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Apnea and Anesthesia

Question:

"John B. Fisher" wrote: > Below is the ONLY article I could find that relates to CSA and anesthesia. > It appears in this case the patient required "mechanical ventilation was > required until recovery of the respiratory drive, which was ablated by

John…. When I was researching OSA just a few weeks ago,  I found a couple of things regarding anaesthetic and printed them out and gave them to my GP.  One of the things I recall, was that OSA’s often have problems with general anaesthetic just as they are coming out of it in the recovery room.  The throat collapses and all hell breaks loose.  Interesting in that back in 1982 I had general for a hernia repair.  I remember waking up and not being able to breathe.  I heard a voice say ‘my God, not another one" and everyone came rushing to the bed.  I felt a tube go down my throat and I passed out.  I found out after the I had suffered ‘respiratory distress’ probably because of my asthma and they had three such occurrences that day. Last October I had surgery for another and different hernia, and because of the previous problem, was given Ventolin and they used special anaesthetic.  When I woke up, I got a written report from the GA doctor saying she had never had so much trouble getting a tube down a patients throat in her life and that I should discuss this with my family doctor.  I did and he said that she probably wasn’t very good at her job.  In hind site, and armed with what I’ve found out about OSA, the signs have been there for years!   I am incredibly angry with the medical profession in general and my GP in particular.  I’ve  managed to track down a GP that has quite a few CPAP patients and have talked to two of them myself.  Got an appointment with him tomorrow.  I’m hoping that he impresses me. Regards, Lee

Response:

(posted and e-mailed) Oops!  Stupid me.  I posted this response before I saw Warren had already said the same thing.  Must be the meds.  I need a nap. Kent Taylor (Mongo) – Hide quoted text — Show quoted text -Mongo wrote in message … >(posted and e-mailed) >Hi REP – >I found this info by Dr. John Loadsman of Australia on this web site: >     http://www.usyd.edu.au/su/anaes/lectures/Sleep_Apnoea.html >I hope that Dr. Loadsman will forgive me for lifting this info from his web page, but I think that >it is so important to be aware of these things that I am risking his ire.  Until I stumbled onto his >web site I did not know that people with OSA have special requirements for anesthesia.  This >frightened me so much that I immediately called MedicAlert (http://www.medicalert.org/ 1-800-IDALERT >(1-800-432-5378)) and ordered one of their bracelets in case I ever have an accident or other >situation that would require emergency treatment while I was unconscious. >Kent Taylor (Mongo)

<snip>

Response:

1. The first thing is you must tell doctors that you have sleep apnea, I was advise to get a medical braclet and wqear it in case of car accident but have yet to do this. he is a few things from a doctors site hope it helps. http://www.usyd.edu.au/su/anaes/lectures/Sleep_Apnoea.html ANAESTHETIC IMPLICATIONS OF OSA Anaesthetic, sedative and analgesic agents may worsen or precipitate OSA due to: – decreased pharyngeal tone – decreased ventilatory response to hypoxia and hypercapnia – decreased arousal response to obstruction, hypoxia, and hypercapnia. Positioning may be important. Patients are usually nursed supine. Nasogastric tubes may decrease airway diameter and worsen or precipitate obstruction. They may also prevent the use of CPAP in those who require it. The chronic effects of OSA (see above) will complicate perioperative management when present. General Perioperative Considerations Preoperative – Assessment of the patient should include risk factors for OSA, review of any relevant investigations, and recognition of any OSA complications when present. Sedative premedicants are best avoided in all but the mildest case and when necessary the patient needs supervision, monitoring and appropriate personnel available in case of obstruction. Induction – Gaseous induction may be difficult and the ability to provide CPAP is essential. Difficult intubation is more likely especially in syndromal and obese patients. Maintenance – Use minimal long acting sedatives. Recovery – This is the most dangerous time for OSA patients. Vigilance is decreasing while residual anaesthetic agents combine with narcotic analgesia to threaten the airway. Arrythmias are said to be common. Patients with known severe OSA should go to ICU. Patients who use CPAP should have it applied as soon as possible. Consider CPAP for others at risk. Analgesia – Local/regional is best if possible. Obviously use extreme caution with opioids and use the lowest dose possible. Beware epidural narcotics. Respiratory depression is thought to be worse than with parenteral administration, even with fentanyl. Specific Perioperative Considerations Nasal packing may cause obstruction. Consider packing around nasopharyngeal airways. Adenotonsillectomy usually results in decreased risk of OSA but watch that postoperative swelling doesn’t make it worse initially. Watch for the development of OSA after palatal surgery, especially velopharyngeal repair – sudden death has occurred – these need close observation in high dependency or better. Tracheostomy may be required. UPPP requires careful management to avoid coughing and straining which may disrupt sutures. Healing with stenosis can result in the need for permanent tracheostomy. Watch for postop swelling and worsened OSA, ideally in high dependency or better. And Later? There is now good evidence that OSA may be implicated in the development of late postoperative myocardial ischaemia, stroke, and unexplained postoperative deaths. Sleep architecture is disrupted perioperatively potentially worsening the risk of late postoperative obstruction and hypoventilation during sleep. Postoperative hypoxaemia is a likely factor in the development of wound breakdown. While there is no absolute evidence that sleep disordered breathing is playing a role in postoperative morbidity and mortality the suggestion is strong enough to warrant further investigation (and hopefully another chapter!). Regards Warren REP <r…@inanna.com> wrote in message

