SCIP & ERAS (Cornelius) Exam II EXPANDED Flashcards
What was the primary goal of the Surgical Care Improvement Project (SCIP)?
a) Decrease accepted standards for surgical procedures
b) To reduce surgical infection rates
c) To extend hospital stays
d) Increase variations in surgical outcomes between facilities
b) To reduce surgical infection rates
Cornelius - what’s an accepted standard for things can include:
* antibiotics,
* patient temperatures.
* Length of hospital stay.
* Infections are a big part of that
Slide 2
Each hospital-acquired infection is estimated to increase the hospital stay by how many days?
a) 3 days
b) 7 days
c) 14 days
d) 10 days
b) 7 days
slide 3
The conservative estimated cost of each hospital-acquired infection is approximately ______.
a) $30,000
b) $10,000
c) $3,000
d) $1,000
c) $3,000
C - it’s very hard to tease out exactly what happened as a result of the prolonged hospital stay or the infection…it’s kinda hard to blame somebody for lack of a better word.
Slide 3
Complications lasting 30 days are estimated to decrease median survival by what percentage?
a) 25%
b) 50%
c) 69%
d) 85%
c) 69%
Slide 3
True or False
As the complication rate and morbidity/mortality rate increase for patients, the payment to the healthcare providers increases as well.
False
C - Payment goes down drastically when complication rates increase, and longer hospital stays are associated with bundled payments
Slide 3
What is the primary goal of the Surgical Infection Prevention (SIP) Project?
a) To reduce hospital costs
b) To decrease surgical wait times
c) To decrease morbidity and mortality of surgical site infections
d) To increase the length of hospital stay
c) To decrease morbidity and mortality of surgical site infections (SSI)
Slide 4
In what year was the Surgical Infection Prevention (SIP) Project initiated by the CDC and CMS?
a) 1995
b) 2000
c) 2002
d) 2005
c) 2002
Slide 4
One of the performance measures for the SIP Project is to ensure antibiotics are started within ______ of incision.
a) 1 hour
b) 2 hours
c) 24 hours
d) 30 minutes
a) 1 hour
slide 4
One of the SIP Project’s performance measures ensures that antibiotics are discontinued within ______ of surgery stop.
a) 12 hours
b) 24 hours
c) 48 hours
d) 72 hours
b) 24 hours
Slide 4
The SIP Project focuses on ensuring that patients are given an antibiotic regimen that is:
a) Based on their medical history
b) Consistent with the surgical team’s preferences
c) Consistent with established guidelines
d) Chosen randomly by the hospital pharmacist
c) Consistent with established guidelines
C - One of the things that really contributes to bacterial resistance is inappropriate use of antibiotics.So people that are getting antibiotics for coughs, colds, fevers, things that are totally inappropriate
Slide 4
Selecting the appropriate antibiotic and timing its infusion correctly has a positive correlation with:
a) Reduction in hospital stay
b) Decreased incidence of SSI
c) Decrease in patient satisfaction
d) Improved recovery time
b) Decreased incidence of SSI
C - the big things that came out of the initial stuff was timing of the antibiotics selection of the appropriate antibiotics and then how long we continued it for because each of those were tied into increased risk of surgical site infection
Slide 5
In the 2001 retrospective review, what percentage of the 34,133 Medicare inpatients received their antibiotic dose within 1 hour of incision?
a) 40.7%
b) 55.7%
c) 92.6%
d) 70%
b) 55.7%
C - what they figured out was patients weren’t getting antibiotics in the appropriate time period for the most part, they were getting the correct antibiotics, but not all the time
Slide 6
What percentage of patients had the correct antibiotic agent administered according to the 2001 retrospective review?
a) 55.7%
b) 40.7%
c) 92.6%
d) 70%
c) 92.6%
slide 6
Only ______% of antibiotics were discontinued within 24 hours of surgery stop in the 2001 retrospective review
a) 55.7%
b) 92.6%
c) 40.7%
d) 30%
c) 40.7%
C -patient specific factors may come into play..maybe they have an allergy…resistance…you just need to have kind of a good reason for it.
2004 Self-reported data showed hospital compliance increased over 3yrs.
Slide 6&7
Which of the following are key aims of the 2005 Surgical Care Improvement Process (SCIP)? (Select 3)
a) Aligning with other measures like SIP
b) Reducing surgical mortality and morbidity
c) Focusing only on cosmetic surgeries
d) Targeting high-incidence and high-cost complications
e) Increasing hospital readmission rates
f) Extending hospital stays to monitor complications
a) Aligning with other measures like SIP
b) Reducing surgical mortality and morbidity
d) Targeting high-incidence and high-cost complications
Slide 8
The multi year national campaign goal of SCIP was to reduce surgical complications by what percentage by 2010?
a) 10%
b) 15%
c) 25%
d) 50%
c) 25%
C - Starting in 2005, their overall goal was to reduce surgical complications by 25% in five years (2010)
slide 8
What national organization was notably missing from the SCIP steering committee that was initiated by the CDC and CMS?
a) ASA
b) APRN
c) ACS
d) AANA
d) AANA - American Association of Nurse Anesthesiology
C - If we don’t advocate for our profession and we don’t step up on the national level, we lose out on things we don’t have a seat at the table.
Slide 9
Prophylactic antibiotics should generally be administered within what time frame before incision?
a) 30 minutes
b) 1 hour
c) 2 hours
d) 3 hours
b) 1 hour
C - appropriate antibiotics within one hour incision….but no less than 15 minutes.
So you have about a 45 minute window in there where you can give the patient the antibiotics and it needs to be at least 15 minutes before incision.
Slide 10
For which antibiotics is a 2-hour window allowed for administration before incision?
a) Penicillin and Cefazolin
b) Vancomycin and Clindamycin
c) Erythromycin and Gentamicin
d) Ampicillin and Metronidazole
b) Vancomycin and Clindamycin
Slide 10
Antibiotics should be discontinued within ______ of surgery end time unless there is documentation of infection or suspected infection.
a) 12 hours
b) 24 hours
c) 48 hours
d) 72 hours
b) 24 hours
Slide 10
For cardiac surgery, antibiotics should be discontinued within ______ of surgery end time unless there is documentation of infection or suspected infection.
a) 12 hours
b) 24 hours
c) 48 hours
d) 72 hours
c) 48 hours
C -With Cephazolin, they figured out that a lot of the cardiac surgery patients already had some degree of antibiotic resistance.
