Postoperative Euglycemic Diabetic Ketoacidosis and Encephalopathy Related to SGLT-2 Inhibitors: A Case Report and Discussion of Diabetes Treatment and "Sweet Pee Encephalopathy" in Perioperative Hospital Management.

During preanesthesia evaluation, patient medications are reviewed and many are not administered on the day of surgery. Additionally, neurosurgical patients can develop postoperative encephalopathy from a variety of etiologies, including metabolic derangements. We report a case of postoperative neurosurgical euglycemic ketoacidosis which presented as unexplained encephalopathy and was the result of continued action of the patient's serum glucose cotransporter-2 (SGLT-2) inhibitor combined with perioperative fasting. A 68-year-old woman with a history of type 2 diabetes mellitus was admitted to the neurocritical care service after resection of a left temporal meningioma. On postop day 1, she became lethargic and with worsening aphasia. Laboratory studies revealed blood glucose 140 to 160 mmol/L, bicarbonate 9 mmol/L, anion gap of 21, and pH of 7.2. Urine was positive for ketones and glucose, and serum was positive for ß-hydroxybutyrate. Endocrinology was consulted and the patient was diagnosed with euglycemic diabetic ketoacidosis and treated with insulin until her anion gap closed. Over the next 2 days, her neurological examination improved to baseline. Although the patient did not take empagliflozin the day of surgery, the drug has a half-life of >12 hours, and other reports have described continued glycosuria for up to 10 days after drug discontinuation. This case illustrates the need for increased awareness of SGLT-2 inhibitors and "sweet pee encephalopathy" among neurosurgical and neurointensivist teams as well as potential modification of perioperative management of patients using newly emerging SGLT-2 inhibiting pharmaceuticals.

Perioperative stroke: incidence, etiologic factors, and prevention.

Stroke is a devastating complication that is difficult to diagnose in the perioperative setting because of the effects of anesthetic and analgesic agents. Lingering anesthesia effects hinder clinicians in identifying stroke symptoms, frequently resulting in a delay in diagnosis and treatment and in unfavorable outcomes. The authors performed a systematic search in PubMed and the Cochrane Central Register. The search aimed to identify studies published between January 1990 and December 2015 related to the common etiologic factors, incidence, risk factors, risk modifiers, and early management of perioperative stroke. Additional articles were identified after review of the references of selected articles. Although perioperative stroke is uncommon, the mortality rate is high. Patients have higher risk of perioperative stroke when undergoing cardiac and vascular operations than uncomplicated orthopedic and general procedures. Preoperative optimization for preexisting risk factors may reduce the rate of perioperative stroke. Prompt, early management can improve patient outcomes. Recognition of the incidence, risk factors, and causes of perioperative stroke may lead to prevention and proper management.

Lumbar plexus block surface landmarks as assessed by computed axial tomography in adult patients with scoliosis: a case series.

BACKGROUND AND OBJECTIVES: Lumbar plexus (LP) block is a common and useful regional anesthesia technique. Surface landmarks used to identify the LP in patients with healthy spines have been previously described, with the distance from the spinous process (SP) to the skin overlying the LP being approximately two-thirds the distance from the SP to the posterior superior iliac spine (PSIS) (SP-LP:SP-PSIS ratio). In scoliotic patients, rotation of the central neuraxis may make these surface landmarks unreliable, possibly leading to an increased block failure rate and an increased incidence of complications. The objective of the present study was to describe these surface landmarks of the LP in patients with scoliosis. METHODS: We selected 47 patients with known thoracolumbar scoliotic disease from our institution's radiology archives. We measured bony landmark geometry, Cobb angle, and the LP location and depth. Additionally, we calculated the SP-LP:SP-PSIS ratio for both the concave and convex sides. RESULTS: In scoliotic patients (31 females and 16 males), the median (range) Cobb angle was 23 (8-54) degrees. The LP depth was 7.5 (5.7-10.7) cm on the concave side of the scoliotic spine and 7.6 (5.4-10.8) cm on the convex side, while the distance from the SP-LP was 3.4 (1.9-4.7) cm on the concave side and 3.7 (2.4-5.1) cm on the convex side. The SP-LP:SP-PSIS ratio was 0.61 (0.20-0.97) and 0.65 (0.45-0.98) on the concave and convex sides, respectively. None of these distances were significantly different between sides. CONCLUSIONS: In patients with scoliotic disease of the spine, there is wide variability in the bony surface landmarks. The location of the LP is generally more medial than expected when compared with both modified and traditional landmarks. A review of the imaging studies and the pre-procedural ultrasound assessment of the anatomy should be considered prior to needle puncture.

