MEDICAL ALERT

To: Developmental Disabilities Service Providers, and others

From: The Region V Forensic Review Committee - DPHHS, Region V Adult Protective Services Bureau & Developmental Disabilities Program, and Montana Advocacy

Program Date: December 12, 2003

Re: Risk of death due to use of pain or sleep medications by patients with sleep apnea

This alert is being issued in an effort to prevent the possible accidental death of individuals with diagnosed or undiagnosed cases of sleep apnea. Death might occur following the ingestion of prescribed narcotic pain or sleep medications or during recovery from surgical anesthesia.

Narcotic pain and sleep medication and anesthesia can be fatal to patients with sleep apnea. Undiagnosed sleep apnea is common. Individuals with Down's syndrome are at high risk of sleep apnea.

Providers of services to people with developmental disabilities are strongly urged to follow the recommendations described in this alert whenever a client is receiving medical care which could involve administration of anesthetics or narcotic pain or sleep medication.

Consult with the treating physician(s) about the possibility of sleep apnea before the administration of prescription pain medications, sleep medications or anesthesia. The occurrence of sleep apnea and the use of these medications could result in death. Provide a copy of this alert to all treating physicians providing service to individuals in your organization.

In Montana recently, a middle-aged man with a developmental disability died following a minor surgical procedure. This man with Down's syndrome had undergone minor surgery at his local hospital. He awoke from the anesthesia and was sent home for recovery the following day. He returned home with a prescription for the narcotic pain medication Lortab (hydrocodone and acetaminophen). He was given the medication as prescribed but died within 17 hours.

The autopsy indicated that Down's syndrome may have been a factor by anatomically compromising the airway. This may have been due to undiagnosed sleep apnea. One study found the incidence of sleep apnea in individuals with Down's syndrome to be 30-50% versus 1-4% in the general population.

Sleep apnea is a common disorder in which breathing stops during sleep for 10 seconds or more, sometimes more than 300 times a night. "Obstructive sleep apnea" may represent cessation of breathing due to mechanical blockage of the airway; "central sleep apnea" appears to be related to a malfunction of the brain's normal signal to breathe. Symptoms of sleep apnea may include restless sleep, loud, heavy snoring (often interrupted by silence and then gasps), falling asleep while driving and/or during the day (at work, watching TV, etc.), morning headaches, loss of energy, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety or depression, obesity, and decreased interest in sex. Not all people with sleep apnea experience all of these symptoms, and not everyone who has these symptoms has sleep apnea. However, it is recommended that people who are experiencing even a few of these symptoms visit their physician for evaluation. Prompt and proper diagnosis of sleep apnea is an important first step to treating the disorder. Problems associated with untreated sleep apnea include hypertension, coronary artery disease, myocardial infarction, stroke, psychiatric problems, impotence, cognitive dysfunction, memory loss, and death.The American Sleep Apnea Association (ASAA), a non-profit organization dedicated to reducing injury, disability, and death from sleep apnea and to enhancing the well-being of those affected by this common disorder, strongly encourages anesthesiologists and pain physicians to screen their patients for sleep apnea before the patients undergo sedation or any type of anesthesia and before they are given pain medications that can affect their respiratory drive or relax their muscles. Most patients with sleep apnea do not know that they have the disorder, and anesthesiologists and pain physicians can play a key role in helping us to reach the undiagnosed.The ASAA further advises, in an article written following the review of eight deaths of individuals in California who died after being given medications for pain or anesthesia and were later found to have sleep apnea: In normal, awake patients, there is a phasic activity of the pharyngeal muscles that contracts them immediately before inspiration, helping to resist the negative pressure generated by the diaphragm and keeping the airway from collapsing. This phasic pharyngeal contraction is markedly reduced both by REM sleep and by narcotic pain administration. Patients with sleep apnea appear to be much more sensitive than normal individuals, even to minimal levels of sedation. The increased sensitivity of their hypoglossal nerves to low doses of anesthesia has been well described.

Why are SAS (sleep apnea syndrome) patients more prone to significant episodes of airway obstruction? The cause of upper airway obstruction in SAS patients was long thought to be the tongue, but fluoroscopy during sleep has shown this is rarely the case. The oropharynx itself is the most collapsible segment of the upper airway and the most likely site of obstruction. Physiologic studies have demonstrated that patients with SAS have narrowed upper airways to start with, so they are more susceptible than other patients to drugs or anesthetics that suppress pharyngeal muscle tone.

The administration of narcotic pain medication in patients with sleep apnea syndrome needs to be closely monitored. One problem observed by the panelists was that pain medication orders for any given patient might be written by different individuals (surgeon, anesthesiologist, or primary care practitioner), not all of whom may be aware of the diagnosis of SAS. Clearly, wider understanding of this syndrome is crucial, and suggestions included red-flagging the charts of these patients to warn of the risks of narcotic usage.

Patients suspected of having SAS need to be handled differently than routine postoperative patients--especially with painful procedures that require significant narcotic pain medication postoperatively. Anesthesiologists may be able to help get this information to surgeons and internists who might also be writing parenteral narcotic orders for these patients. The panelists also hope hospitals can find ways to monitor SAS patients for oxygen saturation more effectively. Although the clinical outcomes in the claims reviewed were devastating, they suggest that further cases may be preventable.Precautions which might be taken include: extended hospitalization following surgery; one to one staffing; pulse oximetry monitoring and/or CPAP (continuous positive airway pressure) machine use, if diagnosed with sleep apnea and doctor ordered.

Risk factors for sleep apnea:

• A family history of sleep apnea
• Excess weight
• A large neck
• A recessed chin
• Male sex
• Abnormalities in the structure of the upper airway
• Smoking
• Alcohol use
• Age

Yet sleep apnea can affect both males and females of all ages (including children) and any weight.

Presenting Symptoms:

• Loud snoring
• Excessive daytime sleepiness (i.e., falling asleep easily and sometimes inappropriately)
• High blood pressure and other cardiovascular complications
• Morning headaches
• Memory problems
• Feelings of depression
• Reflux
• Nocturia (night time urination)
• Impotence

The Forensic Review Committee recommends that residential providers conduct an informal screening of each consumer - placing a check mark next to any identified Risk Factor or Presenting Symptom listed above. This screening check list can then be presented to the consumer's personal and/or treating physician.

(ASAA web site above, Sleep Apnea and Narcotic Postoperative Pain Medication: A Mortality Risk, by Ann Lofsky, M.D.)

The Forensic Review Committee recommends that residential providers conduct an informal screening of each consumer - placing a check mark next to any identified Risk Factor or Presenting Symptom listed above. This screening check list can then be presented to the consumer's personal and/or treating physician.