So we’ll see that a lot of times cardiac surgery patients go on vancomycin and it continues for 48 hours.
Slide 10
Patients on chronic beta-blocker therapy must take their beta-blocker within ____ hours of surgery start.
A. 12
B. 24
C. 48
D. 72
B. 24
Slide 11
Beta-blocker therapy must be ____ after surgery for all patients on chronic beta-blocker therapy.
A. discontinued
B. doubled
C. restarted
D. delayed
C. restarted
Slide 11
According to the guidelines, hair should not be removed by ____ before surgery.
A. Clippers
B. Electric razor
C. Shaving/razor
D. Leaving it untouched
C. Shaving/razor
Use CLIPPERS only
it didn’t get as close to the skin, but it’s still kind of grossly decontaminated that hair. For cleanliness perspective, use a vacuum cleaner or tape to decontaminate the area
Slide 12
A urinary catheter should be removed on or before ____ unless an order exists to extend it.
A. POD 1
B. POD 2
C. POD 3
D. POD 4
B. POD 2
Slide 13
Which of the following are true regarding urinary catheter removal according to Foley measures? (Select 2 that apply)
A. The catheter must be removed on or before POD 3 unless an order exists to extend it.
B. The reason to extend the catheter must be documented.
C. The reason for extending the catheter may be not written on the postoperative admission orders.
D. No documentation is required for catheter extension.
B. The reason to extend the catheter must be documented.
C. The reason for extending the catheter may be not written on the postoperative admission orders.
Slide 13
Cardiac patients must maintain a blood glucose level of ____ both before and after surgery.
A. ≤ 150 mg/dL
B. ≤ 180 mg/dL
C. ≤ 200 mg/dL
D. ≤ 220 mg/dL
C. ≤ 200 mg/dL
180 within 18-24 hours after anesthesia end
Corn: something for you to think about when you’re writing your preoperative and postoperative orders to make sure finger sticks are in there and then some sort of insulin protocol is needed.
Slide 14
When should Sequential Compression Devices (SCDs) be placed during surgery according to DVT measures?
A. For all procedures ≥ 1 hour
B. For all procedures ≥ 2 hours
C. Only for procedures longer than 3 hours
D. Only for emergency surgeries
A. For all procedures ≥ 1 hour
Slide 15
Which of the following measures are part of DVT prophylaxis in surgery? (Select 3 that apply)
A. SCDs placed during surgery for procedures lasting ≥ 1 hour.
B. Orders for DVT prophylaxis on postoperative admission orders
C. RN administration of DVT prophylaxis within 48 hours after surgery.
D. Orders for DVT prophylaxis can be skipped if there is documented reason for not administering it.
A. SCDs placed during surgery for procedures lasting ≥ 1 hour,
B. Orders for DVT prophylaxis on postoperative admission orders (including both pharmacologic and mechanical methods)
D. Orders for DVT prophylaxis can be skipped if there is documentation for not administering it.
RN administration of the appropriate DVT prophylaxis within 24 hours of surgery end
Corn: you’re using a patient’s leg for a blood pressure because maybe they don’t have arms or maybe that’s the surgical site…just be cautious with an SCD inflating over top of your blood pressure cuff.
Slide 15
Which of the following are common chemical prophylaxis medications used to prevent DVT? (Select 2 that apply)
A. Heparin
B. Lovenox
C. Warfarin
D. Fondaparinux
A. Heparin
B. Lovenox
Slide 15
What is the required first temperature in the Post Anesthesia Care Unit (PACU) after leaving the OR to meet the normothermia standard?
A. ≥ 95.0°F within 15 minutes
B. ≥ 96.8°F within 15 minutes
C. ≥ 97.5°F within 10 minutes
D. ≥ 98.6°F within 20 minutes
B. ≥ 96.8°F within 15 minutes
Corn: Now, there are obviously some patients that we want to keep cold and then some patients that we can’t warm up as you know as much if somebody comes in with a core temperature of 94, no matter how hard I try, I’m probably not going to get them.
Up to 96.8 within an hour or two.
So just make sure you document that and then document what you did to keep them warm or to make them warm.
Slide 16
Which of the following are reasons to use active warming for patients in the OR? (Select 2 that apply)
A. To maintain patient comfort
B. To meet core measures for procedures exceeding one hour under general anesthesia
C. To reduce the risk of postoperative infection
D. To ensure a quicker recovery
A. To maintain patient comfort
B. To meet core measures for procedures exceeding one hour under general anesthesia
Normothermia or active warming in OR
Slide 16
A Retrospective cohort study-Stulberg et al. 2010 discovered that when measuring temperature on exposed areas in the OR, there is often ___ and there is a degree of ___ between axillary temperature and core temperature readings.
A. inaccuracy, difference
B. accuracy, difference
C. reliability, variation
D. inconsistency, accuracy
A. inaccuracy, difference
A Retrospective cohort study-Stulberg et al. 2010 discovered that when measuring temperature on exposed areas in the OR, there is often inaccuracy and there is a degree of difference between axillary temperature and core temperature readings.
Corn: So just keep that in mind as well, but for the most part, if possible, we use core temperatures so esophageal bladder probe, nasal probe, those sorts of things.
Slide 17 - END of SCIP
Matching!
