Exam 2 (ERAS)

Question 1

• What is the afferent nociceptive pathway?

Answer 1

• Free nerve endings sense pain & touch via 1st order neurons.
• A delta & C-fibers transduce the signal to the dorsal root ganglion & the dorsal horn.
• There they synapse with 2nd order neurons at Laminae 1, 2 & 5 at the same level of the pain.
• 2nd order neurons transmit the signal to the contralateral side.
• 2nd order neurons transcend via the spinothalamic tract to 3rd order neurons located in the PAG, reticular formation, or thalamus.
• 3rd order neurons send info to somatosensory cortex.

Question 2

• Where do enkephalins assert their effects?

Answer 2

At the 2nd order neurons in the dorsal horn on the ipsilateral side of the pain

Question 3

• What is mandatory for the pre-op phase?

Answer 3

• Formal Pt education.
• Implement risk assessment w/ standard interventions

Question 4

• What is mandatory for the intra-op phase?

Answer 4

• Limit fasting & carb rich beverage up to 2hrs before surgery.
• Opioid-sparing analgesia starts here

Question 5

• How does surgical stress & NPO affect the catabolic pathway?

Answer 5

• ↑ insulin resistance & immunosuppression.
• ↑catecholamines.
• ↑ gluconeogenesis.
• ↑Cortisol, glucagon, GH,
• ↑IL-1 & IL-6.
• ↑ post op tissue loss.
• ↓glucose uptake.

Question 6

• What is an issue with higher doses of Gabapentin?

Answer 6

It may exaggerate sedation

Question 7

• What is mandatory in the post-op phase?

Answer 7

• Early ambulation w/in 8hrs.
• Formal education

Question 8

• How is fluid management done with ERAS?

Answer 8

Goal-directed therapy. Crystalloids but avoid NS

Question 9

• What is a patient’s fluid deficit after bowel prep?

Answer 9

2-3 liters

Question 10

• What type of meds address/fight pain at the dorsal root?

Answer 10

• LA’s Opioids
• 𝝰-agonists
• NMDA antagonists
• COX-2 inhibitors

Question 11

• How do alpha-2 agonists help in ERAS?

Answer 11

They reduce anesthesia requirements

Question 12

• How does ketamine help in ERAS?

Answer 12

Can treat opioid resistant pain

Question 13

• What works better than a TAP block and when is it used?

Answer 13

• QL (Quadratus Lumborum) block.
• For abdominal surgery

Question 14

• What is the minimum fasting time for breast milk, formula & light meal?

Answer 14

• Breast milk 4hrs.
• Formula 6hrs.
• Light meal 6hrs

Question 15

What is the major site for pain modulation in the nociceptive pathway?

Answer 15

The dorsal horn

Question 16

What is allodynia?

Answer 16

A pain response to a typical non-painful stimulus

Question 17

• What are the 4 elements of pain processing?

Answer 17

• Transduction
• Transmission
• Modulation
• Perception

Question 18

• What is transduction?

Answer 18

Noxious stimuli are converted to an action potential

Question 19

• What is transmission?

Answer 19

The action potential is transmitted thru the nervous system

Question 20

• What is modulation?

Answer 20

Altering the signal in the dorsal horn with descending inhibitory fibers such as NE, 5HT, enkephalins

Question 21

• What is perception?

Answer 21

The perception of pain in the somatosensory cortex & limbic cortex.

Question 22

• What elements of pain processing are targeted with ERAS?

Answer 22

All 4 elements.

Question 23

• What medications can influence transduction?

Answer 23

• LA cream
• NSAIDs
• antihistamines
• bradykinin & serotonin antagonists

Question 24

• What meds can influence modulation?

Answer 24

• NMDAr antagonists
• Spinal opioids
• Alpha-2 agonists
• NSAIDs
• NO inhibitors.
• K+ channel openers
• Anticholinesterases.
• CCK antagonists.

Question 25

• What can block transmission of pain?

Answer 25

LA- peripheral nerve, plexus, epidural blocks.

Question 26

• What meds can influence perception?

Answer 26

• Parenteral opioids
• Alpha-2 agonists
• General anesthetics