Diaphragm pacing using the minimally invasive cervical approach.

CONTEXT: The implantation of commercially available phrenic nerve/diaphragm pacers has been available for more than 40 years and has enabled thousands of patients in over 40 countries to achieve freedom from invasive mechanical ventilation. OBJECTIVE: The cervical approach to implantation of these pacers is described, as are the pros and cons of using this technique compared to intrathoracic and sub-diaphragmatic. METHODS: Study design was a retrospective review of 1,522 subjects from the Avery Biomedical Devices (ABD) database who were implanted with the Avery diaphragm pacer. Long term statistics from patients implanted with diaphragm pacers are presented as well. RESULTS: 17% of cervically placed electrodes required at least one replacement compared to 18% of electrodes placed thoracically. Devices implanted cervically show no significant difference in their longevity than those implanted using the thoracic approach (P value of 0.9382 using Two-Sample t-Test). The mean longevity for both approaches was found to be 6.4 years. The majority of electrodes implanted have never required replacement. A majority of CCHS patients were implanted using the thoracic approach and only find it necessary to use the device during sleeping hours. Most of the cervically implanted patients are found to be older at the time of implantation and implanted for diagnoses that require longer daily use of the device. CONCLUSION: The cervical approach for the implantation of phrenic nerve/diaphragm pacers is the most minimally invasive, but underutilized, technique that allows for the use of local or monitored anesthesia, does not require entering any body cavities, and keeps incision size small.

Methamphetamine Use With Subsequent Thyrotoxicosis/Thyroid Storm, Agranulocytosis, and Modified Total Thyroidectomy: A Case Report.

Thyroid storm is a rare, potentially lethal condition involving collapse of the hypothalamic-pituitary-thyroid feedback loop. Thyroid storm carries a significant mortality rate, thus requiring prompt identification and treatment. A 47-year-old woman presented to the emergency department complaining of palpitations, shortness of breath, and emesis for 24 hours after using methamphetamine. Past medical history was significant for untreated hyperthyroidism. Physical examination revealed a prominent, palpable thyroid. The Burch-Wartofsky-Score was 35. Management for thyroid storm included propylthiouracil (PTU), super saturated potassium iodide, intravenous hydrocortisone, and propranolol. However, a rare drug reaction to PTU on day 3 resulted in agranulocytosis. Propylthiouracil was withheld and a modified total thyroidectomy performed on day 8 without complications and the patient discharged on day 10 with levothyroxine. Undertreated hyperthyroidism may predispose patients to catecholamine-induced thyrotoxicosis due to catecholamine hypersensitivity. With known methamphetamine use, methamphetamine toxicity and a methamphetamine-exacerbated thyroid storm need to be included in the differential diagnosis in a patient presenting with signs of thyrotoxicosis. In addition, treating patients with agranulocytosis from PTU with a modified total thyroidectomy using ligation of the vascular supply as the initial surgical step limits release of thyroid hormone into the blood stream during thyroidectomy and decreases the possibility of intra operative thyroid storm.