Match the ingested material with the correct minimum fasting period (hours)
1 - c
2 - d
3 - a
4 - a
5 - a
6 - b
Slide 5 - START OF ERAS
Which of the following is NOT part of the morning of surgery preop process way back in ancient times in 2002?
a) Performing H&P
b) Ensuring the patient was NPO
c) Administering insulin
d) Explaining general anesthesia and OR expectations
e) Expectations for post op pain control
c) Administering insulin
Slide 6
Which of the following premedications may be used in the morning of surgery in the golden times of 2002?
a) Midazolam with or without fentanyl
b) Aspirin and ibuprofen
c) Acetaminophen with or without fentanyl
d) Morphine only
a) Midazolam with or without fentanyl
Slide 6
What was the problem with the COX-2 inhibitors Vioxx and Celebrex?
a) Headaches
b) Unusual hair growth
c) Liver failure
d) Cardiovascular events
d) Cardiovacular events
C - They were having heart attacks and strokes. They weren’t hurting, but they were dead. Celebrex is still used, Vioxx has been recalled
Slide 6
Which of the following drugs is referred to as a “game changer” in the preoperative setting in 2002?
a) Midazolam
b) Fentanyl
c) Paracoxib
d) Celecoxib
e) Vioxx
c) Paracoxib
Slide 6
What is the primary method of anesthesia mentioned in the OR setting in 2002?
a) Spinal blocks
b) General anesthesia
c) Local anesthesia
d) Conscious sedation
b) General anesthesia
C - Everybody got the general anesthetic back then.
Very rarely did we regional nerve blocks, and if we did, it was usually done postoperatively for pain, it wasn’t done preoperatively. It certainly wasn’t done as the sole anesthetic.
Slide 8
Which of the following are components of fluid management in the OR of 2002? (Select 3)
a) 4-2-1 rule for maintenance fluids
b) Accounting for evaporative losses
c) Ignoring bowel prep losses
d) Using the 5-3-2 rule for fluid resuscitation
e) Considering bowel prep
a) 4-2-1 rule for maintenance fluids
b) Accounting for evaporative losses
e) Considering bowel prep in fluid calculations
Slide 8
Which of the following were recognized as major patient dissatisfiers in the OR? (Select 2)
a) Pain
b) Nausea and vomiting
c) Delayed awakening
d) Fluid overload
e) Puritits
a) Pain
b) Nausea and vomiting
Slide 8
Using the 4-2-1 rule. A 70kg patient was NPO for 8 hours. What is this patients calculated fluid deficit?
a) 850
b) 870
c) 808
d) 880
d) 880
40ml + 20mL + 50mL = 110mL/hr
110 x 8hrs = 880 mL deficit from being NPO
Slide 9
When considering bowel prep, how much additional fluid should be added to the deficit?
a) 500-1000 ml
b) 1-2 L
c) 2-3 L
d) 3-4 L
c) 2-3 L
slide 9
For a 70 kg patient, the range of insensible fluid losses is approximately ______ ml/hr.
a) 100-200 ml/hr
b) 210-480 ml/hr
c) 280-560 ml/hr
d) 500-800 ml/hr
c) 280-560 ml/hr
4-8 ml/kg/hr for insensible losses
slide 9
For every 1 ml of blood loss, how much crystalloid should be administered?
a) 1 ml
b) 2 ml
c) 3 ml
d) 4 ml
c) 3 ml
slide 9
Local infiltration by the surgeon is typically done at the ______ to reduce pain. Select 2
a) Peripheral nociceptor
b) Port sites
c) Epidural space
d) Central nociceptor
a) Peripheral nociceptor
b) Port sites
C - laparoscopic cases, their biggest complaints are not the surgery itself. It’s the port sites and then the referred pain from the gas. So use LA and decompress their abdomen
Slide 10
What issue is commonly associated with using epidurals for certain surgeries?
a) Epidurals are typically too expensive
b) There is a high failure rate
c) Epidurals do not provide sufficient pain relief
d) There is a low failure rate
b) There is a high failure rate and difficulty in placing them
C - really the first thing we started doing for cases like this was epidurals.
But the problem we ran into was one we didn’t think about it ahead of time. Lack of experience and of outcome data
Slide 10
Which of the following is a key reason opioids are used in intraoperative pain management?
a) To prevent nausea
b) To ensure cardiovascular stability
c) To decrease the surgery time
d) To reduce the need for postoperative pain control
b) To ensure cardiovascular stability
Slide 12
Which of the following is the primary benefit of using ketorolac in intraoperative pain management?
a) It reduces nausea and vomiting
b) It reduces opioid requirements
c) It increases sedation
d) It improves cardiovascular stability
b) It reduces opioid requirements
Slide 12
Why has the dosage of ketorolac been reduced to 15 mg in most cases?
a) Due to its association with prolonged sedation
b) Due to the risks of bleeding and kidney injury at higher doses
c) Because it causes respiratory depression
d) Because it is no longer effective at higher doses
b) Due to the risks of bleeding and kidney injury at higher doses
C - those patients taking 60mg q6 for five or six days notably would have some impact on their platelet function and kidney injury…so a lot of the bad rap that that Toradol gets came from that time period for what was probably inappropriate administration medication.
slide 12
Which of the following is a common combination for managing both analgesia and sedation, balancing the side effects of each drug?
a) Fentanyl and propofol
b) Ketamine and dexmedetomidine
c) Midazolam and ketamine
d) Ketamine and morphine
b) Ketamine and dexmedetomidine (Ketodex)
C - …ketamine, tends to cause tachycardia, salivation and emergence delirium and precedex tends to cause bradycardia, dry people up and calm people down…So the two balance each other out, same thing.
Ketamine and Propofol is another balanced mix - Ketofol
Slide 12
What is a potential issue with placing an NG tube for every surgery?
a) The NG tube could become dislodged
b) It could lead to overdosing the patient
c) It could suction out the medications
d) It could increase the duration of anesthesia
c) It could suction out the medications, making them ineffective
Slide 13
Why might placing an NG tube during surgery potentially increase the risk of aspiration?
a) It increases airway resistance
b) It introduces air into the stomach
c) It creates an opening through the esophageal sphincter
d) It leads to increased gastric secretions
c) It creates an opening through the esophageal sphincter
C - putting that Ng tube in there, you may make aspiration worse because you’ve actually put an opening through the esophageal sphincter.
slide 13
Which of the following is NOT a factor that increases a patient’s risk of postoperative nausea and vomiting (PONV)?
a) Female gender
b) Non-smoker status
c) Young age
d) Use of opioids postoperatively
e) Short duration of anesthesia
f) History of motion sickness
e) Short duration of anesthesia
Slide 13
What are the top two “things” that patients don’t want to experience after surgery?
