Narkoseeinleitung bei einem Patienten mit Schlaf-Apnoe-Syndrom

Abstract

Based on a case report, we offer brief guidelines on the perioperative management of patients with Sleep-Apnea-Syndrome (SAS) who present with a high incidence of a difficult airway and a high risk of respiratory depression during the perioperative period. A 39 year old male patient with a body mass index of 34.22 kg/m2 and receiving continuous-positive-airway-pressure-(CPAP) therapy for known SAS was scheduled for elective plastic surgery. After induction of anaesthesia and direct laryngoscopy no adequate airway could be established and the patient became hypoxic, hypercapnic and developed hypotension and bradycardia. With the use of a laryngeal mask airway the patient was stabilized and did not show neurologic sequale after immediate awakening. The following fiberoptic intubation of the awake patient, still showing tendency of upper airway obstruction, confirmed the difficult anatomical structures. The subsequent general anesthesia was uneventful. The patient received CPAP therapy and was monitored during the first postoperative night in the Intensive Care Unit. He made an uneventful recovery. He was advised to have regional anaesthesia or planned fiberoptic intubation, where possible, in the case of further anesthetic intervention. SAS has major implications for the anaesthesiologist and whenever patients exhibiting the high risk factors (obesity, male sex, history of intense snoring, impaired daytime performance, nonrefreshing daytime naps) are presented for surgery this condition should be considered. Elective surgery should be postponed until after adequate examination and treatment when necessary. Patients with SAS should always be suspected of having cardiopulmonary dysfunctions such as hypertension, cardiac dysrhythmia or cor pulmonale. It is most important to avoid sedative premedication, to initiate CPAP therapy preoperatively, to encourage regional anaesthesia if possible and to ensure close monitoring over the complete perioperative period. Planned fiberoptic intubation, preferably with surgical personnel available for an emergency airway, is a safe method for the induction of anaesthesia. Postoperatively, patients are at high risk from respiratory depression, even in the awake state. Postoperative opioid analgesia, no matter what route, should only be given under close monitoring. Independently of regional or general anaesthesia there is an increased risk of respiratory depression in the middle of the first postoperative week, suspected to be caused by the catching up on lost REM-sleep, due to shifts in the normal sleep pattern during the first postoperative days.

A Debate on Surgical and Nonsurgical Approaches for Obstructive Sleep Apnea: A Comprehensive Review

“…Here, the medical team was advised to opt for regional anesthesia, only confirming that the sleep apnea syndrome poses an important challenge for the anesthesiologist, especially given patients with sleep apnea are suspected to have associated pathologies, especially cardiovascular ones. It is important to avoid sedatives and initiate CPAP before surgery, and postoperative opioid analgesics should be administered under strict supervision [ 27 ].…”

Kataraktoperation bei einem Patienten mit schwerem obstruktivem Schlafapnoesyndrom

“…Dies ist für den Anästhesisten ebenso von Bedeutung wie das gehäufte Vorkommen schwieriger Atemwegsverhältnisse (erschwerte Bedingungen der Maskenbeatmung [11]),Intubationsprobleme u.a.bedingt durch einen prominenten Zungengrund oder großer Epiglottis [1]) und erhöhte Sensitivität für Sedativa und Opioide mit der Gefahr der Atemwegsobstruktion beim OSAS-Patienten [10]. Die wirkungsvollste und häufigste Behandlung ist die nächtliche nasale Beatmung mit kontinuierlichem Überdruck (CPAP: "Continuous Positive Airway Pressure") [6,16] …”