The role of ERAS in pancreaticoduodenectomy: A systematic review and meta-analysis.

Introduction This study aimed to compare the safety and short-term outcomes of ERAS with standard care for patients undergoing pancreatoduodenectomy (PD) based on literature published following the first publication of ERAS guidelines for PD. Methods Five medical databases were searched for studies that compared ERAS to standard care in adults undergoing PD. Data on postoperative complications, length of hospitalization, readmissions, and time to chemotherapy were analyzed using either a fixed- or random-effects model meta-analysis. Meta-regressions were conducted to investigate the role of operative technique, study origin, and study design. Results Our analysis included 22 studies involving 4043 patients. ERAS was associated with fewer complications (RR: 0.83; 0.75 to 0.91), particularly Clavien-Dindo (CD) grade 1 and 2 complications (RR: 0.82; 0.72 to 0.92), delayed gastric emptying (RR: 0.69; 0.52 to 0.93), and postoperative fistula (POPF) (RR: 0.76; 0.66 to 0.89), and a shorter time to chemotherapy (SMD: -0.68; 95% CI: -0.88 to -0.48). ERAS did not affect the risk for CD grade 3 and 4 complications (RR: 1.00; 0.72 to 1.38), post-pancreatectomy hemorrhage (RR: 0.88; 0.67 to 1.14), length of stay (SMD: -0.56; 95% CI: -1.12 to 0.01), readmission (RR: 1.01; 0.84 to 1.21), and mortality (RR: 0.81; 0.54 to 1.22). The continent of origin was an effect moderator in the role of ERAS in CD grade 1 and 2 complications (p= 0.047) and POPF (p=0.02). Conclusion Implementing ERAS principles in PD improves surgical outcomes without compromising safety. ERAS may also accelerate time to chemotherapy, an essential issue for future research.

Anaesthesia and orphan disease: airway and anaesthetic management in Huntington's disease.

We present a case that highlights the issues surrounding the delivery of a safe general anaesthetic to a patient with Huntington's disease (HD) and bulbar dysfunction. In the case of a 46-year-old patient undergoing laparoscopic percutaneous endoscopic gastrostomy tube insertion, we discuss the rationale behind our chosen method and anaesthetic agents as well as airway issues specific to HD. In a patient whose condition would not allow for an awake fibreoptic intubation, we opted for a modified rapid sequence induction. Special considerations were made with regard to muscle relaxation given the complications associated with inadequate paralysis and reversal in patients with HD. The technique we describe may also apply to other patient categories, such as patients with movement disorders, bulbar dysfunction and dementia.

Impossible mask ventilation after an unusually low dose fentanyl-induced muscle rigidity in a patient with essential tremor: a case report and review of the literature.

Although opioid-induced muscle rigidity occurs more commonly with large doses and rapid administration of the drugs, there is a number of cases reported, where muscle rigidity was experienced with lower doses of opioids. We present and discuss a case of muscle rigidity induced by an unusually low dose of fentanyl as primary agent during induction of anesthesia. A 79 year old male patient, scheduled for hernia repair, and with a preoperative physical examination of slight hand tremor, received a bolus of 100 mcg (1.2 mcg/kg) fentanyl as primary agent for induction. About 40 sec later he stopped responding, lost consciousness and developed neck and masseter muscle spasm with jaw closure and thoracoabdominal rigidity. Blood pressure was increased significantly. Ventilation was impossible. Rapid oxygen desaturation led us to proceed with IV propofol 150 mg and suxamethonium 100 mg. Opioid-induced muscle rigidity may cause life-threatening respiratory compromise and should be readily recognized and treated by anesthesiologists.

Comparison of standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes for tracheal intubation through different sizes of the Airtraq laryngoscope in anesthetized and paralyzed patients: a randomized prospective study.

BACKGROUND: The authors compared the intubation success rate of straight reinforced tracheal tubes emerging from the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) with standard preformed polyvinyl chloride tracheal tubes in anesthetized patients. METHODS: The authors randomly allocated 347 adult patients to be intubated with standard polyvinyl chloride tracheal tubes, standard straight wire-reinforced tracheal tubes, or silicone straight wire-reinforced tubes, through either the larger or the smaller adult laryngoscope sizes. The possible influence of laryngoscope size, tube size, and tube type on intubation failure was examined. RESULTS: Success rates were 100% for polyvinyl chloride tracheal tubes, 78.5% for standard wire-reinforced tracheal tubes, and 75.4% for silicone wire-reinforced tubes (P < 0.01). Compared with the former, patients in the straight standard and silicone wire-reinforced tube groups required more optimization maneuvers (4.1% vs. 42.1%; P < 0.01) and more attempts at successful intubation (0% vs. 7.3%; P < 0.01). The angle created by the tube emerging from the Airtraq guiding channel was inversely correlated to the ratio of the endotracheal tube OD to the width of the channel in the standard and silicone wire-reinforced tube groups (r = -0.95 and r = -0.82, respectively; P < 0.01). Finally, a decrease in 0.1 of the above ratio was associated with a 3.1 (95% confidence interval, 1.9-5.2; P < 0.01) times increase in the odds ratio of intubation failure. CONCLUSIONS: Standard polyvinyl chloride tracheal tubes were found to be superior compared with standard and silicone straight wire-reinforced tubes for intubation through the Airtraq laryngoscope. In the latter groups, a decrease of the ratio of their OD to the width of the Airtraq guiding channel resulted in increased intubation failure.