Select 2
a) Vomiting
b) Pain
c) Nausea
d) ETT gagging
a) Vomiting
d) ETT gagging
Slide 14
True or False
If someone is high risk of PONV you should give them 2-3 different prophylatic agents from different classes
True!
Slide 15
What potential issue arises from giving more fluids and opioids to a patient recovering from a colectomy? Select 2
a) Bowel obstruction or ileus
b) Opioids lead to increased bleeding
c) Fluids can cause bowel edema
d) Fluids can cause urinary retention
a) Bowel obstruction or ileus
c) Fluids can cause bowel edema
Slide 16
Which of the following are common components of PACU management after surgery in 2002? (Select 3)
a) Administering fluids at 110 ml/hr
b) Administering multimodal techniques
c) Encouraging early ambulation
d) Keeping the patient warm
e) Starting a PCA and continuing on the floor
a) Administering fluids at 110 ml/hr
d) Keeping the patient warm
e) Starting a PCA
Slide 16
Enhanced Recovery After Surgery (ERAS) is a systematized and validated perioperative management model based on ______.
a) Surgeon preference
b) Best available evidence
c) Patient request
d) Traditional practices
b) Best available evidence
slide 18
ERAS protocols include ______ and a dedicated multidisciplinary team approach for implementing standardized protocols.
a) Postoperative opioid management
b) Patient education
c) Increased surgical time
d) Fluid restriction
b) Patient education
Slid 18
One of the goals of ERAS is to challenge old surgical management dogmas, such as ______.
a) Preoperative fasting
b) Minimizing opioid use
c) Using only general anesthesia
d) Reducing patient monitoring
a) Preoperative fasting
Slide 18
ERAS is a multidisciplinary strategy aimed at improving outcomes by using a protocolized ______ applied to boost the outcome and enhance recovery phase after surgery.
a) Single approach
b) Scientific pathway
c) Medication plan
d) Fluid restriction plan
b) Scientific pathway
Slide 18
The pre-operative phase begins at the decision for surgery to ________________.
a) After PACU
b) The morning of surgery
c) The night before surgery
d) After the patient is discharged
c) The night before surgery
Slide 19
The intra-operative phase includes the morning of surgery, intra-op, and ______.
a) Post-discharge
b) Pre-op evaluation
c) PACU
d) Surgeon consultation
c) PACU
Slide 19
The post-operative phase includes the remainder of the time at the hospital and continues until ______.
a) The next surgery
b) Discharge from the hospital
c) The intra-operative phase
d) PACU ends
b) Discharge from the hospital
Slide 19
What are the preoperative “Must-Haves” of the ERAS Protocol? Select 2
a) Carbohydrate loading
b) Risk assessment
c) Multimodal analgesia
d) Early ambulation
e) Variable optimization
d) Patient counseling
b) Risk assessment
d) Patient counseling
Formal, pre-surgical patient education - counseling
Risk assessment – intervention with standardized optimization
Slide 20
During the intra-operative phase, ERAS promotes limited fasting and allows carbohydrate-rich drinks up to ______ before surgery.
a) 4 hours
b) 1 hour
c) 2 hours
d) 6 hours
c) 2 hours
- Limited fasting
- Carb-rich drink (Gatorade or protein rich drink) 2 hours prior to cut
Slide 20
True or False
Opioid sparing, multimodal analgesia that continues through discharge is part of the intra-operative phase?
True
C- We also recognize the role of reducing opioids in these patients, but we don’t want them to be in pain. So we still have to have a good analgesic strategy to follow through the patient all the way through discharge.
Slide 20
Post-operative education in ERAS includes formal discharge instructions covering incision care and ______.
a) Pain management
b) Opioid use
c) Mobility recommendations
d) Diet planning
c) Mobility recommendations
C - if I have somebody that lays in bed for days and days, they’re at high risk for DVT. They’re at high risk for infections, they’re high risk for not being clean and winding up with bacteria in that wound.
Slide 20
In the post-operative phase, ERAS protocols emphasize ambulation within ______ of surgery stop time.
a) 4 hours
b) 6 hours
c) 12 hours
d) 8 hours
d) 8 hours
Slide 20
What is a mandatory aspect of the pre-operative phase according to the MSSIC guidelines?
Select 2
A. Smoking cessation
B. Formal presurgical patient education and counseling
C. Nutritional screening (albumin)
D. Implement risk assessments with standardized interventions for optimization
E. Fraility/Delirium
B. Formal presurgical patient education and counseling
D. Implement risk assessments with standardized interventions for optimization
Cornelius - it really continues throughout the whole experience…they also understand what we’re doing for them..so they’re not surprised about how the anesthetic or surgical journey continues.
Slide 21
True or False
Formal, patient-centered approach that is consistent within the hospital, offered to all patients, and does not vary from surgeon to surgeon
True
Formal, patient-centered approach that is consistent within the hospital, offered to all patients, and does not vary from surgeon to surgeon
Slide 22
True or False
Well-informed patients are more likely to have better post-operative outcomes
True
Comprehensive education results in well-informed patients that are more likely to have a better post-operative outcome and realistic expectations
Slide 22
Patient participation in spine education must be documented in the ______ for tracking and registry purposes by an abstractor.
A. Operative report
B. Electronic Medical Record (EMR)
C. Patient questionnaire
D. Nursing notes
B. Electronic Medical Record (EMR)
Cornelius - Ideally, this is offered through the hospital to assure consistency. Hospitals would partner with surgeons to enroll patients to assure that they get the education.
Slide 23
Sites have flexibility in the number of risk assessments they use, but they must include ________.
