SCIP & ERAS (Exam II)

Question 1

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

Answer 1

69%

Question 2

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

Answer 2

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

Question 3

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

Answer 3

Not great

Question 4

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

Answer 4

2005. Aimed at reducing surgical mortality and morbidity. Reduce surgical complications by 25%

Question 5

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

Answer 5

AANA

we must advocate for our profession

Question 6

What are the three antibiotic measures associated with the SCIP?

Answer 6

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

Question 7

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

Answer 7

Vancomycin and Fluoroquinolones

Question 8

When must ABX be discontinued after Cardiac Surgery?

Answer 8

Within 48 hours of cardiac surgery

Question 9

What are the β-blocker measures associated with the SCIP? (2)

Answer 9

• 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.

Question 10

What is the hair removal measure associated with the SCIP?

Answer 10

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

Question 11

What is the foley catheter measure associated with the SCIP?

Answer 11

Urinary catheter removal on or before POD 2 unless order for extension exists. (must be documented)

Question 12

What is the blood sugar measure associated with the SCIP?

Answer 12

Cardiac patients need a controlled post-operative blood glucose of ≤ 200 mg/dL prior to surgery and after.

Question 13

What are the DVT measures associated with the SCIP? (3)

Answer 13

• 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.

Question 14

What are the temperature measures associated with the SCIP? (2)

Answer 14

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

Question 15

What are the new ASA guidelines for preoperative fasting periods?

Answer 15

Question 16

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

Answer 16

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

Question 17

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

Answer 17

(4-2-1 rule)
40ml + 20mL + 50mL = 110mL/hr

110 x 8hrs = 880 mL deficit

Question 18

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

Answer 18

2-3L

Question 19

What type of insensible losses might be seen in a patient? How does it fluctuate with severity?

Answer 19

Minimal: 0-2 mL/kg/hr
Moderate: 2-4 mL/kg/hr
Severe: 4-8 mL/kg/hr

Question 20

What drugs are used for intraoperative pain management? (6)

Answer 20

• Opioids
• Local infiltration by surgeon
• Epidural
• Ketorolac (NSAIDs)
• Dexmedetomidine (⍺₂ agonists)
• Ketamine

Question 21

What benefits do opioids provide for intraoperative pain control?

Answer 21

Cardiovascular stability

Question 22

What 2 primary risks associated with Ketorolac (Toradol) use?

Answer 22

Bleeding & kidney injury

Question 23

What is the intraoperative dose of ketamine?

Answer 23

0.25 - 0.3 mg/kg

(0.2-0.5 mg/kg IV according to reference guide)

Question 24

What are risk factors for PONV? (6)

Answer 24

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

Question 25

What are the top two "things" that patients don't want to experience after surgery?

Answer 25

Vomiting ETT gagging

Question 26

What is the PONV guideline?

Answer 26

Question 27

What are 3 primary PACU management goals?

Answer 27

* Fluids (110mL/hr) * Warm pt * 4/10 pain control

Question 28

What are timeframes for the three phases of care?

Answer 28

Question 29

What are the **preoperative** "Must-Haves" of the ERAS Protocol? (2)

Answer 29

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

Question 30

What are the **intraoperative** "Must-Haves" of the ERAS Protocol? (3)

Answer 30

- Limited fasting - Carb-rich drink up to 2 hours prior to surgery - Opioid sparing-multimodal analgesia continuing through discharge.

Question 31

What are the **postoperative** "Must-Haves" of the ERAS Protocol? (3)

Answer 31

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

Question 32

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

Answer 32

No, should be standardized

Question 33

What are the suggested intraoperative interventions of the ERAS protocol? (not mandatory). (5)

Answer 33

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

Question 34

What are the effects of surgical stress and NPO status on metabolism? (8)

Answer 34

↓ glucose uptake ↑ insulin resistance ↑ gluconeogenesis ↑ catecholamines ↑ Cortisol, glucagon, GH ↑ Immunosuppression ↑ IL-1 and IL-6 ↑ Post-operative lean tissue loss

Question 35

What benefits does CHO (carbohydrate) loading prior to surgery provide? (3)

Answer 35

- ↓ insulin resistance - ↑ patient comfort - No aspiration events *No data on muscle retention*

Question 36

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

Answer 36

- Early nutrition, Meals OOBTC - Post-discharge call to patient within 1 week (pain, concerns, incision status, instructions) - Post-discharge office visit within 2 weeks

Question 37

How should fluid management be implemented? What crystalloid should be avoided if possible?

Answer 37

* Should be implemented with goal directed therapy, using monitors * Avoid NS if possible

Question 38

What are the benefits of **not** doing a bowel prep? (4)

Answer 38

- Earlier return of bowel function - Shorter hospital stay - No difference in rate of anastomotic leaks or wound infections. - Less fluid deficit impact (2-3L)

Question 39

What type of analgesia techniques are preferred over PRN opioids? (3)

Answer 39

- PCA - Regional LA - Neuraxial

Question 40

What drugs each can reduce opioid requirements by 20-30%? (3)

Answer 40

- COX-2 Inhibitors - NSAIDs - Acetaminophen

Question 41

What drug is useful for treating opioid resistant pain?

Answer 41

Ketamine

Question 42

What drugs reduce overall anesthetic drug requirements and not just opioid requirements?

Answer 42

α-2 agonists (clonidine, dexmedetomidine)

Question 43

What is the flowchart for PONV prophylaxis?

Answer 43

Question 44

What might a ERAS pain management protocol look like?

Answer 44

Question 45

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

Answer 45

Neuromuscular blocking