Citations

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 β-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.

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.