What the Anesthesiologist Should Know before the Operative Procedure
Uvulopalatopharyngoplasty (UPPP) is an upper airway operation for sleep disturbances. Sleep disturbances range from loud snoring to severe obstructive sleep apnea. UPPP covers a spectrum of techniques, including transoral surgery to endoscopic laser ablation, and may or may not include concurrent tonsillectomy.
1. What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
Uvulopalatopharyngoplasty is not an emergency operation. Patients with sleep apnea may have significant medical issues, and these issues should be fully evaluated.
2. Preoperative evaluation
Sleep disturbances interfere with alertness, personal and professional performance, and quality of life. Bed partners can also be adversely affected. Obstructive sleep apnea may cause a spectrum of problems, from simple sleep disturbance for the patient and family, to daytime somnolence, hypertension, coronary disease, and pulmonary hypertension.
Medically unstable conditions warranting further evaluation include:
Obesity and metabolic syndrome
Coronary artery disease
Delaying surgery may be indicated due to:
Upper respiratory infections
Unstable cardiac symptoms
Significant pulmonary hypertension
3. What are the implications of co-existing disease on perioperative care?
Like all surgical procedures, the preoperative management of cooexisting disease should be evaluated and optimized, and the common health effects of obstructive sleep apnea should be specifically addressed.
a. Cardiovascular system
Severe obstructive sleep apnea is associated with an increased incidence of left ventricular hypertrophy as well as right heart dysfunction. On the other hand, successful uvulopalatopharyngoplasty has been associated with improvement of cardiac function.
Patients with morbid obesity, angina, and severe obstructive sleep apnea should be evaluated for cardiac disease. Echocardiography is likely the best technique for assessing left and right heart function. A stress test or coronary imaging should be performed if coronary artery disease is suspected.
Müller’s maneuver, or forced inspiration with a closed mouth and pinched nostrils while an endoscope sits in the airway, is sometimes used to exclude subglottic collapse at the source of obstruction. It is important to note that subglottic collapse would not be addressed by uvulopalatopharyngoplasty, and there is controversy about the utility of this test.
Sleep disorders are associated with cognitive impairment. Evaluation of cognitive status preoperatively will be helpful if cognitive issues are recognized postoperatively.
Patients with morbid obesity will be prone to diabetes.
f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
A sleep study will be helpful for assessing the severity of sleep apnea and the success of the procedure.
4. What are the patient's medications and how should they be managed in the perioperative period?
Treatment of pulmonary hypertension may include selective phosphodiesterase inhibitors, prostacyclines, endothelin blockers, and calcium channel blockers. Patients may also be in anticoagulation therapy. Modanifil and armodafinil are used to reduce daytime somnolence. There is often suspicion that gastroesphageal reflux may contribute to the incidence of sleep disturbance, and so proton pump inhibitors are common.
g. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Although not strictly a medication, many patients have been fitted with CPAP masks or oral appliances to reduce airway obstruction. A discussion with the surgical team will help determine if these devices should be used in the immediate post-anesthetic recovery period.
h. What should be recommended with regard to continuation of medications taken chronically?
In general, most medications should be continued through the time of surgery. Management of anticoagulants and platelet inhibitors should be coordinated with the surgical team. Diabetic medications need standard management to balance the perturbation of perioperative fasting and hypoglycemic effect.
i. How to modify care for patients with known allergies –
Avoid allergic triggers.
j. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Avoid latex products.
k. Does the patient have any antibiotic allergies – Common antibiotic allergies and alternative antibiotics
Choose an alternative antibiotic in the case of known allergies.
l. Does the patient have a history of allergy to anesthesia?
Standard considerations should be taken for malignant hyperthermia and neuromuscular disease.
5. What laboratory tests should be obtained and has everything been reviewed?
UPPP is aimed at improving sleep disorders. Patients should have received a sleep study and been evaluated for the severe sequelae of obstructive sleep apnea, including pulmonary hypertension and right heart function. As there is a correlation between obstructive sleep apnea and coronary disease, the patient’s cardiac function should also be evaluated prior to the operation.
Hemoglobin levels: Hemoglobin should be normal, unless obstruct sleep apnea has induced polycythemia.
