Perioperative challenges for same sitting bilateral upper limb surgery in a patient of obstructive sleep apnoea, morbid obesity, hypothyroidism, and orthopnea

Background Analgesia, sedation, and anesthesia all can be dangerous in patients with obstructive sleep apnoea and have been associated with critical events during perioperative management. The risk further increases when obstructive sleep apnoea is associated with other comorbidities. Although regional anesthesia when feasible is preferred over general anesthesia, it is not a clear cut decision always. The dilemma and challenges for the management of such cases still persist. Case presentation We present here a case of 58-year-old male, weighing 98 kg (body mass index 41.86 kg/m 2 ), presented with bilateral forearm bone fractures that was planned for bilateral upper limb surgery in the same sitting. He was newly diagnosed as having obstructive sleep apnoea, a known case of morbid obesity, hypothyroidism, and orthopnea. He was also having anticipated difficult airway. The case was managed successfully under bilateral regional anesthesia. However, patients’ apprehension led to a new challenge which required different management strategies including titrated sevoflurane-based sedation. Conclusions The case highlights the dilemmas and challenges faced by anesthesiologists, use of sevoflurane sedation, need of noninvasive ventilator support, and the limitations in the usual anesthesia machine and interface in the management of patients with obstructive sleep apnoea with multiple comorbidities.