A. Customized interventions
B. Standardized interventions
C. Surgeon-specific interventions
D. One assessment per patient
B. Standardized interventions
Slide 24
The primary goals of risk assessment include which of the following? (Select 2)
A. Reducing surgery-related stress responses
B. Optimizing patient mental and physical status
C. Preventing emergency surgeries
D. Ensuring patient participation in postoperative care
A. Reducing surgery-related stress responses
B. Optimizing patient mental and physical status and functional status
ACSQP - Example: American College of Surgeons Quality Program…Strong for Surgery
Slide 24
Which of the following are considered essential preoperative steps according to the Strong for Surgery guidelines? (Select 4)
A. Smoking cessation
B. Eating well
C. Exercise levels
D. Controlling blood sugar
E. Stress
F. Medicines
A. Smoking cessation
B. Eating well
D. Controlling blood sugar
F. Medicines
Cornelius - this is information they’re putting out there for the patients, but it’s also kind of an evaluation in the screening tool…They really need to follow up somewhere to manage that disease process
These tools are FREE
Slide 25
If a patient is a smoker, what is the surgeon’s first recommended action according to the risk assessment flowchart?
A. Refer to endocrinology
B. Counsel the patient on smoking cessation
C. Perform a lung function test
D. Delay surgery for more than 6 weeks
B. Counsel the patient on smoking cessation
slide 26
Which of the following is NOT a preoperative risk factors that should be addressed according to the risk assessment flowchart?
A. Known diabetes or BMI > 35
B. Anemia or hemoglobin <11.5
C. Blood pressure > 160/90
D. Age over 75 years
E. BMI >30
C. Blood pressure > 160/90
Slide 26
If a patient’s HbA1c level is greater than 8, the surgeon should refer the patient to ______.
A. Geriatrics
B. Bariatrics
C. Endocrinology
D. Pulmonology
C. Endocrinology
Slide 26
What is the recommended course of action for a patient with anemia and hemoglobin (Hgb) < 11.5 according to the risk assessment flowchart? Select 2
A. Refer to endocrinology
B. Delay surgery indefinitely
C. Refer to blood management
D. Recommend immediate surgery
E. Administer iron & EPO
C. Refer to blood management
E. Administer iron & EPO
Surgery should be >2wks after consult
Slide 26
For a patient with a BMI > 40, the risk assessment recommends which of the following actions?
A. Immediate referral to bariatrics
B. Administering oral iron and EPO
C. Scheduling surgery within 2 weeks
D. Recommending avoidance of elective surgery
D. Recommending avoidance of elective surgery
Refer to bariatrics if BMI is >30
Slide 26
For a patient older than 75 years, the risk assessment suggests referring to ______ for a frailty assessment.
A. A geriatrician
B. A cardiologist
C. A neurologist
D. A oldologist
A. A geriatrician
Slide 26
What is a mandatory pre-operative requirement before surgery according to the intra-operative phase guidelines?
A. Unlimited fasting
B. Carbohydrate-rich beverage up to 2 hours before surgery
C. Inserting a Foley catheter in all patients
D. Administering general anesthesia early
B. Carbohydrate-rich beverage up to 2 hours before surgery
Slide 27
Opioid-sparing, multimodal analgesia is mandatory intra-operatively and should be implemented ______.
A. Only during the surgery
B. Starting from the surgery and continuing through discharge
C. After the surgery is complete
D. For patients over 50 years old only
B. Starting from the surgery and continuing through discharge
Evidenced by order set implementation
Slide 27
Which of the following are suggested intra-operative management strategies according to the guidelines? (Select 3)
A. Rare Foley catheter use
B. Maintaining normovolemia
C. Inserting a Foley catheter for all patients
D. Minimizing blood loss
A. Rare Foley catheter use - No placement unless surgery > 4 hrs. If foley placed, out in PACU if possible
B. Maintaining normovolemia -(goal directed fluid mgmt.)
D. Minimizing blood loss -MIS, consider TXA
Slide 27
Which of the following are suggested goals during the intra-operative phase? (Select 3)
A. Maintaining normothermia
B. Preventing nausea
C. Avoiding general anesthesia
D. Maintaining normoglycemia
A. Maintaining normothermia
B. Preventing nausea
D. Maintaining normoglycemia
Slide 27
What is a metabolic effect of surgical stress and being NPO?
Select 2
A. Increased glucose uptake
B. Increased immunosuppression
C. Decreased gluconeogenesis
D. Decreased levels of IL-1 and IL-6
E. Increased insulin resistance
B. Increased immunosuppression
E. Increased insulin resistance
slide 28
Which of the following are consequences of the catabolic pathway triggered by surgical stress and NPO status? (Select 3)
A. Decreased glucose uptake
B. Increased gluconeogenesis
C. Increased cortisol, glucagon, and growth hormone
D. Decreased catecholamine levels
E. Decreased IL-1 and IL-6
A. Decreased glucose uptake
B. Increased gluconeogenesis
C. Increased cortisol, glucagon, and growth hormone (GH)
INCREASED IL-1 and IL-6
Slide 28
The catabolic response to surgical stress leads to increased post-operative lean tissue loss, which affects the following:
Select 3
A. Blood pressure regulation
B. Strength and mobilization
C. Respiratory mechanics
D. Kidney function and fluid retention
E. Post-operative memory retention and mobilization
F. Wound healing
B. Strength and mobilization
C. Respiratory mechanics
F. Wound healing
Slide 28
MSSIC
Which of the following are outcomes of CHO loading noted in the systematic review? (Select 3)
A. Improved insulin resistance
B. Improved patient comfort
C. No aspiration events reported
D. Preservation of muscle mass
E. Increased post-operative complications
F. Significant adverse effects on blood sugar levels
A. Improved insulin resistance
B. Improved patient comfort (hunger, thirst, anxiety, malaise)
C. No aspiration events reported
No conclusion on preservation of muscle mass
Slide 29
In the Penn Neurosurgery ERAS Pain Management Protocol, it is important to set ____ expectations and provide patient education about achieving ____ analgesia.
A. high, complete
B. realistic, optimal
C. unrealistic, total
D. minimal, good
B. realistic, optimal
In the Penn Neurosurgery ERAS Pain Management Protocol, it is important to set realistic expectations and provide patient education about achieving optimal analgesia.*
Slide 30
Which of the following medications are part of the IV/Oral Analgesia in the Penn Neurosurgery ERAS protocol? (Select 4)
A. Gabapentin
B. NSAIDs
C. Acetaminophen
D. Bupivacaine
E. Opioids
F. Dexamethasone
A. Gabapentin (PreOp)
B. NSAIDs (PreOp to Home)
C. Acetaminophen (PreOp to Home)
E. Opioids (PACU to Home)
Slide 30
In the Penn Neurosurgery ERAS protocol, ____ is used for local anesthesia.