Electrolytes: A late sequelae of right heart failure can be hyponatremia.
Coagulation panel: Any patient on anticoagulants should be evaluated for signs/symptoms of bleeding, and a plan to discontinue or bridge anticoagulation medications should be in place prior to the procedure.
Imaging: If obstruct sleep apnea is suspected, there should be an assessment of pulmonary hypertension and left ventricular hypertrophy by echocardiography.
Sleep studies as noted above.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The procedure and surgical exposure is very stimulating. Movement of the patient during the critical stages of the operation can be dangerous. Therefore, neuromuscular blockade is often employed. However, there are reports of local anesthesia with sedation being effective for some variants of the technique.
a. Regional Anesthesia
Topical anesthesia of the airway can be the sole anesthetic, or one can reduce the stimulation under general anesthesia. If cocaine is used, as is common in ENT surgery, the sympathetic stimulation should be monitored carefully and the administration potentially ceased.
Neuraxial: Not used, since innervation is from the cranial nerves.
Peripheral Nerve Block: Usually performed by topical administration.
b. General Anesthesia
Benefits – General anesthesia provides a quiet field and controls the airway.
Drawbacks – The standard issues with acquiring the airway, the minor inconvenience of an endotracheal tube in the field, and the potential for post-operative nausea are drawbacks. The residual effects of general anesthetics may exacerbate post-operative airway obstruction.
Airway concerns – Patients with morbid obesity or severe obstructive sleep apnea may be difficult to intubate. While the ENT surgeon is at hand with additional expertise and instruments, a careful airway evaluation is prudent.
c. Monitored Anesthesia Care
Pure local anesthesia, with or without sedation, has been employed successfully for both “open” and laser-assisted uvuloplasty when tonsillectomy is not included in the procedure. These procedures were performed in the office settings.
6. What is the author's preferred method of anesthesia technique and why?
Because the surgical technique of UPPP varies greatly between institution and practitioner, coordination with the surgeon is important. UPPP on patients with severe obstructive sleep apnea is probably best done in an inpatient setting, where there is complete monitoring of cardiac function, an assured airway, and post-operative care can occur in a setting with airway rescue at hand.
For the majority of patients with mild sleep apnea, or disordered sleep, the anesthetic technique is tailored to the surgical approach. A common method is general anesthetic with an endotracheal tube that will be manipulated by the surgeon to allow access to the posterior pharynx and palate. Muscle relaxants will assist intubation and reduce the likelihood of patient movement. The high level of stimulation can be attenuated with a short acting opioid (remifentanil) or topical anesthesia. Full return of strength is important prior to extubation.
For sedated topically anesthetized cases, a sedative without respiratory depression, such as ketamine or dexmedatomidine, may be helpful.
b. If the patient is intubated, are there any special criteria for extubation?
Like any oral surgery, standard criteria for extubation include hemostasis, lack of swelling or obstructing hematomas, complete return of strength, respiratory drive, and the ability to clear secretions (cough, sensation). Since tracheostomy is a recognized treatment for severe obstructive sleep apnea, patients with severe obstruction should be monitored and considered for elective tracheostomy prior to emergence.
c. Postoperative management
1. What analgesic modalities can I implement?
UPPP pain can be quite severe. Pain management includes narcotics, non-steroidal analgesics, steroid injections, and local anesthetics.
2. What level bed acuity is appropriate?
Complications commonly occur within two hours of emergence. Complications include airway obstruction, bleeding, desaturation, and pulmonary edema. Desaturation frequency and levels were equivalent to the preoperative levels. If the patient does not have severe obstructive sleep apnea, and has no immediate postoperative complications, there is support for discharge the day of surgery.
3. What are common postoperative complications, and ways to prevent and treat them?
Bleeding and airway obstruction require rapid response, including airway support and consideration for reoperation. The degree of complications (specifically airway obstruction) correlates with the preoperative degree of obstructive sleep apnea.
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- a. Cardiovascular system
- b. Pulmonary
- c. Renal-GI:
- d. Neurologic:
- e. Endocrine:
- f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- g. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- h. What should be recommended with regard to continuation of medications taken chronically?
- i. How to modify care for patients with known allergies -
- j. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- k. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics
- l. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management