Sedation with propofol during combined spinal epidural anesthesia: comparison of dose requirement of propofol with and without BIS monitoring

Bispectral [BIS] monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. Sedation has been shown to increase patient satisfaction during regional anesthesia. Propofol is extensively being used as a sedative, providing sedation while patients remain cooperative and can be easily aroused. In this study, we sought to determine whether BIS is a useful adjunctive manoeuvre to reduce the sedative dose of propofol by using BIS. Forty patients of ASA grade I and II, weighing between 30 to 60 kg, undergoing elective gynecological surgery of about 60 minutes duration were included in the study, and randomly divided into two groups. All patients received combined spinal epidural anesthesia [CSEA]. The patients in Group-P [n=20] received propofol without BIS monitoring and those in Group-PB [n=20], received propofol under BIS monitoring. Total doses of propofol consumed in all patients were calculated and compared using paired t-test. A p-value <0.05 was considered to be significant. The mean total dose of propofol consumed was 130.25 mg +/- 46.95 without BIS monitoring [Group-P] compared to 68.49 mg +/- 12.59 in patients [Group-PB] in which BIS was used to monitor the desired sedation level [P< 0.001]. Mean dose to reach required level of sedation was also reduced [68.35 +/- 21.10 vs 29.01 +/- 9.45, P< 0.001]. Use of BIS during propofol infusion reduces requirement of propofol for sedation during regional anesthesia

Scedosporium apiospermum brain abscess: an emerging challenge

Invasive fungal infection of the brain in immunocompromised patients is frequently fatal. New opportunistic fungal infections with resistance to many antifungal agents are identified. Scedosporium species [Pseudallescheria boydii] is one of them. Fortunately, the infection is not common and only occasional cases are encountered. A case of Scedosporium brain abscess was treated in a relatively preserved, immunocompromised elderly lady who did not respond to antifungal treatment with voriconazole. This is the first case of Scedosporium brain abscess to be reported in the Gulf. An emerging medical challenge is highlighted and the literature reviewed

Management strategy of depressed skull fractures

The aim of the study is to examine the efficacy of a conservative approach in the management of depressed skull fractures. A prospective study of 120 patients with depressed skull fractures treated at Salmaniya Medical Complex from January 1998 to December 2006. There were 108 males and 12 females, age range was 12 months to 80 years, and the mean age was 40 years. All patients underwent skull x-ray and cranial CT scan. Depressed fractures due to missile injuries were excluded from the study. Selective criteria for conservative and surgical managements were specified. The group treated conservatively compared favourably with surgical group in outcome. Object fall on the head was the cause of depressed fracture in 30% of our patients, fall from a height in 19%, road traffic accident in 20%, sports injury in 10%, assault in 19.8% and suicidal attempt in 1.2%. Parietal bone was injured in 44%, frontal bone in 32%, temporal bone in 18% and occipital bone in 6%. Seventy-two percent were compound depressed fractures and 28% were simple depressed fractures. Eighty-four patients were managed conservatively, 56 patients with compound fractures [66.7%] and 28 patients [33.3%] with simple fractures. Significant extra-axial haematoma was the indication for elevation of the fracture in 40% of the surgical group, significant wound contamination, brain tissue and CSF in the wound in 5%, frontal sinus involvement in 15%, cosmetic deformity in 25%, fracture on the superior sagittal sinus in 10% and right sided hemiplegia in 5%. Our study demonstrates that 70% of patients with depressed skull fractures can be safely managed conservatively without major surgical intervention. The major proportion of compound depressed skull fractures [66.7%] can be selected for conservative treatment without compromise of health and with a major socioeconomic advantage and short hospital stay

Pituitary apoplexy: Case report with review of literature

A fifty five year old gentleman was admitted with uncontrolled hypertension. Within 24 hours, he became drowsy and later on started complaining of visual deterioration. Neuro-imaging identified pituitary tumor with bleed. He was treated for pituitary apoplexy. He underwent emergency trans-sphenoid decompression of pituitary tumor. He had a very turbulent post operative course and required aggressive management of Diabetes Insipidus with up to 10 liters of IV fluids infusion per day which was later controlled with desmopressin puffs. He was discharged once the condition was brought under control but returned ten days later with upper GI bleeding. He had been on replacement steroids all this time with proton pump inhibitors. He was found to have two superficial non bleeding ulcers in first part of duodenum. He was managed with blood transfusion and high dosage of proton pump inhibitors. Vision gradually improved and has reached almost normal. He has remained symptom free now and being treated medically for his pan-hypopituitarism. Management of pituitary apoplexy is discussed in the light of available literature

Prognosticating factors in the surgery of intramedullary cervical tumour

A young girl presented with features of Brown Sequard plus syndrome. Radiological imaging revealed an intramedullary tumour. The lesion was operated upon and the tumour was found to be intramedullary with a small exophytic component going through a rent in the anterior fissure. The intramedullary component of the tumour was totally excised. The case is discussed and factors influencing a radical excision of such tumours are reviewed

Genial migration of ventriculoperitoneal shunt

Shunt migration is an uncommon complication of shunt surgery. Amongst them, upward migration of shunt into the cranium is still rare. We encountered this complication in two of our patients. The cases are discussed and the literature is reviewed

Prognosticating factors in the surgery of intramedullary cervical tumour

A young girl presented with features of Brown Sequard plus syndrome. Radiological imaging revealed an intramedullary tumour. The lesion was operated upon and the tumour was found to be intramedullary with a small exophytic component going through a rent in the anterior fissure. The intramedullary component of the tumour was totally excised. The case is discussed and factors influencing a radical excision of such tumours are reviewed

Multiple ipsilateral extradural hematoma. a case report

A rare case of two extradural hematomas on the same side in relation to a linear fracture with two different sources of bleeding is reported and its pathogenesis and management discussed

Multifocal glioblastoma: malignant progression in a glioma with unusual computed tomographic presentation

Glioblastoma multiforme rarely presents as multiple primary intracranial tumours in the absence of phakomatosis. An elderly lady presented with late onset seizures with persistent postictal deficit. She was investigated one year back for seizure with a CT scan and a lesion was noted in the left insular region without mass effect. No surgery was indicated. Repeat CT scan showed a metachronous multifocal tumour. She underwent excision of one of the lesions. Histology was consistent with glioblastoma multiforme. Other lesion could not be operated due to its precarious location. The case is reported for its unusual CT presentation and malignant progression