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.

SUMMARY: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 (100z mortality) against larvae, irrespective of the instar stage, but not against pupae of Ae. aegypti (1.5-7.8z mortality). Aquatain AMF, on the other hand, was very effective at controlling the pupal stage (100z mortality), but had limited efficacy against small larvae (38.0z mortality) and large larvae (78.0z mortality). The larvicidal oil was effective against all immature stages (93.3-100z 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.In Taiwan, dengue fever is considered a travel-related disease because the causative viruses are introduced in the early summer by travelers from dengue-endemic countries (1,2). These viruses are subsequently passed to local dengue vectors and then transmitted to local human populations, resulting in small to medium-sized outbreaks. Proactive and emergency strategies (source reduction and the use of insecticide sprays) to control dengue outbreaks have been launched each year for the past decade in Taiwan. The principal methods include the application of adulticides, removal of small containers, the application of larvicides to stagnant water, and the release of mosquito-eating fish such as Macropodus opercularis Ahl and Poecilia reticulata Peters.The most commonly used larvicides to control Aedes aegypti L. worldwide include Bacillus thuringiensis var. israelensis (Bti), pyriproxyfen (an insect growth regulator), temephos (an organophosphate), larvicidal oils, and Aquatain anti-mosquito film (AMF; a monomolecular film) (3,4). These larvicides kill immature stages of mosquitoes through different mechanisms. For example, one such mechanism is larval poisoning over a short duration, with a toxin, such as Bti and temephos, which kill all Ae. aegypti larvae within 24 h (5). A second mechanism is to delay larval development and prevent the emergence of adults. For example, the sand formulation of pyriproxyfen caused 100z mortality in larvae and pupae at 0.2 ppm (5). A third mechanism is physical, as illustrated by Aquatain AMF and larvicidal oils that spread across the water surface and form a very thin film that suffocates larvae and pupae (6). Aquatain AMF treatment (1 mL/m 2 ) causes 48z mortality of Ae. aegypti larvae after 48 h of exposure and 100z mortality of pupae after 3 h of exposure in the...

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 (Pao 2):inspired oxygen concentration (Fio 2) 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.

Introduction. With a rapidly ageing population in Singapore, we see an increasing number of elderly patients undergoing surgery, both elective and emergency. This study aims to look at the anaesthesia techniques employed in a subset of very elderly population undergoing surgery and their subsequent postoperative outcomes, in particular their 30-day mortality, postoperative complication rates, and length of hospital stays. Materials and Methods. We searched from our hospital records between 2012 and 2013 for patients equal to or older than 90 years old who have undergone surgery and retrospectively analysed the types of surgery and mode of anaesthesia used. 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.