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Unrecognized Sleep Apnea in the Surgical Patient^*

Implications for the Perioperative Setting

^* From the Departments of General Internal Medicine (Drs. Kaw, Michota, and Jaffer) and Pulmonary and Critical Care (Dr. Golish), Cleveland Clinic Foundation, Cleveland, OH; the Department of Pulmonary and Critical Care Medicine (Dr. Ghamande), West Virginia University, Morgantown, WV; and the Department of Pulmonary, Critical Care, and Sleep Medicine (Dr. Auckley), Case Western Reserve University, Cleveland, OH.

Correspondence to: Roop Kaw, MD, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: kawr{at}ccf.org

Abstract

Anesthesia and surgery both affect the architecture of sleep. Aside from the postoperative effects of anesthesia and surgery, sleep deprivation and fragmentation have been shown to produce apneas or desaturations even in patients without presumed sleep apnea. Recent epidemiologic data have placed the prevalence of obstructive sleep apnea syndrome (OSAS) at about 5% among Western countries. The problem is further hindered by the difficulty in diagnosing OSAS, as patients with OSAS may present for surgery without a prior diagnosis. Clinical suspicion for OSAS may first be recognized intraoperatively. Adverse surgical outcomes appear to be more frequent in OSAS patients. Immediate postoperative complications may intuitively be attributed to the negative effects of sedative, analgesic, and anesthetic agents, which can worsen OSAS by decreasing pharyngeal tone, and the arousal responses to hypoxia, hypercarbia, and obstruction. Later events are, however, more likely to be related to postoperative rapid eye movement (REM) sleep rebound. In the severe OSAS patient, REM sleep rebound could conceivably act in conjunction with opioid administration and supine posture to aggravate sleep-disordered breathing. REM sleep rebound has also been suggested to contribute to mental confusion and postoperative delirium, myocardial ischemia/infarction, stroke, and wound breakdown. Although the data to guide the perioperative management of patients with moderate-to-severe OSAS is scarce, heightened awareness is recommended. The selected use of therapy with nasal continuous positive airway pressure before surgery and after extubation may be beneficial.

Learning Objectives: 1. Identify common sleep architectures affected by anesthesia and surgery in the perioperative period. 2. State a perioperative complication in Obstructive Sleep Apnea Syndrome patients. 3. Identify perioperative interventions and management techniques that best facilitate improved obstructive sleep apnea syndrome patient care.

Key Words: continuous positive airway pressure • oximetry • perioperative • sleep apnea

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