Super refractory status epilepticus in hashimoto's encephalopathy

We present a case of a 38-year-old woman who was at eight weeks of gestation and was admitted to Sultan Qaboos University Hospital with refractory status epilepticus [SE]. She presented with a two-day history of fever and a depressed level of consciousness that was followed with generalized tonic-clonic seizures. She progressed to refractory SE that required intubation and mechanical ventilation. Autoimmune workup was suggestive of Hashimoto's encephalopathy [HE] as suggested by the high levels of thyroid antibodies. Her magnetic resonance imaging showed bilateral hippocampal and basal ganglia hyperintensities, and electroencephalogram showed bilateral frontal epileptiform discharges. Other autoimmune workup was negative. Intravenous anesthetics were started including propofol, midazolam, ketamine, and thiopentone. She was started on multiple immunosuppressive therapies. Multiple antiepileptics were used including phenytoin, lamotrigine, levetiracetam, sodium valproate, clobazam, phenobarbital, and lacosamide. The outcome was unusual in terms of refractoriness to immunotherapy treatment despite a confirmed diagnosis. We did a literature review of all cases with HE presenting with SE with their clinical characteristics and outcome

Avoidance of laryngeal injuries during gastric intubation

Gastric intubation is a common and simple procedure that is often performed on patients who are sedated or anaesthetised. If the gastric tube [GT] is inserted blindly while the patient is unconscious, this procedure may result in easily preventable complications such as laryngeal trauma. We present an interesting case where the blind placement of a orogastric tube [OGT] in an anesthetised 52-year-old female patient at Sultan Qaboos University Hospital in Oman resulted in significant arytenoid trauma. This led to delayed tracheal extubation. The movement of the GT from the oropharyngeal area to the upper oesophageal sphincter can be visualised and controlled with the use of Magill forceps and a laryngoscope. Therefore, this report highlights the need for GT insertion procedures to be performed under direct vision in patients who are unconscious [due to sedation, anaesthesia or an inherent condition] in order to prevent trauma to the laryngeal structures

Adult sickle cell disease a five-year experience of intensive care management in a university hospital in Oman

Sickle cell disease [SCD] is an inherited disease caused by an abnormal type of haemoglobin. It is one of the most common genetic blood disorders in the Gulf area, including Oman. It may be associated with complications requiring intensive care unit [ICU] admission. This study investigated the causes of ICU admission for SCD patients. This was a retrospective analysis of all adult patients >/= 12 years old with SCD admitted to Sultan Qaboos University Hospital [SQUH] ICU between 1st January 2005 and 31st December 2009. A total number of 49 sickle cell patients were admitted 56 times to ICU. The reasons for admission were acute chest syndrome [69.6%], painful crises [16.1%], multi-organ failure [7.1%] and others [7.2%]. The mortality for SCD patients in our ICU was 16.1%. The haemoglobin [Hb] and Hb S levels at time of ICU admission were studied as predictors of mortality and neither showed statistical significance by Student's t-test. The odds ratio, with 95% confidence intervals, was used to study other six organ supportive measures as predictors of mortality. The need for inotropic support and mechanical ventilation was a good predictor of mortality. While the need for non-invasive ventilation, haemofiltration, blood transfusions and exchange transfusions were not significant predictors of mortality. Acute chest syndrome is the main cause of ICU admission in SCD patient. Unlike other supportive measures, the use of inotropic support and/or mechanical ventilation is an indicator of high mortality rate SCD patient

Complications of central venous catheterisation breakage of guidewire- a disaster averted

Central venous catheterisation [CVC] is a common bedside invasive procedure done in medical practice. Even though it is a safe procedure when done with ultrasound guidance, difficulties and complications do occur even in experienced hands. Here, we describe the difficulties encountered in the form of the breakage of the guidewire while inserting a CVC in a patient with sickle cell disease