news:rep-ya02408000R0109991946370001@news.pacbell.net… – Hide quoted text — Show quoted text -> I am going to have some minor abdominal surgery (tubal ligation). I haven’t > spoken with the surgeon yet, but the usual procedure is to use general > anesthesia for this type of surgery. I’ve had this type of surgery before > under general anesthesia and had to be resusscitated {sorry, can’t remember > how to spell tonight}. I know the surgery can be done with a local but it > supposed to hurt like hell that way. At that time, no one knew I had apnea. > Now that it is known, it is possible to safely undergo general anesthesia > with special attention to not kill me? Or would it best to bite the bullet > and have it done with a local?  Not having the surgery is not really an > option.

Response:

(posted and e-mailed) Hi REP – I found this info by Dr. John Loadsman of Australia on this web site:      http://www.usyd.edu.au/su/anaes/lectures/Sleep_Apnoea.html I hope that Dr. Loadsman will forgive me for lifting this info from his web page, but I think that it is so important to be aware of these things that I am risking his ire.  Until I stumbled onto his web site I did not know that people with OSA have special requirements for anesthesia.  This frightened me so much that I immediately called MedicAlert (http://www.medicalert.org/ 1-800-IDALERT (1-800-432-5378)) and ordered one of their bracelets in case I ever have an accident or other situation that would require emergency treatment while I was unconscious. Kent Taylor (Mongo) —–start of Dr. Loadsman’s info—– ANAESTHETIC IMPLICATIONS OF OSA Anaesthetic, sedative and analgesic agents may worsen or precipitate OSA due to: – decreased pharyngeal tone – decreased ventilatory response to hypoxia and hypercapnia – decreased arousal response to obstruction, hypoxia, and hypercapnia. Positioning may be important. Patients are usually nursed supine. Nasogastric tubes may decrease airway diameter and worsen or precipitate obstruction. They may also prevent the use of CPAP in those who require it. The chronic effects of OSA (see above) will complicate perioperative management when present. General Perioperative Considerations Preoperative – Assessment of the patient should include risk factors for OSA, review of any relevant investigations, and recognition of any OSA complications when present. Sedative premedicants are best avoided in all but the mildest case and when necessary the patient needs supervision, monitoring and appropriate personnel available in case of obstruction. Induction – Gaseous induction may be difficult and the ability to provide CPAP is essential. Difficult intubation is more likely especially in syndromal and obese patients. Maintenance – Use minimal long acting sedatives. Recovery – This is the most dangerous time for OSA patients. Vigilance is decreasing while residual anaesthetic agents combine with narcotic analgesia to threaten the airway. Arrythmias are said to be common. Patients with known severe OSA should go to ICU. Patients who use CPAP should have it applied as soon as possible. Consider CPAP for others at risk. Analgesia – Local/regional is best if possible. Obviously use extreme caution with opioids and use the lowest dose possible. Beware epidural narcotics. Respiratory depression is thought to be worse than with parenteral administration, even with fentanyl. Specific Perioperative Considerations Nasal packing may cause obstruction. Consider packing around nasopharyngeal airways. Adenotonsillectomy usually results in decreased risk of OSA but watch that postoperative swelling doesn’t make it worse initially. Watch for the development of OSA after palatal surgery, especially velopharyngeal repair – sudden death has occurred – these need close observation in high dependency or better. Tracheostomy may be required. UPPP requires careful management to avoid coughing and straining which may disrupt sutures. Healing with stenosis can result in the need for permanent tracheostomy. Watch for postop swelling and worsened OSA, ideally in high dependency or better. And Later? There is now good evidence that OSA may be implicated in the development of late postoperative myocardial ischaemia, stroke, and unexplained postoperative deaths. Sleep architecture is disrupted perioperatively potentially worsening the risk of late postoperative obstruction and hypoventilation during sleep. Postoperative hypoxaemia is a likely factor in the development of wound breakdown. While there is no absolute evidence that sleep disordered breathing is playing a role in postoperative morbidity and mortality the suggestion is strong enough to warrant further investigation (and hopefully another chapter!).

