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Specialty Spotlight
Sleep
Apnea
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Ostermeier AM, Roizen MF, Hautkappe M, et al
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opiods in Patients with Sleep Apnea
Anesth Analg 85: 452-460, 1997
Three patients with sleep apnea [ 2 reported in this article] who had sudden postoperative arrests associated with epidural opiods were reported.
Case 1 was a woman, 41, operated for right hip revision arthroplasty. She had history of sleep apnea, morbid obesity and juvenile rheumatoid arthritis. She received epidural analgesia consisting of 0.06% bupivacaine, 7 mL/hour, plus fentanyl, 10 micro-g/mL after surgery. Two days after surgery she was found to be unresponsive, with slow, deep respirations, an arterial blood pressure of 84/40 mm Hg., and a heart rate of 70/min. Later in the day, cardiac arrest occurred 3 times and she died. Autopsy revealed no cause of death.
Case 2 was a man, 66, operated for bilateral knee arthroplasty. He had history of sleep apnea, hypertension, and deviated nasal septum. He had epidural anesthesia, and during recovery he was given epidural infusion of 0.06% bupivacaine, 7 mL/hour, and fentanyl, 10 micro-g/mL. On the third postoperative day, he was found to be unresponsive and could not be resuscitated.
The authors conclude that patients with sleep apnea syndrome are at particularly high risk of postoperative respiratory depression from any mode of analgesic therapy, and that guidelines for management of such patients need to be created. Continuous nasal positive airway pressure before and after surgery, for 24 to 48 hours has been recommended. Tracheal extubation should be attempted only after the patient is fully conscious and the upper airway is patent. Corticoid administration must be considered to reduce airway edema if present. Such patients go into sudden respiratory arrest without any warning and need to be constantly monitored.
