Clinical Utility of Ultrasonographic Guidance for Arterial Catheterization in Patients with Obesity: A Randomized Controlled Trial.

OBJECTIVES: To compare the success and complication rates of radial artery catheterization using ultrasound guidance versus the conventional palpation technique in obese patients by anesthesia residents with similar levels of experience in both methods, and to measure the skin-to-artery distance of radial, brachial, and dorsalis pedis arteries using ultrasound with standardized anatomic landmarks. DESIGN: Prospective, randomized controlled trial SETTING: Single tertiary center PARTICIPANTS: Eighty adults with a body mass index (BMI) ≥30 kg/m2 INTERVENTIONS: Ultrasound guidance or conventional palpation method MEASUREMENTS AND MAIN RESULTS: The primary outcome was the first-attempt success rate of arterial catheterization. The skin-to-artery distance of the radial artery was significantly greater in the BMI groups of 40 to 49 kg/m2 and ≥50 kg/m2 compared to the BMI group of 30 to 39 kg/m2 (mean difference, 1.0 mm; 95% confidence interval [CI], 0.4-1.7; p = 0.0029) for BMI 40-49 kg/m2 vs 30-39 kg/m2 and 1.5 mm (95% CI, 0.6-2.4 mm; p = 0.0015) for ≥50 kg/m2 vs 30-39 kg/m2. Similar findings were observed for the brachial artery. BMI was inversely associated with first-attempt success rates (p = 0.0145) and positively with time to successful catheterization (p = 0.0271). The first-attempt success and vascular complication rates of catheterization did not differ significantly between the ultrasound guidance group (65.0% and 52.5%, respectively) and the conventional palpation group (70.0% [p = 0.6331] and 57.5% [p = 0.6531], respectively). CONCLUSION: The results of this study do not support the routine use of ultrasonography during radial arterial catheterizations for obese adults when junior practitioners perform the procedure.

Cigarette smoking, opioid consumption, and pain intensity after major surgery: An observational study.

BACKGROUND: Chronic exposure to nicotine may change pain perception and promote opioid intake. This study aimed to evaluate the putative effect of cigarette smoking on opioid requirements and pain intensity after surgery. METHODS: Patients who underwent major surgery and received intravenous patient-controlled analgesia (IV-PCA) at a medical center between January 2020 and March 2022 were enrolled. Patients' preoperative smoking status was assessed using a questionnaire by certified nurse anesthetists. The primary outcome was postoperative opioid consumption within 3 days after surgery. The secondary outcome was the mean daily maximum pain score, assessed using a self-report 11-point numeric rating scale, and the number of IV-PCA infusion requests within three postoperative days. Multivariable linear regression models were used to calculate the regression coefficient (beta) and 95% confidence interval (CI) for the association between smoking status and outcomes of interest. RESULTS: A total of 1162 consecutive patients were categorized into never smokers (n = 968), former smokers (n = 45), and current smokers (n = 149). Current smoking was significantly associated with greater postoperative opioid consumption (beta: 0.296; 95% CI, 0.068-0.523), higher pain scores (beta: 0.087; 95% CI, 0.009-0.166), and more infusion requests (beta: 0.391; 95% CI, 0.073-0.710) compared with never smokers. In a dose-dependent manner, smoking quantity (cigarette per day) was positively correlated with both intraoperative (Spearman's rho: 0.2207, p = 0.007) and postoperative opioid consumption (Spearman's rho: 0.1745, p = 0.033) among current smokers. CONCLUSION: Current cigarette smokers experienced higher acute pain, had more IV-PCA infusion requests, and consumed more opioids after surgery. Multimodal analgesia with nonopioid analgesics and opioid-sparing techniques, along with smoking cessation should be considered for this population.

Rheumatoid Arthritis Associated with Dry Eye Disease and Corneal Surface Damage: A Nationwide Matched Cohort Study.

