2022 Volume 50 Issue 4 Pages 143-145
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and frequent comorbid obesity. We present the safe perioperative management of a patient with narcolepsy who required mandibular surgery. A 22-year-old man (weight, 69.8 kg ; height, 160.8 cm ; BMI, 27.2) was scheduled to undergo a sagittal splitting ramus osteotomy. He was diagnosed as having narcolepsy at the age of 15 years, of having obstructive sleep apnea syndrome (OSAS) at the age of 20 years, and experienced drowsiness while driving at the age of 21 years (weight, 48 kg ; height, 156 cm ; BMI, 19.7) ; he was prescribed modafinil (200 mg) at this time. After taking his daily dose of modafinil (100 mg) on the morning of the surgery, general anesthesia was induced and maintained with air-oxygen-sevoflurane, remifentanil, and rocuronium to maintain his BIS value between 40 and 60. Following the osteotomy, his mandible was fixed using a 7-mm setback. After surgery, he emerged from anesthesia within 10 min at a BIS value of 92 and was extubated. His intraoperative course was uneventful, with no hemodynamic instability occurring. Postoperative hypertension required a reoperation for hemostasis with intravenous sedation under SpO2 monitoring and capnography. Six months later, he was referred to a hospital for a reevaluation of his OSAS. His AHI (apnea hypopnea index) was exacerbated from 17.2/h to 26.0/h as a result of him being overweight (21.8 kg), rather than the downward position of the hyoid bone caused by the setback of the mandibular bone. BIS monitoring of the sevoflurane and remifentanil anesthesia during the surgery was useful for preventing postoperative oversedation in this narcoleptic patient. Modafinil is a central neurological stimulant (a non-amphetamine, wake-promoting compound used for excessive daytime sleepiness). Its reported side effects include postoperative hemodynamic instability. Further studies examining the perioperative risk when anesthetics and central neurological stimulants are combined in narcolepsy patients with OSAS are needed.
