What are the preoperative clearance considerations for a 39-year-old female with narcolepsy (excessive daytime sleepiness) and cataplexy (sudden loss of muscle tone)?

Preoperative Clearance Considerations for Narcolepsy with Cataplexy

Patients with narcolepsy and cataplexy require careful medication management and anesthetic planning during the perioperative period to prevent symptom exacerbation and complications.

Medication Management

Continuation of Narcolepsy Medications

• Continue narcolepsy medications through the perioperative period whenever possible 1, 2
• Abrupt discontinuation can lead to:
  • Withdrawal symptoms
  • Worsening of narcolepsy symptoms
  • Increased risk of cataplexy episodes during stressful perioperative period 3

Specific Medication Considerations

1. Modafinil/Armodafinil

   • First-line treatment for excessive daytime sleepiness 1, 4
   • Continue through morning of surgery
   • Monitor for potential drug interactions with anesthetic agents
   • Typical dose range: 200-400mg daily 1

2. Sodium Oxybate (Xyrem/Xywav)

   • FDA-approved for both cataplexy and excessive daytime sleepiness 5
   • Has CNS depressant effects (black box warning) 6
   • Usually administered in two divided nighttime doses
   • Discontinue night before surgery due to potential interaction with anesthetic agents
   • Resume as soon as possible postoperatively 2

3. Antidepressants for Cataplexy

   • TCAs, SSRIs, SNRIs used for cataplexy management
   • Continue through perioperative period to prevent cataplexy episodes
   • Monitor for potential serotonin syndrome with certain anesthetic agents 3

Anesthetic Considerations

Preoperative Assessment

• Document baseline narcolepsy symptoms and current treatment regimen
• Assess for comorbid sleep disorders (sleep apnea, periodic limb movements) 7
• Evaluate for autonomic dysfunction which may affect hemodynamic stability 2

Anesthetic Technique

• Consider total intravenous anesthesia (TIVA) over inhalational agents 2
• Use depth of anesthesia monitoring (BIS/Entropy) to avoid over-sedation 2
• Regional anesthesia techniques may be advantageous when appropriate 2
• Multimodal analgesia with short-acting agents preferred 2

Potential Complications

• Autonomic dysregulation during anesthesia
• Delayed emergence from anesthesia
• Postoperative exacerbation of narcolepsy symptoms
• Inadequate pain control (reported in 18% of narcolepsy patients) 3
• Increased risk of cataplexy episodes with emotional stress of surgery 3

Postoperative Management

Recovery Period

• Monitor for prolonged sedation effects
• Ensure adequate pain control (narcolepsy patients report higher rates of inadequate pain relief) 3
• Resume narcolepsy medications as soon as possible

Discharge Planning

• Counsel regarding potential worsening of narcolepsy symptoms postoperatively
• Warn about increased risk of drowsy driving after anesthesia 3
• Ensure follow-up with sleep specialist if symptoms worsen

Special Considerations

• Patients with cataplexy report higher rates of surgical complications (70% vs 31%) 3
• Multiple surgeries increase risk of complications, difficulty waking, and inadequate pain relief 3
• Consider scheduling procedure earlier in the day to minimize disruption to sleep-wake cycle

Communication with Surgical Team

• Ensure all team members are aware of narcolepsy diagnosis
• Discuss medication plan with anesthesiologist in advance
• Document specific concerns related to narcolepsy in preoperative assessment

Pitfalls to Avoid

1. Discontinuing narcolepsy medications without a plan for perioperative management
2. Failing to counsel patients about potential worsening of symptoms postoperatively
3. Inadequate pain management leading to sleep disruption and symptom exacerbation
4. Not recognizing cataplexy episodes which may be triggered by perioperative stress

Following these guidelines will help minimize perioperative risks and complications in patients with narcolepsy and cataplexy undergoing surgical procedures.