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Sleep Apnea and Same-day Surgery

It is well known that sleep apnea* can be a complicating
factor in the administration of general anesthesia. It is also known that when
the anesthesiologist is aware of the sleep apnea in the patient undergoing
surgery and takes appropriate measures to maintain the airway, the risks of
administering anesthesia to people with sleep apnea can be minimized.

Although there have been no clinical trials on anesthesia in sleep apnea
patients, clinical experience confirms that anesthesia can be problematic in
these patients. The cause of potential problems is seen in an anatomic and
physiologic understanding of sleep apnea: the syndrome of obstructive sleep
apnea is characterized by repetitive episodes of upper airway obstruction during
sleep. ("Apnea" literally means "without breath" and is clinically defined as a
cessation of breath that lasts at least ten seconds.) Sleep apnea may be
accompanied by sleep disruption and arterial oxygen desaturation.

General anesthesia suppresses upper airway muscle activity, and it may impair
breathing by allowing the airway to close. Anesthesia thus may increase the
number of and duration of sleep apnea episodes and may decrease arterial oxygen
saturation. Further, anesthesia inhibits arousals which would occur during
sleep. Attention to sleep apnea should continue into the post-operative period
because the lingering sedative and respiratory depressant effects of the
anesthetic can pose difficulty, as can some analgesics.

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 (also known as out-patient or ambulatory surgery) may not be appropriate
for some sleep apnea surgery patients.

Before surgery, the anesthesiologist should first conduct a thorough
preoperative assessment (including history of anesthesia) and physical
examination. The use of preoperative sedatives must be considered carefully as
sedative medication, like anesthesia, suppresses upper airway muscle activity.
During surgery, maintaining the patency of the airway is the anesthesiologist's
primary concern. The period of awakening from anesthesia after surgery can also be problematic
for sleep apnea patients. In patients who have undergone surgery to treat sleep
apnea, the airway can be narrowed from swelling and inflammation. There may also
be some upper airway swelling secondary to intubation and extubation. As
mentioned, the lingering sedative and respiratory depressant effects of the
anesthetic can pose difficulty. If narcotics are found to be necessary in the
post-operative period, appropriate monitoring of oxygenation, ventilation, and
cardiac rhythm should be provided as narcotic analgesics can precipitate or
potentiate apnea that may result in a respiratory arrest. Perioperative
vigilance must continue into the postoperative period.

Many patients require postoperative intubation and mechanical ventilation
until fully awake. Patients who already use a prescribed CPAP (Continuous
Positive Airway Pressure) machine should utilize it, but the pressure should be
monitored to ascertain that it is adequate. CPAP can also be employed
postoperatively in other patients without their own machine to support
breathing. For certain patients, it may be judicious to admit them to an
intermediate care or intensive care area postoperatively to facilitate close
monitoring and airway support measures.

Therefore it is deemed wise to let sleep apnea patients remain in the care of
medical personnel until it can be ascertained that their breathing will not be
obstructed. While sleep apnea patients may require a longer period of time in
the care of medical personnel than would otherwise be required of the surgical
procedure, this precaution is prudent and enables anesthesiologists to provide
safe anesthetic care for sleep apnea patients.

Approved by the ASAA Board of Directors June, 1999.

It should be remembered that the overwhelming majority of sleep apnea
cases have not been identified
. Thus it is not sufficient simply to ask if a
patient has sleep apnea. Instead, health care professionals must ask proper
screening questions of their patients, especially those individuals at risk for
sleep apnea and those children undergoing a tonsillectomy and adenoidectomy,
before making decisions on patient care.

A source of information for the general public is the article "On the Cutting Edge" from the Winter 2007 issue of the ASAA newsletter WAKE-UP CALL.

*There are three types of sleep apnea: obstructive, central, and mixed (a
combination of the two). Obstructive sleep apnea is the most common. Patients
with mixed sleep apnea should be treated as if they had obstructive. Pure
central sleep apnea, while rare, also requires consideration.