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  • Syndrome characterized by sleep-induced relaxation of pharyngeal muscle tone leading to upper airway obstruction
  • Risk factors include obesity, tonsillar hypertrophy, craniofacial abnormalities (e.g., micrognathia), ingestion of alcohol/sedatives, male gender, and middle age
  • Signs and symptoms: snoring, observed apnea during sleep, daytime somnolence, difficulty concentrating, morning headache
  • Associated findings may include episodic hypoxemia, hypercarbia, polycythemia, hypertension, pulmonary hypertension, RV failure
  • “Gold standard” test is polysomnography
  • Severity may be measured by the apnea/hypopnea index (AHI), the number of apneic or hypopneic events per hour:
    • Mild—5–20
    • Moderate—21–40
    • Severe—>40
  • Treatment is essentially medical (nasal CPAP) and reduces the incidence and severity of CV complications. Surgical treatment (UPPP, turbinectomy, septoplasty, etc.) is only an adjuvant


  • Focused history and physical examination to evaluate patient’s likelihood of having OSA
  • Consider use of STOP-BANG questionnaire, a validated scoring system to assess risk of obstructive sleep apnea
  • If likelihood of sleep apnea is high:
    • Decide to either manage patient based on clinical criteria alone or have patient obtain additional workup or treatment (typically takes several weeks)
    • Decide whether procedure should be performed on an outpatient or an inpatient basis
    • Assess for difficult airway and obtain specialized airway equipment if deemed necessary
    • Use preoperative sedation cautiously if at all
    • Consider gabapentin premedication (900 mg po preoperatively) followed by 300 mg every 6 hours for at least 24 hours to reduce analgesic requirements

Table Graphic Jump Location
Table 13-1 STOP-BANG Questionnaire

  • If possible, completely avoid benzodiazepines
  • Preoxygenate thoroughly as these patients are more prone to desaturation
  • Have video laryngoscope (i.e., GlideScope, McGrath laryngoscope, etc.) and/or fiber-optic available to aid in intubation because majority of OSA patients are obese with difficult airways
  • Avoid nitrous oxide if patient has history of pulmonary hypertension
  • If general anesthesia, extubate fully awake and with full muscle strength
  • Consider the use of regional or local techniques when appropriate
  • Consider limiting opioids and instead relying on local/regional analgesia (field block, epidural catheter)
  • If moderate sedation is used, continuously monitor adequacy of ventilation
  • Dexmedetomidine might be a better option for sedation (MAC) than propofol
  • Consider use of CPAP during sedation


  • Consider use of nonopioid postoperative analgesia (e.g., regional techniques, NSAIDs)
  • Especially avoid continuous infusion of opioids
  • Continue CPAP if feasible
  • Consider discharge of patient from PACU into a monitored setting (step-down)
  • Avoid discharge of patient from PACU to home/unmonitored setting until patient is no longer at risk of postoperative respiratory depression

1. Gross JB, ...

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