Obstructive sleep apnea

Top concerns

1. 1.Heightened sensitivity to opioids and sedatives: multimodal, opioid-sparing analgesia is the core strategy
2. 2.Screen everyone (STOP-Bang ≥3 raises suspicion; ≥5 high risk) — most OSA arriving for surgery is undiagnosed
3. 3.Extubate awake, ideally semi-upright, after full reversal confirmed quantitatively
4. 4.Postop: continuous pulse oximetry where feasible; resume the patient's own CPAP early (have them bring the device)
5. 5.Sedative premedication is rarely appropriate
6. 6.Ambulatory suitability is a real decision (SAMBA guidance): comorbidity control + postop opioid needs drive it

Drug do's and don'ts

• AVOIDSedative premeds (benzodiazepines)— Obstruction before the case even starts; use non-sedating anxiolysis strategies.
• AVOIDOpioid monotherapy for postop pain— The classic OSA death pattern is opioids + unmonitored ward + night one.
• PREFERRegional/multimodal (acetaminophen, NSAIDs, dexmedetomidine, blocks)— Every opioid-free milligram is airway margin.

Airway & positioning

• Anticipate difficult mask ventilation; ramped/semi-upright induction and recovery
• CPAP in PACU is a treatment, not an escalation — use it early

Pearls

• The riskiest hours are postop night one, unmonitored, opioid-dosed — your plan should still be working then.
• 'Bring your CPAP machine' belongs in the preop phone call.

Suggested reading

• ASA Practice Guidelines: Perioperative Management of OSA (2014)
• SAMBA consensus statement (ambulatory OSA)

Educational quick-reference only — defer to clinical judgment, institutional protocols, and the primary texts above.