From: Maxine Westland

Here's a great article for every WLS pre-op with Obstructive Sleep Apnea. This article also contains good information for all pre-operative patients.

Anesthesia and the apnea patient.
Dave Hargett

Dr. John Palmeri, M.D., an anesthesiologist who practices at Central DuPage Hospital explained some important considerations for sleep apnea patients undergoing surgical or medical procedures involving anesthesia. This report is adapted with permission from an article published in the monthly newsletter of the A.W.A.K. E. group of Elk Grove Village, Illinois. The article was prepared by Dave Hargett, the newsletter editor and moderator for that group. Dave is very active in national and regional efforts to educate people about sleep apnea and is an active participant in an online support group, in addition to his local duties. The Newsletter of the Elk Grove Village A.W.A.K.E. group is informative and lively and demonstrates that members receive worthwhile and varied education and support activities. (The editor)

Our program for the evening was presented by Dr. John Palmeri, an anesthesiologist who practices at Central DuPage Hospital. Dr. Stuart Morgenstein, an ENT specialist who works with our group, recruited Dr. Palmeri to speak after receiving a letter from Dave Hargett. Dave asked several questions about anesthesia and how it impacts the apnea patient. The focus of Dr. Palmeri's talk was to address these questions.

Dr. Morgenstein took the podium to introduce our speaker.
Dr. Morgenstein also introduced Dr. Greg Dauber, an oral surgeon, who often works as a "team" member in conjunction with Dr. Hart, Dr. Morgenstein and Dr. Palmeri where surgery is deemed necessary on a sleep apnea patient. Dr. Morgenstein also commented that getting an anesthesiologist to speak isn't easy. They're all very busy people, but he was able to get his first choice to agree to speak to us. Dr. John Palmeri is a member of the Department of Anesthesiology at Central Dupage Hospital, a very talented and gifted anesthesiologist and a caring and committed physician. He also told us that he had warned Dr. Palmeri that we were a sophisticated, aggressive audience.

How can anesthesia impact a person with sleep apnea?
What is the job of the anesthesiologist?

Before addressing the questions that Dave had raised, Dr. Palmeri made some general comments about anesthesia. He pointed out that there is a lot of mystique about what anesthesiologists do. "We're the guys you meet right before surgery -- you never see us again, but you get a big bill from us", a line which drew lots of laughter in agreement.

The purpose of anesthesia is to keep you comfortable during an otherwise noxious procedure -- surgery hurts. The anesthesiologist is there to guarantee your safety and protection during the procedure.

He is also responsible for monitoring your vital signs, heart rate, respiratory rate, oxygen saturation level, and your blood pressure.

Depending on where the surgery is and the type of surgery, there are different ways to achieve the goal of keeping you comfortable. The most common is general anesthesia, which is a means to render the patient unconscious, so that you don't react to or feel your surgery.

The usual procedure is to get you off to sleep with intravenous drugs of a sedative nature. Then you are kept asleep with inhaled gases, administered through a mask over your nose and mouth, or occasionally through an endotracheal tube inserted through the mouth and into the windpipe.

However, it is not always necessary to put you to sleep, depending on the surgery. (Normal sleep is very different from the 'sleep' induced by anesthesia, which is more like a coma. Ed) Frequently, the anesthesiologist just provides sedation to keep you comfortable. For example, with a peripheral procedure or a superficial one, the surgeon can apply local anesthesia to the surgical area so that you can't feel what the surgeon is doing.

The anesthesiologist can then provide sedation so that you're not so aware of what's going on.

Sedation increases the risk of obstruction, especially for people who have sleep apnea.
Providing sedation to any patient, though, usually causes some relaxation of the musculature of the pharynx and throat and can cause obstruction. Patients with obstructive sleep apnea tend to be more sensitive to what would otherwise be nonobstructive doses of drugs. It's important for the anesthesiologist to know that you have obstructive sleep apnea (OSA). That's a risk that he should be aware of.

Regional anesthesia.
Another way to provide comfort during surgery is regional anesthesia, especially for extremities like arms and legs, and some abdominal procedures. Parts of the body can be numbed without giving any centrally acting drugs.

Narcotics.
Normally narcotics are used to relieve pain. Narcotics suppress everyone's drive to breathe. If one has a lower respiratory drive to begin with, narcotics can make that even more dramatic. By numbing just the part of the body being operated on, there is no need to give centrally acting drugs.

Spinal or epidural anesthesia.
The most common ways to give regional anesthesia are the "spinal" or the "epidural". Epidural is quite often used to relieve the pain of labor. Many surgeries below the ribcage can be done with epidural. For patients with sleep apnea, this is an especially nice way to work, because it provides comfort and safety without affecting the respiratory drive or the musculature of the pharynx. On the other hand, it does require more cooperation from the patient, as you will be more aware of what's going on. You might hear the pounding of a hammer or the powering up of a drill, for example. While this might be unpleasant, it is an option.

There are risks and benefits in anything you do and in any choices you make, but you can have some control in determining the type of anesthesia depending on the type of surgery.
Talking with the anesthesiologist.
Not all anesthesiologists are as sensitive to or aware of the problems associated with sleep apnea patients. Dr. Palmeri urged all of us to make contact with the anesthesiologist before surgery, preferably a day or two before. Sometimes it isn't practical to meet with the specific anesthesiologist, because the schedule might not be set, but most anesthesiology departments will have someone talk to you about your options and your concerns. Otherwise, it is quite likely (especially with the large number of outpatient or same day surgeries being done today) that you will not meet the anesthesiologist until right before the operation. Working with the anesthesiologist ahead of time lets him try to come up with a plan for attacking your comfort and safety relative to pre-existing problems such as OSA.

