Bang, the Berlin Questionnaire, Epworth sleepiness scale, etc.) 4.88 (0.33) 33 (100) 29 (88)
 Actigraphy, respiratory, polygraphy, and polysomnography 4.27 (0.88) 29 (88) 15 (46)
 Potential methods to use in the perioperative setting 4.67 (0.54) 32 (97) 23 (70)
OSA
 Definition, epidemiology, and risk factors 4.94 (0.24) 33 (100) 31 (94)
 Clinical presentation 4.79 (0.48) 32 (97) 27 (82)
 Anesthetic considerations 5.00 33 (100) 33 (100)
 OSA in children and pregnant patients 4.70 (0.59) 31 (94) 25 (76)
 Pathophysiology of upper airway collapse in OSA 4.79 (0.48) 32 (97) 27 (82)
 Comorbidities and complications 4.76 (0.56) 31 (94) 27 (82)
 Treatment options (surgery, CPAP, and oral appliances) 4.79 (0.48) 32 (97) 27 (82)
 Perioperative guidelines and management 4.94 (0.24) 33 (100) 31 (94)
Central sleep apnea and periodic breathing
 Definition, epidemiology, and risk factors 4.67 (0.54) 32 (97) 23 (70)
 Clinical presentation 4.55 (0.56) 32 (97) 19 (58)
 Anesthetic considerations 4.82 (0.46) 32 (97) 28 (85)
 Treatment 4.64 (0.60) 31 (94) 23 (70)
 Perioperative management 4.82 (0.39) 33 (100) 27 (82)
Obesity hypoventilation syndrome
 Definition, epidemiology, and risk factors 4.76 (0.56) 31 (94) 27 (82)
 Clinical presentation 4.67 (0.60) 31 (94) 24 (73)
 Anesthetic considerations 4.82 (0.53) 31 (94) 29 (88)
 Perioperative implications and management 4.82 (0.53) 31 (94) 29 (88)
Anesthetic implications of other sleep disorders
 Overview and anesthetic implications of nonrespiratory sleep disorders 4.19 (1.09) 25 (76) 17 (53)
 Central disorders of hypersomnolence: narcolepsy 3.91 (0.96) 23 (70) 9 (28)
 Central disorders of hypersomnolence: idiopathic hypersomnia 3.66 (1.15) 20 (61) 8 (25)
 Circadian rhythm sleep-wake disorders 3.72 (1.11) 20 (61) 9 (28)
 Parasomnias 3.56 (1.13) 18 (55) 7 (21)
 Restless legs syndrome 3.69 (1.15) 21 (64) 8 (25)
Sleep in the hospialized patient
 Implications of sleep disturbances to patient health 4.34 (1.07) 28 (85) 19 (59)
 Sleep hygiene in perioperative and critical care setting 4.44 (0.95) 27 (82) 21 (66)
 Sleep and strategies to improve sleep in ICU 4.56 (0.84) 30 (91) 22 (69)
 Pain, analgesia, and disrupted sleep 4.78 (0.49) 31 (94) 26 (61)
Impact of sleep deprivation on physician wellness
 Performance deficit during sleep deprivation 4.47 (0.72) 28 (85) 19 (59)
 Strategies for good sleep hygiene 4.50 (0.72) 28 (85) 20 (63)
 Sleep, stress, and burn out 4.53 (0.67) 29 (88) 20 (63)
 Effects of shift work on sleep 4.44 (0.67) 29 (88) 17 (53)
aData are presented as mean values of ratings on a 5-point Likert scale, where 5 indicates strong agreement and 1 indicates strong disagreement.
bPercentage of participants who selected either “agree” or “strongly agree.”
Abbreviations: CPAP, continuous positive airway pressure; ICU, intensive care unit; OSA, obstructive sleep apnea; STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference and Gender.

