Anesthetic Management of a Patient With a Vagal Nerve Stimulator and Poorly Controlled Seizures

Vagal nerve stimulation (VNS) is an emerging adjunctive therapy for patients with drug-resistant epilepsy. While it can reduce seizure frequency, it rarely results in complete seizure control. It introduces unique challenges in the perioperative setting, including risks of intraoperative seizures, VNS-induced bradyarrhythmias, and respiratory complications. We present a complex case of a 63-year-old woman with treatment-resistant epilepsy managed with VNS, who underwent open reduction and internal fixation (ORIF) for bilateral femur fractures. On the night before surgery, the patient experienced a tonic-clonic seizure with status epilepticus on the surgical floor, managed with intravenous levetiracetam and midazolam. Despite neurology clearance, intraoperative seizure activity was suspected under general anesthesia, identified by a sudden rise in Bispectral Index (BIS) values. The episode was treated with intravenous levetiracetam, resulting in BIS stabilization and presumed seizure resolution. This case underscores the heightened perioperative seizure risk in patients with VNS, the importance of continuing antiepileptic therapy, maintaining vigilant intraoperative monitoring, including BIS or continuous electroencephalography (cEEG) monitoring, and selecting anesthetic agents that minimize pro-convulsant potential. The anesthesia team, in collaboration with neurologists, should be well-versed in VNS function, associated complications, and emergency deactivation procedures. This multidisciplinary approach is crucial to optimizing surgical outcomes in patients with refractory epilepsy, providing a comprehensive and reassuring treatment process.