Preoperative lung ultrasound for confirming the double-lumen endotracheal tube position for one-lung ventilation: A systematic review and meta-analysis.

Objectives: Insertion of a double-lumen endotracheal tube (DLT) is the most commonly used method for one-lung ventilation (OLV). This meta-analysis was aimed at investigating the performance of lung ultrasound in assessing the DLT position in OLV. Methods: Electronic databases were searched for related trials from inception to October 2022. The primary outcome was the performance of ultrasound or clinical evaluation in confirming the correctness of the DLT position, using fiberoptic bronchoscopy or intraoperative direct visualization of lung collapse as the gold standard. The secondary outcome was the time required to confirm or adjust the DTL position. Results: Five randomized controlled trials and three observational studies involving 771 patients were included in the meta-analysis. The pooled sensitivity and specificity of ultrasound were 0.93 (95% confidence interval [CI]: 0.79-0.98) and 0.61 (95% CI: 0.41-0.77), respectively, while those of clinical evaluation were 0.93 (95% CI: 0.73-0.99) and 0.35 (95% CI: 0.25-0.47), respectively. The pooled procedure duration was 122.27 s (95% CI: 20.85-223.69) with ultrasound and 112.03 s (95% CI: 95.30-128.76) with clinical evaluation. The area under the curve for discriminating the DLT position was 0.86 (95% CI: 0.82-0.88) for ultrasound and 0.52 (95% CI: 0.48-0.57) for clinical evaluation. Conclusions: Compared to clinical evaluation, ultrasound has a similar sensitivity but a better specificity for confirming the correctness of the DLT position. Ultrasound is an acceptable imaging tool for assessing DTL placement in OLV.

Effects of opioids administered via intravenous or epidural patient-controlled analgesia after caesarean section: A network meta-analysis of randomised controlled trials.

Background: Post-caesarean section analgesia is important physiologically and psychologically for both mothers and infants. Patient-controlled analgesia is a well-established method of administering opioids for postoperative pain. However, to date, no study has systematically investigated the effects of opioids administered through intravenous patient-controlled analgesia (IVPCA) or patient-controlled epidural analgesia (PCEA) in parturients who have undergone caesarean section. Methods: This systematic review and network meta-analysis aimed to evaluate the analgesic and adverse effects of opioids administered via IVPCA or PCEA in parturients who have undergone a caesarean section. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched from inception through 02 10, 2022 for relevant records. Randomised controlled trials (RCTs) that compared opioids administered via IVPCA or PCEA and reported outcomes of interest were included. Studies were excluded if the solution for patient-controlled analgesia contained antiemetics and/or other analgesics in addition to opioids. The methodological quality of RCTs was assessed using the revised Cochrane Risk of Bias Tool. Summary data were extracted from each eligible study. The primary outcome was pain intensity, and the secondary outcomes were opioid-related adverse effects. Frequentist network meta-analyses were performed using a contrast-based random-effects model. This study is registered with PROSPERO, CRD42021254040. Findings: Twenty-three studies with 2589 parturients were included. Compared with IVPCA morphine as a reference treatment, PCEA fentanyl had better analgesic effects at 4 h (mean difference [MD] in the visual analogue scale score, -0.75; 95% confidence interval [CI] [-1.16, -0.34]) and 8 h (MD, -0.93; 95% CI [-1.57, -0.28]) and yielded lower odds of developing nausea/vomiting (odds ratio [OR], 0.27; 95% CI [0.09, 0.80]) and sedation/drowsiness (OR, 0.22; 95% CI [0.11, 0.45]). However, PCEA fentanyl may be more likely to cause pruritus than IVPCA treatments. Interpretation: Considering the analgesic efficacy; opioid-induced nausea, vomiting, and sedation; and the well-being of breastfed infants, PCEA fentanyl may be the treatment of choice for post-caesarean section analgesia. Funding: The Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (TCRD-TPE-111-27).

Video-Assisted Stylet Intubation with a Plastic Sheet Barrier, a Safe and Simple Technique for Tracheal Intubation of COVID-19 Patients.