A. Lidocaine
B. Bupivacaine
C. Ropivacaine
D. Tetracaine
B. Bupivacaine
Slide 30
Which of the following medications are listed under “Other Adjuncts” in the protocol?
A. Acetaminophen and NSAIDs
B. Dexamethasone and muscle relaxers
C. Bupivacaine and gabapentin
D. IV opioids and NSAIDs
B. Dexamethasone and muscle relaxers
Slide 30
What is the rescue analgesia option listed in the Penn Neurosurgery ERAS Pain Management Protocol?
A. NSAIDs
B. Acetaminophen
C. IV Opioids
D. Muscle relaxers
C. IV Opioids
Slide 30
Which medications are administered on the morning of surgery according to the ERAS protocol at the Cleveland Clinic? (Select 2)
A) Acetaminophen
B) Gabapentin
C) Ketamine
D) Lidocaine
E) Ketorolac
A) Acetaminophen 1 g PO
B) Gabapentin 300-600 mg PO
Slide 31
Which medications are used pre-incision according to the ERAS protocol at the Cleveland Clinicl? (Select 3)
A) Ketamine
B) Lidocaine
C) Gabapentin
D) Ketorolac
E) Local Anesthetic
A) Ketamine 0.25 mg/kg
B) Lidocaine 1.5 mg/kg
E) Local Anesthetic at Incision Site (Lidocaine 1% 1 mL/kg or 2.5 mg/kg max dose)
Slide 31
Which medications are used during surgery before closure according to the ERAS protocol at the Cleveland Clinic? (Select 2)
A) Ketamine
B) Lidocaine
C) Ketorolac
D) Fentanyl
E) Acetaminophen
A) Ketamine 5 mcg/kg/min infusion
B) Lidocaine 1.5 mg/kg/h infusion
Slide 31
Which medications are used after closure during surgery according to the ERAS protocol at the Cleveland Clinic? (Select 4)
A) Ketorolac
B) Fentanyl
C) Morphine
D) Lidocaine
E) Local Anesthetic
A) Ketorolac 15-30 mg IV
B) Fentanyl (Epidural analgesia)
C) Morphine (Epidural analgesia)
E) Local Anesthetic at Incision Site (0.25% Bupivacaine 1mL/kg or 2.5 mg/kg max)
Slide 31
Which medications are used for postoperative pain management according to the ERAS protocol at the Cleveland Clinic? (Select 2)
A) Ketorolac
B) Acetaminophen
C) Ketamine
D) Lidocaine
E) Gabapentin
A) Ketorolac <120 mg/d for 72h
B) Acetaminophen 1g q6h until discharge
Slide 31
What is the mandatory time frame for early ambulation post-surgery?
A) Within 4 hours of surgery stop time
B) Within 6 hours of surgery stop time
C) Within 8 hours of surgery stop time
D) Within 12 hours of surgery stop time
C) Within 8 hours of surgery stop time
Slide 32
Which of the following are part of formal education at discharge according to post-op protocols? (Select 2 that apply)
A) Incision care
B) Mobility recommendations
C) When to return to work
D) Postoperative nutrition
A) Incision care
Corn: What about that incision? You know, your incision becomes red. It starts to weep.Or they start to develop signs of compartment syndrome
B) Mobility recommendations
Corn: somebody I did a nerve block on and I’m telling them what I want them to worry about in the next 12 to 24 hours…They need to know that I don’t want them avoiding pain medications and then they wake up in excruciating pain when that blocks weren’t off…They need to understand that they’re not going to be able to move their arm, leg, what have you.
Slide 32
The postoperative analgesia plan focuses on the continuation of ___ that was started in the intraoperative phase.
A) Opioid-based analgesia
B) Multimodal opioid-sparing analgesia
C) Sedative-based pain management
D) Non-pharmacologic therapy only
B) Multimodal opioid-sparing analgesia
Slide 32
What are the suggested post-operative interventions of the ERAS protocol? (Select 3 that apply)
A) Early ambulation within 8 hours of surgery stop time
B) Early nutrition, back to baseline diet
C) Post-discharge call to patient within 1 week
D) Formal education at discharge on incision care
E) Post-discharge office visit within 14 days
B) Early nutrition, back to baseline diet
* Meals out of bed in chair
C) Post-discharge call to patient within 1 week (7 days)
* Pain
* concerns
* status of incision,
* clarification of post-op instructions
E) Post-discharge office visit within 14 days
* Surgeon, mid-level, or RN
Slide 32
True or False
Flotrak, Cheetah, and Clearsight are technologies used in goal-directed fluid therapy.
True
Corn: what we really transition to instead of the shotgun approach with like the 421 rule was goal directed therapy. So we’re using a lot of monitors, especially like noninvasive stuff
Slide 33
What type of fluids are suggested to play a greater role in fluid management?
A) Crystalloids
B) Colloids
C) Normal Saline
D) Hypertonic saline
B) Colloids
Corn: we’re using colloids and a little bit bigger role than we had in the past and that does come with some risk, but it’s something you need to think about.
Slide 33
Which type of fluid is recommended to avoid if possible in goal directed fluid therapy?
A) Lactated Ringer’s (LR)
B) Normal Saline (NS)
C) D5W
D) 0.45% saline
B) Normal Saline (NS)
Corn: We’ve also transitioned away from giving everybody normal saline because we know it’s not a great agent to use for these patients.
Slide 34
Which of the following are benefits or considerations of not having a bowel prep according to the ERAS protocol? (Select 3 that apply)
A) Earlier return of bowel function
B) Shorter hospital stay
C) Higher rate of anastomotic leaks
D) Subtract 2-3 liters from fluid deficit
E) Increased wound infection rates
A) Earlier return of bowel function
B) Shorter hospital stay
D) Subtract 2-3 liters from fluid deficit
Slide 35
True or False
Skipping bowel prep leads to a higher rate of wound infections.
