quickly. In general, I have found that patients with OSA tend to
require less narcotic compared with the general population. It
would be wise to consider remifentanil, which is metabolized quick-
ly by esterases in the blood and tissues, instead of fentanyl, mor-
phine or hydromorphone, which are metabolized much slower and
can accumulate in adipose tissue. Both dexmedetomidine and keta-
mine are great adjuncts, because they're good sedatives and cause
very little respiratory depression. Additionally, IV NSAIDs, aceta-
minophen and ketorolac are excellent for treating pain without any
respiratory depression.
Desflurane is a better choice than both sevoflurane and isoflurane
if a volatile anesthetic must be used. Desflurane provides faster
wash-in and wash-out than sevoflurane or isoflurane in obese
patients, and recovery is much faster after desflurane administration.
If you're going to use muscle relaxants, make sure the patient has
been fully reversed before extubating. I would recommend sugam-
madex over neostigmine because it's a more rapid-acting and reliable
antagonist of residual muscle paralysis. The patient should have ade-
quate tidal volume and respiratory rate along with intact airway
reflexes and acceptable concentrations of end-tidal CO
2
.
When and where it is appropriate, I strongly recommend a regional
anesthetic technique instead of or along with general anesthesia.
Besides regional anesthesia, early administration of local anesthetic
can seriously cut down on the amount of respiratory depressing anes-
thetic drugs.
5. Post-op care of your OSA patients
If patients have been identified as having OSA and have a CPAP
machine, they should be told to bring it with them on the day of sur-
gery, and it should be used post-operatively until it is deemed appro-
4 8 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 7