Response:

On Wed, 01 Sep 1999 19:46:37 -0700, r…@inanna.com (REP) wrote: >I am going to have some minor abdominal surgery (tubal ligation). I haven’t >spoken with the surgeon yet, but the usual procedure is to use general >anesthesia for this type of surgery. I’ve had this type of surgery before >under general anesthesia and had to be resusscitated {sorry, can’t remember >how to spell tonight}. I know the surgery can be done with a local but it >supposed to hurt like hell that way. At that time, no one knew I had apnea. >Now that it is known, it is possible to safely undergo general anesthesia >with special attention to not kill me? Or would it best to bite the bullet >and have it done with a local?  Not having the surgery is not really an >option.

My last surgery the anesthetist asked me just before we "went in" what I wanted.  I told him about my apnea and that during my last surgery (which was my very first and done under general anesthesia)  I was reported to "have produced an exteme amount of mucous".  That influenced him to go for a local.  My impression of this speciality is a positive one. They are extremely patient oriented, competant and very good at calming one’s fears, both with words and little "magic wands".  Hope it all goes well. Max

Response:

- Hide quoted text — Show quoted text ->John B. Fisher scribbled carelessly in message … >> REP, be certain to discuss your obstructive sleep apena >> with your surgeon and anethesiologist.  Also be certain the >> receive a copy of your concern and a copy of the statement >> (see the URL below) from the American Sleep Apnea >> Association … >Okay, let’s try again.  Discuss the situation AND provide a written copy of >your concerns along with that statement from the American Sleep Apnea >Association.  Your insurance might be interested as well in both items. >Regards, >=jbf= >John B. Fisher

Hay Jonn….eye new whatt yoo ment. Trevurr  :-)

Response:

TPoun wrote: > John…is there anything relating to CSA and > anesthetic effects ?

Trevor, first of all I’m glad "ewe new whatt eye ment."  ;^)  On that other post.  Somedays I wonder about these fingers of mine .. they seem to want to do the walking without me! Below is the ONLY article I could find that relates to CSA and anesthesia. It appears in this case the patient required "mechanical ventilation was required until recovery of the respiratory drive, which was ablated by anaesthetic drugs, epidural morphine and high inspired oxygen concentrations".  In other words it appears that if CSA is present the surgery, oxygen and anaesthetic drugs can completely supress the respiratory drive.  As usual, when in doubt discuss it with your doctors and anesthesiologists. Regards, =jbf= John B. Fisher <><  <><  <><  <><  <><  <><  <><  <><  <><  <><  <><  <>< TITLE:  Anaesthesia for a patient with central alveolar hypoventilation syndrome (Ondine’s Curse). AUTHORS:  Wiesel S; Fox GS AUTHOR AFFILIATION:  Department of Anaesthesia, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec. SOURCE:  Can J Anaesth 1990 Jan;37(1):122-6 CITATION IDS:  PMID: 2295095 UI: 90106822 ABSTRACT:  The perioperative anaesthetic management of an adult patient with central alveolar hypoventilation syndrome (CAHS), Ondine’s Curse, is described for anterior resection of a carcinoma of the bowel. This rare syndrome results in alveolar hypoventilation, hypercarbia, hypoxaemia with secondary polycythaemia, pulmonary artery hypertension, and cor pulmonale. Epidural morphine was used for postoperative analgesia in an attempt to improve postoperative respiratory function. However, postoperative mechanical ventilation was required until recovery of the respiratory drive, which was ablated by anaesthetic drugs, epidural morphine and high inspired oxygen concentrations. The pathophysiology and treatment of this syndrome are reviewed.

