To the Editor
I would like to respond to Dr. Weinger’s lead article, published in the 2006-2007 winter issue of the APSF Newsletter, which discusses the dangers of postoperative opioids. My particular interest is in regard to postoperative pain control for the obstructive sleep apnea (OSA) population. It seems much of the data we have related to this safety issue are based on the use of parenteral opioids postoperatively. Specifically, the article mentions Dr Lofsky’s report on the effect opioids have on the neural efferent system, which is said to be responsible for depression of upper airway patency. The opioid delivery of reference in this discussion was patient-controlled analgesia (PCA). My questions are 1) Has our specialty determined the safety of oral opioid-based analgesics for the ambulatory patient with OSA, and 2) What is the impact of the provision of parenteral opioids as part of the general anesthetic or immediate postoperative pain relief in the OSA patient being discharged to home? I ask these questions in light of the fact that there is an alteration in perioperative sleep that is pronounced in the OSA population and observed in the 24-hour postoperative period. This alteration, which is partly due to the exposure to anesthetics and analgesics, is worsened by the effect of rapid eye movement (REM) sleep rebound1 and can create a tenuous postoperative period while the patient is home unmonitored.
Drs. Weinger and Morell did provide their personal suggestion that it is likely safer for OSA patients to be discharged home on oral analgesics rather than be admitted and receive parenteral opioids. I can easily agree with this due to all of the potential life-threatening risks of PCA or intermittently dosed opioids when monitoring is substandard, but are there any objective data to substantiate this anecdotal evidence? As a resident physician, I am becoming increasingly aware of the growing ambulatory surgery population as well as an increasing prevalence of OSA as the obesity epidemic continues.2 I would like to know that as I care for patients in the ambulatory setting, with either formal or presumptive clinical diagnosis of OSA, the provision of perioperative opioids is not placing them at higher risk for incurring a life-threatening respiratory event while recovering at home.
Michelle Lawrence, MD
- Benumof JL. Obesity, sleep apnea, the airway and anesthesia. ASA Refresher Courses in Anesthesiology 2002;30:27-40.
- Kaw R, Michota F, Jaffer A, et al. Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting. Chest 2006;129:198-205.