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Obstructive sleep apnea uncovered after high spinal anesthesia: a case report

[L’apnée obstructive du sommeil révélée après une rachianesthésie haute : une présentation de cas]

From the Department of Anesthesia, McGill University Health Center – Montreal General Hospital, Montreal, Quebec, Canada.

Address correspondence to: Dr. Francesco Carli, Department of Anesthesia, D10-144, Montreal General Hospital, 1630 Cedar Av., Montreal, Quebec H3G 1A4, Canada. Phone: 514-934-1934; E-mail: franco.carli{at}mcgill.ca; or paul.wieczorek{at}mail.mcgill.ca

Purpose: To illustrate how a patient’s previously undiagnosed obstructive sleep apnea was uncovered after administration of a spinal anesthetic with a high sensory blockade, and to discuss possible explanations for this occurrence and anesthetic implications.

Clinical features: A 55-yr-old male presented for osteotomy and open reduction and internal fixation of his left femur secondary to malunion from a previous fracture. Past medical history consisted of hypertension, hypercholesterolemia, bipolar disorder, gastroesophageal reflux disease, and cluster headaches. A combined spinal-epidural technique was chosen. Isobaric bupivacaine 0.5% (15 mg), was provided for the spinal anesthetic, along with 1 mg iv midazolam for procedural sedation and 0.5 mg iv droperidol for mild nausea. Throughout the operation, many apneic events were noted, often with respiratory efforts. The patient was easily arousable during each event and would breathe normally until the next episode. Vital signs remained stable throughout. Postoperative respirology consultation was requested, and a sleep study revealed severe obstructive sleep apnea. The patient was subsequently started on continuous positive airway pressure with marked improvement in symptoms, including the cluster headaches.

Conclusion: Recent literature suggests that high spinal blockade can result in altered levels of arousal by producing a de-afferentation of peripheral proprioceptive and sensory stimuli necessary for maintaining an awake state. In patients predisposed to upper airway obstruction, decreasing the level of consciousness can result in airway obstruction as occurs during sleep in these patients. This serves to underline the importance of considering capnography for all cases utilizing a neuraxial anesthestic technique.