Airway Pressure Release Ventilation Combined With Prone Positioning in Acute Respiratory Distress Syndrome: Old Tricks New Synergy: A Case Series.

Airway pressure release ventilation (APRV) shares several overlapping mechanisms with prone positioning in improving ventilation-perfusion mismatch in patients with acute respiratory distress syndrome (ARDS). However, the combination of APRV and prone positioning is seldom performed because assist/controlled ventilation remains the mainstay ventilatory mode. We describe 5 cases of severe ARDS where APRV and prone positioning were applied. All patients' partial pressure of arterial oxygen (PaO2):inspired oxygen concentration (FiO2) ratios improved after treatment, and 3 patients were extubated within 72 hours of turning supine. In our experience, APRV can be safely used in the prone position in a select subgroup of ARDS patients with resulting significant oxygenation improvement.

Outcomes of the Extreme Elderly Undergoing Anaesthesia and Surgery amongst Southeast Asians.

RESULTS: Sixty-two patients were identified. The mean age is 93.6 years. Majority were ASA 2 and ASA 3 patients. The most common type of surgery performed was orthopaedic, followed by vascular and urologic. Seven of the 62 patients required re-operations. Regional was the predominant anaesthetic technique employed, followed by general anaesthesia. Intraoperative hypotension was seen in 16 of the patients, all of whom recovered uneventfully. Hypothermia, desaturation, and hypertension were the top three complications observed in the recovery. Seventeen patients were admitted to a high-dependency facility postoperatively. The mean length of stay was 13.7 days. The 30-day mortality was 1.6 percent. CONCLUSIONS: We have provided a snapshot of very elderly patients coming for surgery. The results show that this group of elderly patients do well postoperatively with relatively low complication and 30-day mortality rates. The outcomes presented can be used as a guide for risk counseling in the perioperative period.

Facilitating Airway Surgery in a Morbidly Obese Patient Using Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE).

Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) is a relatively new noninvasive oxygenation technique with a broad range of applications. It is used in the treatment of type one respiratory failure, as a preoxygenation tool, as a rescue and temporising measure in difficult airways, and as step-down oxygen therapy in patients after extubation. Its use has also been described in laryngeal surgeries, but they mainly involved normal-weight subjects or were used as a bridging oxygenation therapy before definitive airway is secured. The major benefits of using THRIVE in obese subjects undergoing laryngeal surgery include a tubeless and uninterrupted surgical field. This advantage is especially crucial in obese patients as they tend to have limited oropharyngeal space, rendering a shared airway technically challenging for surgeons. However, concerns of potential difficult airway and shorter safe apnoeic time in the obese population limit its use. In this case, we report its use as the sole oxygenation strategy in a morbidly obese patient undergoing airway surgery. Our experience suggests that THRIVE can provide a conducive operating field and adequate oxygenation in short apnoeic laryngeal procedures in the obese population, without causing excessive hypercarbia.

Protocol for a single-centre prospective observational study of postoperative delirium following total joint arthroplasties among South East Asians.

INTRODUCTION: Postoperative delirium is a serious and common complication in older adults following total joint arthroplasties (TJA). It is associated with increased risk of postoperative complications, mortality, length of hospital stay and postdischarge institutionalisation. Thus, it has a negative impact on the health-related quality of life of the patient and poses a large economic burden. This study aims to characterise the incidence of postoperative delirium following TJA in the South East Asian population and investigate any risk factors or associated outcomes. METHODS AND ANALYSIS: This is a single-centre prospective observational study recruiting patients between 65 and 90 years old undergoing elective total knee arthroplasty or total hip arthroplasty. Exclusion criteria included patients with clinically diagnosed dementia. Preoperative and intraoperative data will be obtained prospectively. The primary outcome will be the presence of postoperative delirium assessed using the Confusion Assessment Method on postoperative days 1, 2 and 3 and day of discharge. Other secondary outcomes assessed postoperatively will include hospital outcomes, pain at rest, knee and hip function, health-related quality of life and Postoperative Morbidity Survey-defined morbidity. Data will be analysed to calculate the incidence of postoperative delirium. Potential risk factors and any associated outcomes of postoperative delirium will also be determined. ETHICS AND DISSEMINATION: This study has been approved by the Singapore General Hospital Institutional Review Board (SGH IRB) (CIRB Ref: 2017/2467) and is registered on the ClinicalTrials.gov registry (Identified: NCT03260218). An informed consent form will be signed by all participants before recruitment and translators will be made available to non-English-speaking participants. The results of this study will be presented at international conferences and submitted to a peer-reviewed journal. The data collected will also be made available in a public data repository. TRIAL REGISTRATION NUMBER: NCT03260218.

Efficacy of various larvicides against Aedes aegypti immatures in the laboratory.

We conducted a laboratory study to evaluate the efficacy of control agents against small larvae, large larvae, and pupae of Aedes aegypti to determine an appropriate larvicide regime to employ in emergency dengue control programs. The control agents included Bacillus thuringiensis var. israelensis (Bti), pyriproxyfen (an insect growth regulator), a larvicidal oil, Aquatain AMF (polydimethylsiloxane, a monomolecular film), and temephos at the recommend application dosages and rates. Our results showed that Bti, pyriproxyfen, and temephos were efficacious (100% mortality) against larvae, irrespective of the instar stage, but not against pupae of Ae. aegypti (1.5-7.8% mortality). Aquatain AMF, on the other hand, was very effective at controlling the pupal stage (100% mortality), but had limited efficacy against small larvae (38.0% mortality) and large larvae (78.0% mortality). The larvicidal oil was effective against all immature stages (93.3-100% mortality). Therefore, we concluded that for effectively interrupting the dengue transmission cycle, larvicides that kill the pupal stage (Aquatain AMF or larvicidal oil) should be included in an emergency dengue control program in addition to Bti, pyriproxyfen, or temephos.