Vagal nerve stimulation is an important adjunctive therapy for medically refractory epilepsy and major depression. Additionally, it may prove effective in treating obesity, Alzheimer's disease, and some neuropsychiatic disorders. As the number of approved indications increases, more patients are becoming eligible for surgical placement of a commercial vagal nerve stimulator (VNS). Initial VNS placement typically requires general anesthesia, and patients with previously implanted devices may present for other surgical procedures requiring anesthetic management. In this review, we will focus on the indications for vagal nerve stimulation (both approved and experimental), proposed therapeutic mechanisms for vagal nerve stimulation, and potential perioperative complications during initial VNS placement. Anesthetic considerations during initial device placement, as well as anesthetic management issues for patients with a preexisting VNS, are reviewed.
We describe a case of severe back pain following thoracic epidural placement. We discuss the differential for such a case, and the management as well.One of the most feared complications of epidural placement is epidural hematoma. Back pain following epidural catheter placement can have several causes, from those of a trivial nature to those that are a true medical emergency, and can range in degree from mildly sore to excruciating in nature. We present a case of severe back pain shortly following epidural catheter placement that mimicked epidural hematoma but was not. CaseA 66 year old 80 kilogram white male with non-small cell carcinoma of the lung was scheduled for a thoracotomy with excision of the mass. His past medical history was significant for a 100 pack-year cigarette smoking history, hypertension, and osteoarthritis. He took no antithrombotic or antiplatelet drugs, and had no history of bleeding diatheses or easy bruising. His coagulation studies were within normal limits, specifically a platelet count of 428, PT/INR 10.8/1.0, and PTT of 29. After sedation with 2 milligrams of midazolam administered intravenously, an epidural catheter was placed at the level of T6/T7 via a midline insertion for postoperative pain control preoperatively in the holding room. The placement itself was unremarkable, with loss of resistance (with air) at 7 centimeters, and the catheter was easily threaded to 12 centimeters at the skin. A 3 milliliter test dose of 1.5% lidocaine with epinephrine 1:200,000 was negative. The patient tolerated the procedure well.The patient's entrance into the operating room was delayed for a time. Three and a half hours later, the holding room staff advised us that the patient was complaining of severe back pain. The patient was found to be sitting on the side of the bed, asking for the epidural catheter to be removed. He said lying on the bed was too painful. He related that his pain was 10/10, sharp in nature, in the immediate area of the epidural catheter. He also related that dorsiflexion of his feet worsened the pain. There was slight radiation of the pain superiorly. His strength in all extremities was normal, and his patellar reflexes were intact. The epidural site was normal in appearance, and no blood or clear fluid was obtained upon aspiration of the catheter.A stat magnetic resonance imaging (MRI) was ordered, and neurosurgery was alerted to be on standby in case an epidural hematoma was discovered on imaging. The MRI showed no evidence of epidural hematoma, and the epidural catheter was visible in the epidural space; there was an incidental finding of a hemangioma in the body of the T4 vertebra. Furthermore, there was no significant disc disease or osteoarthritic changes.The catheter was removed following the MRI; over the next few hours, his pain gradually decreased. The patient was treated with opiate analgesics overnight, and the surgery was postponed. The patient underwent his planned thoracotomy the next day, and his postoperative pain was managed by intravenous, and t...
: With this interdepartmental collaboration, as part of a larger institutional initiative, we hope to improve short- and long-term outcomes for surgical patients with uncontrolled diabetes, as well as improve costs and utilization of health care resources in our institution. Our glycemic control committee, which follows bimonthly metrics, including 90-day readmission rates for surgical patients, has noted a decline from 7.9% in 2009 to 4.5% in the 2012-2013 fiscal year. Our aggressive preoperative and postoperative blood glucose management has been a significant factor in this improvement.
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