SCIP & ERAS (Exam II) Flashcards
Complications lasting 30 days decrease median survival rate by ____%.
69%
What are the antibiotic performance metrics associated with the SIP (Surgical Infection Prevention Project)?
- ABX started within 1 hr of incision
- ABX regimen consistent w/ guidelines
- ABX d/c within 24hours of surgery stop
What did compliance with three metrics of SIP project look like?
Not great
When was the Surgical Care Improvement Project (SCIP) implemented?
What was the intended result?
- Aimed at reducing surgical mortality and morbidity. Reduce surgical complications by 25%
What national organization was notably missing from the SCIP steering committee?
AANA
we must advocate for our profession
What are the three antibiotic measures associated with the SCIP?
- ABX within 1 hour of incision
- Correct ABX based on procedure
- D/C ABX in 24 hours unless documented reason. (within 48 hours for cardiac sx)
What are the two antibiotics that can be given within 2 hours of incision?
Vancomycin and Fluoroquinolones
When must ABX be discontinued after Cardiac Surgery?
Within 48 hours of cardiac surgery
What are the β-blocker measures associated with the SCIP? (2)
- 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.
What is the hair removal measure associated with the SCIP?
- Documentation of appropriate hair removal w/ clippers only (no razors).
What is the foley catheter measure associated with the SCIP?
Urinary catheter removal on or before POD 2 unless order for extension exists. (must be documented)
What is the blood sugar measure associated with the SCIP?
Cardiac patients need a controlled post-operative blood glucose of ≤ 200 mg/dL prior to surgery and after.
What are the DVT measures associated with the SCIP? (3)
- SCDs placed for all surgeries longer than 1 hour.
- Orders for DVT prophylaxis on post-operative admission orders.
- RN administration of DVT prophylaxis within 24 hours of surgery end.
What are the temperature measures associated with the SCIP? (2)
- Normothermic or active warming in OR
- 1st temp in PACU ≥ 96.8F within 15 minutes of leaving OR.
What are the new ASA guidelines for preoperative fasting periods?
What pre-medications are typically given in the pre-operative area?
Midazolam (and/or fentanyl)
COX-2 Inhibitor (Paracoxib, celecoxib, etc)
A 70kg patient was NPO for 8 hours. What is this patients calculated fluid deficit?
(4-2-1 rule)
40ml + 20mL + 50mL = 110mL/hr
110 x 8hrs = 880 mL deficit
How much of a fluid deficit occurs due to bowel prep?
2-3L
What type of insensible losses might be seen in a patient? How does it fluctuate with severity?
Minimal: 0-2 mL/kg/hr
Moderate: 2-4 mL/kg/hr
Severe: 4-8 mL/kg/hr
What drugs are used for intraoperative pain management? (6)
- Opioids
- Local infiltration by surgeon
- Epidural
- Ketorolac (NSAIDs)
- Dexmedetomidine (⍺₂ agonists)
- Ketamine
What benefits do opioids provide for intraoperative pain control?
Cardiovascular stability
What 2 primary risks associated with Ketorolac (Toradol) use?
Bleeding & kidney injury
What is the intraoperative dose of ketamine?
0.25 - 0.3 mg/kg
(0.2-0.5 mg/kg IV according to reference guide)
What are risk factors for PONV? (6)
- Female gender
- Non-smoker
- Young
- Duration of anesthesia
- Post-operative opioid use
- Hx of PONV or motion sickness
What are the top two “things” that patients don’t want to experience after surgery?
Vomiting
ETT gagging
What is the PONV guideline?
What are 3 primary PACU management goals?
- Fluids (110mL/hr)
- Warm pt
- 4/10 pain control
What are timeframes for the three phases of care?
What are the preoperative “Must-Haves” of the ERAS Protocol? (2)
- Formal pre-surgical patient education and counseling
- Risk assessment w/ standardized optimization
What are the intraoperative “Must-Haves” of the ERAS Protocol? (3)
- Limited fasting
- Carb-rich drink up to 2 hours prior to surgery
- Opioid sparing-multimodal analgesia continuing through discharge.
What are the postoperative “Must-Haves” of the ERAS Protocol? (3)
- Ambulation within 8 hours of surgery stop time
- Formal discharge education (incision and mobility specifically)
- Continuation of opioid-sparing multimodal analgesia
Can patient education vary from surgeon to surgeon according to the ERAS protocol?
No, should be standardized
What are the suggested intraoperative interventions of the ERAS protocol? (not mandatory). (5)
- No foley unless sx > 4 hours
- Minimize blood loss
- Normovolemic, -thermic, -glycemic
- PONV prevention
- Foley out in PACU
What are the effects of surgical stress and NPO status on metabolism? (8)
↓ glucose uptake
↑ insulin resistance
↑ gluconeogenesis
↑ catecholamines
↑ Cortisol, glucagon, GH
↑ Immunosuppression
↑ IL-1 and IL-6
↑ Post-operative lean tissue loss
What benefits does CHO (carbohydrate) loading prior to surgery provide? (3)
- ↓ insulin resistance
- ↑ patient comfort
- No aspiration events
No data on muscle retention
What are the suggested post-operative interventions of the ERAS protocol? (not the must-haves).
- Early nutrition, Meals OOBTC
- Post-discharge call to patient within 1 week (pain, concerns, incision status, instructions)
- Post-discharge office visit within 2 weeks
How should fluid management be implemented? What crystalloid should be avoided if possible?
- Should be implemented with goal directed therapy, using monitors
- Avoid NS if possible
What are the benefits of not doing a bowel prep? (4)
- Earlier return of bowel function
- Shorter hospital stay
- No difference in rate of anastomotic leaks or wound infections.
- Less fluid deficit impact (2-3L)
What type of analgesia techniques are preferred over PRN opioids? (3)
- PCA
- Regional LA
- Neuraxial
What drugs each can reduce opioid requirements by 20-30%? (3)
- COX-2 Inhibitors
- NSAIDs
- Acetaminophen
What drug is useful for treating opioid resistant pain?
Ketamine
What drugs reduce overall anesthetic drug requirements and not just opioid requirements?
α-2 agonists (clonidine, dexmedetomidine)
What is the flowchart for PONV prophylaxis?
What might a ERAS pain management protocol look like?
Mg⁺⁺ may potentiate ________ drugs thus leading to increased skeletal muscle relaxation.
Neuromuscular blocking