Rheumatoid arthritis is potentially connected to ocular disorders, such as corneal inflammation and lacrimal gland destruction. This study aimed to evaluate the risk of dry eye disease (DED) and corneal surface damage among patients with rheumatoid arthritis. In a nationwide cohort study, we utilized Taiwan's National Health Insurance research database and conducted propensity score matching to compare the risks of DED and corneal surface damage between patients with and without rheumatoid arthritis. Proportional hazards regression analyses were used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for the outcomes of interest. The matching procedure generated 33,398 matched pairs with 501,377 person-years of follow-up for analyses. The incidence of DED was 23.14 and 10.25 per 1000 person-years in patients with and without rheumatoid arthritis, respectively. After adjusting for covariates, rheumatoid arthritis was significantly associated with DED (aHR: 2.03, 95% CI: 1.93−2.13, p < 0.0001). The association was generally consistent across the subgroups of age, sex, use of systemic corticosteroids, and different comorbidity levels. In addition, patients with rheumatoid arthritis had a higher risk of corneal surface damage (aHR: 1.36, 95% CI: 1.21−1.51, p < 0.0001) compared to control subjects. Other independent factors for corneal surface damage were age and sleeping disorders. Rheumatoid arthritis was associated with an increased risk of DED and corneal surface damage. Ophthalmological surveillance is required to prevent vision-threatening complications in this susceptible population.

Dose-response relationship between epidural bupivacaine dose and mortality risk after surgical resection of nonsmall-cell lung cancer.

BACKGROUND: Preclinical studies have shown that local anesthetics may modify the growth and invasion of cancer cells. However, few clinical studies have evaluated their impact on cancer outcomes after tumor resection. METHODS: In this single-center cohort study, patients who underwent surgical resection of stage IA through IIIB nonsmall-cell lung cancer and used patient-controlled epidural analgesia from 2005 to 2015 were recruited and followed until May 2017. Data of the epidural bupivacaine dose for each patient were obtained from infusion pump machines. Proportional hazards regression models were used to analyze the associations between bupivacaine dose with postoperative cancer recurrence and all-cause mortality. RESULTS: A total of 464 patients were analyzed. Among these patients, the mean bupivacaine dose was 352 mg (± standard deviation 74 mg). After adjusting for important clinical and pathological covariates, a significant dose-response relationship was observed between epidural bupivacaine dose and all-cause mortality (adjusted hazard ratio: 1.008, 95% confidence interval: 1.001-1.016, p = 0.029). The association between bupivacaine dose and cancer recurrence were not significant (adjusted hazard ratio: 1.000, 95% confidence interval: 0.997-1.002, p = 0.771). Age, sex, body mass index, mean daily maximum pain score, and pathological perineural infiltration were independently associated with bupivacaine dose. CONCLUSION: A dose-dependent association was found between epidural bupivacaine dose and long-term mortality among patients following surgical resection of nonsmall-cell lung cancer. Our findings do not support the hypothetical anticancer benefits of local anesthetics. More studies are needed to elucidate the role of local anesthetics in cancer treatment.

The Association between General Anesthesia and New Postoperative Uses of Sedative-Hypnotics: A Nationwide Matched Cohort Study.

Sedative−hypnotic misuse is associated with psychiatric diseases and overdose deaths. It remains uncertain whether types of anesthesia affect the occurrence of new postoperative uses of sedative−hypnotics (NPUSH). We used reimbursement claims data of Taiwan's National Health Insurance and conducted propensity score matching to compare the risk of NPUSH between general and neuraxial anesthesia among surgical patients who had no prescription of oral sedative−hypnotics or diagnosis of sleep disorders within the 12 months before surgery. The primary outcome was NPUSH within 180 days after surgery. Multivariable logistic regression models were used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI). A total of 92,222 patients were evaluated after matching. Among them, 15,016 (16.3%) had NPUSH, and 2183 (4.7%) were made a concomitant diagnosis of sleep disorders. General anesthesia was significantly associated both with NPUSH (aOR: 1.17, 95% CI: 1.13−1.22, p < 0.0001) and NPUSH with sleep disorders (aOR: 1.11, 95% CI: 1.02−1.21, p = 0.0212) compared with neuraxial anesthesia. General anesthesia was also linked to NPUSH that occurred 90−180 days after surgery (aOR: 1.12, 95% CI: 1.06−1.19, p = 0.0002). Other risk factors for NPUSH were older age, female, lower insurance premium, orthopedic surgery, specific coexisting diseases (e.g., anxiety disorder), concurrent medications (e.g., systemic steroids), postoperative complications, perioperative blood transfusions, and admission to an intensive care unit. Patients undergoing general anesthesia had an increased risk of NPUSH compared with neuraxial anesthesia. This finding may provide an implication in risk stratification and prevention for sedative−hypnotic dependence after surgery.