Table 3. - Additional Topics Identified by Participants (n = 28)
Topic Mean agreement score (SD)a No. of participants in agreement (%)b No. of participants who strongly agree (%)
OSA
 Differences between clinical presentation of pediatric versus adult OSA 4.21 (0.96) 23 (82) 13 (46)
 When questionnaires (eg, STOP-Bang, Berlin Questionnaire, Epworth sleepiness scale) are not applicable 4.54 (0.51) 28 (100) 15 (54)
 Indications and efficacy of various surgical airway modification options to treat OSA (eg, drug-induced sleep endoscopy and genioglossus stimulation) 4.11 (0.83) 22 (79) 10 (36)
 Anesthesia for the fiberoptic diagnosis of OSA and its anatomical location 4.11 (1.03) 20 (71) 13 (46)
 Role of oxygen therapy in patients at risk for OSA 4.54 (0.58) 27 (96) 16 (57)
Impact of sleep deprivation
 Impact of sleep deprivation on immune system 4.00 (0.90) 21 (75) 9 (32)
 Impact of sleep deprivation on pulmonary muscle function 4.07 (0.90) 22 (79) 10 (36)
 Sleep deprivation and delirium 4.61 (0.69) 25 (89) 20 (71)
 Effect of alcohol and other recreational drugs on sleep 4.21 (0.83) 21 (75) 13 (46)
Noninvasive ventilation
 Different noninvasive ventilation modalities and their indications in sleep-disordered breathing 4.79 (0.42) 28 (100) 22 (79)
 CPAP therapy compliance strategies 4.29 (0.85) 21 (75) 15 (54)
 Pressure considerations in sleep-disordered breathing 4.32 (0.77) 25 (89) 13 (46)
 Mask/interface options 4.25 (0.75) 25 (89) 11 (38)
 Advanced PAP therapies for complicated sleep-disordered breathing 4.07 (0.90) 22 (79) 10 (36)
Perioperative considerations in sleep-disordered breathing
 Postoperative respiration monitoring strategies 5.00 28 (100) 28 (100)
 Preoperative considerations in sleep-disordered breathing 4.89 (0.42) 27 (96) 26 (93)
 Indications for and appropriate use of high care and intensive care facilities 4.75 (0.52) 27 (96) 22 (79)
 Indications for sleep medicine consultation 4.54 (0.69) 27 (96) 17 (61)
Future pathways in sleep medicine and anesthesia
 Sleep medicine and fellowship training 3.75 (1.00) 17 (61) 7 (25)
 Pathways to certification in sleep medicine 3.71 (1.08) 18 (64) 7 (25)
 What a sleep medicine practice could look like (eg, in academic versus private practice setting) 3.32 (1.22) 15 (54) 4 (14)
aData are presented as mean values of ratings on a 5-point Likert scale, where 5 indicates strong agreement and 1 indicates strong disagreement.
bPercentage of participants who selected either “agree” or “strongly agree.”
Abbreviations: CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea; PAP, positive airway pressure; STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference and Gender.

Low levels of agreement (55%–76%) were found for topics related to anesthetic considerations of other sleep disorders, including hypersomnolence, idiopathic hypersomnia, parasomnias, restless legs syndrome, and circadian rhythm sleep-wake disorders. Additional core topics identified in the second round of the survey include noninvasive ventilation (75%–100% agreement for all subtopics under this category) and perioperative considerations in sleep-disordered breathing (96%–100% agreement for all subtopics under this category) (Table 3).

DISCUSSION

There is an evolving need and support for the development of postgraduate and continued medical education training programs aimed at improving the skills of health care providers in the perioperative setting. OSA, for example, is associated with substantial morbidity and increased risk of postoperative complications, yet remains underdiagnosed and may be first identified in the perioperative setting.1–5 While knowledge of sleep medicine is recognized as important for the practice of anesthesiology, the components of sleep medicine that should be included in the anesthesia residency curricula are not well-defined. For example, the ABA initial certification content outline mentions sleep medicine–related content on only 4 of 44 total pages and does not identify any topics beyond OSA.10 Although anesthesiologists are in a unique position to identify and optimize the management of patients with sleep-disordered breathing,25 there is a lack of a consensus-based curriculum which clearly defines the topics that sleep medicine training should offer to anesthesiologists in training.

We provide a framework of key topics which can aid in the development of a sleep medicine curriculum for anesthesiology residency programs. Consensus was achieved on most listed topics, emphasizing the perceived importance of sleep medicine to the practice of anesthesiology. The greatest level of consensus was evident in the “Pharmacology and Sleep” section, with very high agreement also seen with “central sleep apnea and periodic breathing,” “obesity hypoventilation syndrome,” “the effects of anesthesia and surgery on sleep and circadian rhythms,” and “perioperative considerations in sleep-disordered breathing.” All these topics reflect practical knowledge related to the practice of anesthesiology and perioperative medicine. Conversely, the topics listed under the “anesthetic implications of other sleep disorders” achieved less agreement among the experts, likely due to the perceived lower impact of these conditions on the perioperative management of patients.

The importance of the identified topics to patient care is supported by the recent literature.3–5,20,21,26–33 The SASM and other Societies have published guidelines and consensus statements on various topics regarding sleep apnea and anesthesia.20,21,27–30 For instance, patients with central sleep apnea have an increased rate of unplanned intensive care admissions, readmission, and mortality necessitating increased levels respiratory monitoring.31 Resting oxyhemoglobin saturation and the STOP-Bang (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference and Gender) questionnaire both predict sleep apnea in patients on opioids for chronic pain.32 Obesity hypoventilation syndrome is associated with increased postoperative complications, emphasizing the need for preoperative hypercapnia recognition.33

To our knowledge, this is the first study to identify high-priority topics for a sleep medicine curriculum for anesthesiology training programs based on the consensus of numerous experts in the field. A previous study in 2013 proposed curricular elements of sleep medicine for anesthesiology programs following a literature review and discussion with colleagues, however details were not provided on the process to choose the components.17 The Delphi survey method allowed consultation with experts across a wide geographical area that was relatively easy to facilitate; it allowed participants to remain anonymous, and thus free of influence of personality or social pressure, and its combination of ranking and open-ended questions allowed for input and consensus to help identify specific content of sleep medicine that can inform design of anesthesia residency curricula.

