An Investigation of Optimal Anesthesia for Morbidly Obese Patients Undergoing Bariatric Surgery: A Randomized Controlled Trial

The investigators will conduct a clinical trial using permuted block randomization and conforming to the CONSORT Statement to investigate multiple clinical outcomes in obese patients undergoing LSG at Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. Three randomizations will be conducted, including radial artery catheterization using ultrasound guidance or blind palpitation, preoxygenation using HFNC or CPAP, and volatile anesthesia with desflurane or sevoflurane with or without M-Entropy guidance. A computer-generated list of randomizations (Research Randomizer, www.randomizer.org) will be used for these group allocations.

1. Exploring potential risk factors of difficult intubation using ultrasound: A prospective single-blind cohort study

Before surgery, all enrolled patients will be examined for appearance features regarding difficult airway, including interincisor distance (< 3 cm or not), mentohyoid distance, thyromental distance (< 6.5 cm or not), neck movement (< 80 degrees or not), neck circumference measured at the thyroid cartilage (> 43 cm or not), modified Mallampati score, upper lip bite test, and mandibular prognathism test. Besides, ultrasound will be used to assess upper airway anatomy, including pretracheal soft tissue depth27 and height and width of tongue base. Regarding pretracheal soft tissue depth, the distance from the skin to the anterior aspect of the trachea will be measured at three levels: vocal cords, thyroid isthmus, and suprasternal notch. The amount of soft tissue at each zone is calculated by averaging the amounts of soft tissue in millimeters obtained in the central axis of the neck and 15 millimeters to the left and right of the central axis.

Moreover, the increased tongue volume and deposition of fat at the base of tongue in obese people has been shown to be highly associated with risk of obstructive sleep apnea. To measure the anatomy of tongue base, with the patient in a seated position, the convex transducer in the frequencies 1.5 to 5.0 MHz (GE C1-5-RS, GE Healthcare, Chicago, IL, USA) of a portable ultrasound device (LOGIQTM, GE Healthcare, Chicago, IL, USA) will be introduced to the skin of the neck in the submental region coronally, immediately cephalad to the body of the hyoid bone, and then in the area between the hyoid bone and the symphysis of the mandible. The patients will be instructed to avoid tongue movements, swallowing, or talking. Maximal width of tongue base, tongue base height, and maximal height of mid-tongue will be measured. The same anesthesiologist will perform all ultrasound measurements before surgery. Upon arrival at operating room, patients will be initially placed in a ramped position and then moved into a reverse Trendelenburg position to achieve a 30-degree incline of the thorax before preoxygenation.

After induction of anesthesia, another anesthesiologist, blinded to all preoperative evaluation, will perform all laryngoscopies in this study. The laryngoscopy intubation will be performed using a size-3 or -4 Macintosh (Rüsch Inc., Duluth, GA, USA) blade and a styletted endotracheal tube. The laryngoscopic view will be graded according to Cormack and Lehane's classification with external laryngeal pressure applied.59 Laryngoscopy views graded as III or IV are defined as difficult. In case of failed direct laryngoscopy despite external laryngeal manipulation in the first attempt, video-assisted laryngoscope GlideScope® (Verathon Medical, Bothell, WA, USA) will be used as an intubation rescue technique. The video-assisted laryngoscope will be kept on standby at the operating room before induction. The correct placement of the endotracheal tube will be confirmed by capnography. 2. Radial artery catheterization using ultrasound guidance or blind palpation: An open-label randomized controlled trial