SCIP & ERAS (Cornelius) Exam II EXPANDED Flashcards by Kimberly Diane Hill

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

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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

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The conservative estimated cost of each hospital-acquired infection is approximately ______.

a) $3,000
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

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Complications lasting 30 days are estimated to decrease median survival by what percentage?

a) 25%
b) 50%
c) 69%
d) 85%

c) 69%

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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

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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)

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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

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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

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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

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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

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Selecting the appropriate antibiotic and timing its infusion correctly has a positive correlation with:

a) Reduction in hospital stay
b) Increased incidence of SSI
c) Decrease in patient satisfaction
d) Improved recovery time

b) Increased 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 side infection

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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

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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%

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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.

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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

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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)

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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.

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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.

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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

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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

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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.

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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

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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

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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

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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 ## Footnote Slide 13

Which of the following are true regarding urinary catheter removal according to Foley measures? (Select all 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. ## Footnote 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.* ## Footnote 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 ## Footnote Slide 15

Which of the following measures are part of DVT prophylaxis in surgery? (Select all 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 documentation 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.* ## Footnote Slide 15

Which of the following are common chemical prophylaxis medications used to prevent DVT? (Select all that apply) A. Heparin B. Lovenox C. Warfarin D. Fondaparinux

A. Heparin B. Lovenox ## Footnote 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.* ## Footnote Slide 16

Which of the following are reasons to use active warming for patients in the OR? (Select all 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* ## Footnote 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.* ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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*** ## Footnote 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 ## Footnote 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.* ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote slide 9

For a 70 kg patient, the range of insensible fluid losses is approximately ______ ml/hr. a) 100-200 ml/hr b) 200-400 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 ## Footnote 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 ## Footnote 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* ## Footnote 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*** ## Footnote 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 ## Footnote 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 ## Footnote 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.* ## Footnote 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 (Ketodex) 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** ## Footnote 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, making them ineffective d) It could increase the duration of anesthesia

c) It could suction out the medications, making them ineffective ## Footnote 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.* ## Footnote 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 ## Footnote 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 ## Footnote 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! ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote Slide 18

The pre-operative phase begins at the decision for surgery and ends ______. a) After PACU b) On the morning of surgery c) The night before surgery d) After the patient is discharged

c) The night before surgery ## Footnote 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 ## Footnote 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 ## Footnote 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* ## Footnote 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* ## Footnote 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.* ## Footnote 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.* ## Footnote 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 ## Footnote 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.* ## Footnote 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** ## Footnote 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* ## Footnote 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.* ## Footnote 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 ## Footnote 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** ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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*** ## Footnote 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*** ## Footnote 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 ## Footnote Slide 26

What is a **mandatory** pre-operative requirement before surgery according to the i**ntra-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 ## Footnote 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* ## Footnote 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* ## Footnote 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 ## Footnote 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 ## Footnote 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* ## Footnote 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 E. Wound healing ## Footnote 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* ## Footnote 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**.* ## Footnote 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) ## Footnote Slide 30

In the Penn Neurosurgery ERAS protocol, ____ is used for local anesthesia. A. Lidocaine B. Bupivacaine C. Ropivacaine D. Tetracaine

B. Bupivacaine ## Footnote 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 ## Footnote 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 ## Footnote Slide 30