False
No difference in rates of anastomotic leaks or wound infections
Slide 35
Which of the following is NOT associated with carbohydrate loading up to 2 hours prior to surgery?
A. Reduced insulin resistance
B. Increased rate of pulmonary aspiration
C. Reduced thirst, hunger, and anxiety
D. Shorter hospital stay
E. More muscle strength and lean body mass
B. Increased rate of pulmonary aspiration
Slide 36
Which of the following analgesia techniques are preferred over PRN opioids? (Select 3 that apply)
A. Neuraxial opioids
B. Patient-controlled analgesia (PCA)
C. Regional techniques
D. PRN oral opioids
E. Intramuscular opioids
A. Neuraxial opioids
B. Patient-controlled analgesia (PCA)
C. Regional techniques
Slide 37
Which of the following are a problem associated with IV opioids based on the study (2)?
A. Patients achieve a steady state for an extended period.
B. Patients experience a short duration of steady-state pain control.
C. There is an increased risk of nausea and vomiting.
D. Patients maintain a steady state without complications.
B. Patients experience a short duration of steady-state pain control.
C. There is an increased risk of nausea and vomiting.
Slide 38
Which of the following drugs reduce opioid requirements by 20-30%? Select 3 that apply.
A. NMDA antagonists
B. COX-2 inhibitors
C. Opioids
D. Acetaminophen
E. NSAIDs
F. α₂-Agonists
B. COX-2 inhibitors
D. Acetaminophen
E. NSAIDs
Corn: *We have this habit of not doing consistent pain management and just letting the patient drive it, so we’ll let them be in pain. Then we’ll have them ask for opioids. If we give patients 24 hours of these medications: intense Tylenol, skeletal muscle relaxants, Cox inhibitors, all these sorts of things really provide them with a lot better pain coverage.
Slide 39 and 40
Which of the following medications are used during the transduction phase of the pain pathway? Select 4 that apply.
A. Local anesthetics (LA) infiltration
B. Acetaminophen
C. COX-2 inhibitors
D. Anti-inflammatory agents
E. Opioids
F. NMDA antagonists
G. α₂-Agonists
H. Volatile anesthetics
A. Local anesthetics (LA) infiltration
B. Acetaminophen
C. COX-2 inhibitors
D. Anti-inflammatory agents
Slide 40
Which of the following medications are used during the modulation phase of the pain pathway? Select 5 that apply.
A. Local anesthetics
B. Opioids
C. α₂-Agonists
D. NMDA antagonists
E. COX-2 inhibitors
F. Acetaminophen
G. Volatile anesthetics
A. Local anesthetics
B. Opioids
C. α₂-Agonists
D. NMDA antagonists
E. COX-2 inhibitors
Slide 40
Which of the following medications is used during the transmission phase of the pain pathway?
A. Local anesthetics (LA) via peripheral nerve catheter
B. Acetaminophen
C. COX-2 inhibitors
D. NMDA antagonists
A. Local anesthetics (LA) via peripheral nerve catheter
Slide 40
Which of the following medications are used during the translation phase of the pain pathway? Select 5 that apply.
A. Opioids
B. α₂-Agonists
C. NMDA antagonists
D. Volatile anesthetics
E. Acetaminophen
F. COX-2 inhibitors
G. Local anesthetics
H. Anti-inflammatory agents
A. Opioids
B. α₂-Agonists
C. NMDA antagonists
D. Volatile anesthetics
E. Acetaminophen
Slide 40
Which of the following are benefits of a peripheral nerve block? Select 3 that apply.
A. Superior analgesia compared to opioids
B. Reduced postoperative nausea and vomiting (PONV)
C. Increased duration of stay
D. Reduced duration of stay
A. Superior analgesia compared to opioids
B. Reduced postoperative nausea and vomiting (PONV)
D. Reduced duration of stay
Doesn’t always work
Slide 41
Which drug is useful for treating opioid-resistant pain?
A. Acetaminophen
B. COX-2 inhibitors
C. Ketamine
D. NSAIDs
C. Ketamine
Slide 41
Which drugs reduce overall anesthetic drug requirements? select 2
A. COX-2 inhibitors
B. Clonidine
C. Dexmedetomidine
D. Acetaminophen
E. NSAIDs
α-2 agonists
B. Clonidine
C. Dexmedetomidine
Slide 41
Epidural anesthesia is associated with which of the following? Select 3 that apply.
A. Potentially improved pain relief
B. 30% failure rate
C. Reduced surgical stress response
D. Increased surgical stress response
Epidural (local anesthesia +/- adjuncts)
A. Potentially improved pain relief
B. 30% failure rate
C. Reduced surgical stress response
Slide 41
Which of the following medications reduce opioid requirements? Select 4 that apply.
A. Gabapentin
B. Corticosteroids
C. NSAIDs
D. Acetaminophen
E. Ketamine
A. Gabapentin
B. Corticosteroids
C.NSAIDs
D. Acetaminophen
Slide 41
Which of the following drugs obstruct the use of central regional blocks?
A. Anticoagulants
B. Acetaminophen
C. Opioids
D. NSAIDs
A. Anticoagulants
due to interference with blood coagulation
Slide 43
Which of the following is the cornerstone of pain relief in thoracic and abdominal surgery?
A. Transversus abdominis plane block
B. Thoracic epidural analgesia
C. Local anesthetics
D. Intravenous opioids
B. Thoracic epidural analgesia
Slide 43
Which of the following statements are true about the multimodal approach to perioperative pain management? Select 2 that apply.
A. It combines regional and systemic analgesia.
B. It is considered the most appropriate strategy for perioperative pain management.
C. It relies solely on opioid use for pain control.
D. It increases overall opioid requirements.
E. It only utilizes systemic analgesia techniques.
A. It combines regional and systemic analgesia.
B. It is considered the most appropriate strategy for perioperative pain management.
Slide 43
Which of the following statements is true regarding the comparison between transversus abdominis plane (TAP) block and epidural analgesia?
