Lessons learned from the anesthetic management of patients with narcolepsy

Background and Goal of Study
Narcolepsy is a neurological disorder that affects sleep regulation and is associated with increased risk of perioperative complications. The aim of this study is to systematically review the literature concerning the anesthetic management of patients with narcolepsy.

Materials and Methods
A search was conducted in the Medline database. We included all studies of patients with narcolepsy submitted to anesthesia. The parameters analyzed were: type of anesthesia, premedication, withdrawal of medication for narcolepsy, use of depth of anesthesia monitors, time for extubation and perioperative complications.
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￼Results and Discussion
Nineteen case reports and one case series were included. We did not find clinical trials. The only review article found was written prior to the publishment of almost all case reports.
Excessive sleepiness, sleep paralysis and hypnagogic/hypnopompic hallucinations were reported in 3 narcoleptic patients after inhalational anesthesia. However, 6 reports of uneventul inhalational anesthesias were also found. Concerning intravenous anesthesia for narcoleptic patients, 6 case reports were found, showing no complications. A case series of 10 narcoleptic patients who underwent 27 general anesthesias showed that time for extubation did not differ from that observed in age and procedure match controls, during the same period.
Cataplexy episodes were reported in 2 narcoleptic patients undergoing spinal anesthesia and femoral nerve block. We found 2 case reports of epidural blocks and 1 case of an axillary brachial plexus block, with no complications.
Depth of anesthesia monitors were used in less than half of the patients. BIS® or entropy monitoring can be important to optimize anesthetic administration and to monitor a possible narcoleptic episode.
Benzodiazepines were administered preoperatively in four cases. Two of the patients had narcoleptic events intra ou post-operatively.
In the majority of cases, the patient’s usual medication for narcolepsy was continued on the day of surgery, which may have contributed to a more rapid and complete recovery of consciousness.

Conclusions
Avoidance of sedative premedication, continuation of medication for narcolepsy on the day of surgery, use of short-acting anesthetic agents and depth of anesthesia monitoring may be beneficial measures in the management of narcoleptic patients.