Risks of general anaesthesia in people with obstructive sleep apnoea

Abstract

Sleep is an integral part of human existence and is now, more than ever, the subject of clinical and research interest. Why do we spend approximately one third of our lives asleep? Sleep probably has a recovery function, especially for the brain. Throughout rapid eye movement sleep, neuronal connections in the catecholamine system are created, and this activity is essential to maintain cognitive function.w1 During rapid eye movement sleep in particular, the body is at its most relaxed state, and a three dimensional collapse of muscle (musculus genioglossus and musculus geniohyoideus) and fatty tissue around the upper airway may cause obstruction.1 When a pre-existent narrowing and slackening of the upper airway is also present, 2 apnoeas (complete cessation of breathing for 10 seconds or more) or hypopnoeas ( > 50% diminishing of airflow or oxygen desaturations > 3% for 10 seconds or more) may result. The prevalence of obstructive sleep apnoea in middle age is 2% for women and 4% for men.3 In practice, obstructive sleep apnoea seems to be under-reported; obstructive sleep apnoea is undiagnosed in an estimated 80% of patients. 4 Patients with obstructive sleep apnoea are particularly vulnerable during anaesthesia and sedation. w2This is not only the case for operations or other invasive interventions aiming at alleviation of obstructive sleep apnoea through reduction of the obstructive upper airway; even after surgery not related to obstructive sleep apnoea, such as hip and knee operations, patients with obstructive sleep apnoea are at risk of developing respiratory and cardiopulmonary complications postoperatively. Serious complications include reintubations and cardiac events.6 Anaesthetic management must focus on and deal with the increased likelihood of morphological alterations of the upper airway leading to an increased rate of difficulties in securing and maintaining a patent airway. 7In this review we discuss the various anaesthetic aspects of obstructive sleep apnoea, including preoperative, perioperative, and postoperative points of special interest. We also cover the various management options.

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

“…Positioning severely obese patients in 45°or 30°reverse Trendelenburg may aid in the prevention of gastroesophageal reflux and, thus, aspiration by alleviating increased intra-abdominal pressure (31,32). Apart from the ASA guidelines for the management of the difficult airway (38), few authors comment on the availability of different airway devices perioperatively (27). No information on the benefits of additional clinicians during induction and emergence from anesthesia to aid in potentially critical difficult airway management situations is available.…”

“…In two recent studies, Ͼ70% of patients presenting for gastric bypass surgery had sleep apnea by polysomnography (25,26). Several authors emphasize the need for surgeons and anesthesiologists to be aware of potential preoperative and postoperative complications in patients with OSA (7,(25)(26)(27)). An increased risk for difficult intubation (7,8) and for postextubation complications has been reported (7) in obese adult patients with OSA, and many of these patients may be particularly sensitive to opioid and sedative medications (7,28).…”

Validation of simulation for recruitment to training posts in anaesthesia

“…Simulation in anaesthesia is increasingly being used for training and assessment of competencies [1], but its role in recruitment is less widely acknowledged. Medical simulation has been used as part of the selection process for training posts in anaesthesia at the South West Peninsula Deanery for the past 2 years.…”

Perioperative management of the obese surgical patient

“…89,90 Patients with OSA, a frequent accompaniment of obesity (see above), have pharmacodynamic alterations with an increased sensitivity to certain sedatives. 91 …”