Care of Patients at Risk for Sleep Apnea Who Receive Sedation
Sleep apnea is the most widely known sleep disorder besides insomnia. Estimates are that more than 18 million people have sleep apnea, and it is more common in men than women. People of all ages and both sexes can have sleep apnea. Due to apneic events, restful sleep patterns are interrupted resulting in excessive sleepiness and next-day fatigue. Increasing prevalence for sleep apnea requires the integration of a sleep apnea management (SAM) program to reduce the risk of experiencing an adverse event after receiving sedation.1
What are the Consequences of Untreated Sleep Apnea?
Patients with sleep apnea are four times as likely to have serious complications, two times as likely to have some post-surgical and post-procedure complications and have significantly longer hospital stays. If you suspect your patient has sleep apnea, evaluation by a doctor specializing in sleep disorders is recommended. A screening for sleep apnea should be done prior to receiving pain medications, sedation, or anesthesia. At a minimum, ask your patients who are preparing to receive a sedating drug: “Do you snore?” “Have you been noted to stop breathing during your sleep?” and “Do you have difficulty staying awake when sitting quietly or while driving?”
Without proactive treatment of sleep apnea the patient receiving drugs that cause sedation has an increased risk for other health risk factors such as elevated blood pressure due to increased effort to sustain adequate oxygenation and ventilation during sleep. The risk for ischemic heart disease is elevated and atrial fibrillation is twice as likely to occur if sleep apnea is untreated.
Sleep deprivation contributes to elevated blood sugar and blood pressure plus weight gain. Left untreated, elevated insulin contributes to diabetes. Also, with increased weight gain, sleep apnea becomes more severe, contributing to elevated blood pressure.
Medications that Affect Sleep Apnea
Drugs, which create respiratory suppression, are commonly used in a perioperative and invasive procedural care plan: benzodiazepines for relaxation, narcotics for pain control, antiemetics (phenergan) for nausea, hypnotics for sleep and antidepressants for mood or sleep. Close observation and continuous respiratory monitoring is required when substantial analgesia is required, especially when delivered intravenously with a Patient Controlled device. IV PCA used with patients at risk for sleep apnea creates increased risk for over sedation by the patient, who has increased need for pain control leading to increased sedation: increased somnolence from chronic sleep deprivation coupled with drug induced sedation promotes risk for an adverse event. To protect the patient, PAP therapy is required to sustain ventilation while managing pain control.
Anesthesia may cause re-sedation in many patients 6–12 hours after recovery. This creates a risk for an adverse event and requires increased nursing assessment and continuous respiratory monitoring. This is exacerbated by the presence of excessive daytime sleepiness due to the accumulated sleep deprivation from untreated sleep apnea. When observing your patient for the effects of sedation, it is critical to differentiate between sedation and sleepiness: does the patient need to be stimulated often to respond to your requests, and does the patient fall asleep easily without stimulation.2
Increased sedation also increases the patient’s risk for falls, especially later in the night when sedation and sleepiness become more pronounced.
Intervention to Prevent Adverse Events
With the integration of a dedicated sleep apnea management program, continuous monitoring of oxygenation and ventilation reduces the possibility of adverse events. The postoperative or post-procedure management plan should take into consideration the need for close observation by the clinical team and should be combined with the use of PAP when sedated and asleep. Standing Orders used with patients diagnosed or at risk for sleep apnea receiving sedation, pain control, anxiolytics, and antiemetics provide a standardized treatment plan to reduce the risk of a negative outcome when caring for the patient with sleep apnea.3
Impact on Care Continuum of Sleep Apnea
A sleep apnea management program requires a number of clinical services and a diverse care team to effectively reduce the risk for an adverse outcome:
• Anesthesia – risk for respiratory depression due to anesthetics and medications
• Operating Services and Surgeons – risk for adverse events post-procedures
• Radiology – monitoring for over-sedation during invasive procedures
• Endoscopy – monitoring sedation used during procedure
• Emergency Department – management of pain control
• Heart Institute – monitoring for increased sedation
• Neurology – risk for stroke
• Cardiology – management of ischemic heart disease
• Pulmonology – treatment of pulmonary hypertension
• Gastroenterology – treatment of acid reflux or GERD
• Endocrinology – management of co-morbid diabetes
• Internal Medicine – management of co-morbid hypertension
• Psychiatry – depression from loss of sleep and reduced quality of life
• Risk Management – impact of adverse events
• Administration – Support for equipment and staffing resources
The evidence suggests that there is a significant and under- appreciated risk for serious injury from sedating agents, opioids, and other drugs in the post-procedure or postoperative period. These agents cause life-threatening respiratory depression in the patients at risk for sleep apnea. To protect these patients from an adverse event, and still maintain control of pain, monitoring of ventilation and oxygenation with audible alarms and frequent assessment of vital functions is required. Treatment of sleep apnea with the use of positive air pressure implemented in PACU and following a procedure with sedation will protect the patient from experiencing an unexpected event.
We recommend that patient monitoring must continue after discharge. The newly diagnosed patient must be encouraged to be evaluated with a sleep study. They need to be educated about the dangers of ignoring treatment for sleep apnea and they need to understand how the risks for respiratory and cardiovascular complications are more serious for patients with sleep apnea. For example, their chance of having an auto related accident due to sleepiness and fatigue is significantly greater than the general populations.
Implementing a sleep apnea monitoring program for patients undergoing sedation for medical or surgical procedures will reduce patient health risks, reduce professional medical liabilities and create new revenue streams for disease management services for newly diagnosed sleep apnea patients.
Kathryn Hansen, BS, REEGT, CPC Sleep Center Management Institute Senior Advisor
1. Den Herder C, Risks of general anaesthesia in people with obstructive sleep apnea. BMJ 2004; 329:955–9.
2. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–93.
3. Preventing and managing the impact of anesthesia awareness. Sentinel Event Alert Joint Commission on Accreditation of Healthcare Organizations October 6, 2004; Issue 32.