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Bueno, D. Huntley, D. Navarro, J. Colomina" "autores" => array:4 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Bueno" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Huntley" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Navarro" ] 3 => array:2 [ "nombre" => "J." 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Escalona Belmonte, S. Romero Molina, E. Sepúlveda Haro, A. Malo Manso, J.L. Guerrero Orriach" "autores" => array:5 [ 0 => array:3 [ "nombre" => "J.J." "apellidos" => "Escalona Belmonte" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Romero Molina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Sepúlveda Haro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "A." "apellidos" => "Malo Manso" "email" => array:1 [ 0 => "alfredomalomanso@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 4 => array:3 [ "nombre" => "J.L." "apellidos" => "Guerrero Orriach" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitario Virgen de la Victoria, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Málaga, IBIMA, grupo de investigación A-21, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Narcolepsia y anestesia libre de opioides: revisión y caso clínico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Narcolepsy is a rare chronic sleep disorder that manifests as excessive daytime sleepiness with dysregulation of REM (rapid eye movement) sleep. Patients feel the irresistible urge to sleep, and enter the REM phase within a few minutes of falling asleep. Despite being rare, with an estimated prevalence of 0.05% of the general population, it is the second most common sleep disorder after insomnia.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Narcolepsy is also associated with cataplexy, sleep paralysis and hallucinations. Cataplexy is defined as a sudden loss of muscle tone caused by an emotional trigger. In sleep paralysis, which usually occurs in the transition between sleep and wakefulness, the patient has the sensation of being conscious but is unable to move or speak. Hallucinations, defined as vivid experiences involving someone or something, are classified as hypnagogic when they occur at the beginning of sleep, and hypnopompic when they occur upon waking.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Research into the pathophysiology of this disease has revealed the autoimmune destruction of orexin- or hypocretin-producing neurons in the hypothalamus that play a crucial role in regulating sleep. This could be due to genetic factors involving the HLA-DQB1*06:02 allele. Other genetic mechanisms independent of this system and environmental factors may also play a role.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These hypothalamic neurons project widely to the central nervous system (CNS) creating noradrenergic, serotonergic, histaminergic, cholinergic, and dopaminergic connections that not only regulate sleep but also various functions that include the sympathetic nervous system, eating, and emotions.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Narcolepsy is often overlooked, so clinical suspicion is essential for diagnostic studies, which usually consist of polysomnography to detect abnormal periods of REM sleep during the sleep cycle, and the multiple sleep latency test. In the latter, 5 consecutive 20-min naps separated by a 2-h break are recorded on a polygraph to measure the latency of the appearance of sleep signs in the EEG and whether REM sleep occurs. Latency below 5<span class="elsevierStyleHsp" style=""></span>min and at least 2 initiations of REM sleep suggest narcolepsy. Other tests include determination of hypocretin 1 in cerebrospinal fluid or HLA DQB1*06:02 gene testing.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Narcolepsy is classified as type 1 when cataplexy occurs or hypocretin concentration in cerebrospinal fluid is below 110<span class="elsevierStyleHsp" style=""></span>pg/mL, and as type 2, when no cataplexy occurs and hypocretin concentration is normal or has not yet been measured. Type 1 narcolepsy is related to the loss of hypocretin-secreting neurons, while the cause of type 2 remains unknown.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The disease is treated with wakefulness-promoting agents with different mechanisms of action, such as modafinil, methylphenidate and sodium oxybate, as well as other drugs aimed at addressing other symptoms such as cataplexy and fragmented sleep, mainly antidepressants and benzodiazepines.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Many of these patients also present obstructive sleep apnoea syndrome, which is treated in the normal manner.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Various lifestyle modifications are also recommended, such as taking several short naps throughout the day or taking extra caution when driving.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methodology</span><p id="par0050" class="elsevierStylePara elsevierViewall">We performed a narrative non-systematic literature review of articles published on Pubmed. The descriptors used were <span class="elsevierStyleItalic">narcolepsy, anaesthesia, surgery, perioperative, opioid, obstructive, apnea and sleep</span>. These were used both individually and with <span class="elsevierStyleItalic">AND</span> and <span class="elsevierStyleItalic">OR</span> connectors to create the following combinations: <span class="elsevierStyleItalic">narcolepsy AND anaesthesia AND opioid, OR narcolepsy AND anaesthesia AND sleep, OR narcolepsy AND anaesthesia AND perioperative, OR narcolepsy AND anaesthesia AND surgery, OR narcolepsy AND anaesthesia and obstructive</span>. We retrieved 89 articles, which were then reviewed critically to identify the grades of recommendation of the techniques used in these patients. The search was not limited by date, due to the scarcity of articles related to anaesthesia management in these patients and the absence of studies with a high level of evidence.