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Mar: Sem 4 - Principles II > Exam 2: SCIP & ERAS > Flashcards

Exam 2: SCIP & ERAS Flashcards

1
Q

Complications lasting 30 days decrease median survival rate by ____%.

A

69%

nice

S3

each infection estimated to increase the hospital stay by 7 days, and increase the cost by $3000

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2
Q

What are the 3 antibiotic performance metrics associated with the SIP (Surgical Infection Prevention Project)?

A
  • ABX started within 1 hr of incision
  • ABX regimen consistent w/ guidelines
  • ABX d/c within 24hours of surgery stop

S4

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3
Q

What did compliance with three metrics of SIP project look like?

A

S6

no bueno

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4
Q

When was the Surgical Care Improvement Project (SCIP) implemented?
What was the intended result?

A

Began in 2005, Aimed at reducing surgical mortality and morbidity.

S8

also trying to align SCIP with other measures (like temp etc) not just abx

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5
Q

What national organization was notably missing from the SCIP steering committee?

A

AANA

S9

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6
Q

What are the three antibiotic measures associated with the SCIP?

A
  1. ABX within 1 hour of incision (2 hrs for vanco and clinda)
  2. Correct ABX based on procedure
  3. D/C ABX in 24 hours unless documented reason. (w/in 48hrs of cardiac sx)

S10

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7
Q

What are the two antibiotics that should be given within 2 hours of incision?

A

Vancomycin and Fluoroquinolones

S10

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8
Q

When must ABX be discontinued after Cardiac Surgery?

A

Within 48 hours of cardiac surgery

S10

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9
Q

What are the β-blocker measures associated with the SCIP?

A
  • β blocker within 24 hours of surgery start for all patients on chronic β blocker therapy.
  • β blocker restarted after surgery for all patients on chronic β blocker therapy.

S11

sometimes this core measure is removed because sympathetctomy isn’t necessary for all pts

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10
Q

What is the hair removal measure associated with the SCIP?

A
  • Documentation of appropriate hair removal w/ clippers only (no razors).

S12

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11
Q

What is the foley catheter measure associated with the SCIP?

A

Urinary catheter removal on or before POD 2 unless order for extension exists.
- reason to extend must be documented

S13

We are going more towards noninvasive urinary control now (voiding before procedure or straight cath)

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12
Q

What is the blood sugar measure associated with the SCIP?

A

Cardiac patients need a controlled post-operative blood glucose of ≤ 200 mg/dL at 6am prior to surgery and after.
- 180mg/dL within 18-24 hours after anesthesia end

S14

be careful about dropping the BG too quickly, and makesure the BG checks are in your preop/pacu orders for the RNs

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13
Q

What are the DVT measures associated with the SCIP?

A
  • SCDs placed for all surgeries unless under 1 hour.
  • Orders for DVT prophylaxis on post-operative admission orders.
  • RN administration of DVT prophylaxis within 24 hours of surgery end.

S15

We have also started using chemical prophylaxis (heparin 5000U or lovenox)

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14
Q

What are the temperature measures associated with the SCIP?

A
  • Normothermic or active warming in OR
  • 1st temp in PACU ≥ 96.8F within 15 minutes of leaving OR.

S16

Added in 2010

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15
Q

What are the new ASA guidelines for preoperative fasting?

A

S5

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16
Q

What pre-medications are typically given in the pre-operative area?

A

Midazolam (and/or fentanyl)
COX-2 Inhibitor (Paracoxib, celecoxib, etc)

S6

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17
Q

A 70kg patient was NPO for 8 hours. What is this patients calculated fluid deficit?

A

40ml + 20mL + 50mL = 110mL/hr

110 x 8hrs = 880 mL deficit

S9

1st 10kg = 4ml/kg/hr
2nd 10kg = 2mL/kg/hr
each 1kg > 20kg = 1mL/kg/hr

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18
Q

How much of a fluid deficit occurs due to bowel prep?

A

2-3L

S9

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19
Q

How much insensible losses might be seen in a patient?

A

4-8 mL/kg/hr

This doesn’t pass the sniff test. For a 50kg patient this would be 2400 mL per day on the low end.

S9

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20
Q

What drugs are used for intraoperative pain management?

A
  • Opioids
  • Local LA infiltration by surgeon
  • Epidural
  • Ketorolac
  • Dexmedetomidine
  • Ketamine
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21
Q

What drugs act on the sensory receptors at the site of pain?

A
  • NSAIDs
  • local

S10

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22
Q

What drugs act on the modulation part of the pain pathway?

A
  • Neuraxial
  • Alpha 2
  • opioids

S10

23
Q

What drugs act on the interpretation part of the pain pathway?

A
  • Opioids
  • Alpha 2
  • Ketamine

S10

24
Q

What benefits do opioids provide for intraoperative pain control?

A

Cardiovascular stability

S10

25
Q

What risks are associated with Ketorolac (Toradol) use?

A

Bleeding & kidney injury

S12

this was mostly because back in the day they gave wayyy to much of it - keep your dose at 15mg (aka ceiling dose)

26
Q

What is the intraoperative dose of ketamine?