Response:

Hi- I had a hysterectomy last year and had general anesthesia. I also had a breast lump removed a month before that for which I was mildly sedated. Because I was awake but sedated, I was concerned I would have trouble staying awake and therefore maintaining my airway. So the anesthesiologist provided a bit more pain meds so I wouldn’t feel as tense and therefore I needed a bit less to help me relax. And I used my CPAP throughout the entire surgery. For the major surgery, I was intubated the entire time so it was totally safe. No way my airway could have collapsed with a tube stuck down my throat. They were initially going to do the surgery at one hospital, but when they learned about the apnea, the anesthesiologist insisted the surgery be done at another hospital in case there were4 any respiratory emergencies. I also made VERY SURE that he made VERY SURE that the moment they took the tube out ion the recovery room, the CPAP was put on immediately. One problem I did have was that, due to the intubation and then the CPAP, my throat was so dry that the walls of my throat were sticking together and THAT caused me some difficulty breathing in the recovery room. The idiot nurse kept insisting that I was fine and should just relax and that I really could breathe. Gee that’s nice. Coulda fooled me! I asked for some ice chips or something and she refused, saying only the doctor could allow that. When I said "So call the doctor", she was incredulous I should be so disrespectful and demanding of THE DOCTOR. I had to have a full blown fit before ashe finally called someone. So-  the point of all of this is that you might want to have the anesthesiologist leave standing orders for the recovery room staff to allow ice chips or a wet mouth sponge to moisten your throat with. Other than that- anesthesia reallay was pretty simple with the basic precautions noted above. Good luck with your tubal ligation! Susan REP <r…@inanna.com> wrote:

: I am going to have some minor abdominal surgery (tubal ligation). I haven’t : spoken with the surgeon yet, but the usual procedure is to use general : anesthesia for this type of surgery. I’ve had this type of surgery before : under general anesthesia and had to be resusscitated {sorry, can’t remember : how to spell tonight}. I know the surgery can be done with a local but it : supposed to hurt like hell that way. At that time, no one knew I had apnea. : Now that it is known, it is possible to safely undergo general anesthesia : with special attention to not kill me? Or would it best to bite the bullet : and have it done with a local?  Not having the surgery is not really an : option. —                                              polit…@netcom.com

Response:

I am going to have some minor abdominal surgery (tubal ligation). I haven’t spoken with the surgeon yet, but the usual procedure is to use general anesthesia for this type of surgery. I’ve had this type of surgery before under general anesthesia and had to be resusscitated {sorry, can’t remember how to spell tonight}. I know the surgery can be done with a local but it supposed to hurt like hell that way. At that time, no one knew I had apnea. Now that it is known, it is possible to safely undergo general anesthesia with special attention to not kill me? Or would it best to bite the bullet and have it done with a local?  Not having the surgery is not really an option.

Response:

REP wondered about surgery and anesthesia… REP, be certain to discuss your obstructive sleep apena with your surgeon and anethesiologist.  Also be certain the receive a copy of your concern and a copy of the statement (see the URL below) from the American Sleep Apnea Association:     http://www.sleepapnea.org/sameday.htm Basically, they should be able to use general anesthesia.  But knowing that you will obstruct means different procedures must be taken. Regards, =jbf= John B. Fisher

Response:

John B. Fisher scribbled carelessly in message … > REP, be certain to discuss your obstructive sleep apena > with your surgeon and anethesiologist.  Also be certain the > receive a copy of your concern and a copy of the statement > (see the URL below) from the American Sleep Apnea > Association …

Okay, let’s try again.  Discuss the situation AND provide a written copy of your concerns along with that statement from the American Sleep Apnea Association.  Your insurance might be interested as well in both items. Regards, =jbf= John B. Fisher

Response:

On Wed, 01 Sep 1999 19:46:37 -0700, r…@inanna.com (REP) wrote: >I am going to have some minor abdominal surgery >Now that it is known, it is possible to safely undergo general anesthesia >with special attention to not kill me?