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Narcolepsy and anaesthesia</span><p id="par0055" class="elsevierStylePara elsevierViewall">Few studies, mainly case reports or case series, have described or evaluated anaesthesia management in narcoleptic patients. However, there are several factors to be taken into account in these patients in terms of both the disease itself and the anaesthetic drugs administered, which can cause respiratory and haemodynamic instability.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In theory, the difficulty involved in managing these patients derives from potential drug interactions and the risk of postoperative exacerbation of the manifestations of the disease, such as hypersomnia, cataplexy and sleep paralysis. Both the drugs used to treat narcolepsy and commonly used anaesthesia agents are metabolized through the cytochrome p450 system, so there is a risk of drug interactions.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The pathophysiology of narcolepsy – orexin deficiency – can delay emergence in narcoleptic patients undergoing general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">To give an example of alterations caused by narcolepsy drugs, amphetamines deplete endogenous catecholamine reserves, thus increasing sensitivity to anaesthetic agents and altering the sympathetic response to hypotension. Dysautonomia associated with narcolepsy can also lead to haemodynamic alterations.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">16–18</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Because of their depleted catecholamine reserves, narcoleptic patients require the use of direct sympathetic agonists such as epinephrine or norepinephrine instead of ephedrine.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Sodium oxybate also has implications for anaesthesia, since its use in patients with obstructive sleep apnoea syndrome (OSAS) can exacerbate desaturation during sleep, worsen OSAS, and cause hypoventilation.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Narcoleptic patients present sleep-related breathing disorders that are probably due to role played by orexin in upper airway muscle tone. According to different studies, up to 24.8% meet the criteria for OSAS, a percentage that can increase to 40% in surgical series. This syndrome carries a perioperative risk of respiratory or haemodynamic complications, including ischaemic heart disease.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Opioid-free anaesthesia (OFA)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Based on recommendations put forward in various studies, the high prevalence of OSAS in these patients - which is worsened by drugs commonly used to treat narcolepsy, and the respiratory complications that can be expected due to their pathophysiology, we believe the narcoleptics are candidates for an opioid-free anaesthetic technique.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Opioids provide good perioperative analgesia, but their side effects are particularly harmful in certain groups of patients, including narcoleptics. In addition to their other well-known postoperative side-effects, such as nausea, opioids present effects that could severely complicate the postoperative recovery of these patients, mainly, drowsiness, respiratory depression and weakness of the pharyngeal muscles favouring obstructive phenomena during sleep.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">22–24</span></a> In view of this, guidelines recommend the use of opioid-sparing anaesthetic regimens in patients diagnosed with OSAS.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> The success of OFA in other populations that suffer from OSAS suggests that it could also be beneficial in narcoleptics.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Patients must give their informed consent before this protocol can be used due to the off-label use of certain drugs (lidocaine, dexmedetomidine) during anaesthesia. In addition, patients must not present absolute or relative contraindications for OFA, including hypersensitivity to the drugs used or advanced heart block (grade 2 or 3) without pacemaker, uncontrolled hypotension, cerebrovascular disease acute, liver failure and sepsis.