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Central Disorders of Hypersomnolence, Restless Legs Syndrome, and Surgery with General Anesthesia: Patient Perceptions

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Central Disorders of Hypersomnolence, Restless Legs Syndrome, and Surgery with General Anesthesia: Patient Perceptions Central Disorders of Hypersomnolence, Restless Legs Syndrome, and Surgery With General Anesthesia: Patient Perceptions Vincent LaBarbera, Emory University Paul Garcia, Emory University Donald Bliwise, Emory University Lynn Marie Trotti, Emory University Journal Title: Frontiers in Human Neuroscience Volume: Volume 12 Publisher: Frontiers Media | 2018-03-20, Pages 99-99 Type of Work: Article | Final Publisher PDF Publisher DOI: 10.3389/fnhum.2018.00099 Permanent URL: https://pid.emory.edu/ark:/25593/s92v2 Final published version: http://dx.doi.org/10.3389/fnhum.2018.00099 Copyright information: © 2018 LaBarbera, García, Bliwise and Trotti. This is an Open Access work distributed under the terms of the Creative Commons Attribution 3.0 Unported License (http://creativecommons.org/licenses/by/3.0/). Accessed September 27, 2021 12:18 AM EDT ORIGINAL RESEARCH published: 20 March 2018 doi: 10.3389/fnhum.2018.00099 Central Disorders of Hypersomnolence, Restless Legs Syndrome, and Surgery With General Anesthesia: Patient Perceptions Vincent LaBarbera 1, Paul S. García 2,3, Donald L. Bliwise 1 and Lynn M. Trotti 1* 1 Sleep Center and Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States, 2 Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, United States, 3 Research and Anesthesiology Service Lines, Atlanta VA Medical Center, Atlanta, GA, United States Introduction: The importance of obstructive sleep apnea in patients undergoing surgery with general anesthesia is well-defined, but the surgical and anesthetic implications of other sleep disorders are less clear. We sought to evaluate response to surgery with general anesthesia in patients with central disorders of hypersomnolence or restless legs Edited by: syndrome. Matthew Tucker, Methods: We surveyed patients on their most recent surgical procedure with general School of Medicine Greenville, University of South Carolina, anesthesia, querying about procedure, recovery, and any changes in sleep disorder United States symptomatology following the procedure. Reviewed by: Farid Talih, Results: Forty-five patients with restless legs syndrome and 57 patients with central American University of Beirut, disorders of hypersomnolence (15 narcolepsy type 2, 1 narcolepsy type 1, 30 idiopathic Lebanon hypersomnia, 1 Kleine-Levin syndrome, and 10 subjective sleepiness) completed the Giovanni Cizza, Novo Nordisk (United States), survey, with response rates of 45.5 and 53.8%, respectively. While patients in both United States groups were equally likely to report surgical complications and difficulty awakening from *Correspondence: anesthesia, hypersomnolent patients were more likely to report worsened sleepiness Lynn M. Trotti = [email protected] (40% of the hypersomnolent group vs. 11% of the RLS group, p 0.001) and worsening of their sleep disorder symptoms (40% of the hypersomnolent group vs. 9% of the RLS Received: 14 September 2017 group, p = 0.0001). Accepted: 05 March 2018 Published: 20 March 2018 Conclusion: Patients with sleep disorders other than sleep apnea frequently Citation: report surgical or anesthetic complications. Patients with hypersomnolence disorders LaBarbera V, García PS, Bliwise DL commonly perceive that their sleep disorder worsened following a procedure; whether and Trotti LM (2018) Central Disorders of Hypersomnolence, Restless Legs this might be related to long term effects of general anesthesia in a particularly vulnerable Syndrome, and Surgery With General clinical population requires further study. Anesthesia: Patient Perceptions. Front. Hum. Neurosci. 12:99. Keywords: general anesthesia, idiopathic hypersomnia, narcolepsy, restless legs syndrome, excessive daytime doi: 10.3389/fnhum.2018.00099 sleepiness Frontiers in Human Neuroscience | www.frontiersin.org 1 March 2018 | Volume 12 | Article 99 LaBarbera et al. Sleep Disorders and General Anesthesia INTRODUCTION via agent-specific binding sites being the mechanism by which most commonly used pharmacologic agents (i.e., isoflurane, The importance of obstructive sleep apnea for the perioperative sevoflurane, desflurane, propofol, and etomidate) produce management of surgical patients is now widely acknowledged general anesthesia (Garcia et al., 2010). and codified within professional guidelines (American Society A recent, controlled, retrospective study of patients with of Anesthesiologists Task Force on Perioperative Management narcolepsy, primarily type 2, who underwent general anesthesia of patients with obstructive sleep apnea, 2014). In contrast, reported similar intraoperative and phase 1 anesthetic recovery the potential importance