Both your surgeon and your anesthesiologist need to know this in order to put you to sleep safely.

Response:

In article <x9mz3.4152$6A1.12…@news3.mco>, "John B. Fisher" <john_b_fis…@bellsouth.net> wrote: > John B. Fisher scribbled carelessly in message … > > REP, be certain to discuss your obstructive sleep apena > > with your surgeon and anethesiologist.  Also be certain the > > receive a copy of your concern and a copy of the statement > > (see the URL below) from the American Sleep Apnea > > Association … > Okay, let’s try again.  Discuss the situation AND provide a written copy of > your concerns along with that statement from the American Sleep Apnea > Association.  Your insurance might be interested as well in both items.

My insurance is well aware of my apnea and my impending surgery – it’s paying for both! While it makes me cheaper to insure – no pregnancies with all their expenses – getting me off methylprogesterone is going to help the blood clots in my leg and take some strain off my goofy kidneys, also making me cheaper to insure. Thanks for the info. I am *very* difficult to anesthesize. During two prior surgeries, I had woken up during the procedures (most memorably as they were preparing to crack my jaw to remove my impacted wisdom teeth). During the last one, it seemed for a few moments as though I wasn’t going to wake up – ever, but the most terrifying part was waking up tied to a bed because I’d ripped out the trach tube so many times almost completely unable to breathe. After reading the info on the website, I’m at lot less anxious. Thanks again! (Incidentally, I didn’t see the ‘white light’ or dead relatives – I had fallen asleep in addition to being anesthetized.)

Response:

In article <7ql46o$…@dfw-ixnews7.ix.netcom.com>, Wachob <polit…@netcom10.netcom.com> wrote: > Other than that- anesthesia reallay was pretty simple with the basic > precautions noted above. Good luck with your tubal ligation!

Thank you! I can hardly wait! Even if it hurts as much as the laprascopy, I think the sheer joy will more than make up for it. Thanks also for passing on your stories of surviving major surgery alive and well, despite bitchy nurses. What I’m having done is like trimming a cuticle compared to what you’ve gone through (plus I want this done) and I feel a lot more confident after reading your story and Mr Fisher’s information. Hope you’re doing well!

Response:

>http://www.sleepapnea.org/sameday.htm >Basically, they should be able to use general anesthesia.  But knowing that >you will obstruct means different procedures must be taken. >Regards, >=jbf= >John B. Fisher

John…is there anything relating to CSA and anesthetic effects ? Trevor

Response:

I had shoulder surgery six weeks ago and had similar concerns.  I spoke to my pulmonologist who stated that general anesthesia is better since they will put a tube down your throat that will keep the airway open. The pulmonologist called the surgeon and informed him of my situation.  I also told the anesthesiologist a week before surgery and immediately prior to surgery.  I made sure that everyone that I saw was aware of my condition. You should do the same. Constantly remind them.  It worked well for me.  They had TWO anesthelogists to put me under and keep an eye on me.  The nurses in post-op were aware as were the nurses that took care of me overnight.  I did not use a CPAP machine that night but they had an oxygen supply hooked up to my nose (very comfortable) and they constantly monitored my blood oxygen level with something attached to one finger. Good luck, Bob REP <r…@inanna.com> wrote in message

news:rep-ya02408000R0109991946370001@news.pacbell.net… – Hide quoted text — Show quoted text -> I am going to have some minor abdominal surgery (tubal ligation). I haven’t > spoken with the surgeon yet, but the usual procedure is to use general > anesthesia for this type of surgery. I’ve had this type of surgery before > under general anesthesia and had to be resusscitated {sorry, can’t remember > how to spell tonight}. I know the surgery can be done with a local but it > supposed to hurt like hell that way. At that time, no one knew I had apnea. > Now that it is known, it is possible to safely undergo general anesthesia > with special attention to not kill me? Or would it best to bite the bullet > and have it done with a local?  Not having the surgery is not really an > option.

Response:

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