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In summary, our protocol consists of the intravenous administration of 2<span class="elsevierStyleHsp" style=""></span>g metamizole, 50<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen, 10<span class="elsevierStyleHsp" style=""></span>mg dexamethasone, and 3<span class="elsevierStyleHsp" style=""></span>g magnesium sulphate prior to anaesthesia induction. Induction and maintenance are performed with a syringe pump containing 10<span class="elsevierStyleHsp" style=""></span>mg/ml lidocaine, 1<span class="elsevierStyleHsp" style=""></span>mg/ml ketamine, and 1<span class="elsevierStyleHsp" style=""></span>μg/ml dexmedetomidine. The infusion rate is calculated according to the requirements of the patient and the surgery. Perfusion is reduced by half for eduction, and is maintained while the patient is in the postanaesthesia care unit (PACU). Induction is achieved with 2–3<span class="elsevierStyleHsp" style=""></span>mg/kg propofol and 1<span class="elsevierStyleHsp" style=""></span>mg/kg rocuronium. Anaesthesia can be maintained with intravenous infusion of the hypnotic or halogenated anaesthetic agent best suited to the characteristics of the patient. Prior to eduction, 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron are given for antiemetic prophylaxis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The use of this protocol in bariatric surgery in our hospital has been published previously and has been shown to be safe. Its main advantages include reduction of postoperative nausea and vomiting, reduction of desaturation episodes, and shorter PACU stay.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Case report</span><p id="par0115" class="elsevierStylePara elsevierViewall">A 47-year-old female patient (72<span class="elsevierStyleHsp" style=""></span>kg, 166<span class="elsevierStyleHsp" style=""></span>cm) diagnosed with narcolepsy was scheduled for lumpectomy and selective biopsy of the sentinel node for infiltrating lobular cancer in the left breast.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition to narcolepsy, her history included four uneventful caesarean sections under general and epidural anaesthesia. She had no known drug allergies, did not smoke and had no other toxic habits. Her only background treatment was modafinil to control excessive sleepiness, which was maintained until the morning of the intervention. She had a family history of grandfather and father with undiagnosed “sleep attacks”. Her grandmother died at the age of 49 due to breast cancer, and her maternal aunt underwent a hysterectomy and oophorectomy. Preoperative blood panel and ECG were unremarkable, and she had no difficult airway predictors.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The patient was received in the surgical area, her identity and her informed consent were checked, and she was offered the possibility of an opioid-free anaesthetic technique with a good risk/benefit balance for her clinical situation. Our opioid-free anaesthesia protocol includes the use of preoperative oral gabapentin, but given the side-effects of this drug – drowsiness and sedation – it was not used in this patient.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The patient was taken into the operating room, where an 18G peripheral venous line was placed and monitoring was started: non-invasive blood pressure (NIBP) 121/84<span class="elsevierStyleHsp" style=""></span>mmHg, continuous electrocardiogram within normal range, heart rate 77 beats per minute, pulse oximetry (SaO<span class="elsevierStyleInf">2</span>) 98% and a bispectral index (BIS) of 97. She was given 2<span class="elsevierStyleHsp" style=""></span>g metamizole, 50<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen, 10<span class="elsevierStyleHsp" style=""></span>mg dexamethasone, and 3<span class="elsevierStyleHsp" style=""></span>g magnesium sulphate.</p><p id="par0135" class="elsevierStylePara elsevierViewall">After administering a 0.1<span class="elsevierStyleHsp" style=""></span>ml bolus with the syringe pump (7.2<span class="elsevierStyleHsp" style=""></span>μg dexmedetomidine, 7.2<span class="elsevierStyleHsp" style=""></span>mg ketamine, and 72<span class="elsevierStyleHsp" style=""></span>mg lidocaine), anaesthesia was induced with 160<span class="elsevierStyleHsp" style=""></span>mg propofol. A size 4 laryngeal mask airway was inserted, without observing and significant haemodynamic changes.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Anaesthesia was maintained with desflurane to maintain BIS values (BIS XP®, Aspect Medical Systems, Newton, MA) of around 40–60. Syringe pump infusion of between 0.05 and 0.25<span class="elsevierStyleHsp" style=""></span>ml/kg/h was started (3.6–18<span class="elsevierStyleHsp" style=""></span>μg/kg/h dexmedetomidine, 3.6–18<span class="elsevierStyleHsp" style=""></span>mg/kg/h ketamine, and 36–180<span class="elsevierStyleHsp" style=""></span>mg/kg/h lidocaine), adjusting the perfusion rate to keep blood pressure and heart rate parameters within normal values throughout the intervention. The EEG tracing monitored by BIS showed no alterations during the intervention. Mechanical ventilation was initially pressure controlled, and switched to pressure support mode once spontaneous respiration had resumed.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Thirty minutes before the end of the surgery, 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron and 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine were administered, and 10<span class="elsevierStyleHsp" style=""></span>min before eduction the syringe pump infusion rate was reduced to 0.05<span class="elsevierStyleHsp" style=""></span>ml/kg/h (3.6<span class="elsevierStyleHsp" style=""></span>μg/kg/h dexmedetomidine, 3.6<span class="elsevierStyleHsp" style=""></span>mg/kg/h ketamine and 36<span class="elsevierStyleHsp" style=""></span>mg/kg/h lidocaine). As per our usual practice, the surgeon infiltrated the surgical wound with 10<span class="elsevierStyleHsp" style=""></span>ml 0.125% levobupivacaine. After an intervention lasting 75<span class="elsevierStyleHsp" style=""></span>min, eduction and removal of the laryngeal mask airway were uneventful, and the patient was transferred to the PACU, where haemodynamic and respiratory parameters remained normal, no supplementary oxygen was required, and pain was rated 0 on a numerical rating scale. The patient presented none of the cataplexy or profound drowsiness typical of her syndrome.