A

0.25 - 0.3 mg/kg

lecture on slide 12

27
Q

What is Corn’s dose for intraop Precedex?

A

do 20mcg for a short case and 40mcg for a long case
* it comes in 4mcg/mL so do 5mL syringe for 20mcg and 10mL syringe for the 40mcg

S12

28
Q

What are risk factors for PONV?

A
  • Female gender
  • Non-smoker
  • Young
  • Duration of anesthesia
  • Post-operative opioid use
  • Hx of PONV or motion sickness

S15

Note: that for every point increase, the % increases by 20%.

29
Q

What are the top two “things” that patients don’t want to experience after surgery?

A

nausea/vomiting/gagging
pain

S14

30
Q

What is the PONV guideline?

A

S15

Even with a low score, Corn would still give some….because we don’t need to be an ass

31
Q

What are timeframes for the three phases of Enhanced Recovery After Surgery (ERAS)?

A

S19

32
Q

What are the preoperative “Must-Haves” of the ERAS Protocol?

A
  • Formal pre-surgical patient education and counseling
  • Risk assessment w/ standardized optimization

S20

33
Q

What are the intraoperative “Must-Haves” of the ERAS Protocol?

A
  • Limited fasting
  • Carb-rich drink 2 hours prior to cut
  • Opioid sparing-multimodal analgesia continuing through discharge.

S20

34
Q

What are the postoperative “Must-Haves” of the ERAS Protocol?

A
  • Ambulation within 8 hours of surgery stop time
  • Formal discharge education (incision and mobility specifically)
  • Continuation of opioid-sparing multimodal analgesia

S20

35
Q

Can patient education vary from surgeon to surgeon according to the ERAS protocol?

A

No.

S22

36
Q

What are the suggested Pre-op phase for risk assessment examples?

A
  • blood sugar
  • smoking cessation/fasting
  • nutritional screening (albumin)
  • medications/polypharmacy
  • narcotics/alcohol use
  • anemia
  • frailty/delirium
  • physical activity/prehab
  • BMI/obesity
  • risk assessment and prediction tool
  • OSA

S21

Sites are required to implement risk assessment tools with interventions in place for optimization

37
Q

What are the suggested intraoperative interventions of the ERAS protocol? (not the must-haves).

A
  • No foley unless sx > 4 hours
  • Minimize blood loss
  • Normovolemic, -thermic, -glycemic
  • PONV prevention
  • Foley out in PACU

S27

38
Q

What are the effects of surgical stress and NPO status on metabolism? (catabolic pathway)

A

↓ glucose uptake
↑ insulin resistance
↑ gluconeogenesis
↑ catecholamines
↑ cortisol
↑ Immunosuppression
↑ Interleukins (1 & 6)
↑ Post-operative lean tissue loss

S28

39
Q

What benefits does CHO (carbohydrate) loading prior to surgery provide?

A
  • ↓ insulin resistance
  • ↑ patient comfort
  • No aspiration events
  • No data on muscle retention

S29

40
Q

When to use each pain pathway during pain management

A

S30

41
Q

What are the suggested post-operative interventions of the ERAS protocol? (not the must-haves).

A
  • Early nutrition
  • Post-discharge call to patient within 1 week (pain, concerns, incision status, instructions)
  • Post-discharge office visit within 14 days

S32

42
Q

What crystalloid should be avoided if possible in goal directed fluid therapy?

A

NS

S33

43
Q

What are the benefits of not doing a bowel prep?

A
  • Earlier return of bowel function
  • Shorter hospital stay
  • No difference in rate of anastomotic leaks or wound infections.

And we don’t have the 2-3L fluid deficit

S35

44
Q

What type of analgesia techniques are preferred over PRN opioids?

A
  • PCA
  • Regional LA
  • Neuraxial

Not only do we keep pts comfy with these alternates, but we also see much tighter control with the PCA (less peaks and troughs and more steady state maintained)

S37

45
Q

What drugs reduce opioid requirements by 20-30%?

A
  • COX-2 Inhibitors
  • NSAIDs
  • Acetaminophen

S41

46
Q

What drug is useful for treating opioid resistant pain?

A

Ketamine (also has an opioid sparing effect)

S41

47
Q

What drugs reduce overall anesthetic drug requirements?

A

α-2 agonists (clonidine, dexmedetomidine)

S41

48
Q

What two drugs in general reduce opioid requirements?

A

Gabapentin and Corticosteroids

S41

49
Q

What pain management improves pain relief and reduces surgical stress response by 30%?

A

Epidural with or without local adjuncts

S41

50
Q

What pain managment have suprerior analgesia (vs opioids) reduced PONV and reduced duration of stay?

A

Peripheral Nerve block

S41

51
Q

What is the flowchart for PONV prophylaxis?

A
52
Q

Mg⁺⁺ may potentiate ____ drugs thus leading to increased skeletal muscle relaxation.

A

Neuromuscular blocking

53
Q

What is a really good idea for a peripheral nerve block when abdominal surgery is happening? Whats a good alternative?

A

TAP block (Transversus Abdominus)
QL block (quadratus lumborum) - usually better for sensory, but more difficult per Corn

Mar: Sem 4 - Principles II (27 decks)

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