Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Outcome of patients with acute pancreatitis requiring intensive care admission: a retrospective study from a tertiary care center of Pakistan

Background and Objective: Acute pancreatitis [AP] is an inflammatory disease. Patients presenting with severe disease may require intensive care unit [ICU] admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome

Methods: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay [LOS] in ICU and hospital

Results: Total 85 patients were identified of having AP requiring ICU admission. 56 percent of these cases were referred from emergency. Mean Ranson score [RS] was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48 percent of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52 percent, out of which 82 percent died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen [BUN], PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome

Conclusion: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated

Anaesthetic management of supratentorial tumor craniotomy using awake-throughout approach

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length of stay in hospital

Airway management in a patient with severe Ankylosing Spondylitis causing Bamboo Spine: use of Aintree Intubation Catheter

Management of a case of ankylosing spondylitis can be very challenging as the airway and the central neuraxial blockade are extremely difficult to handle. Fiberoptic intubation may lead to predictable success in the face of difficult airway. We are presenting a new technique of fiberoptic intubation in a young patient, suffering from severe ankylosing spondylitis, came for total hip replacement surgery. There was anticipated difficult airway due to severe limitation in neck movement and it was successfully managed by using Aintree Intubation Catheter [AIC] with intubating fiberoptic bronchoscope

Complications and interventions associated with epidural analgesia for postoperative pain relief in a tertiary care hospital

Epidural analgesia is one of the commonly used methods of postoperative pain control despite its associated complications. Early recognition and intervention is required to minimize the effect of these complications. Present audit was conducted to find out the incidence of complications and type of interventions required to change the outcome. The record of all the patients who had epidural catheter placed for postoperative pain management reviewed from the departmental acute pain management register. Parameters included level of insertion, drugs used, number of days infusion continued and complications like nausea, vomiting, motor block, sedation, dural tap, catheter pull out, hypotension and itching. In addition, the intervention done to manage these complications was also recorded. Total 1706 entries of epidurals were recorded in study period 2001 to 2007. The overall incidence of the complication was 26.6%. The common complications were motor block [13.4%], dural tap [1.2%], ineffective pain control [2.4%], accidental catheter pull outs [3.8%] and problems associated with the delivery system of drug [1.7%]. The 12% of patients required intervention for the particular complications. The regime was discontinued in 28%, drug concentration changed in 21.5% while the other modes of pain management were used in 19% of patients. 0.9% of patients required epidural blood patch while 2% of patients required catheterization for urinary retention. This audit shows the importance of regular assessment and early intervention to manage epidural related complications in improving outcome

Acute postoperative pain management by a surgical team in a tertiary care hospital: patients satisfaction

To assess the acute postoperative pain management by a surgical team and patient satisfaction in a tertiary care teaching hospital. 105 patients, ASA I and II, both sexes, mean age of 35.1 +/- 14.6 years, scheduled for general surgery under routine practice conditions, were included in the study. All patients were assessed 12 and 24 hours postoperatively by two numerical visual analogue scale [VAS 0-10], related to rest and dynamic pain. Patients were also requested to indicate their satisfaction level with the help of VAS. Data was analyzed by SPSS version 10. Student t test was applied to find significant differences between the groups. At 12 hours postoperatively mean rest and dynamic pain scores were 3.85 +/- 2.45 and 5.32 +/- 2.61 respectively. At 24 hours postoperatively mean rest and dynamic pain scores were 2.84 +/- 1.86 and 4.65 +/- 2.47 respectively. Overall, female patients experienced more pain but there was no statistically significant difference apart from rest pain at 24 hours. Forty-seven [44.8%] patients were very satisfied, 42 [40%] moderately satisfied and 16 [15.2%] patients were mildly satisfied with the pain management. Overall management of acute postoperative pain by surgical team in a tertiary care hospital was satisfactory. Most of patients were moderately to very satisfied by the care provided

BIS monitoring in a patient with history of awareness and a difficult airway

We describe a case where bispectral index [BIS] monitoring was used successfully to guide an inhaled induction technique for a difficult airway. The patient was a 34 years old male who had a previous history of awareness during anaesthesia. He was also morbidly obese with a Mallampatti score of III on preoperative examination