Postoperative Catastrophes with Obstructive Sleep Apnea Patients: Two Sad Accounts

By Kerrin Leon White - September 22, 2000

Recently I answered an e-mail question that gave me shivers. It came from a nurse, who worked at a hospital in risk management - which means, the people the hospital calls in when something has gone very wrong.

I'm going to tell you a story that is basically true; but I'll change a few incidentals to avoid identification by someone with first-hand knowledge of this case. I don't want to scare away questioners of this sort!

An obese man with sleep apnea, under treatment with CPAP, underwent an operation that ordinarily does not carry much risk. He came through the surgery, but on his first postoperative night, in the hospital, he died.

Can you guess why?

The doctor did take his sleep apnea into account, to a certain extent, by ordering postoperative pulse oximetry to monitor his blood oxygen levels.

Prolonged cessation of breathing can result in significant "oxygen desaturation". Repeated often enough, oxygen deprivation can damage vital organs - like the liver, brain, or heart. But in the usual course of sleep apnea, treated or untreated, this seems to be a rare occurrence.

However, very prolonged cessation of breathing can do worse than that, as I'm sure you realize. Stop breathing long enough, and you're dead. This does not require repeated events; the first time is the last.

The operation itself does not carry this risk. If general anesthesia is used, intubation does the breathing for the patient. Nevertheless, certain postoperative factors can and probably do aggravate apnea. One is the sedative after-effect of the anesthetic; another is the similar effect of major pain medications. Yet another is the possibility that the intubation procedure has caused swelling of tissues in the upper airway.

These represent real problems. But CPAP can often work to prevent airway closure and obstruction, even in the face of sedative drugs and tissue swelling.

What most likely let the patient die was simple: he received no CPAP on the night after his surgery.

I don't know why; I don't want to hear some rationalization of this fatal mistake. I know it happens too often, without any excuse. I also had the terrifying experience of awakening after one operation, still sedated, without my CPAP machine, which I had brought to the hospital - but the doctor had my family take back home! The nightmarish part was, that I kept dozing off, yet somehow not quite losing consciousness as in normal sleep. Instead, I experienced each time the cessation of my own breathing.

I ended up struggling out of bed, despite the pain, making repeated trips back and forth to the bathroom, just to keep myself awake.

This kind of horror story results from profound ignorance of doctors about sleep, its diseases, and their management. That ignorance is commonplace.

The second case came to my attention as a report from the patient's family.

This man, also obese, though less so than the first, had a milder case of sleep apnea.

His surgery included a couple of procedures often described as minor. Nevertheless, one of them typically causes a great deal of postoperative pain, requiring narcotic analgesics. This procedure, a uvulopalatopharyngoplasty or UPPP, is often done for sleep apnea despite its notorious lack of effectiveness, and potential for making apnea even worse.

This man made it home from the hospital. He saw his surgeon shortly thereafter. Within a few days, he had died - in his sleep, very soon after his bedtime dose of pain medication.

This man also lacked the benefit of CPAP.

In his case, the surgeon, purporting to treat his sleep apnea as part of the operation, had never tried him on CPAP.

Sometimes it happens that a patient with sleep apnea refuses to try CPAP, and prefers surgery. Maybe, sometimes, this bad decision takes place with a little encouragement from his sleep specialist, who might happen to have his prior specialty training as an otolaryngologist - otherwise known as an Ear Nose & Throat surgeon.

But this time, it was not the patient who made the bad choice; it was the surgeon, acting against the express wishes and expectations of patient and family, to say nothing of a consultant who had given a second opinion against this surgery!

How, you should wonder, can this be? Doesn't surgery require the informed consent of the patient?

The answer is, Yes - unless the patient is incapable of giving "informed" consent. This might apply, for example, to a patient with Alzheimer's disease, or one in coma. Or, as in this instance, the patient might be unable to reason about the surgeon's last-minute change of plans because he had been already sedated in preparation for surgery. (I'll bet you never thought of that way around an individual's consent--or lack thereof!)

But, you should also wonder, doesn't such a case require the consent of the family?

Yes again - and in this case, the surgeon would undoubtedly say that he had obtained this from them. The family says that, with the patient, operating room, and surgical staff all ready to proceed, the surgeon came to them with his change of plans. Yes, they had an alternative: to refuse the surgery on the patient's behalf. Yet, think carefully what kind of self confidence and self-assertion that would require, to call a halt to everything at the last minute--or risk having an angry surgeon go in to operate on a loved one?

So, the family gave way to the surgeon's last-minute about-face in plans - I would not want to go so far as to say that they freely and willingly consented.

To the patient's surprise, when he awakened, he had undergone two procedures, not just the one he expected, but also the one for sleep apnea that he thought he had refused! The latter, incidentally, was responsible for the intense pain he suffered, despite narcotic analgesics, in those few last days of torment remaining to him.

Do you think this account improbable? Could the family have misrepresented what happened?

Maybe, but I doubt it. I believe those events probable, because I underwent yet another experience, bearing similarities to that second case, myself - only, I survived to tell the tale.

Many years ago, the first time I had any surgery, I had a prolonged, painful muscular reaction to the "muscle relaxant" used in most anesthesia. When I called the surgeon, he identified this as a well known, if uncommon, adverse reaction that a few unfortunates like myself might have to this routine medication. However, he assured me, if I only mentioned it to any surgeon or anesthesiologist I encountered in the future, that doctor would at once understand what happened, and use an alternative type of muscle relaxant.

It turned out just as he predicted, through three procedures I had later on, each one at a different hospital. Each time I forewarned the doctors, and there was no problem. I never even bothered to learn the name of the alternative muscle relaxant.

Then I encountered a less knowledgeable anesthesiologist, at a less prestigious--but conveniently nearby--hospital.

I never saw this doctor until minutes before the procedure, although I had tried to contact him by phone. Therefore, I had faxed - and mailed - an explanation of my problem, making it clear that I needed a muscle relaxant different from the usual one.

As the anesthesiologist met me for the first time, just before the procedure, a nurse came up to him with a copy of this letter. It was obvious he had never seen it before. He glanced at it, but said nothing. I thought everything would go as usual, so routine as to require no discussion. My meeting with that doctor ended abruptly.

Only minutes later, in the operating room, already woozy from medication that had just been injected, I looked up to see the gas mask, in the anesthesiologist's hand, descending on my face. Just before I lost consciousness, he said, quite distinctly, in a matter-of-fact manner, without any note of apology:

"I don't know any other medication."

Here I will stop, or else I would go on and on, to the point of tedium. However, I will not say: Enough said. I will just say: more than enough for now.