Use of a minimally invasive cardiac output monitor to optimise haemodynamics in a patient with mitral valve disease undergoing cerebrovascular surgery

Patients with mitral valve disease undergoing cerebrovascular surgery face increased inherent risks due to their associated cardiac comorbidities. As such, the anaesthetic management of such patients is distinctly challenging. Simultaneous consideration of both the cerebrovascular and underlying cardiac conditions determines key anaesthetic issues, as fluids and vasopressors or inotropes need to be titrated according to haemodynamic variables in order to optimise cerebral blood flow without compromising cardiac function. We report a 45-year old female patient with mild mitral stenosis and moderate-to-severe mitral regurgitation who presented to the Khoula Hospital, Muscat, Oman, in 2016 following a ruptured anterior communicating artery aneurysm requiring urgent surgical intervention. As highlighted in this case, the Volume View EV1000[TM][Edwards Life sciences, Irvine, California, USA] system is a minimially invasive haemodynamic monitor that can help immensely in the perioperative management of such patients

Early versus late tracheostomy for patients with high and low cervical spinal cord injuries

Objectives: This study aimed to evaluate the effects of early versus late tracheostomies among patients with cervical spinal cord injuries [CSCIs]

Methods: This retrospective study included 69 adult CSCI patients who underwent bedside percutaneous tracheostomies at the Intensive Care Unit of Khoula Hospital, Muscat, Oman, between January 2011 and October 2015. The tracheostomy was considered early if the procedure took place within one week of the CSCI. The impact of an early tracheostomy on patient outcomes was analysed in terms of duration of mechanical ventilation and intensive care unit [ICU] stay among patients with high [C1-C2 vertebrae] and low [C3-C7 vertebrae] CSCIs. Ventilator dependence, bradycardia episodes and surgical intervention outcomes were also examined

Results: Patients with a high CSCI who underwent an early tracheostomy spent significantly fewer days on mechanical ventilation compared to those who underwent a late tracheostomy [9.3 +/- 7.2 days versus 13.7 +/- 3.2 days; P = 0.041]. Low CSCI patients who received an early tracheostomy also experienced significantly fewer days on mechanical ventilation compared to those undergoing a late tracheostomy [12.1 +/- 10.4 days versus 25.2 +/- 17.7 days; P = 0.035]. Moreover, ICU mortality was significantly lower for high CSCI patients who underwent an early tracheostomy [P = 0.015]. However, there was no association between length of ICU stay and either type of CSCI or timing of the tracheostomy procedure

Conclusion: An early tracheostomy is beneficial in reducing the duration of mechanical ventilation among patients with CSCIs, irrespective of the level of injury

Combination of continuous dexmedetomidine infusion with titrated ultra-low-dose propofol-fentanyl for an awake craniotomy

An awake craniotomy is a continuously evolving technique used for the resection of brain tumours from the eloquent cortex. We report a 29-year-old male patient who presented to the Khoula Hospital, Muscat, Oman, in 2016 with a two month history of headaches and convulsions due to a space-occupying brain lesion in close proximity with the left motor cortex. An awake craniotomy was conducted using a scalp block, continuous dexmedetomidine infusion and a titrated ultra-low-dose of propofol-fentanyl. The patient remained comfortable throughout the procedure and the intraoperative neuropsychological tests, brain mapping and tumour resection were successful. This case report suggests that dexmedetomidine in combination with titrated ultra-low-dose propofolfentanyl are effective options during an awake craniotomy, ensuring optimum sedation, minimal disinhibition and a rapid recovery. To the best of the authors' knowledge, this is the first awake craniotomy conducted successfully in Oman

rare early complication of tracheostomy

A polytrauma patient on ventilator was admitted to ICU with open tracheostomy, GCS 8/15 and unequal pupils. After 10 days, he was weaned from the ventilator. The patient had respiratory problems i.e. expiratory stridor, shortness of breath, dysphonia and dyspnea on closing tracheostomy. It was diagnosed as a case of asthma, and the patient responded to salbutamol nebulization and intravenous steroid therapy. However, after some time, he desaturated and a plan for rapid sequence intubation was made. Endotracheal tube could not be negotiated beyond vocal cords, so an unprepared tracheostomy without proper equipment had to be immediately done by an anesthetist to save the patient's life. CT scan revealed tracheal stenosis. This case demonstrates that patients with a short 15-days history of previous tracheostomy may have tracheal stenosis

Green urine: a rare and benign side effect of propofol infusion

We are presenting a case of a young head injury patient, who developed discolouration of the urine to green in ICU following propofol infusion as sedation in ICU. It is advisable to know the rare complication of Propofol infusion in the ICU patients to prevent the unnecessary panic of discolouration of the urine

Management of sodium imbalance in neurosurgical patients

The present study was undertaken to find the incidence of various sodium [Na] anomalies their management and outcome in the neuro surgical intensive care unit [NICU]of Khoula hospital. A total of 50 patients were followed up for serum Na of 50 patients were grouped as syndrome of inappropriate ADH secretion [SIADH] cerebral salt wasting [CSW] and diabetes inspidus [DI], according to strict diagnostic criteria. Twenty seven patients [54%] had Na anomalies. Of the 14 hyponatremic patients, 7 were CSW, 3 were SIADH and 4 were SIADH who later become CSW. Of the 13 hypernatremic patients, 2 were dehydration, 3 were DI and in 8 cases, who died, hypermatremia was seen as a terminal event. In view of the high incidence of Na imbalance in neuro patients, strict diagnostic criteria and treatment flow charts need to be followed

Fraser's syndrome clinical spectrum and anaesthetic considerations in neonatal period

Fraser's syndrome which is a rare autosomal recessive disorder characterised by cryptophthalmos, defect of auricle, genital anomaly and syndactyly was seen in a neonate. This baby had all the findings originally described by Fraser and earlier known as cryptophthalmos syndactyly syndrome. The baby was taken for coloboma repair and then subsequently for syndactyly release after one month. On both occasions, anaesthetists had difficulty in intubating the baby due to laryngeal stenosis which is a rare association of Fraser's syndrome. The ultimate prognosis of such babies is poor due to multisystem involvement and as there is defect not only of eyelid formation but also associated ocular anomaly, the likelihood of achieving adequate visual perception is small