Sleep Test Required Before Surgery

[So Well]

DEAR DR. : I am overweight and scheduled to have my hip replaced. The anesthesiologist asked me if I snore. I told him, 'yes, I do snore nightly.' I also have high blood pressure. As a result of my answers, he wants me to have a sleep test before my surgery. He said I probably have sleep apnea and he needed to know before he would "put me under." What does sleep apnea have to do with my getting a new hip?

A: First of all, your anesthesiologist is following the guidelines of The American Academy of Anesthesiology. Based on your answers, you could be at high risk for surgery. Anesthesiologists are becoming more aware of the dangers that sleep apnea poses in regards to surgery. Recent studies have shown the incidence of cardiac and pulmonary complications are twice as high in the period right after surgery in people with sleep apnea. There are a number of reasons for this; however, the major one is exquisite sensitivity to anesthetics and pain killers resulting in more severe and prolonged apneas.
http://www.azdailysun.com/lifestyles/he ... cca08.html

[Julie]

BUT - if your doctor, anesthesiologist and nurse in charge of the recovery room (make SURE someone talks to her/him ahead of time) are aware of your apnea, they will hook you up to Cpap (bring your own machine and mask) immediately after you come into the Recovery Room, because that's the iffy place where things could go wrong if you're not hooked up (but still out cold). It's not during surgery where you're being monitored, but afterward that counts. You'll be fine as long as you're hooked up post-op.

[LoQ]

BUT - if your doctor, anesthesiologist and nurse in charge of the recovery room (make SURE someone talks to her/him ahead of time) are aware of your apnea, they will hook you up to Cpap (bring your own machine and mask) immediately after you come into the Recovery Room, because that's the iffy place where things could go wrong if you're not hooked up (but still out cold). It's not during surgery where you're being monitored, but afterward that counts. You'll be fine as long as you're hooked up post-op.

Everyone in my family vomits when recovering from general anesthesia. For some reason the recovery people don't give you the anti-nausea medication that actually WORKS until all of the useless drugs have been tried and shown to fail. At my sister's last surgery, the anesthesiologist had the nerve to tell her, after she vomited repeatedly through various ineffective drugs, "if we know a person is going to have trouble, we just do X" where "X" was something like "put Y in the drip when we are reversing the anesthesia."

Now why can't they just do "X" for EVERYONE! Why must we all vomit our guts up, and THEN they take action? Basically, at that point, it's really too late to keep you from vomiting in the mask, but oh, well.

[Kevin G.]

It probably makes sense to have ths sleep study in any case but a question should be asked is whether it is more expensive to perform the sleep study or for the anethesiologist to assume that you have sleep apnea?

Is there increased medical risk if your anethesiologist assumes that you have sleep apnea and you don't?

Will the sleep study cause a delay in your surgery that will cause problems.

[jonquiljo]

Recent studies have shown the incidence of cardiac and pulmonary complications are twice as high in the period right after surgery in people with sleep apnea. There are a number of reasons for this; however, the major one is exquisite sensitivity to anesthetics and pain killers resulting in more severe and prolonged apneas.
http://www.azdailysun.com/lifestyles/he ... cca08.html

What you posted was an Internet Q&A that some sleep Dr. published. He seemed a bit enamored with himself and sleep medicine. Sleep medicine is important but not the answer to all of our medical problems. When you read things from someone like that, you have to take into account the source and wonder if he was a bit enamored with himself and his occupation.

While some of the above statements may be true, they are only true when totally in context. Yes, people with apnea get worse if they are given central nervous system depressants. But to say that and conclude the statement given above is really taking statistics (again) too far. What they need to do is pay attention to the patient when he or she is in surgery because a lot of anesthesiologists like to multi-task and work on more than one patient at a time. I guess that wasn't accounted for in their statistical arguments.

What, are they not going to give a replacement to someone if they are overweight and have apnea? If so, it would be "defensive medicine" more than anything else. Boy, I'm glad this guy is not my sleep Dr!

[Slartybartfast]

The wife (recovery room RN) says they recover folks from surgery with their own CPAP machines all the time. For that type of surgery, you'll be on a ventilator and after being out for that length of time, it'll take a while to wake you up. So it's important that, when the tube comes out, you can breathe on your own without your uvula strangling you after the sturgeon has done all that nice stitchery on your derriere.

I think they're making sure your pressure settings are in order so no surprises while you're recovering.

[jdm2857]

after the sturgeon has done all that nice stitchery on your derriere.

I don't care how good his stitchery is, I'm not letting a fish operate on me.

[So Well]

What you posted was an Internet Q&A that some sleep Dr. published. He seemed a bit enamored with himself and sleep medicine. Sleep medicine is important but not the answer to all of our medical problems. When you read things from someone like that, you have to take into account the source and wonder if he was a bit enamored with himself and his occupation.

..... Boy, I'm glad this guy is not my sleep Dr!

If I were the sleep doc, I would be glad you are not my patient.

I am surprised how people take that OP. None of you have mentioned what I thought was the most important part of the article: It was the anesthesiologist, not the sleep doc, who suggested the sleep study. That is excellent news to me that anesthesiologists are now screening undiagnosed patients for sleep apnea before the day of surgery.

Another item of importance was that The American Academy of Anesthesiology has sleep apnea in their guidelines. That was more good news to me.

