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Postoperative Catastrophes with OSA Patients: Two Sad Accounts

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Sep 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.

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