What are the ASA practice guidelines for fasting with the following ingested materials: clear liquids, breast milk, formula. light meal, fried foods or meat?
clear liquids: 2 hours
breast milk: 4 hours
formula or light meal: 6 hours
fried food or meat: 8 hours
list some meds than can be given pre-operatively for anxiety and pain…
midazolam
fentanyl
Celebrex or Paracoxib (COX-2 inhibitors)
Following the 4-2-1 rule, what is the calculated fluid deficit for a 70kg patient who has been NPO for 8 hours?
10 kg (x4) = 40
10 kg (x2) = 20
50 kg (x1) = 50
40 + 20 + 50 = 110 ml/hour x 8hr = 880 ml fluid deficit
How much do you add to your estimated fluid deficit if your patient has had bowel prep?
2-3 L
What is the range for insensible losses?
4-8 ml/kg/hr
How much crystalloid do you give for every 1 ml of blood loss?
3 ml of crystalloid
What intraoperative pain meds offer the most cardiovascular stability?
opioids
What are some risk factors of PONV?
- female gender
- non-smoker
- young age
- duration of anesthesia
- postoperative opioid use
What does ERAS stand for?
Enhanced Recovery After Surgery
What is ERAS?
is a systematized and validated perioperative management model based on available evidence that encompasses several interventions and challenges old dogmas such as preoperative fasting. Uses a multidisciplinary team approach to enhance recovery after surgery.
According to ERAS, what are important benchmarks in the pre-operative period?
formal, pre-surgical patient education and risk assessment tools
According to ERAS, what are two mandatory benchmarks in the intra-operative period?
limited fasting (carbohydrate rich beverage up to 2hr prior to surgery)
opioid sparing multimodal analgesia that continues through discharge
What are some suggested benchmarks for the intraoperative phase?
avoid indwelling catheter unless surgery is > 4hr (if placed, removed in PACU)
minimize blood loss
use goal directed fluid replacement
normothermia
normoglycemia
PONV prevention
According to ERAS, what are two mandatory benchmarks in the post-operative period?
ambulation within 8hr of surgery stop
formal discharge education that includes incisional care and mobility recommendations
What are some suggested benchmarks in the post-op phase?
early nutrition (in chair)
post discharge call with patient within 7 days
post discharge clinic visit within 14 days with surgeon or mid-level or RN
According to ERAS standards, what defines formal patient education?
patient-centered approach this is consistent within the hospital offered to all patients that DOES NOT vary from surgeon to surgeon
describe the effect of surgical stress and NPO status on metabolism
NPO - immunosuppression - insulin resistance - decreased glucose uptake - gluconeogenesis - catecholamine surge - increased cortisol, glucagon and GH, increased IL-1 and IL-6, post-op lean tissue catabolism - decreased strength, slowed mobilization and wound healing
What did the carbohydrate loading studies find in regards to patient outcomes?
CHO rich drinks significantly improved insulin resistance and patient reported comfort.
No conclusions about preserved muscle mass and no aspiration events reported.
With ERAS what has changed in regards to the fluid management protocol?
movement towards goal directed therapy, avoid NS if possible, and there is a greater role for colloids
What drugs reduced opioid requirements by 20-30%?
Cox-2 inhibitors or NSAIDS and Tylenol
What drug can be used to treat opioid resistant pain?
Ketamine
alpha-2 agonists are opioid sparing and reduce_____________________.
anesthesia requirements
what offers superior analgesia to opioids?
peripheral nerve blocks
What are two other medication classes used for reducing opioid requirements?
Gabapentin and Corticosteroids