As the COVID-19 pandemic evolves, infection with the Omicron variants has become a serious risk to global public health. Anesthesia providers are often called upon for endotracheal intubations for COVID patients. Expedite and safe intubation can save patient's life, while minimizing the virus exposure to the anesthesia provider and personnel involved during airway intervention is very important to protect healthcare workers and conserve the medical work force. In this paper, we share clinical experience of using a video-assisted intubating stylet technique combined with a simple plastic sheet barrier placed over the patients' mouth for tracheal intubation during the Omicron crisis in Taiwan. We demonstrated that the use of an intubating stylet combined with plastic sheet barrier is swift, safe, and accurate in securing the airway in patients with COVID-19.

Lung Point-of-Care Ultrasound for Unexpected Hypoxemia during Anesthesia.

This is a case report showing acute hypoxemia during anesthesia. Immediate differentiation using lung POCUS (point-of-care ultrasound), in addition to physical examination and portable chest radiography, was made. This is the first case report of sputum impaction due to pneumonia causing hypoxemia that has been detected by lung POCUS during anesthesia.

Rapid screening for mutations associated with malignant hyperthermia using high-resolution melting curve analysis.

OBJECTIVES: The diagnosis of malignant hyperthermia (MH) is based on clinical signs or laboratory testing. The gold standard laboratory test is the in vitro contracture test, although it is invasive, expensive, and only performed at specialized centers. Genetic diagnosis is another option, although direct mutation screening is a laborious task. Therefore, we evaluated whether high-resolution melting (HRM) curve analysis could be used as a rapid screening tool to target MH-associated mutations. MATERIALS AND METHODS: The feasibility of HRM analysis was evaluated using plasmids that were constructed by cloning wild-type or mutated versions of the ryanodine receptor 1 (RYR1) gene into the pCR2.1 plasmid. We obtained engineered plasmids and patient DNA extracted from blood samples with known wild-type or mutated sequences that are associated with MH. Amplicon lengths were kept relatively short (<250 bp) to improve discrimination between the engineered and patient plasmids. Real-time polymerase chain reaction (PCR) cycling and HRM analysis of the engineered plasmids and patient DNA were performed using the LightCycler 480 System (Roche). RESULTS: The HRM results were clearly different from those obtained using real-time PCR. Furthermore, the HRM analysis provided sufficient resolution to identify two single-nucleotide variants in the tested RYR1 exons. CONCLUSION: We conclude that HRM analysis can provide high resolution for identifying single-nucleotide variants in RYR1, which might be useful for predicting the risk of MH in the preanesthesia setting.

Evaluating the "holiday season effect" of hospital care on the risk of mortality from pulmonary embolism: a nationwide analysis in Taiwan.

We aimed to determine whether hospital admissions during an extended holiday period (Chinese New Year) and weekends were associated with increased mortality risk from pulmonary embolism (PE), compared to admissions on weekdays. We conducted a nationwide retrospective cohort study using Taiwan's National Health Insurance Research Database. Data of newly diagnosed PEs during the months of January and February from 2001 to 2017 were obtained from patient records and classified into three admission groups: Chinese New Year (≥ 4 consecutive holiday days), weekends, and weekdays. The adjusted odds ratios (aORs) (95% confidence intervals [CIs]) for 7-day and in-hospital mortality were calculated using multivariable logistic regression models. The 7-day and in-hospital mortality risks were higher for patients admitted during the Chinese New Year holiday (10.6% and 18.7%) compared to those admitted on weekends (8.4% and 16.1%) and weekdays (6.6% and 13.8%). These higher mortality risks for holiday admissions compared to weekday admissions were confirmed by multivariable analysis (7-day mortality: aOR = 1.68, 95% CI 1.15-2.44, P = 0.007; in-hospital mortality: aOR = 1.41, 95% CI 1.05-1.90, P = 0.022), with no subgroup effects by sex or age. Hospital admission for PE over an extended holiday period, namely Chinese New Year, was associated with an increased risk of mortality.

Mortality risk from acute aortic dissection among hospital admissions during weekends and holiday season.

