title: Anesthesia considerations for patients with an implanted deep brain stimulator undergoing surgery: a review and update.
abstract: OBJECTIVE
  Deep brain stimulation (DBS) can be an effective treatment option for patients with essential tremor and Parkinson's disease. This review provides an overview on the functioning of neurostimulators and recent advances in this technology and presents an updated guide on the anesthetic management of patients with an implanted neurostimulator undergoing surgery or medical intervention.
  
  
  METHODS
  A search was conducted on MEDLINE®, EMBASE™, and Cochrane Database of Systematic Reviews databases to identify studies published in English from 1974 to December 2015. Our search also included relevant and available incident reports from the manufacturers, Health Canada, the United States Food and Drug Administration, and the European Medicines Agency. Thirty of 232 articles identified were found to be relevant to this review.
  
  
  RESULTS
  Deep brain stimulation systems now offer a range of options, including pulse generators with dual-channel capabilities, rechargeable batteries, and current-control modes. Preoperatively, the anesthesiologist should ascertain the indications for DBS therapy, identify the type of device implanted, and consult a DBS specialist for specific precautions and device management. The major perioperative concern is the potential for interactions with the medical device resulting in patient morbidity. Neurostimulators should be turned off intraoperatively to minimize electromagnetic interference, and precautions should be taken when using electrosurgical equipment. Following surgery, the device should be turned on and checked by a DBS specialist.
  
  
  CONCLUSIONS
  The anesthesiologist plays an important role to ensure a safe operating environment for patients with an implanted DBS device. Pertinent issues include identifying the type of device, involving a DBS-trained physician, turning off the device intraoperatively, implementing precautions when using electrosurgical equipment, and checking the device postoperatively.
authors.affiliation: Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
authors.forename: Tze Yeng
authors.initials: TY
authors.lastname: Yeoh
authors.affiliation: Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
authors.forename: Pirjo
authors.initials: P
authors.lastname: Manninen
authors.affiliation: Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
authors.forename: Suneil K
authors.initials: SK
authors.lastname: Kalia
authors.affiliation: Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. lashmi.venkatraghavan@uhn.on.ca.
authors.forename: Lashmi
authors.identifier: http://orcid.org/0000-0002-1506-7000
authors.initials: L
authors.lastname: Venkatraghavan
mesh_terms: D000758:Anesthesia / Q000379:methods*; D000072080:Anesthesiologists; D046690:Deep Brain Stimulation / Q000295:instrumentation / Q000379:methods*; D004565:Electroconvulsive Therapy; D006801:Humans; D008279:Magnetic Resonance Imaging