A. TAP block is less effective for postoperative pain than epidural analgesia.
B. TAP block has a better effect on hemodynamic stability and hospital stay than epidural analgesia.
C. Epidural analgesia provides better hemodynamic stability than TAP block.
D. Both TAP block and epidural analgesia result in increased hospital stays.
B. TAP block has a better effect on hemodynamic stability and hospital stay than epidural analgesia.
Slide 43
Which of the following pain management techniques is an alternative that can be used with fewer side effects and good analgesic properties?
A. Intravenous opioids
B. Thoracic paravertebral block
C. General anesthesia
D. Acetaminophen
B. Thoracic paravertebral block
Slide 43
Which block is suggested to be a more reliable approach for pain after abdominal surgery compared to TAP blocks?
A. Paravertebral block
B. Epidural block
C. Quadratus lumborum (QL) block
D. Femoral nerve block
C. Quadratus lumborum (QL) block
QL are more extensive sensory blocksvs TAP blocks (T10-L3vs.T10-T12,).
Slide 44
Where can TAP (Transversus Abdominis Plane) blocks be performed? Select 3 that apply.
A. Chest (sub-xiphoid area)
B. Ilio-inguinal region
C. Lower back
D. Upper extremities
E. Abdomen
A. Chest (sub-xiphoid area)
B. Ilio-inguinal region
E. Abdomen
Slid 45-47
Which of the following is NOT part of the ERAS preoperative components?
A. Preoperative counseling
B. Discharge planning
C. No/selective bowel prep
D. Venous thromboembolism prophylaxis
E. Antibiotic prophylaxis
F. Prewarming
G. Postoperative physical therapy
G. Postoperative physical therapy
Slide 48
Which preoperative components in ERAS are questioned or require further consideration? Select 2 that apply.
A. Venous thromboembolism prophylaxis
B. Prewarming
C. Reduced fasting duration
D. Carbohydrate loading
C. Reduced fasting duration
D. Carbohydrate loading
Slide 48
Clear fluids can be taken up to __ hours before anesthesia, but solids should be stopped __ hours before.
A. 1, 4
B. 2, 6
C. 3, 5
D. 4, 7
B. 2, 6
“Intake of clear fluids should be allowed until 2 h before induction of anaesthesia. Solids should be allowed until 6 h.”
Slide 49
Which of the following are considered adult patient-related risk factors for postoperative nausea and vomiting (PONV)? Select 3 that apply.
A. History of PONV or motion sickness
B. Non-smoker status
C. Strabismus surgery
D. Female gender
A. History of PONV or motion sickness
B. Non-smoker status
D. Female gender
Slide 51
Which of the following are considered environmental risk factors for postoperative nausea and vomiting (PONV) in adults? Select 2 that apply.
A. Postoperative opioids
B. Female gender
C. Emetogenic surgery
D. Non-smoker status
A. Postoperative opioids
C. Emetogenic surgery (type and duration)
Slid 51
Which risk factors are specific to children in the context of PONV? Select 2 that apply.
A. Surgery longer than 30 minutes
B. History of PONV causing headaches
C. Age > 3 years
D. Emetogenic surgery
A. Surgery longer than 30 minutes
C. Age > 3 years
strabismus surgery
History of PONV
Slide 51
Which of the following factors should be considered when deciding on a PONV prevention strategy? Select 3 that apply.
A. Patient preferences
B. Cost-effectiveness
C. Reducing baseline risks
D. Patient’s smoking history
A. Patient preferences
B. Cost-effectiveness
C. Reducing baseline risks
Slide 51
In patients with low risk for PONV, what is the recommended management strategy?
A. Use of more than 2 interventions
B. Wait and see approach
C. Pick 1 or 2 interventions
D. Multimodal approach
B. Wait and see approach
Slide 51
For patients with medium risk of PONV, the recommended strategy is to:
A. Use a wait-and-see approach
B. Pick 1 or 2 interventions
C. Use a multimodal approach
D. Administer no prophylaxis
B. Pick 1 or 2 interventions
Slide 51
Which of the following is recommended for patients with a high risk of PONV?
A. Wait and see
B. Use more than 2 interventions or a multimodal approach
C. Administer a single prophylactic treatment
D. Avoid pharmacologic treatments
B. Use more than 2 interventions or a multimodal approach
Slide 51
Which of the following intraoperative components of ERAS anesthesia are considered “OK”? Select 3 that apply.
A. Active warming
B. Avoiding long-acting opioids
C. Multimodal pain management
D. Goal-directed fluid therapy
E. Avoiding NG tubes
A. Active warming
C. Multimodal pain management
E. Avoiding NG tubes
and Multimodal PONV prophylaxis
Slide 52
Which of the following intraoperative components are not as certain in the ERAS anesthesia plan? Select 2 that apply.
A. Active warming
B. Multimodal PONV prophylaxis
C. Avoiding long-acting opioids
D. Goal-directed fluid therapy
C. Avoiding long-acting opioids
Can I potentially damage my patients vital organs by underperfusing?
D. Goal-directed fluid therapy
Am I taking care of my patient Practitioner’s opioid dependence
Slide 52
Anesthesia is not a __!
a. challenge
b. science
c. cook book
d. recipe
e. talent
f. game
g. lifestyle
h. drug
c. cookbook
Don’t always do the same thing, because that’s what you’re comfortable.You really need to tailor your anesthetic plan to those patients
Slide 52
What is the perspective on one of the barriers to implementing ERAS?
A. Resistance to evidence-based medicine
B. Inadequate training of staff
C. Skepticism about change
D. Lack of teamwork
C. Skepticism about change
Corn: But I think this bottom one is really the biggest part. People are very skeptical of change
Slide 53
Which of the following outcomes is associated with the implementation of ERAS protocols? (Select 3 that apply)
A. Reduced morphine (equivalent) use
B. Increased morphine (equivalent) use
C. Improved pain scores
D. Increased length of stay in the hospital
E. Decreased length of stay in the hospital
A. Reduced morphine (equivalent) use
C. Improved pain scores
E. Decreased length of stay in the hospital
Slide 54