BACKGROUND: Acute aortic dissection is a life-threatening condition associated with high mortality rate. Findings from previous studies addressing the "weekend effect" on the mortality rate from an acute aortic dissection mortality have been inconsistent. Furthermore, the effect of admission for acute aortic dissection during the holiday season has not been previously investigated. OBJECTIVE: Our aim was to evaluate the effect of admission for acute aortic dissection during holiday season or weekends on the risk of mortality. METHODS: We conducted a retrospective analysis of nationwide cohort data from the Taiwan's National Health Insurance Research Database. We collected data on all adult patients hospitalized for acute aortic dissection between 2001 and 2017 in Taiwan and classified them into the following three groups based on day of admission: holiday season (at least 4 consecutive days; n = 280), weekend (n = 1 041), and weekday (n = 3 109). The following three outcomes were evaluated: in-hospital mortality, 7-day mortality, and 180-day mortality. RESULTS: A multivariable logistic regression was used to adjust for possible cofounders on the measured outcomes. Compared to weekday admissions for acute aortic dissection, weekend admissions resulted in a 29% increase in the risk of in-hospital death (aOR = 1.29; 95% CI, 1.05-1.59; P = 0.0153), with a 25% increase in the 7-day (aOR = 1.25; 95% CI, 1.001-1.563; P = 0.0492) and 20% increase in the 180-day mortality risk (aOR = 1.20; 95% CI, 1.01-1.42; P = 0.0395). Of note, admission over the holiday season did not result in a higher mortality risk than for weekday admissions; this finding, however, might reflect insufficient statistical power on subgroup analysis. CONCLUSION: Patients admitted for acute aortic dissection during the weekends are at higher risk of mortality compared to those admitted on weekdays. Our finding likely reflects inadequate staffing and team experience of weekend staff and can guide healthcare policy makers to improve patient outcomes.

The workload of obstetric doctors working in different modes at a medical center.

OBJECTIVE: The workload of obstetric and gynecologic (OB-GYN) physicians has been an unprecedented increase because of the decrease in the number of such physicians. This study aimed to demonstrate that the hospitalist mode was the best mode for the work-life balance of OB-GYN physicians. MATERIALS AND METHODS: This was a retrospective study in a tertiary academic hospital. Patients were admitted to the labor ward for delivery. The number of deliveries performed by each OB-GYN physician in different working modes was measured. We reviewed the medical charts of women admitted for delivery as well as the shift schedule of OB-GYN physicians from January 1, 2018, to June 30, 2018. We classified deliveries into three modes: the traditional mode (patient designation), on-call mode, and the hospitalist mode. Traditional mode was the work mode currently. On-call mode and the hospitalist mode were simulated conditions. The number of deliveries and the total OB-GYN physician worked time for their shift were recorded. The differences between the three modes and between OB-GYN physicians were assessed using analysis of variance. RESULTS: In total, 237 deliveries were recorded over 6 months (3 deliveries were excluded from our data); these deliveries were performed by four OB-GYN physicians named A to D. Significant differences in workload were noted between OB-GYN physicians working in the traditional mode and those in the on-call mode, but no significant differences were noted among those working in the hospitalist mode. All OB-GYN physicians worked an average of seven shifts, and no significant differences among them were noted. CONCLUSION: The hospitalist mode might be the optimal mode for OB-GYN physicians to achieve a favorable work-life balance if their original main jobs are obstetric practice.

Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience.

Since its outbreak in China, the Coronavirus disease 2019 (COVID-19) pandemic has caused worldwide disaster. Globally, there have been 71,581,532 confirmed cases of COVID-19, including 1,618,374 deaths, reported to World Health Organization (data retrieved on December 16, 2020). Currently, no treatment modalities for COVID-19 (e.g., vaccines or antiviral drugs) with confirmed efficacy and safety are available. Although the possibilities and relevant challenges of some alternatives (e.g., use of stem cells as immunomodulators) have been proposed, the personal protective equipment is still the only way to protect and lower infection rates of COVID-19 among healthcare workers and airway managers (intubators). In this article, we described the combined use of a plastic sheet as a barrier with the intubating stylet for tracheal intubation in patients needing mechanical ventilation. Although conventional or video-assisted laryngoscopy is more popular and familiar to other groups around the world, we believe that the video-assisted intubating stylet technique is much easier to learn and master. Advantages of the video stylet include the creation of greater working distance between intubator and patient, less airway stimulation, and less pharyngeal space needed for endotracheal tube advancement. All the above features make this technique reliable and superior to other devices, especially when a difficult airway is encountered in COVID scenario. Meanwhile, we proposed the use of a flexible and transparent plastic sheet to serve as a barrier against aerosol and droplet spread during airway management. We demonstrated that the use of a plastic sheet would not interfere or hinder the intubator's maneuvers during endotracheal intubation. Moreover, we demonstrated that the plastic sheet was effective in preventing the spread of mist and water spray in simulation models with a mannequin. In our experience, we found that this technique most effectively protected the intubator and other operating room personnel from infection during the COVID-19 pandemic.

