Awake craniotomy (AC) enables maximal tumor resection near eloquent cortex, but its implementation in resource-limited settings presents distinct anesthetic challenges. We describe the establishment of an AC program in a low-resource neurosurgical center, emphasizing constraints related to team inexperience, limited patient literacy, absence of neuronavigation and cortical mapping, and restricted availability of short-acting anesthetic agents. Adaptive strategies included multidisciplinary training, simplified patient education materials, use of dexmedetomidine and ropivacaine for conscious sedation and scalp block, continuous intraoperative communication to compensate for lack of neurophysiologic monitoring, and dose conversions compatible with older infusion pumps. Despite these limitations, five ACs were successfully completed with stable sedation, adequate analgesia, and favorable patient cooperation. This article provides practical insights for anesthesiologists working in similar environments to help ensure successful and safe awake craniotomy practices in resource-constrained settings.
Background & Objective: The intensive care unit (ICU) management of neurosurgical patients is critical for early detection of complications, optimizing recovery, and improving outcomes. The study aimed to determine the outcomes of neurosurgical patients admitted to ICU. Methodology: After taking exemption from ethical review committee, study was conducted from November 2020 to May 2023 at ICU of a The Aga Khan University Hospital, Pakistan. All adult neurosurgical patients requiring ICU admission were included. Data including demographic variables, comorbid conditions, reasons for ICU referral, complications and expected outcomes were gathered and was analyzed using R. Studio. Results: Total 93 neurosurgical patients (mean age of 40 years, 69% males) were analyzed. Most of them were admitted to ICU after supratentorial craniotomy (40%). ICU course for them was associated with neurological (78%), metabolic (78%), respiratory (56%), cardiovascular (38%), and infectious (34%) complications. 50% of patients required tracheostomy. The mean length of stay (LOS) in ICU was 6.99 days with ICU mortality of 14.6%. Significant number of these patients (77%) were transferred from the ICU to ward care. The average LOS in ward was 8.43 days, with ward mortality of seven percent. The average LOS in hospital stay was 15.3 days. Comparison of adverse outcomes revealed, patients admitted from ward tend to have the longest ICU stay, higher frequency of having neurological deficit, seizures and sepsis. While higher chances of unsuccessful extubation and need of tracheostomy in patients presented with head injury. Conclusion: Despite medical advances, morbidity and mortality remain high in neurosurgical patients. The high incidence of neurological, metabolic and respiratory complications and related outcome particularly patients coming from ward and after trauma needs special consideration.
PURPOSEFinancial toxicity (FT) affects cancer care in low- and middle-income countries (LMICs), affecting treatment adherence and quality of life. This study assesses FT prevalence and associated factors among patients with gastrointestinal cancer across distinct health care systems in Pakistan.METHODSA cross-sectional study was conducted across three tertiary care centers in Karachi: Aga Khan University Hospital (AKUH, private, fee-for-service), Jinnah Postgraduate Medical Centre (JPMC, public, free), and Cancer Foundation Hospital (CFH, private-philanthropy, subsidized). FT was assessed using the Urdu version of the Comprehensive Score for FT–Functional Assessment of Chronic Illness Therapy (COST-FACIT). Multivariable negative binomial regression identified factors linked to high FT.RESULTSOf 375 patients, 44.5% were from AKUH, 33.6% from JPMC, and 21.9% from CFH. Mean age was 50.8 ± 14.4 years, with 62.4% males. Only 8.3% had health insurance, and median International Wealth Index was 79.9 (IQR, 57.1-95.1). Catastrophic health care expenditure affected 41.7%. Mean COST-FACIT score was 16.0 ± 7.4; 46.1% experienced mild FT (score: 14-26) and 41.9% moderate FT (score: ≤14). Delaying or forgoing care, borrowing money, selling assets, and cutting essentials were strongly associated with increased FT (P < .001). Patients at AKUH reported higher FT than JPMC (incidence rate ratio [IRR], 0.84 [95% CI, 0.74 to 0.97]). Younger patients (21-50 years; IRR, 0.66 [95% CI, 0.46 to 0.95]) and those receiving chemotherapy (IRR, 0.89 [95% CI, 0.81 to 0.98]) experienced higher FT. Females (IRR, 1.36 [95% CI, 1.17 to 1.58]) and higher socioeconomic status (IRR, 1.39 [95% CI, 1.06 to 1.83]) were associated with lower FT.CONCLUSIONNearly 85% of patients with GI cancer faced FT. Younger age, male gender, lower socioeconomic status, and systemic therapy were associated with higher FT. Subsidized care, financial support, and institution-specific strategies are critical to mitigating FT in LMIC health care systems.
The Clinical Assessment Scoring System for Tracheostomy (CASST) was developed to predict the need for elective tracheostomy in head and neck cancer surgery, but evidence on its external performance remains limited. This prospective study evaluated the predictive accuracy of CASST and its concordance with clinical decision-making in patients undergoing major oral cancer surgery. A secondary objective was to describe short-term postoperative airway complications stratified by CASST category. All patients undergoing major oral cancer resections at a tertiary care centre between September 2021 and January 2024 were enrolled and followed prospectively. CASST scores were computed preoperatively but did not guide airway management decisions. Among 258 patients, 126 (48.8%) underwent elective tracheostomy. Only 31.7% of these procedures aligned with CASST score recommendations (score ≥7). The CASST score demonstrated a sensitivity of 31.7%, specificity of 91.7%, positive predictive value of 78.4%, and negative predictive value of 58.5%. The area under the receiver operating characteristic curve was 0.617, demonstrating poor overall discrimination. Short-term postoperative complications did not differ significantly between CASST risk groups. While CASST demonstrates high specificity, its low sensitivity and frequent misalignment with clinical practice limit its standalone utility. Further refinement and integration with intraoperative findings may improve its applicability in airway management planning.
PurposeTo describe a novel tissue-sparing surgical technique-the Qidwai Quilt Pull-Over Patch-graft (Q-POP) technique-for the management of impending or established glaucoma drainage implant (GDI, ACP) tube exposure in high-risk eyes with conjunctival scarring and mechanical stress.MethodsThis report presents a single-case description of a monocular patient with severe nystagmus, extensive conjunctival fibrosis, and prior multiple ocular surgeries who developed progressive conjunctival thinning over a GDI (ACP) tube. A minimally invasive subconjunctival tunneling approach was used to deliver and position a scleral patch graft over the tube without a limbal-based peritomy.ResultsThe Q-POP technique provided stable tube coverage with minimal conjunctival manipulation. Postoperatively, the graft remained flat and well-positioned with no evidence of re-exposure, conjunctival dehiscence, inflammation, or intraocular pressure instability during follow-up.ConclusionsThe Q-POP technique offers a safe, reproducible, and cost-neutral alternative for managing tube exposure in eyes with compromised conjunctiva where conventional peritomy-based repairs carry high risk. This method may be particularly valuable in eyes subjected to mechanical stress like nystagmus. Larger case series are warranted to assess long-term outcomes and broader applicability.