</p><p id="par0150" class="elsevierStylePara elsevierViewall">After discharge from the PACU she was admitted to the ward where she made good progress and was discharged home 24<span class="elsevierStyleHsp" style=""></span>h later.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">In a retrospective study that included 10 patients diagnosed with narcolepsy, no significant increases in perioperative risk were reported, but several patients presented self-limiting adverse effects.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Cavalcante et al.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> conducted a case–control study to compare surgical outcomes in patients diagnosed with narcolepsy who were matched with controls by age, sex, and type and year of surgery. They concluded that these patients do not have a higher rate of complications or length of PACU stay, but they do tend to require more urgent care on the ward, mainly due to haemodynamic instability probably due to prolonged use of central nervous system stimulators.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Some authors have publish case reports in which they have attempted to avoid the use of narcotics or long-acting drugs in order to avoid anaesthesia-related complications. Honca et al.,<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> for example, used sevoflurane and nitrous oxide for an emergency caesarean section in a pregnant woman who had not been taking her usual medication during pregnancy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Similarly, Takekawa et al.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> observed that prolonged emergence from general anaesthesia would be expected in patients with narcolepsy given their orexin deficiency, and hypothesized that it would be best to use short-acting drugs, reduce the doses of analgesic and hypnotic drugs, and use a combination of general anaesthesia and locoregional techniques. They presented a case report in which they used propofol, remifentanil and femoral nerve block, thereby avoiding the need for opioids that could delay emergence in their patient. These authors also reported that fentanyl was administered for postoperative pain control, but commented that they should have performed sciatic nerve block instead.</p><p id="par0175" class="elsevierStylePara elsevierViewall">However, some authors have observed that neuraxial techniques worsen the symptoms of narcolepsy.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Hu et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> published a systematic literature review to clarify the postoperative outcomes and anaesthetic considerations in these patients, although they draw attention to the paucity of randomized clinical trials in this patient population, with most studies being case reports or observational studies. These authors found that continuing chronic medication, choosing regional anaesthesia over general anaesthesia, and using multimodal analgesia with short-acting agents to avoid the effects of opioids gave the best outcomes in narcoleptic patients, and also indicated that outcomes such as mortality or hospital stay did not differ in this patient population.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Several authors recommend the use of BIS monitors in these patients, not only to achieve an adequate level of hypnosis, but also to detect and monitor episodes of cataplexy or other manifestations of narcolepsy, even in patients under regional anaesthesia. Dahaba et al.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> reported that BIS was shown to correlate to various conditions that could influence the electroencephalogram, and when combined with electromyogram (EMG) monitoring was capable of detecting cataplexy episodes with the consequent muscle weakness. In their case report of a patient under regional anaesthesia, they describe how they first observed a pattern of alternating high and low BIS values that correlated with high and low EMG values, followed by a phase of stable BIS of around 75, leading to a final phase of a complete cataleptic episode with total loss of muscle power in which the BIS stabilized at around 45. The alternating values in the initial phase correspond to a state of low vigilance in which BIS values were spuriously increased by high EMG activity. In the second and third phases, BIS values fell as a consequence of the sleep drive typical of this disease, which results in increased θ waves and a decrease in α and β waves. They emphasize that this first phase, with rapid changes in BIS and EMG, could alert to an imminent narcoleptic crisis.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Hershner et al.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a> recently published an article reporting the results of a survey of narcoleptics who had undergone surgery. Most reported that they received no counselling from their doctors regarding possible increased daytime sleepiness, perioperative risks, or the possibility of exacerbation of the disease. The survey also revealed that more than half of the respondents had experienced an adverse effect, and up to 17% had experienced two adverse effects.