Anesthesia and Long-term Oncological Outcomes: A Systematic Review and Meta-analysis.

BACKGROUND: Whether propofol elicits a survival benefit over volatile anesthetics during cancer surgery remains inconclusive. The primary aim of this systematic review and meta-analysis is to compare the effects of propofol-based total intravenous anesthesia (TIVA) with any volatile anesthesia on long-term oncological outcomes. The secondary aim is to compare propofol-based TIVA with specific volatile agents on long-term oncological outcomes. METHODS: We searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library from inception through March 3, 2020. Randomized control trials and observational studies that compared the effects of propofol-based TIVA and volatile anesthesia on long-term oncological outcomes, which also reported hazard ratios (HR) as effect estimates, were considered eligible for inclusion. Using the inverse variance method with a random-effects model, HR and 95% confidence intervals (CI) were calculated. Trial sequential analysis was incorporated to test if the results were subject to a type I or type II error. RESULTS: Nineteen retrospective observational studies were included. Patients who received propofol-based TIVA during cancer surgery were associated with significantly better overall survival than those who received volatile anesthesia (HR = 0.79, 95% CI, 0.66-0.94, P = .008, I2 = 82%). In contrast, no statistically significant difference was observed in recurrence-free survival between patients who received propofol-based TIVA and volatile anesthesia during cancer surgery (HR = 0.81, 95% CI, 0.61-1.07, P = .137, I2 = 85%). In the subgroup analysis by different volatile anesthetics, patients who received propofol-based TIVA were associated with better overall survival than those who received desflurane (HR = 0.54, 95% CI, 0.36-0.80, P = .003, I2 = 80%). In contrast, there was no statistically significant difference in overall survival between patients who received propofol-based TIVA and those who received sevoflurane (HR = 0.92, 95% CI, 0.74-1.14, P = .439, I2 = 70%). In the trial sequential analysis of overall survival, the cumulative Z curve reached the required heterogeneity-adjusted information size and crossed the traditional significance boundary. In contrast, in the trial sequential analysis of recurrence-free survival, the cumulative Z curve did not cross the traditional significance boundary. However, the required heterogeneity-adjusted information size has not yet been reached. CONCLUSIONS: Propofol-based TIVA is generally associated with better overall survival than volatile anesthesia during cancer surgery. Further large-scaled, high-quality randomized control trials are warranted to confirm our findings.

Serum cystatin C is independently associated with aortic arterial stiffness in patients with type 2 diabetes.

BACKGROUND: Higher cystatin C levels are associated with an increased cardiovascular risk. We evaluated the association between serum cystatin C and aortic arterial stiffness in patients with type 2 diabetes mellitus (DM). METHODS: Fasting blood samples were collected from 170 patients with type 2 DM. Carotid-femoral pulse wave velocity (cfPWV) values > 10 m/s were used to define the high aortic arterial stiffness group. RESULTS: Sixty-seven patients with DM (39.4%) were defined as the high aortic arterial stiffness group. Patients with DM in the high aortic arterial stiffness group had older age (P = 0.003), higher systolic blood pressure (P < 0.001), diastolic blood pressure (P = 0.045), triglyceride (P = 0.046), blood urea nitrogen (P = 0.038), creatinine (P = 0.006), urine albumin-to-creatinine ratio (P = 0.004), and serum cystatin C (P < 0.001) levels but lower estimated glomerular filtration rate (P < 0.001). Multivariate logistic regression analysis showed that serum cystatin C level (each increase of 0.1 mg/l, odds ratio: 1.369, 95% confidence interval (CI): 1.049-1.787, P = 0.021) was still an independent predictor of aortic arterial stiffness in patients with DM. CONCLUSION: Serum cystatin C level positively correlated with aortic arterial stiffness among patients with type 2 DM.