To me, the sleep doc's only importance was to relate the story in the Arizona Daily Sun. But not to downplay that, it is important for awareness as is evidenced by the patient's question showing lack of awareness.

[roster]

So Well, I am with you on this one and I go a step beyond the recovery room. If I were a surgeon or anesthesiologist or even a sturgeon*, I would not want to operate (except emergency) on a patient with untreated sleep apnea.

I don't want to operate on a fatigued, sleep-deprived patient. I want him treated and rested before the surgery.

When he is discharged from the hospital, I want him to be able to go home and sleep and breathe simultaneously.



*

In general, the most difficult aspect of fish surgery is the provision of adequate and safe anesthesia, and several different anesthetic regimens are provided. Once one is familiar with the normal anatomy of the piscine patient, the basic concepts of surgery prevail, including appropriate surgical approach, hemostasis, and gentle tissue manipulation. Specific surgical procedures, celiotomy, liver biopsy, renal biopsy, and laparoscopy are discussed. Finally, successful outcome of a surgical manipulation often rests in the postoperative management of the surgical patient.

[kteague]

Just knowing a patient likely has sleep apnea will not provide them with the itiration info that will be needed to put them on cpap. Also, the info from a sleep study defining OSA, CSA, Complex Apnea, or UARS could make a difference in the type of post surgical treatment delivery type. I would like to see cpap treatment for known apnea patients be mandatory post surgery except when the surgery type prevents it. We've had forum members speak of running into major trouble being intubated due to their apnea. Just wondering what precautions are taken when a sleep apnea patient is put to sleep before being intubated. I would think all anesthesiologists would all over this.

[ozij]

From Mayo Clinic Proceedings 2001 (yes, that was in 2001)
Postoperative Complications in Patients With Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study

[Kevin G.]

About 2 years ago I had surgery. They were interested in whether I had sleep apnea but did not require a sleep study or put me on a CPAP machine. This was in a fairly good hospital. My sense is that the important thing was that they were aware of the issue and were monitoring me.

Previously I had been in the hospital for several days. Did not have the chance to bring my machine. The machine that they gave me was a low end CPAP when I was used to an APAP.

[Slartybartfast]

[snip]

It was the anesthesiologist, not the sleep doc, who suggested the sleep study. That is excellent news to me that anesthesiologists are now screening undiagnosed patients for sleep apnea before the day of surgery.

FWIW, likely not much, the (drop-dead gorgeous) gas-passer in the O.R. is the main reason I'm here. While the docs were counting their tools and dictating notes after removing a large** cyst from my back (4" incision) that required only "twilight" anesthesia, my ears pricked up when I heard the anesthesiologist say the words "apneic breathing." She had asked me in pre-op whether I had sleep apnea, and I told her (truthfully) that I had never been diagnosed, but my wife says I snore. But then, so does the cat. So when I heard those words I managed to rouse myself enough to ask, "Do I have sleep apnea?" She replied, "You need to have a sleep study."

So I did. And I had to tell my wife that she was right. Again.

** When I saw the sturgeon for the pre-op consult, he kept saying, "Wow." and, "Gee." Scared the heck out of me at the time.
When I returned for the post-op checkup, I turned around and pulled up my shirt and he said "Wow." He poked and prodded with his finger, then he said, "Gee, that healed up quickly. You have nice skin."

[PST]

I can't remember if I have ever talked about this. If I'm repeating myself, I apologize. My work requires me to review hundreds of medical malpractice cases in detail every year, and to glance briefly at the facts in hundreds more. I see cases occasionally that involve sleep apnea issues, and most of the serious ones have a common pattern. I do no believe that I have ever seen a claim that injury or death was caused by the failure to put a patient on CPAP after surgery. Instead, the most common allegation is that anesthesiologists and others failed to take into account OSA as a sign that a patient might be difficult to intubate. There are several other factors, like a short, thick neck, that are also signs. If there is reason to believe that a patient may be difficult to intubate, then steps are taken, like waiting a little longer than normal to remove an endotracheal tube after surgery, or waiting for a higher level of consciousness than in other patients, and having special equipment and personnel ready to reintubate the patient quickly. I believe anesthesiologists are much more attuned to apnea issues than they were 15 years ago, and that there is also increasing sensitivity to the need for patients who will be staying in the hospital to have their CPAP available for normal sleep. I don't get the impression, however, that CPAP is normally used in the PACU for patients coming out of general anesthesia. I could be wrong, though. My experience is all from the odd perspective of seeing cases in which something went radically wrong.

[jonquiljo]

If I were the sleep doc, I would be glad you are not my patient.

Yes - you would be glad not to have me as a patient as I don't cut these people much of a break. I've seen too many people ignored to death by medical personnel lately. There seems to be a great deal of that going around these days. And Internet Q&A physicians are generally not a great source of information.

The study posted was interesting. The average patient was a couple years shy of 70 and had a BMI of 31-34 (though I am not a big fan of the BMI metric). So these were really big older people! Is that a normal sampling of the average person receiving a hip replacement? Most of those I know who are getting replacements are younger and thinner.

It's good to hear that some anesthesiologists are keeping tabs on this - especially on older, overweight patients. But do they do anything about it pre and post -operatively? This study was done from a patient database, so the surgeries have long been performed. The real place to get this kind of awareness is in the beginning - at the PCP level.

A good question would be how many people here were originally referred for a sleep study by a PCP or by a specialist? Hopefully it's from PCP's - but I'm afraid it most likely will not be.