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Narcolepsy is probably a little known, under-diagnosed disease. It presents anaesthesiologist with a challenge because of the risk of adverse reactions to common anaesthetic agents, the long-term effects of the drugs used to treat narcolepsy, and the risk of postoperative complications. In view of this, the few reports published in the literature recommend using drugs with a short half-life that will not delay emergence, trigger more severe manifestations of the disease, or cause haemodynamic instability. The use of short-acting anaesthetic agents is also known to benefit patients with OSAS, a condition that is frequently associated with narcolepsy.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">The anaesthesia technique described in this report is safe, consistent with recommendations made in previous articles, and is supported by the good intra- and postoperative evolution of our patient. More powerful studies with better methodology and a higher grade of recommendation are needed in the future. Despite the scant evidence of the effects of opioid-free anaesthesia in narcolepsy patients, its benefit in conditions associated with this disease, such as OSAS, strongly suggest its potential role in the anaesthesia management of these patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0205" class="elsevierStylePara elsevierViewall">This research has not received specific aid from agencies of the public sector, commercial sector or non-profit entities.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1491454" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1354135" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1491455" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1354136" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Narcolepsy and anaesthesia" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Opioid-free anaesthesia (OFA)" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Case report" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-21" "fechaAceptado" => "2020-07-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1354135" "palabras" => array:6 [ 0 => "Narcolepsy" 1 => "Anaesthesia" 2 => "Surgery" 3 => "Perioperative" 4 => "Opioid" 5 => "Apnea" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1354136" "palabras" => array:6 [ 0 => "Narcolepsia" 1 => "Anestesia" 2 => "Cirugía" 3 => "Perioperatoria" 4 => "Opioide" 5 => "Apnea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Narcolepsy is the second most common sleep disorder. It is characterized by excessive daytime sleepiness together with other symptoms such as cataplexy, sleep paralysis, and hallucinations. The pathophysiology and treatment of this disease, together with its associated syndromes, can severely interfere with anaesthesia.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Due to the lack of quality evidence on which to base a high grade of recommendation for anaesthesia in these patients, we performed a non-systematic, narrative review of the literature in Pubmed. We used the descriptors narcolepsy, anaesthesia, surgery, perioperative, opioid, obstructive, apnea and sleep both individually and with AND and OR connectors.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The recommendation to avoid opioids and the stability of opioid-free anaesthesia (OFA) make this approach an option to consider in these patients. We describe a case in which it was used safely.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducción</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La narcolepsia es el segundo trastorno del sueño en frecuencia y se caracteriza por somnolencia excesiva durante el día junto con otros síntomas como cataplejía, parálisis del sueño y alucinaciones. Su fisiopatología y tratamiento, así como los síndromes que asocia, pueden interferir de forma severa con el acto anestésico.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Metodología</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Debido al déficit de evidencia de calidad que aporte un grado de recomendación alto en la anestesia de estos pacientes, se realizó una revisión narrativa de la literatura no sistemática en Pubmed. Como descriptores se usaron <span class="elsevierStyleItalic">narcolepsy, anesthesia, surgery, perioperative, opioid, obstructive, apnea y sleep</span> y se emplearon de forma individual y cruzándolos con conectores <span class="elsevierStyleItalic">AND</span> y <span class="elsevierStyleItalic">OR</span>.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La recomendación de evitar opioides y la estabilidad de la anestesia libre de opioides (OFA), hace de esta última una opción para estos pacientes. Se describe un caso en el que se empleó de forma segura.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Escalona Belmonte JJ, Romero Molina S, Sepúlveda Haro E, Malo Manso A, Guerrero Orriach JL. Narcolepsia y anestesia libre de opioides: revisión y caso clínico. Rev Esp Anestesiol Reanim. 2021;68:165–170.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0160" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Narcolepsy: clinical features, co-morbidities & treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Peacock" 1 => "R.M. 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