CHIEF resident in the section of anaesthesia and intensive care at the University Hospital of the West Indies, Dr Deborah Douglas, says patients presenting for surgical procedures who also have obstructive sleep apnea pose a unique challenge for anaesthetists.

Speaking with the Jamaica Observer in a recent interview, Dr Douglas explained that each case is considered on a patient-by-patient basis, and that the type of surgery – whether low, intermediate or high risk – as well as the level of obstructive sleep apnea, which can be mild, moderate or severe, are taken into consideration before administering anaesthetic.

Obstructive sleep apnea is a disorder in which breathing is briefly and repeatedly interrupted during sleep. Depending on whether it is mild, moderate or severe, sequelae (conditions which are the consequence of a previous disease or injury) increase the farther along the continuum a patient lies.

Dr Douglas explained that the goal of the anaesthetist – a medical specialist who administers anaesthetics resulting in insensitivity to pain before surgical operations – is to achieve preoperative optimisation. She explained further that this is to ensure that the patient is as healthy as possible before surgery to improve the patient’s ability to tolerate the operation as well as improve their post-operative outcome.

“Now, if you are coming for what we consider a low-risk surgery and you have mild obstructive sleep apnea, then we will be more concerned about post-operative and how we can deal with your obstructive sleep apnea afterwards,” she told Your Health Your Wealth.

She said that, more than likely, a patient with mild obstructive sleep apnea would not have as many sequelae, such as hypertension, type two diabetes or heart disease, as patients with moderate to severe obstructive sleep apnea. As such, anaesthetists expect that that patient’s operative course will not be as challenging.

Dr Douglas said too that a patient with mild obstructive sleep apnea could be sent to recovery then back to the hospital’s ward after surgery, whereas, patients with moderate to severe obstructive sleep apnea would have to be keenly watched after surgical procedures.

She also said that the level of obstructive sleep apnea would determine the type of anaesthetic, whether general or regional, that a patient receives.

“General anaesthetic is the one where we actually put you to sleep and you stay asleep for the entire procedure,” Dr Douglas explained. “The regional anaesthetic is, say for instance you have broken one of your feet, we may be able to just numb the foot that is in question as opposed to putting you to sleep, and just going to work on the foot.”

Dr Douglas said that it is recommended, as much as possible, that regional anaesthetic is done for people with obstructive sleep apnea because of the unique challenges posed.

“Right off the bat you are thought to have what we call a difficult airway and the difficult airway classification means that we may have challenges putting you to sleep and putting that breathing tube in.

“So when I have any patient with obstructive sleep apnea or moderate to severe obstructive sleep apnea coming to theatre, who requires a general anaesthetic, I am usually quite cautious and I set up for all problems that may be associated with a difficult airway,” she reasoned.

The chief resident said too that because conditions such as hypertension, heart disease and type two diabetes might be at play, a patient with severe to moderate obstructive sleep apnea is not in the best of health, so their tolerance for major surgery may be reduced.

In this case, she said, the anaesthetist has to ensure that they get the patient in the best possible position to tolerate the surgical stress.

Dr Douglas said after a patient with severe to moderate obstructive sleep apnea is finished with surgery, medical practitioners may or may not entertain placing them in a high dependency or an intensive care unit, adding that this has nothing to do with the type of surgery done, but the fact that they have obstructive sleep apnea.

“It is just because you were under anaesthesia for an extended period of time, we expect that your post-operative course may be challenging and we just want to make sure that you are okay. So we keep you a little longer than just sending you to the recovery area, then subsequently putting you on the ward, which we might do with somebody who has mild obstructive sleep apnea,” she said.

Putting people to sleep, according to Dr Douglas, is not a walk in the park. She said that with obstructive sleep apnea patients they have to be watched keenly, because once they are taken from a state of anaesthesia it is expected that they are going to have some residual effect in terms of probably being a little bit sleepy.

However, she was quick to point out that this happens to all patients who undergo general anaesthesia, or even sedation.

Dr Douglas said patients with severe obstructive sleep apnea are usually advised to get a sleep machine and that if they are coming in for surgery, they are advised to bring this machine with them so that they can immediately be placed on it when the are awakend after surgery.

“We usually tell our surgeons, if you have a high suspicion that a patient has obstructive sleep apnea, send them to the anaesthetist in the clinic setting so that we can start working with them in preparation for surgery,” she said. “Don’t just put these patients on the ward and then we come and see them, and then we have a problem because we are uncomfortable; we are not going to proceed because of the significant risk.”

Dr Douglas reiterated that the key is to work out a plan with these patients to get them in a better position before going into surgery.