Qustion about a case I winessed recently.

[Dr Peper]

Hi guys. Med student and long time lurker here.

Recently I was shadowing in anesthesia, and a patient with an interesting complication came up. They were an ASA1 moderately obese 40yo M presented to gen surg for a procedure under GA... All standard so far... The interesting thing is that this individual has complex sleep apnea, with a confirmed history of Shane-Stokes (sp?) respirations.

He also failed to bring his uber-fancy CPAP machine.

Even the attendings had a difference of opinion. Some said the patient should be sent intubated and ventilated to the Med ICU. Others thought he could be sent to the PACU with an oral airway and high-flow O2 (and a special note to the nurse watching him).



I know this is an unusual complication, but I figured you guys know every complication in and out, and would be able to comment on the best course of treatment and explain WHY.

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[urge]

What was the complication?


BTW, I don't think an obese pt with sleep apnea on cpap is an ASA 1. Most likely a 3 at least.

 

[Mman]

Hi guys. Med student and long time lurker here.

Recently I was shadowing in anesthesia, and a patient with an interesting complication came up. They were an ASA1 moderately obese 40yo M presented to gen surg for a procedure under GA... All standard so far... The interesting thing is that this individual has complex sleep apnea, with a confirmed history of Shane-Stokes (sp?) respirations.

He also failed to bring his uber-fancy CPAP machine.

Even the attendings had a difference of opinion. Some said the patient should be sent intubated and ventilated to the Med ICU. Others thought he could be sent to the PACU with an oral airway and high-flow O2 (and a special note to the nurse watching him).



I know this is an unusual complication, but I figured you guys know every complication in and out, and would be able to comment on the best course of treatment and explain WHY.

A fat person with sleep apnea? That's par for the course. The only unusual thing you have described to me is that the patient is actually compliant with CPAP (despite not bringing it with them today). And yes, that would make them ASA 3. If you need a machine to keep you breathing adequately at night, you are certainly not a completely healthy person with no systemic disease (ASA 1).

As for how the patient should be managed postop, it depends mostly on the type of surgery they were having. If they had carpal tunnel release, they can go home the same day. If they were having a 12 hour whipple, they might need postop ventilation in the ICU.

If he was having some random uneventful surgery, he'd probably get extubated and sent to the PACU with a nasal airway in place and orders for RT to bring a CPAP machine to place on him in PACU even though the mask wouldn't be fitted to his face.

 

[Planktonmd]

The Cheyne Stokes breathing indicates that the patient has central sleep apnea possibly with some obstructive component since he is obese.
This is the kind of patient that can be very sensitive to opiates and other CNS depressants.
The management post-op depends on the type of surgery he is getting and the need for systemic opiates post-op.
In general every measure should be taken to decrease or eliminate the need for opiates if the plan is to discharge the patient home.
Regional anesthesia is a great option here if possible.
If this is a surgery that produces significant postop pain and requires high doses of systemic opiates then they should have a low threshold to admit this patient for at least 24 hours and use CPAP and ETCO2 monitoring while in the hospital.

 

[fakin' the funk]

Hi guys. Med student and long time lurker here.

Recently I was shadowing in anesthesia, and a patient with an interesting complication came up. They were an ASA1 moderately obese 40yo M presented to gen surg for a procedure under GA... All standard so far... The interesting thing is that this individual has complex sleep apnea, with a confirmed history of Shane-Stokes (sp?) respirations.

He also failed to bring his uber-fancy CPAP machine.

Even the attendings had a difference of opinion. Some said the patient should be sent intubated and ventilated to the Med ICU. Others thought he could be sent to the PACU with an oral airway and high-flow O2 (and a special note to the nurse watching him).

I know this is an unusual complication, but I figured you guys know every complication in and out, and would be able to comment on the best course of treatment and explain WHY.

Cheyne-Stokes respirations, bro.

It shouldn't be a problem getting a CPAP machine anywhere this patient is having surgery (i.e., not an ambulatory surgery center). Most patients know their CPAP settings, usually 5, 8, 10, or 12. This guy may have something fancy like BiPAP with autoflow or what have you, but you can approximate. Surgery or no surgery, this dude needs some PAP at night.

Minor or moderate surgery, obviously definitely extubate, have CPAP around at extubation, otherwise for postop.
Major surgery, depends on the usual assessments of respiratory/circulatory/neurologic status, expected postop outcome, but pt almost certainly ICU whether tubed or not.

 

[nap$ter]

Hi guys. Med student and long time lurker here.

Recently I was shadowing in anesthesia, and a patient with an interesting complication came up. They were an ASA1 moderately obese 40yo M presented to gen surg for a procedure under GA... All standard so far... The interesting thing is that this individual has complex sleep apnea, with a confirmed history of Shane-Stokes (sp?) respirations.

He also failed to bring his uber-fancy CPAP machine.

Even the attendings had a difference of opinion. Some said the patient should be sent intubated and ventilated to the Med ICU. Others thought he could be sent to the PACU with an oral airway and high-flow O2 (and a special note to the nurse watching him).



I know this is an unusual complication, but I figured you guys know every complication in and out, and would be able to comment on the best course of treatment and explain WHY.

every opportunity to send a special note to the nurse should be seized.

 

[fakin' the funk]

every opportunity to send a special note to the nurse should be seized.

Especially because she will DEFINITELY be on break when the pt has hypoxic PEA...

 

[Dr Peper]

Cheyne-Stokes respirations, bro.

Note to self: being in med school does not make one a good speller.



Anyway, AFAIK, this case was done under GA with some Ketamine added to the mix because it is less of a respiratory depressant. The anesthesia and surgery itself were unremarkable, but the primary source of discussion was how to prevent the patient from developing cheyne-stokes respirations and/or complete apnea in recovery. Simple PAP or BiPAP will keep the airway open, but if the apnea is central in origin it doesn't matter how open the airway is.

And as mentioned by the poster above, I would bet money that the patient develops apnea within seconds of the PACU nurse leaving his bedside.



Any other thoughts on keeping this patient breathing and oxygenated post-op?

 

[Mman]

Note to self: being in med school does not make one a good speller.



Anyway, AFAIK, this case was done under GA with some Ketamine added to the mix because it is less of a respiratory depressant. The anesthesia and surgery itself were unremarkable, but the primary source of discussion was how to prevent the patient from developing cheyne-stokes respirations and/or complete apnea in recovery. Simple PAP or BiPAP will keep the airway open, but if the apnea is central in origin it doesn't matter how open the airway is.

And as mentioned by the poster above, I would bet money that the patient develops apnea within seconds of the PACU nurse leaving his bedside.



Any other thoughts on keeping this patient breathing and oxygenated post-op?

The patient's own BiPAP machine probably has a preset backup rate so that if the patient goes too long without trigger a breath it will give him an assisted breath.