Last year, I attended a conference where I learned some things about sleep that really got my attention. Did you know that scientists and physicians can demonstrate objective physical and mental/cognitive deficits in anyone who doesn’t get at least seven hours of sleep in one night? That’s simply incredible to me, and, as result, our family made some decisions to prioritize sleep.
But that’s not the only aspect of sleep that I’ve been focusing on this year. We’ve recently been doing a lot of research on a serious medical condition called sleep apnea. It’s for a wrongful death medical malpractice case where we believe it played a central role.
In that case, a man in his 30s died after an elective surgery that lasted less than an hour. The medical experts that Painter Law Firm retained to review the case concluded that the anesthesia providers, an anesthesiologist and certified registered nurse anesthetist (CRNA), were at fault for failing to plan ahead and control this patient’s ability to breathe as he recovered from general anesthesia and a regional interscalene block.
What is obstructive sleep apnea?
The consensus among sleep medicine professionals is that over 20 million Americans have sleep apnea. Of that total, 80% of the people with moderate to severe obstructive sleep apnea have never been diagnosed. While it’s most common in men over 40 years old who are overweight, anyone can have obstructive sleep apnea—even babies and children.
So, what exactly is obstructive sleep apnea? It’s a condition where a person’s airway is blocked, and, thus, breathing stops. It’s usually caused by the tongue collapsing against the soft palate, which then collapses against the back of the throat while a person is asleep. This cuts off the airway.
Here some common signs and symptoms of obstructive sleep apnea:
• Loud snoring
• Episodes where you stop breathing during sleep
• Instances where you wake up making a strange gasping or choking noise
• Being sleepy during the day or having a tough time with concentration or staying on task
The Mayo Clinic recommends seeing a doctor when these signs and symptoms are serious enough that your snoring is loud enough to disturb others, you wake up with gasps or chokes, someone notices that you repeatedly stop breathing while sleeping, or you’re extremely sleepy during the day.
Anesthesia and obstructive sleep apnea
But there’s something else that I really think you should be aware of.
Obstructive sleep apnea and general anesthesia don’t work well together. I recently took the deposition of an anesthesiologist expert witness who was hired by two defendant anesthesia providers whom we’ve sued on behalf of our client. Check out what he had to say about obstructive sleep apnea: “I think these are some of the most challenging patients that we as anesthesiologists take care of.”
In 2014, the American Society of Anesthesiologists published excellent practice guidelines for the perioperative (immediately before, after, and during surgery) management of patients with obstructive sleep apnea. Some of the key points include:
• Before surgery, an anesthesiologist should review the patient’s medical records, interview the patient and family to screen for undiagnosed obstructive sleep apnea, and conduct a physical exam. The exam should include looking for signs like body mass index/overweight status/obesity, a thick neck, a thick tongue, and assessment of the patient’s natural airway.
If you’re participating in a pre-operative or pre-anesthesia assessment where questions are asked about sleep, pay attention and give thorough answers.
• Patients already diagnosed with obstructive sleep apnea should be instructed to bring their CPAP equipment with them, so it may be used to promote a safe, stable airway. The guidelines recommend consideration of using CPAP during sedation.
• For patients with diagnosed or a high risk of obstructive sleep apnea, anesthesiologists should make special decisions for the anesthesia technique, airway management, and patient monitoring.
• The guidelines recommend general anesthesia with a secure airway over sedation without a secure airway. A secure airway typically involves intubation, which is placing an endotracheal breathing tube through the mouth and down the throat to keep the airway patent/open.
• Obstructive sleep apnea patients have a higher risk of post-operative respiratory compromise. In other words, their airway may collapse after surgery and emergence (wearing off of) general anesthesia.
• When possible, patients with obstructive sleep apnea should be positioned in the lateral (side), prone (stomach), or sitting positions rather than supine (on the back). The same positioning is preferred throughout the recovery proves. Studies have shown that positioning can improve apnea-hypoxia (cessation of breathing and low oxygen levels) scores.
• Don’t extubate (remove the breathing tube of) patients until they’re fully awake and alert, preferably in the semi-upright, lateral, or prone positions (versus supine).
• Providing continuous supplemental oxygen until the patient can maintain their baseline oxygen saturation levels on room air.
• Keeping patients longer in the recovery room or post-anesthesia care unit (PACU). This means delaying discharge to home, where they won’t be monitored, until they’re no longer at risk of post-operative respiratory depression.
I trust that you can appreciate that obstructive sleep apnea is serious business, and even riskier when mixed with general anesthesia.
If you or a loved one has been seriously injured because of medically mismanaged sleep apnea during surgery or anesthesia—or if you think that may be an issue—contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.