Downloaded from http://journals.lww.com/aacr by BhDMf5ePHKbH4TTImqenVNtKptvhFPG0Cf4edEerosiLhx/wCYioa4kKhtq+oPAX on 09/23/2018 Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. 160 cases-anesthesia-analgesia.org September 15, 2018 • Volume 11 • Number 6 Copyright © 2018 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000771 W e describe a pediatric patient who underwent neck dissection for removal of a tumor and had unexpected transient central sleep apnea in the recovery room post anesthesia. Parental written consent was obtained for this publication. CASE SUMMARY The patient was a 15-year-old girl with a right parapha- ryngeal schwannoma presenting for tumor resection. The tumor was originally found during a tonsillectomy for asymmetric tonsil enlargement at an outside hospital. Her medical history included herpes labialis managed with valaciclovir, and new-onset snoring and rhinitis secondary to the mass. No other symptoms concerning for sleep apnea, such as nocturnal apnea, gasping, or daytime fatigue, were reported. The patient’s weight was 37.8 kg and body mass index 14.6. An intravenous (IV) catheter was placed under nitrous oxide sedation, after which nitrous oxide was immediately switched off. She was induced with 2 mg of midazolam, 0.5 mg of hydromorphone, and 150 mg of propofol, and noted to be an easy mask-ventilation with no obstruc- tion after induction of anesthesia. She was intubated with a neuromonitoring (NIM®) endotracheal tube by direct laryngoscopy without diffculty. A preoperative magnetic resonance imaging (MRI) demonstrated tumor size of 3.8 × 3.5 × 6.0 cm located next to major blood vessels, includ- ing the right carotid artery and internal jugular vein. A type and cross was obtained. An additional IV line and arterial line were placed in addition to standard American Society of Anesthesiologists monitors. Neuromuscular blocking agents were not used during the case. A preauricular infratemporal fossa approach was used to resect the tumor. The schwannoma was extensively involved with the sympathetic trunk. It also involved the vagus nerve, which was minimally connected and easily enucleated away from the mass. Exposure of the mass did not reveal the superior laryngeal nerve, raising the suspi- cion that it may have had sympathetic chain and vagal nerve components and was not entirely a sympathetic schwan- noma. The vagus and hypoglossal nerves were intact at the end of the procedure. The carotid artery and jugular vein were also dissected and the lower cervical fascia was har- vested to protect the carotid artery. Microneuro repair of the great auricular nerve was performed. Neuromonitoring consisted of recurrent laryngeal nerve vagal complex moni- toring using the NIM® endotracheal tube and vagus nerve stimulation. The nerve stimulator was used to map the posi- tion of the vagus nerve by the surgeons. Estimated blood loss was 400 mL with the lowest hemo- globin noted to be 8. The patient was not transfused. She received a total of 2500 mL of crystalloids and maintained excellent urinary output. She received postoperative nau- sea and vomiting prophylaxis in the form of dexametha- sone and ondansetron. Anesthesia was maintained using 0.3% isofurane and a propofol drip at 50–200 µg/kg/min, titrated down throughout the case to off 1.5 hours before extubation. Pain was controlled throughout the procedure using a remifentanil drip (0.3–0.8 µg/kg/min, turned off 40 minutes before extubation). Hydromorphone 1 mg in 0.5-mg aliquots and 550 mg IV acetaminophen were given before extubation, with 0.5 mg hydromorphone given with induction (5 hours before) and 0.5 mg given 1.5 hours before extubation. The patient had an uneventful anesthetic and was stable throughout the procedure without periods of sig- nifcant hemodynamic changes. She was extubated without diffculty, breathing at a respiratory rate of 15, with an initial respiratory rate in the recovery unit of 19. The IV line was fushed before transfer to the recovery unit to avoid residual anesthetics being given to patient. In the recovery unit, she reported no pain or nausea, but did appear pale. In the immediate postoperative period, she reported vertigo and appeared drowsy, but was able to answer questions appropriately. She received no medications in the postanesthesia care unit. One hour later, she fell asleep and had 2 episodes of central apnea lasting longer than 20 seconds and associated with hypoxia to 50% that resolved when awakened. While asleep, she made no respiratory effort: no chest rise was noted and end-tidal CO 2 was zero on the monitor. While awake she was noted to be neurologi- cally intact and did not appear narcotized or drowsy, and her pupils were not constricted, ruling out opioid-related som- nolence, the most likely explanation for sleep apnea in a post- operative patient. An attending anesthesiologist requested We describe a pediatric patient who underwent neck dissection for removal of a tumor and had unexpected transient central sleep apnea in the recovery room. To the best of our knowledge, this is the frst report in the existing literature of central sleep apnea after surgical manipulation of the vagal nerve under anesthesia. (A&A Practice. 2018;11:160–1.) From the Departments of *Anesthesiology and †Otolaryngology, Vanderbilt University, Nashville, Tennessee. Accepted for publication February 21, 2018. Funding: None. The authors declare no conficts of interest. Address correspondence to Camila B. Walters, MD, Vanderbilt University, 2200 Children’s Way, Suite 3115, Nashville, TN 37232. Address e-mail to camila.walters@vanderbilt.edu. Central Sleep Apnea Post Vagal Nerve Manipulation and Stimulation During Neck Tumor Resection: A Case Report Camila B. Walters, MD,* James M. Kynes, MD,* Rhonda Tucker, CRNA,* and James Netterville, MD† CASE REPORT E