Anesthetics Opioids and Barbiturates

Recommendations for safe perioperative care in the OSA patient include the use of CPAP preoperatively, consideration of intubation over fiberoptic bronchoscope during surgery, and the use of CPAP and regional anesthesia postoperatively rather than the continuous administration of opiates (26). Nasal CPAP can eliminate the postoperative risk of hypoxemia, which would then allow the use of adequate parenteral or oral analgesics. Analgesia has been achieved safely with intravenous morphine sulfate or meperidine hydrochloride (Demerol®) (intensive care unit) and oral oxycodone (OxyContin®, Roxicodone®), while patients were receiving CPAP during all periods of sleep after surgery. There were no significant reductions in SpO2 regardless of the severity of OSA syndrome or obesity (26).

All opiates have the potential to worsen sleep apnea, compromise breathing, and even cause sleep apnea is some cases. Opioids depress respiration, by direct effect on brainstem respiratory centers and by reducing the ventilatory responsiveness to carbon dioxide and hypoxia. Central sleep apnea (CSA) was present in 30% of individuals on methadone maintenance therapy with the severity directly related to the blood level of methadone (27). CSA occurs in less than 1% of the general population (28). Any patient with CSA or OSA taking an opiate medication is at risk of cessation of breathing during sleep without proper nonpharmacologic treatment (e.g., PAP). Persons with sleep apnea should be counseled that any opiate, even oral acetaminophen/hydrocodone (Vicodin®), the most commonly prescribed opiate for acute pain, can be dangerous due to impairment of normal respiratory function. Alternative pain control (e.g., nonsteroidal anti-inflammatory drugs like ibuprofen) should be used in patients whose apnea is not well-controlled with PAP (6,27).

Barbiturates, such as phenobarbital, pentobarbital (Nembutal®), secobarbital (Seconal®), and mephobarbital (Mebaral®) have well-established respiratory-depressant effects and they should not be used in patients with OSA. A less potent barbiturate, butalbital, is found in headache remedies like Fiorinal®. It can also compromise respiratory function and it should be avoided in OSA patients (15).

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