OSA Can Complicate Anesthesia Delivery
Respiratory Therapists and Anesthesiologists Must Be Vigilant
By Sharlene Sephton
An anesthesia mask looms over the patient undergoing surgery. The glare from the lights overhead dim, and consciousness slips away. Seduced into slumber, his upper airway muscles relax, closing off the passage. He ceases breathing.
If this was a typical night at home in bed, his brain would sense trouble and briefly awaken him to restart his breathing. But as he lies on the operating table, the anesthesia inhibits these arousals, and the amount of oxygen in his bloodstream falls dangerously low.
This scenario demonstrates the risks anesthesia presents for obstructive sleep apnea patients. "Although there have been no clinical trials on anesthesia in sleep apnea patients, clinical experience confirms that anesthesia can be problematic in these patients," according to Christin Engelhardt, executive director of the American Sleep Apnea Association (ASAA).
Yet, with meticulous preparation, careful maintenance of the airway during surgery, and postoperative vigilance, anesthesia can be delivered safely.1
Preoperative Assessment
"Not all patients are aware that they suffer from obstructive sleep apnea," says David J. Plevak, MD, associate professor of anesthesiology at the Mayo Clinic, Rochester, Minn. "It's an illness that is not completely appreciated and is underdiagnosed."
Therefore, he stresses that a patient with OSA not undergo elective procedures until a preoperative assessment, including a physical examination and previous history of anesthesia or surgery, is performed. Dr. Plevak suggests several key questions to ask patients:2
Do you snore nightly?
Has anyone ever said that you stop breathing in your sleep?
Do you feel tired and groggy on awakening?
Do you fall asleep easily during the day?
Do you frequently have headaches in the morning? (However, this symptom is nonspecific.)
"Anesthesiologists have an important role in detecting OSA symptoms," Engelhardt agrees. "By asking patients these questions during pre-surgery screening, they will start to take their symptoms more seriously."
If sleep apnea is suspected, a sleep study may be warranted. Other specialized tests, such as an echocardiogram or pulmonary function tests, can help clarify physical findings that might suggest systemic or pulmonary hypertension, heart failure or impaired oxygenation, all of which are markers of OSA.2
Once OSA is recognized, the anesthesiologist will know to use caution when administering sedatives and maintaining proper airway control throughout the surgery.
Postoperative Considerations
This vigilance should continue into the postoperative period, Dr. Plevak says. "Certain medications that patients are given during surgery may be lingering in the immediate post-op period and exacerbate periods of apnea."
CPAP should be used in the recovery room and the pressure monitored because after anesthesia it may need to be increased. In most cases, allowing medications time to be metabolized is all that is necessary. In severe instances, continuing mechanical ventilation in recovery may be required.
"The worst case is that someone be transferred from a monitored area to an unmonitored area and they develop apnea episodes causing a medical emergency. It might lead to patient demise," Dr. Plevak says.
However, several anesthesiologists alerted the ASAA about insurance companies that have refused to allow OSA patients to be kept under the care of medical personnel where they could be monitored appropriately, according to Engelhardt. In response, the ASAA board of directors approved last year a statement on same-day surgery that reads, in part:
"Given the nature of the disorder, it may be fitting to monitor sleep apnea patients for several hours after the last dose of anesthesia and opioids or other sedatives, longer than non-sleep apnea patients require and possibly through one full natural sleep period. Hence there is concern that same-day surgery may not be appropriate for some sleep apnea surgery patients."3
The ASAA is hoping respiratory therapists and anesthesiologists will help to increase the recognition of sleep apnea among their patients by thorough screening and will take the necessary steps, including informing hospitals and third-party payors of the precarious relationship between sleep apnea and anesthesia, to provide safe delivery of anesthesia.
References
1. Ogan OU, Plevak DJ. Sleep apnea and anesthesia. WAKE-UP CALL [ASAA newsletter] 1996 Jun/July.
2. Ogan OU, Plevak DJ. Anesthesia safety is always an issue with obstructive sleep apnea. Anesthetic Patient Safety Foundation Newsletter 1997;12(2):14-15.
3. Sleep apnea and same-day surgery accessed via the Web at http://www.sleepapnea.org/resources/pubs/sameday.html.
Sharlene Sephton is editor of ADVANCE.
Sleep Tracks, Advance for Managers of Respiratory Care, June, 2000.
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