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Thoracic epidural anaesthesia for awake thoracic surgery in severely dyspnoeic patients excluded from general anaesthesia

OBJECTIVES General anaesthesia (GA) carries high risks of ventilator dependency with increased morbidity and mortality in patients with severe respiratory disease. It also presents an ethical dilemma if surgery remains the only treatment option for patients with advanced terminal chronic respiratory disease. Thoracic epidural anaesthesia for awake thoracic surgery (TEATS) in high-risk patients with dyspnoea at rest could avoid ventilator dependency and speed up recovery even in patients with severe dyspnoea. This retrospective observational study analysed indications, management and outcome of patients contraindicated to GA undergoing awake thoracic surgery with thoracic epidural anaesthesia.

METHODS From 716 patients requiring thoracic surgery, nine were contraindicated to GA. Eight patients [American Society of Anesthesiologists (ASA) 4] had a maximum grade four of the modified Medical Research Council dyspnea scale (MMRC). Two patients (ASA 3, grade 1 MMRC and ASA 4, grade 4 MMRC) refused GA.

RESULTS Patients (female : male ratio 1.25 : 1, age 19–76 years) had the following chronic respiratory diseases: pulmonary fibrosis (n = 2), pulmonary metastases (n = 3), chronic obstructive pulmonary disease (n = 1), alveolitis (n = 1) and myopathy (n = 2). Surgical indications were: thoracotomy (n = 6) for pleurectomy to treat recurring pneumothorax (n = 3), pleurostomy (n = 1), emphysema surgery (n = 1), lung biopsy (n = 1) and thoracoscopy (n = 3) for pleural/lung biopsy (n = 2), pneumothorax (n = 1). Lidocaine 20 mg/ml or ropivacaine 7.5 mg/ml was titrated to achieve an anaesthesia level T2–T12. No patient required GA [time of surgery: 46–128 min, mean = 76 min, standard deviation (SD) = 23 min]. Seven patients had light sedation with TCI propofol, remifentanyl or both and remained responsive. Fifty percent of patients received phenylephrine or ephedrine to maintain arterial pressure. Two patients went into hypercapnia, which was reversed with assisted mask ventilation. One patient suffered acute respiratory distress 7 days postoperatively and died of intestinal bleeding on Day 25. There were no postoperative complications in other patients. Excluding Patient 9 always remaining in a medical intensive care unit (ICU), the mean postoperative ICU stay in thoracic surgery was 4.4 days (SD 5.2). Hospital discharge was between 5 and 40 days after surgery.

CONCLUSIONS TEATS with/without sedation was an alternative to GA for thoracotomy/thoracoscopy in severely dyspnoeic patients (MMRC grade 4, ASA 4) without postoperative sequelae.

Airborne Transmission of Ebola Highly Unlikely, Experts Say

The evidence from this epidemic, and prior Ebola outbreaks, strongly suggests that the deadly virus cannot be transmitted through a cough or sneeze, said Dr. Armand Sprecher, a public health specialist with the aid organization Doctors Without Borders.

"If there were significant airborne transmission, we would see spontaneously generated cases that were not linked to a known case. There would be cases of casual transmission," Sprecher said in response to questions from health professionals.

When experts investigate how people have contracted Ebola, "it inevitably tracks back to a significant exposure" involving direct contact with either a very sick person or a dead body teeming with the virus, Sprecher said.

That's why new guidelines for health care workers treating Ebola patients focus on full-body suits that leave no exposed skin, said Dr. Arjun Srinivasan, associate director for healthcare-associated infection prevention programs at the U.S. Centers for Disease Control and Prevention.

"The best evidence that we have suggests that the overwhelming route of transmission is through contact with contaminated fluids with broken skin or mucous membranes," Srinivasan said.

The fluids in question are primarily vomit and diarrhea, which develop as Ebola infection progresses. The experts said people become more infectious as they grow sicker with Ebola, as the amount of virus in their system escalates.

Within the first day of the disease, when you simply have a fever and no production of bodily fluids, you don't see disease transmission through casual contact, Srinivasan said. "So we assume that it is not easily transmissible during the incubation period or even into the first day or two of the disease," he said.

No one in the family of America's first diagnosed Ebola patient, Thomas Eric Duncan, became infected even though they were in the house with him when he became sick with vomiting and diarrhea, experts noted.

"I think that's a particularly important thing for us all to remember," Srinivasan said.

However, the experts admitted that these assertions are based on observations by epidemiologists, rather than by hard scientific evidence. Not enough research has been done to provide definitive answers because Ebola outbreaks have been so rare.

Young Children and e-Cigarette Poisoning

Electronic nicotine delivery systems include a variety of devices, such as electronic cigarettes (e-cigarettes), e-hookahs, and modified or tank-style devices. These devices typically contain a battery, a liquid-filled cartridge, and a heating element. The liquid in these devices is often called e-liquid or e-juice. The devices typically deliver nicotine; flavorings such as fruit, mint, bubble gum, and chocolate; and other chemicals through an inhaled aerosol.

There are both single-use, disposable devices and reusable devices. Some reusable devices use cartridges prefilled with the e-liquid so that the user inserts a new cartridge when the previous cartridge is empty, whereas other reusable devices require users to refill the cartridge themselves with e-liquid from a bottle. Although most devices are designed to deliver nicotine, some devices can be modified to use other substances, such as marijuana oil. ...

The Impact of Screening Tools on Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care

Conclusions Office-based assessment can significantly increase COPD diagnosis by primary care physicians. Future trials must evaluate whether screening can improve outcomes for patients with COPD. (Source: American Journal of Preventive Medicine)

Emerging novel and antimicrobial-resistant respiratory tract infections: new drug development and therapeutic options

The emergence and spread of antimicrobial-resistant bacterial, viral, and fungal pathogens for which diminishing treatment options are available is of major global concern.

New viral respiratory tract infections with epidemic potential, such as severe acute respiratory syndrome, swine-origin influenza A H1N1, and Middle East respiratory syndrome coronavirus infection, require development of new antiviral agents.

The substantial rise in the global numbers of patients with respiratory tract infections caused by pan-antibiotic-resistant Gram-positive and Gram-negative bacteria, multidrug-resistant Mycobacterium tuberculosis, and multiazole-resistant fungi has focused attention on investments into development of new drugs and treatment regimens.

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