Obstructive sleep apnea, pain, and opioids: is the riddle solved?

PURPOSE OF REVIEW: Perioperative opioid-based pain management of patients suffering from obstructive sleep apnea (OSA) may present challenges because of concerns over severe ventilatory compromise. The interaction between intermittent hypoxia, sleep fragmentation, pain, and opioid responses in OSA, is complex and warrants a special focus of perioperative outcomes research. RECENT FINDINGS: Life-threatening opioid-related respiratory events are rare. Epidemiologic evidence suggests that OSA together with other serious renal and heart disease, is among those conditions predisposing patients for opioid-induced ventilatory impairment (OIVI) in the postoperative period. Both intermittent hypoxia and sleep fragmentation, two distinct components of OSA, enhance pain. Intermittent hypoxia may also potentiate opioid analgesic effects. Activation of major inflammatory pathways may be responsible for the effects of sleep disruption and intermittent hypoxia on pain and opioid analgesia. Recent experimental evidence supports that these, seemingly contrasting, phenotypes of pain-increasing and opioid-enhancing effects of intermittent hypoxia, are not mutually exclusive. Although the effect of intermittent hypoxia on OIVI has not been elucidated, opioids worsen postoperative sleep-disordered breathing in OSA patients. A subset of these patients, characterized by decreased chemoreflex responsiveness and high arousal thresholds, might be at higher risk for OIVI. SUMMARY: OSA may complicate opioid-based perioperative management of pain by altering both pain processing and sensitivity to opioid effect.

Airway management in an infant with tessier N. 4 anomaly.

Children with craniofacial abnormalities provide a challenge to an anesthesiologist being one the commonest cause of expected difficult airway. Difficult airway management should be predicted and planned in advance to avoid critical problems. It is important to understand the development and characteristics of the more common anomalies and their peculiar anesthetic challenges in order to construct a safe anesthetic plan. We describe the successful airway management of a Tessier N. 4 anomalous child with left orofacial cleft, cleft lip and cleft palate.

Traumatic tracheoesophageal fistula in a 5-year old.

Tracheosophageal fistula following blunt trauma is rare and diagnosis and management can be difficult. All reported cases have involved victims above 12 years of age. Here we report the anesthesia management, for surgery, of a tracheoesophageal fistula caused by blunt trauma in a 5-year-old boy.