Morphometric and ultrasonographic determinants of difficult laryngoscopy in obese patients: A prospective observational study.

BACKGROUND: Obese people have a higher risk of difficult laryngoscopy due to their thick neck, large tongue, and redundant pharyngeal soft tissue. However, there is still no established predictive factor for difficult laryngoscopy in obese population. METHODS: We conducted a prospective assessor-blind observational study to enroll adult patients with a body mass index of 30 kg·m-2 or higher undergoing laparoscopic sleeve gastrectomy at a medical center between May 2020 and August 2021. Conventional morphometric characteristics along with ultrasonographic airway parameters were evaluated before surgery. The primary outcome was difficult laryngoscopy, defined as a Cormack and Lehane's grade III or IV during direct laryngoscopy. Logistic regression analyses were performed to evaluate the association between included factors and difficult laryngoscopy. Discrimination performance of predictive factors was assessed using area under the receiver operating characteristic curve (AUC). RESULTS: A total of 80 patients were evaluated, and 17 (21.3%) developed an event of difficult laryngoscopy. Univariate analyses identified five factors associated with difficult laryngoscopy, including age, sex, hypertension, neck circumference, and cross-sectional area of tongue base. After adjusting for these variables, neck circumference was the only independent influential factor, adjusted odds ratio: 1.227 (95% confidence interval, 1.009-1.491). Based on Youden's index, the optimal cutoff of neck circumference was 49.1 cm with AUC: 0.739 (sensitivity: 0.588, specificity: 0.889; absolute risk difference: 0.477, and number needed to treat: 3). CONCLUSION: Greater neck circumference was an independent risk factor for difficult laryngoscopy in obese patients. This finding provides a way of reducing unanticipated difficult airway in this high-risk population.

A Comparison of Oxygenation Efficacy between High-Flow Nasal Cannulas and Standard Facemasks during Elective Tracheal Intubation for Patients with Obesity: A Randomized Controlled Trial.

Obese patients are predisposed to rapid oxygen desaturation during tracheal intubation. We aimed to compare the risk of desaturation between high-flow nasal oxygenation (HFNO) and classical facemask oxygenation (FMO) during rapid sequence intubation for elective surgery in obese patients. Adults with a body mass index ≥30 kg·m−2 undergoing laparoscopic sleeve gastrectomy at a medical center were randomized into the HFNO group (n = 40) and FMO group (n = 40). In the HFNO group, patients used a high-flow nasal cannula to receive 30 to 50 L·min−1 flow of heated and humidified 100% oxygen. In the FMO group, patients received a fitting facemask with 15 L·min−1 flow of 100% oxygen. After 5-min preoxygenation, rapid sequence intubation was performed. The primary outcome was arterial desaturation during intubation, defined as a peripheral capillary oxygen saturation (SpO2) <92%. The risk of peri-intubation desaturation was significantly lower in the HFNO group compared to the FMO group; absolute risk reduction: 0.20 (95% confidence interval: 0.05−0.35, p = 0.0122); number needed to treat: 5. The lowest SpO2 during intubation was significantly increased by HFNO (median 99%, interquartile range: 97−100) compared to FMO (96, 92−100, p = 0.0150). HFNO achieved a higher partial pressure of arterial oxygen (PaO2) compared to FMO, with medians of 476 mmHg (interquartile range: 390−541) and 397 (351−456, p = 0.0010), respectively. There was no difference in patients' comfort level between groups. Compared with standard FMO, HFNO with apneic oxygenation reduced arterial desaturation during tracheal intubation and enhanced PaO2 among patients with obesity.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study.

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25-0.35), pneumonia (OR 0.82, 95% CI 0.76-0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54-0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73-0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.