SCIP/ERAS Flashcards
SCIP stands for….
Surgical care improvement project (scip)
Each infection estimated to….(3)
↑ hospital stay 7 days
↑ cost $3,000
Complications lasting 30 days decrease median survival 69%
SCIP goal
Goal: decrease morbidity and mortality of SSI
SCIP performance measures (3)
Proportion of pts who get abx started within 1 hr of incision (no less than 15m minutes before incision)
Proportion given abx regimen consistent with guidelines
The proportion of pts whose abx is discontinued within 24 hrs of surgery stop
Why were the performance measures selected.
Based on evidence that abx administered no less than 15 minutes before incision and no more than an hour our= decreased risk of infection. Abx outside 24 hr period = increased risk of bacteria developing resistance to the abx or if gave dose that was inadequate or gave an inappropriate abx.
SCIP abx measures
Administration of prophylactic antibiotic within 1 hr of incision
Correct antibiotic choice based on procedure
Discontinued antibiotics within 24 hours of surgery end time unless there is documentation of infection or suspected infection
When vancomycin and clindamycin administered for SCIP
2hrs of incision
When are abx dc for cardiac surgery
w/in 48 hrs
SCIP Beta blockers measures
Beta-blocker must be taken within 24 hours of surgery start for all patients on chronic beta-blocker therapy
Beta-blocker restarted after surgery for all patients on chronic beta-blocker therapy
SCIP hair measures
Documentation of appropriate hair removal;
Clippers only
No razor/shaving
SCIP foley measures
Urinary catheter removal on or before POD 2 unless an order exists to extend the catheter;
Reason to extend must also be documented
Reason to extend may not be written on postoperative admission orders
SCIP sugar measures
Cardiac patients with controlled post-operative blood glucose of </= 200 mg/dl at 6am
180 within 18-24 hours after anesthesia end
SCiP DVT measures
SCDs placed during surgery for all procedures >/= 1 hr
Orders for appropriate DVT prophylaxis on the postoperative admission orders.
Unless documentation criteria for not administering pharmacologic and mechanical prophylaxis
RN administration of the appropriate DVT prophylaxis within 24 hours of surgery end
SCIP temperature measure
Normothermia or active warming in OR
1st temp in PACU >/= 96.8F within 15 minutes of leaving OR
96.8 F in Celcius
37
NPO guidlines
clear liquids = 2 hrs
breast milk = 4 hrs
infant formula= 6 hrs
light meal/ non human milk = 6 hrs
fried fatty foods, meat = 8 hrs
Toradol ceiling
15 mg
Pts a risk for PONV (6)
young
female
non smoker
duration of anesthesia
postoperative opioid use
hx of PONV/motion sickness
ERAS Elements – “The Must-Haves”
Pre-Operative- Formal, pre-surgical patient education - counseling
Risk assessment – intervention with standardized optimization
Intra-Operative- Limited fasting, carbohydrate rich drink up to 2 hrs before surgery
Opioid sparing, multimodal analgesia that continues through discharge
Post-Operative- Ambulation w/in 8 hrs of surgery stop time
Formal discharge education that includes incision care and mobility recommendations
Formal Patient Education
Comprehensive education results in well-informed patients that are more likely to have a better post-operative outcome and realistic expectations
Formal, patient-centered approach that is consistent within the hospital, offered to all patients, and does not vary from surgeon to surgeon
Facilitates dynamic patient participation throughout his/her care
Smoking; if quit 2-4 weeks out = increased risk of …….
Smoking; if quit 2-4 weeks out = increased risk of bronchospasm and increased sections because the ciliary are mobilizing
INtraop phase ERAS protocals
Limited fasting and Carbohydrate rich beverage up to 2 hours before surgery
Opioid-sparing, multimodal analgesia (PO premeds)
*Evidenced by order set implementation
*Starts here, goes through discharge
Place foleys when sx is how long?
> 4hrs
What to give to decrease blood loss
TXA
Effects of surgical stress and NPO on metabolism (7)
inc immunospupression and insulin resistance
dec glucose uptake
inc glucogenesis
inc catecholamine surge
inc cortisol, glucagon, GH
inc IL1, IL6
Inc Post op lean tissue loss; strength, mobilization, wound healing, and resp mechanics
Post op ERAS protocals
Early Ambulation – w/in 8 hrs. of surgery stop time
Formal education at discharge regarding:
*Incision care
*Mobility recommendations
what fluid management considerations do we need to add if the pt received bowel prep
Subtract 2-3 L from fluid deficit!!
Carbohydrate Loading (7)
Up to 2 hours prior to surgery
Rate of pulmonary aspiration has not increased
Reduced thirst, hunger, anxiety
Reduced insulin resistance
More muscle strength and lean body mass
Accelerated recovery
Shorter hospital stay
Multimodal Pain Management
Cox 2 inhibitor or NSAID
Acetaminophen
Ketamine
⍺-2 Agonist (clonidine, dexmedetomidine)
Epidural (local anesthesia +/- adjuncts)
Gabapentin
Corticosteroids
Peripheral Nerve Block
Potentially improved pain relief and reduced surgical stress response 30% failure rate
Epidural
Reduced anesthesia requirements (not just opioids!)
a 2 agonists (clonidine/ dexmedetomidine)
Opioid sparing effect, can treat opioid resistant pain
Ketamine
Superior analgesia (vs opioids), reduced PONV, reduced duration of stay
Doesn’t always work
Peripheral Nerve Block
What is a TAP block
Transversus Abdominis Plane
help in area of the diaphgram
Erector Spinae coverage
provides coverage of 4-6 levels
field blocks
TAP block, QL and Erector Spinae; field blocks. Putting LA in a fascial plane that the nerve runs.
QL blocks compared to TAp blocks
QL blocks result inmore extensive sensory blocksthan TAP blocks (T10-L3vs.T10-T12,).
Compared with TAP blocks, the QL block, which is a regional variation of the TAP block, has been suggested to be a more reliable approach for pain after abdominal surgery
PONV prophylaxis and treatment strategies
- avoid nitrous oxide and opioids/ volatiles
- Zofran
- Decadron
- Propofol
- P3 median nerve block (chemo trigger in the body that helps reduce ponv)
- scolapalamine (placed 2-6 hrs before) (consider SE; dry mouth, confusion)
- histamine blockers; benedryl
- Droperidol and Haloperidol; low dose help N/V