The anesthesiologist will try to get a thorough history and do a physical exam before the surgery. In many patients, difficulty with the airway will be detected through this exam. But if you already know about it, such as us OSA patients, be pro-active and raise the issue. Sleep apnea patients often have more difficulty with their airway. It is the anesthesiologist's job to help you breathe while asleep, either with the face mask or the tube. Placing the endotracheal tube into the windpipe can be more difficult with OSA patients, so it is valuable to know this ahead of time to help with selecting the right equipment and strategies.

Using your CPAP while in hospital.
Bringing the CPAP to the hospital is an issue Dave asked about. Dr. Palmeri said there was nothing to be lost by doing this, but he saw less need for this for same day surgery compared to surgery that involved an overnight stay. Typically the patient goes from surgery to the recovery room where he/she is closely observed. Problems there are easily handled. However, once back in the hospital room, the vigilance and monitoring is less intense. Having your CPAP there may be useful. He indicated that he had never had a patient use CPAP while in the recovery room. (In later discussion, Dr. Hart indicated that he felt strongly that there should be use of the CPAP in the recovery room.)

Elton Monken raised an issue about the use of his Bi-Pap machine in the hospital after some recent surgery, where the hospital engineering staff came up and inspected his machine in the middle of the night. Dr. Morgenstein pointed out that this is required by the Joint Commission on Hospital Accreditation. He suggested that if we take our CPAP machines to the hospital for possible use, we should ask that they be inspected as soon as possible, so that there is no problem when we want to use them. It is also probably a good idea to have a copy of the prescription covering your prescribed pressure.

Dr. Palmeri also indicated that there are some drugs that they use that can erase memory from the time they are given to you. While under the influence, the patient can have lucid conversations but later have absolutely no recall whatsoever. The patient may think that they were "put under" but they may not have been. (Both Dave Hargett and John Angel described surgeries where such drugs might have been used on them.) However, there is still a need to be careful with sleep apnea patients, as there are differences in tolerance levels among patients.

After surgery.
The relief of pain after surgery should also be a concern to us sleep apnea patients. In dealing with post-surgical pain, the most common drugs used are narcotics, either through an IV or a shot. These can be a threat to sleep apnea patients by depressing the drive to breathe. Epidural post-surgical anesthesia can help.

More about epidural anesthesia--how it works and use after surgery.
He described epidural anesthesia in more detail. The spinal cord is a cord surrounded by a sac of fluid, and the nerves of the spinal cord come down the midline and at different levels branch out. With epidural anesthesia, a thin, plastic tube called a catheter is inserted through the back, near the spinal cord, and local anesthetic (similar to those used by dentists) is administered to those nerves, blocking the pain. An epidural doesn't actually puncture the sac of fluid surrounding the spinal cord. It sits outside and applies the drugs to nerves as they come out of the spinal cord. This enables the anesthesiologist to numb different parts of the body, usually the lower half. This is normally used for surgery, but once in place can also be used to control post-surgical pain by continuing to administer more dilute solutions of drugs, while avoiding the use of IV drugs that act on the entire body. An epidural is often favored during childbirth because it avoids providing drugs to the baby. A "spinal is usually a one shot deal. The needle goes deeper, drugs are administered, and then the needle comes out. These drugs usually last up to 12 hours.

While many people don't like the idea of having a needle inserted into their back, and many have a fear of paralysis, nerve damage from this type of procedure is actually extremely rare. It is a really practical and safe way to have anesthesia for many procedures. But it does require cooperation from the patient, as the patient is usually awake and aware of what is going on.

Other types of surgery.
Surgery above the ribcage almost always requires a general anesthetic.

Some of the new minimally invasive surgeries, where there is no major incision, such as laparascopic hernia repairs, gall bladder surgeries, etc., actually require general anesthesia and intubation because of the way the surgery changes the physiology of the diaphragm and the lungs.

Emergency situations.
Since there is always the possibility that the sleep apnea patient could be brought into an emergency room and need surgery, when the patient is unconscious and no one knows about the patient's apnea, the use of a Medic Alert or similar medical warning bracelet or necklace is probably a good idea.

Summary:
Talk to your anesthesiologist ahead of time. While the final choice of the type of anesthesia will be a team decision between the patient, surgeon and anesthesiologist, and will be based on the circumstances; the patient can have some control over the choice.

Avoid general anesthesia if you can.
Avoid the use of narcotics if possible.
Take your CPAP and prescription to the hospital when you have surgery.
Have your CPAP inspected by the hospital engineering staff if you anticipate using it.

This is a patient's recollection (aided by a tape recorder) of the talk given to the members of the Elk Grove Village A.W.A.K.E. group on the topic of "Anesthesia and the Apnea Patient". The information is presented here as general background for sleep apnea patients prior to undergoing any surgical or medical procedure requiring anesthesia, but should not be construed as medical advice, since the writer is a sleep apnea patient with no medical degree.

For comments, or to connect with the

Elk Grove Village, Illinois A.W.A.K.E. Group,

write to Dave Hargett.
Used with permission of Dave Hargett.

Phantom of the Night includes additional information about dealing with the risks of anesthesia and medical procedures including forms for identification of the apnea patient and information to share with your physician and anesthesiologist.

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