The American Society of Pain and Neuroscience (ASPN) Guidelines for Radiofrequency Ablative Procedures in Patients with Implanted Devices

Radiofrequency ablation (RFA) is a treatment modality used in interventional pain management to treat several conditions including chronic neck or back pain, sacroiliac joint pain, major joint pain, and pain from sites that can be isolated to a sensory nerve amenable to RFA. The goals of such procedures are to reduce pain, improve function, delay need for surgical intervention, and reduce pain medication consumption. As applications for RFA expand through novel techniques and nerve targets, there is concern with how RFA may impact patients with implanted medical devices. Specifically, the electrical currents used in RFA produce electromagnetic interference, which can result in unintentional energy transfer to implanted devices. This may also interfere with device function or cause damage to the device itself. As the number of patients with implanted devices increases, it is imperative to establish guidelines for the management of implanted devices during RFA procedures. This review aims to establish guidelines to assist physicians in the preoperative, intraoperative, and postoperative management of implanted devices in patients undergoing procedures using radiofrequency energy. Here, we provide physicians with background knowledge and a summary of current evidence to allow safe utilization of RFA treatment in patients with implanted devices such as cardiac implantable electronic devices, spinal cord stimulators, intrathecal pumps, and deep brain stimulators. While these guidelines are intended to be comprehensive, each patient should be assessed on an individual basis to optimize outcomes.

Anesthetic considerations in patients with implantable devices and chronic pain surgery

The use of advanced invasive techniques for the control of chronic pain in patients with multiple comorbidities is becoming increasingly common. Neuromodulation offers a new management alternative involving the infusion of one or more drugs into the epidural or intrathecal space through a fully implantable infusion pump. It also involves spinal stimulation, a minimally invasive technique in which electrodes are positioned in the epidural space and connected to a pulse generator that is implanted subcutaneously and generates pulses designed to suppress the noxious stimulus. This article will describe the anesthetic considerations in cases of implantable drug delivery systems, and spinal and peripheral nerve stimulation devices. Additionally, patients with electrical or drug neuromodulation devices may present to anesthetic practice for surgical indications unrelated to their chronic pain pathology. Hence the importance of being familiar with the basic components of these devices, how they work, what drugs they use and the potential associated complications in the perioperative context, in order to ensure proper management and patient safety.

Laparoscopic bowel resection in the presence of a lumbo-peritoneal shunt: a rare case

The presence of a cerebrospinal fluid (CSF) shunt was previously considered a contra-indication to laparoscopic surgery, however, case reports appeared that describe laparoscopic surgery proceeding with no adverse outcomes in such patients. The majority of these reports relate to laparoscopic cholecystectomy. Here we present what we believe to be only the second report of a patient undergoing laparoscopic bowel resection in the presence of a lumbo-peritoneal shunt. With this case we aim to add to the evidence that more major laparoscopic procedures can be performed safely in the presence of CSF shunts and with a brief review of the current evidence, have suggested appropriate monitoring and precautionary measures for approaching these procedures.

Anaesthetic management of intracranial hypertension and pregnancy. A case report

Hydrocephalus is an active distension of the ventricular system of the brain. The improved survival rates of patients with neurosurgical pathology is accompanied by a greater number of non-neurosurgical procedures in patients who have therapeutic neurosurgical devices. The real incidence of pregnancy in patients with obstructive hydrocephalus controlled with ventriculoperitoneal shunt (VPS) is unclear. We present a case of a pregnant 34-year-old female with a VPS for obstructive hydrocephalus. Due to VPS obstruction secondary to uterus volume, she presented several episodes of neurological impairment during pregnancy. An elective caesarean section (C-section) and VPS review were planned for the same operative time. This rare case reflects the challenge that the anaesthesiologist has to face in order to provide the best and simultaneous management of the wellbeing of the mother, the mother's brain and the foetus.