of other sleep disorders is less clear. among patients with narcolepsy and controls (Cavalcante et al., Concern about anesthetic-induced worsening of restless legs 2017). However, it identified an increased risk of emergency syndrome (RLS), a sensorimotor sleep disorder resulting in response team activation during post-operative hospitalization nocturnal leg discomfort and sleep disruption, was raised among those with narcolepsy. Anecdotally, we have noted in a prospective series that found an RLS incidence of 9% that a seemingly large proportion of our hypersomnolent in patients undergoing spinal anesthesia (Högl et al., 2002). patients report complicated recoveries from surgeries involving This finding was not replicated in a second study (Crozier general anesthesia. To expand upon the existing literature et al., 2008), albeit with a study population with very different regarding anesthetic response in patients with non-apneic sleep composition. The perioperative period may be a time of disorders, we performed a pilot study, systematically assessing heightened vulnerability to worsening RLS symptoms, because patients’ perceptions of their surgical/anesthetic recovery and of prolonged immobility, blood loss, iatrogenic sleep loss, post-operative course in those with central disorders of temporary cessation of symptomatic treatment, and use of hypersomnolence and restless legs syndrome. medications such as metoclopramide that can worsen RLS (Högl et al., 2012; Goldstein, 2015). However, the possibility of acute or chronic effects of general anesthesia has not been well-defined in METHODS RLS patients. Similarly, relatively little study has been directed at Potential subjects were identified from existing research anesthetic implications for patients with central disorders registries. For the hypersomnolent group, we screened all of hypersomnolence. This group of disorders, which includes enrolled patients for a history of surgery with general anesthesia, narcolepsy type 1 (with cataplexy), narcolepsy type 2 (without first by chart review and then via telephone interview. As the RLS cataplexy), and idiopathic hypersomnia, results in persistent and registry is larger, having been established more than 10 years ago, pathologic daytime sleepiness despite adequate or prolonged we screened only those patients in the RLS registry who had been amounts and quality of nocturnal sleep. Kleine-Levin syndrome, evaluated at the Sleep Center in the 18 months prior to the study, also a central disorder of hypersomnolence, refers to a syndrome to obtain a similar group size. The RLS patients were similarly consisting of bouts of recurrent hypersomnia separated by screened for a history of surgery with general anesthesia. periods of relative normalcy. Potential concerns for the Patients underwent comprehensive sleep medicine evaluation perioperative management of patients with central disorders at the Emory Sleep Center, a tertiary referral center. Patients of hypersomnolence raised by case reports and small case with central disorders of hypersomnolence were studied with series include: (1) the appearance of peri-operative cataplexy, overnight polysomnography followed by multiple sleep latency sleepiness, or other disease-specific symptoms; (2) the chronic test and classified as having narcolepsy type 1 or 2, idiopathic use of psychotropic and/or vasoactive medications, including hypersomnia, or Kleine-Levin syndrome (2014). Cases meeting amphetamines, in patients with these disorders; and (3) delayed clinical but not electro-physiologic criteria were classified as emergence from anesthesia (Mesa et al., 2000; Peláez et al., having subjective excessive daytime sleepiness (sEDS) (Pizza 2004; Burrow et al., 2005; Fischer et al., 2006; Ozkose et al., et al., 2013). Hypersomnolent patients are routinely offered 2007; Staikou et al., 2007; Doyle and Wilkinson, 2008; Dahaba diagnostic lumbar puncture as part of their evaluation and were et al., 2009; Morimoto et al., 2011; Stoicea et al., 2014; Tzabazis considered eligible for inclusion in the present study if their et al., 2015; Aflaki et al., 2017). The concern regarding delayed CSF demonstrated in vitro potentiation of GABA-A receptors emergence may be particularly relevant to a subgroup of patients >60% (Rye et al., 2012). Patients with restless legs syndrome were with central disorders of hypersomnolence who demonstrate diagnosed based on face-to-face interview conforming to criteria the presence of a positive allosteric modulator of gamma- of the International Restless Legs Syndrome Study Group (Allen aminobutyric acid Type A (GABA-A) receptors within spinal et al., 2003, 2014). Patients with both RLS and a central disorder fluid (Rye et al., 2012). GABA is known to be a key player in of hypersomnolence were excluded. sleep onset (Lu and Greco, 2006; Franks and Zecharia, 2011) Identified patients with a
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