The limitations of the study are related to the limitations of the Delphi technique, survey design, response rates, and lack of a formal needs assessment. The results from the small sample size and low response rates may not be applicable to the wider population of anesthesiology practitioners. We did not perform a pretest survey and content validity has not been built for this tool. The criteria for determining what constitutes a consensus are arbitrary and was set at 80% for the purpose of the study to reflect a comparatively high standard.14,23,24 The majority of respondents were anesthesiologists and not sleep medicine physicians, and none who answered were dual-trained physicians, which may impact the selection of topics deemed important. Additionally, face validity may introduce subjectivity in our findings as our results are based on a panel of sleep medicine and anesthesia experts. Other important stakeholder groups such as residents, educational experts, closed claims, experts, and program directors had low response rates or were not included. Finally, pediatric sleep medicine topics were not included.

Of note, a needs assessment and formal evaluation of the prevalence of the identified sleep medicine topics in anesthesiology residency curricula among different institutions was not performed. Thus, the extent to which these topics are already included in curricula across North America is not known. Some topics may be included within residency curricula, but may not be applied in clinical practice. Since anesthesiologists train in an apprenticeship model, both perioperative lessons and the didactic curriculum are impactful in the development of well-trained residents. These core topics provide additional information to guide clinical teaching in the perioperative environment.

In conclusion, the results of our survey will be instrumental to program directors and specialty boards in defining specific topics of sleep medicine that is for developing novel anesthesia residency training curricula, revamping currently existing curricula, guiding clinical teaching, and designing Maintenance of Certification in Anesthesiology program and Continued Medical Education–related activities.

ACKNOWLEDGMENTS

The authors acknowledge the contributions of Alia Kashgari, MBBS, FRCPC; Vidya T. Raman, MD, MBA, FASA, FAAP; Susana Vacas, MD; Enrico M. Camporesi, MD; Anthony G. Doufas, MD, PhD; Eric Deflandre, MD; Yamini Subramani, MD; Anupama Wadhwa, MBBS, MSc, FASA; Petrus A. Swart, MD; Eva Christensson, MD, DESA; Jennifer E. Dominguez, MD, MHS; Suzanne Karan, MD; and Stephen C. Haskins, MD; David Wong, MD.

DISCLOSURES

Name: Linor Berezin, BSc.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: None.

Name: Mahesh Nagappa, MD.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: None.

Name: Jean Wong, MD.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: J. Wong reports research support from the Ontario Ministry of Health and Long-Term Care, Anesthesia Patient Safety Foundation, Merck Inc and is a recipient of a Merit Research Award, University of Toronto, Department of Anesthesiology and Pain Medicine.

Name: Jefferson Clivatti, MD.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: None.

Name: Mandeep Singh, MD.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: M. Singh is a recipient of the Canadian Anesthesiologists’ Society Career Scientist Grant and a Merit award, Department of Anesthesiology and Pain Medicine, University of Toronto.

Name: Dennis Auckley, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Jean G. Charchaflieh, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Malin Jonsson Fagerlund, MD, PhD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Bhargavi Gali, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Girish P. Joshi, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: G. P. Joshi has received honoraria from Baxter and Pacira Pharmaceuticals.

Name: Frank J. Overdyk, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Michael Margarson, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Babak Mokhlesi, MD, MSc.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Tiffany Moon, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Satya K. Ramachandran, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Clodagh M. Ryan, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Roman Schumann, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: R. Schumann receives royalties from Wolters/Kluwer as an author and reviewer of 2 obesity-related chapters in Up-To-Date, Waltham, MA, USA.

Name: Toby N. Weingarten, MD.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Christine H.J. Won, MD, MSc.

Contribution: This author helped with manuscript preparation and gives approval for its submission.

Conflicts of Interest: None.

Name: Frances Chung, MD.

Contribution: This author helped with the study conception, protocol design, manuscript preparation, and gives approval for its submission.

Conflicts of Interest: F. Chung reports research support from the Ontario Ministry of Health and Long-Term Care, University Health Network Foundation, Up-to-date royalties, consultant to Takeda Pharma and Masimo, STOP-Bang proprietary to University Health Network.

This manuscript was handled by: Richard C. Prielipp, MD.

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