Perioperative General Anesthesia Management for Tooth Extraction in a Patient Who was Implanted with Vagus Nerve Stimulator for Intractable Epilepsy

<p>In order to reduce refractory epilepsy seizures, vagus nerve stimulation therapy is sometimes carried out as an adjuvant seizure therapy. Here we report a case of perioperative general anesthesia management for tooth extraction in a patient with severe intellectual disabilities who was implanted with a vagus nerve stimulator（VNS） for intractable epilepsy.</p><p>The patient is a 26-year-old man. At 4 years old, he became severely intellectually disabled with intractable epilepsy due to sequelae of herpes encephalitis, and at 23 years old, he was implanted with VNS via corpus callosotomy in our hospital in the neurosurgery department. Although he takes multiple antiepileptic drugs, he still has frequent epileptic seizures every day. He was counseled by his home dentist to have his wisdom teeth extracted and introduced to the department of oral surgery in our hospital. We planned to extract 4 wisdom teeth under general anesthesia because we could not expect his cooperation during the surgery.</p><p>To prevent his perioperative seizures, we prepared benzodiazepine diazepam and a magnet which can temporarily apply a strong electric stimulus by holding it over the VNS at the time of epilepsy seizure aura. During status epilepticus, we planned to let him be examined by a doctor of neurosurgery. Propofol and remifentanil were used as general anesthetics, but no epileptic seizures occurred during the operation. After the operation, he had a slight fever, and the day after the operation, a diazepam suppository was administered due to tonic seizure. For two days after the operation, as his body temperature rose to 38°C, we referred him to the department of infectious diseases. However, pneumonia and other infection diseases were not present, and he was discharged three days after the operation.</p><p>The patient suffered from frequent seizures despite VNS being implanted, and careful handling was required for perioperative seizures. In addition, as patients with epilepsy may suffer from heat retention, it is difficult to distinguish this from infectious fever, and we also had to pay attention to body temperature management.</p>