Case report: continuous interscalene block associated with neck hematoma and postoperative sepsis.

Continuous peripheral nerve blockade is often used for the management of postoperative pain, even in ambulatory patients. The reported incidence of infectious complications after continuous nerve blockade is low. We report a case of Staphylococcus aureus sepsis after total shoulder arthroplasty in a patient who presented to her surgeon 8 days postoperatively with lethargy and labored breathing. Preoperatively, the patient had received a continuous interscalene block for analgesia that was associated with a neck hematoma. After readmission, exploratory laparotomy, and extensive hospital stay, the patient was discharged to an extended care facility in good condition.

Sciatic nerve catheter placement: success with using the Raj approach.

BACKGROUND: Continuous regional analgesia has increased in popularity and is becoming standard of care for many painful surgical procedures. Various approaches of sciatic catheter insertion have been proposed, each with attributes and disadvantages. We investigated whether the Raj approach that uses a simple midpoint landmark between the ischial tuberosity and greater trochanter will facilitate sciatic catheter placement. METHODS: After informed consent, 20 patients were recruited to receive sciatic catheter placement using the Raj approach. An insulated Tuohy needle was inserted perpendicular to skin at the midpoint of a line between the ischial tuberosity and greater trochanter. After sciatic nerve stimulation, a catheter was inserted 2-4 cm past the end of the needle and secured. The catheters were then incrementally injected with 30 mL of 1.5% mepivacaine. Twenty minutes after local anesthetic injection, sensory block was assessed using cold and pinprick tests, whereas motor block was assessed using a modified Bromage score. Complications and side effects were recorded. RESULTS: In all instances, blocks were easy to perform and were successful. No major side effects or complications were noted. CONCLUSION: Use of a simple landmark between easily identifiable bony structures enhances the simplicity and placement of a sciatic nerve catheter and is recommended for use in clinical practice.

Real-time three-dimensional ultrasound for continuous popliteal blockade: a case report and image description.

Two-dimensional ultrasound guidance has been used as an adjunct for neural blockade. With the development of newer ultrasound technology, three-dimensional ultrasound imaging is now available and may offer improved visualization of anatomic structures and relationships. We describe the successful blockade of the popliteal nerve with three-dimensional ultrasound guidance and image description.

Continuous popliteal sciatic nerve block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

BACKGROUND: This randomized, double-blinded, placebo-controlled study investigated the efficacy of patient-controlled regional analgesia using a sciatic perineural catheter in the popliteal fossa and a portable infusion pump for outpatients having moderately painful, lower extremity orthopedic surgery. METHODS: Preoperatively, patients (n = 30) received a sciatic nerve block and perineural catheter in the popliteal fossa. Postoperatively, patients were discharged with both oral opioids and a portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days. Investigators and patients were blinded to random group assignment. Daily end-points included pain scores, opioid use and side effects, sleep quality, and symptoms of catheter- or local anesthetic-related complications. RESULTS: Ropivacaine (n = 15) infusion significantly reduced pain compared with saline (n = 15) infusion ( < 0.001). For example, the average pain at rest (scale: 0-10) on postoperative day 1 (median, 25th -75th percentile) was 4.0 (3.5-5.5) for the saline group, versus 0.0 (0.0-0.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were significantly decreased in the ropivacaine group. For example, on postoperative day 1, median tablet consumption was 8.0 (5.0-10.0) and 0.0 (0.0-0.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were more than 10-fold greater for saline administration than for ropivacaine infusion (P < 0.001). Overall satisfaction was significantly greater in the ropivacaine group. Other than two inadvertent catheter dislodgements, no catheter- or local anesthetic-related complications occurred. CONCLUSIONS: After moderately painful orthopedic surgery of the lower extremity, ropivacaine infusion using a portable mechanical pump and a popliteal sciatic perineural catheter at home decreased pain, opioid use and related side effects, sleep disturbances, and improved overall satisfaction.