ERAS (enhanced recovery after surgery) - EXAM 2 Flashcards
Fasting Times
Clear liquids
2 hrs
Fasting times
breast milk
4hrs
Fasting times
infant formula
6 hrs
Fasting Times
Non-human milk
6 hrs
Fasting times
light meal
6 hrs
Fasting Times
Fried foods, fatty foods, meat
8 hrs
What adverse effects were celebrex/vioxx causing when give pre-op?
- CV events - heart attacks & strokes
vioxx recalled
What is the 4, 2, 1 rule?
calculates NPO deficit and maintenance rate
* 1st 10 kg = 4mL/kg/hr
* 2nd 10 kg = 2mL/kg/hr
* remaining kg = 1mL/kg/hr
- 1st 1/2 in 1st hour
- 1/4 in 2nd hour
- 1/4 in 3rd hour
How much are insensible losses?
- min:
- mod:
- severe:
- min: 0-2mL/kg/hr (sinus)
- mod: 2-4mL/kg/hr
- severe: 4-8mL/kg/hr
What is the toradol dose we use now?
15mg 1-2x
What is a “go to” IVP dexmedetomidine dose?
20-40mcg (4 mcg/mL)
* 5mL syringe or 10mL syringe
Why don’t we put an NGT in everyone anymore?
- makes reflux worse b/c you put an opening in the esophageal sphincter
What is considered “pre-op” period?
- decision for surgery to night before surgery
What is considered the “intra-op” period?
- morning of surgery
- intra-op
- PACU
What is considered the “post-op” period?
- leave PACU
- remainder of time @ hospital
- post-discharge
ERAS - must haves
pre-op - 2 things
- formal, pre-surgical pt education
- risk assessment
ERAS - must haves
Intra-op: 2 things
- limited fasting - carb rich drink up to 2hrs before surgery
- opioid sparing, multi-modal analgesia
ERAS - must haves
post-op - 2 things
- ambulation w/i 8 hrs of surgery stop
- formal discharge education (incision care, mobility recs)
Pre-op phase:
What are some risk assessment examples?
- blood sugar
- smoking cessation
- medications, polypharmacy
- anemia
- frailty/delirium
- BMI/obesity
- OSA
Pre-op phase:
What are the 2 goals of risk assessment?
- optimize the physical, mental, and functional status
- reduce the dramatic stress response of surgery
What are 7 effects of surgical stress & NPO on metabolism?
- increased immunosuppression & insulin resistance
- decreased glucose uptake
- increased gluconeogenesis
- increased catecholamine surge
- increased cortisol, glucagon, GH
- increased IL-1 & IL-6
- increased lean tissue loss
Penn neurosrugery ERAS pain mgmt
Pre-op:
- Gaba
- NSAIDs
- Opioids
Penn neurosrugery ERAS pain mgmt
intra-op:
- NSAIDs
- Opioids
- LA - bupivacaine
- dexamethasone
Penn neurosurgery ERAS pain mgmt
PACU & postop floor
- NSAIDs
- Opioids
- Acetaminophen
- Dexamethasone
- Muscle relaxers
- IV opioids
Penn neurosurgery ERAS pain mgmt
Home
- NSAIDs
- Opioids
- Tylenol
- Muscle relaxers
Ketamine pre-incision dose:
intra-op infusion:
0.25 mg/kg bolus
infusion: 5mcg/kg/min
What are the 3 benefits of not using a bowel prep?
- earlier return of bowel function
- shorter hospital stay
- no diff. in rates of anastamotic leaks or wound infections
According to the ASA task force, what 3 meds are preferred over PRN opioids?
- neuraxial opioids
- PCA - basal
- regional techniques
What is the cornerstone of pain relief in thoracic & abdominal surgery?
- thoracic epidural
What is a block option for pts undergoing C-section instead of putting duramorph in spinals?
TAP block
What types of regional anesthesia can be used for thoracic surgeries?
- Thoracic epidural
- erector spinae block
- thoracic paravertebral block
- TAP block
What types of blocks/regional can be used for abdominal surgeries?
- Epidural
- TAP (T10-T12)
- QL (T10-L3)
Where can TAP blocks be done?
subxiphoid - ilioinguinal
pretty much anywhere
Sure things to do for ERAS in pre-op:
- pre-op counseling
- d/c planning
- no/selective bowel prep
- DVT prophylaxis
- pre-warming
- Abx prophylaxis
4 things to do for ERAS in intra-op:
- active warming
- multi-modal pain mgmt
- avoid NGT
- multi-modal PONV prophylaxis
