Clinical Considerations for Implanted Neurological Devices in Patients Undergoing Hyperbaric Oxygen Therapy: A Case Report and Review of Manufacturer Guidelines.

Patients with implanted medical devices are increasingly referred for hyperbaric oxygen therapy (HBOT), and the safety of exposing some of these devices to hyperbaric environments has not previously been explored. There is a paucity of evidence surrounding the management of implanted neurological devices such as neurostimulators and intrathecal drug delivery (IDD) pumps in the context of HBOT. However, these devices can be expected to harbor unique risks; for example, vacant space in the reservoir of an implanted IDD pump may change in pressure and volume during the compression and decompression phases of HBOT, resulting in a damaged or dysfunctional device. We present the case of a 27-year-old woman with cerebral palsy referred for HBOT to manage a necrotizing soft tissue infection cultured from a dehiscent abdominal wound at the previous implantation site of an intrathecal baclofen pump. An HBOT protocol was ultimately chosen in partnership with the patient and her family, but treatment was not performed due to a paucity of evidence that the implanted IDD pump could safely withstand hyperbaric exposure. In this review, we have synthesized manufacturer recommendations regarding the management of implanted neurological devices before, during, and after HBOT to inform future decision-making in this setting. Among these recommendations, we highlight that neurostimulators should be switched off for the duration of HBOT and implanted pumps should be refilled prior to each treatment session to minimize empty reservoir space.

The Treatment of Perioperative Spinal Cord Injury With Hyperbaric Oxygen Therapy: A Case Report.

STUDY DESIGN: Case report (level IV evidence). OBJECTIVE: To describe a potential novel application of hyperbaric oxygen therapy (HBOT) in the successful treatment of a postoperative spinal cord injury. SUMMARY OF BACKGROUND DATA: A 68-year-old man presented with an acute spinal cord injury (ASIA impairment scale D), on the background of degenerative lower thoracic and lumbar canal stenosis. He underwent emergent decompression and instrumented fusion (T9-L5), with an uncomplicated intraoperative course and no electrophysiological changes. Immediate postoperative assessment demonstrated profound bilateral limb weakness (1/5 on the Medical Research Council [MRC] grading scale, ASIA impairment scale B), without radiological abnormality. METHODS: Conventional medical management (hypertension, level 2 care) was instigated with the addition of Riluzole, with no effect after 30 hours. At 36 hours 100% oxygen at 2.8 atmospheres was applied for 90 minutes, and repeated after 8 hours, with a further three treatments over 48 hours. RESULTS: The patient demonstrated near-immediate improvement in lower limb function to anti-gravity (MRC grading 3/5) after one treatment. Motor improvement continued over the following treatments, and after 2 weeks the patient was ambulatory. At 4 months, the patient demonstrated normal motor function with no sphincteric disturbance. CONCLUSION: The application of HBOT contributed to the immediate and sustained improvement (ASIA B to ASIA E) in motor recovery after postoperative spinal cord injury. HBOT may represent a new avenue of therapy for spinal cord injury, and requires further prospective investigation. LEVEL OF EVIDENCE: 4.

Propofol enhances the field excitatory postsynaptic potentials in CA1 hippocampal slices of young and aged mice.

BACKGROUND: Increasing age was shown to decrease the requirements for propfol. However, the mechanisms of ageing-induced potentiation of anesthetic actions have not been clearly explored. The aim of this study is to compare the effects of propofol on the field excitatory postsynaptic potentials (fEPSPs) in hippocampal slices of young and aging mice. METHODS: Brain slices were prepared from C57BL6 male young (2 months) and aging (>12 months) mice. The dendritic field excitatory postsynaptic potential was recorded from the CA1 stratum radiatum using patch clamp electrophysiological methods. A bipolar concentric stimulating electrode was placed along the Schaffer collateral for othodromic stimulation. The effects of clinically-relevant concentrations of propofol were studied in the young and ageing mouse tissues. RESULTS: Propofol application increased the orthodromically evoked fEPSP produced in slices taken from young and older animals. A striking feature in the I/O relationship was the decreased enhancement of the fEPSPs by propofol in slices from older mice. A clinically relevant concentration of propofol, 10 µmol/L, showed more significant enhancement in amplitude and area under the curve (AUC) of fEPSP in young compared to tissues from older mice (amplitude: young (24.9 ± 3.4)%, old (4.6 ± 1.6)%; AUC young (30.6 ± 5.4)%, old (2.1 ± 1.7)%). There was no statistically significant difference between the paired-pulse facilitation (PPF) ratios calculated for the responses obtained in tissues from young mice. In slices from older mice, in the presence of 10 µmol/L propofol, PPF was decreased and returned to baseline after washout (baseline 1.21 ± 0.01, propofol: 1.16 ± 0.01). Bicuculline (15 µmol/L) blocked the enhancement of propofol on fEPSP in tissues from young and old mice. CONCLUSION: The fEPSP of slices from aging mice demonstrates diminished sensitivity to the enhancing actions of propofol.

Forearm rescue cuff improves tourniquet tolerance during intravenous regional anesthesia.

BACKGROUND AND OBJECTIVES: Tourniquet pain during intravenous regional anesthesia (IVRA) of the upper limb is common and can limit tourniquet inflation time. We hypothesize that a forearm rescue cuff is better tolerated than the traditional rescue cuff of a double-cuff tourniquet. METHODS: After Institutional Review Board (IRB) approval and informed consent, 10 healthy unmedicated volunteers took part in a prospective, randomized, cross-over study. Following inflation of the proximal tourniquet cuff on the upper arm, a standardized IVRA with 0.5% lidocaine, 0.6 mL/kg was administered. When the volunteer complained of tourniquet pain, or at 30 minutes, the initial cuff was changed to a rescue cuff. During session A, the rescue cuff was the traditional distal cuff of the double-cuff tourniquet. During session B, a single forearm cuff was used. When the volunteer experienced the same level of tourniquet pain, the rescue cuff was deflated and the study session ended. The tourniquet time for the rescue cuff, the visual analog scale (VAS) pain score, and the incidence and duration of side effects were recorded. RESULTS: The forearm rescue cuff was tolerated significantly longer than the arm rescue cuff (49 +/- 15 v 29 +/- 11 minutes, 95% confidence interval [CI] 7 to 32 minutes, P