Principles 2 Fall 2025 > ERAS > Flashcards

ERAS Flashcards

Test 2 (96 cards)

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1
Q

ERAS =

A

Enhanced recovery after surgery

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2
Q

Preop fasting guidelines: clear liquids

A

2 hrs

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3
Q

Preop fasting guidelines: breastmilk

A

4 hrs

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4
Q

Preop fasting guidelines: infant formula

A

6 hrs

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5
Q

Preop fasting guidelines: non-human milk

A

6 hrs

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6
Q

Preop fasting guidelines: light meal

A

6 hrs

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7
Q

Preop fasting guidelines: Fried foods, fatty foods, meat

A

8 hrs

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8
Q

What happens when you preop the pt the morning of surgery? (5)

A
  1. H&P
  2. Ensure NPO guidelines were followed
  3. Explain anesthetic plan
  4. Give expectations for postop recovery/pain control
  5. Premedicate prior to sx
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9
Q

_________ (3) are Cox-2 inhibitors that can be given ______ surgery.

A
  1. Celebrex
  2. Vioxx
  3. Paracoxib

Before

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10
Q

T/F: COX-2 inhibitors work peripherally only

A

F

They work peripherally and centrally

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11
Q

What is included in your fluid deficit/predicted fluid needs?

A
  1. 4-2-1 rule
  2. Bowel prep, if used
  3. Insensible losses
  4. Blood loss
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12
Q

What is the 4-2-1 rule? How much is it for a 70kg pt?

A

1st 10 kg –> 4 x 10 = 40ml/hr

2nd 10 kg –> 2 x 10 = 20ml/hr

> 20 kg –> 1 x (remainder) =

70 kg pt = 110 ml/hr

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13
Q

What is the fluid deficit for bowel prep?

A

2 - 3 L

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14
Q

Value: insensible losses

A

4 - 8 ml/kg/hr

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15
Q

With blood loss for every 1ml of blood loss you need to replace it with ____ of crystalloid

A

3 ml

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16
Q

What are problems with/ fluid replacement? (3)

A
  1. Potential fluid overload
  2. Delusional anemia
  3. Bowel distention
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17
Q

________ (2) provide pain management at the periphery

A
  1. NSAIDs
  2. Local
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18
Q

________ (3) provide pain management at the spinal cord (transmission)

A
  1. Epidural
  2. Alpha-2
  3. Opioids
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19
Q

________ (3) provide pain management centrally

A
  1. Ketamine
  2. Alpha-2
  3. Opioids
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20
Q

Why are epidurals unlikely for colonectomies? (3)

A
  1. Lack of outcome data
  2. Difficulty in placing
  3. High failure rate
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21
Q

Why are thoracic epidurals more difficult? (2)

A
  1. Not done often
  2. Spinous processed more acutely downward than lumbar
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22
Q

The potential space in the lumbar region is _______ than the thoracic region

A

Smaller

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23
Q

What is Ketorolac used for? What is the benefit of it? What are the risks associated with/ it? (2)

A

Its used for NSAID used pain management

It reduces opioid requirements

  1. Increase bleeding risks
  2. Increase risk of kidney injury
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24
Q

Dexmedetomidine ______ opioid requirements .

A

Reduces

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25
T/F: Ketamine doesn't work well for bowel procedure
F It does work well .
26
What are additional intraop considerations for bowel procedures/colonectomies? (4)
1. NGT suction per surgeons request (only if requested dt not being recommended) 2. Abx protocol 3. Keep pt warm 4. PONV prophylaxis
27
Why do we put an NGT in for bowel procedures vs an OGT?
Pt most likely going to need gastic tube post surgery -- Cannot keep in OGT post surgery.
28
What are risk factors that increase the risk of PONV? (6)
1. Female gender 2. Duration of anesthesia 3. **Non-smoker** 4. Postop opioid use 5. Young age 6. Hx of PONV or motion sickness
29
PONV =
Postop N/V
30
What are the top 4 complaints from anesthesia in order? Why is this irrelevant?
1. Vomiting 2. Gagging on ETT 3. Pain 4. Nausea We need to Tx PONV aggressively dt higher rank; even higher than pain
31
PONV risk %: 0 risk factor
10%
32
PONV risk %: 1 risk factors
20%
33
PONV risk %: 2 risk factors
40%
34
PONV risk %: 3 risk factors
60%
35
PONV risk %: 4 risk factors
80%
36
More than 2 PONV risk factors is considered ______
High risk
37
What are the fluid requirements for bowel sx in PACU?
110 ml/hr
38
What are the PACU priorities for bowel Sx? (3)
1. Fluids (110ml/hr) 2. Warm pt 3. Pain management (goal 4/10)
39
What is the pain management goal for bowel sx? How do we accomplish this? (2)
4/10 1. Bolus w/ opioids until comfortable --> PCA 2. Continue PCA on the floor
40
ERAS is based on the _________. What is it defined as? Who/What does it include?
Best available evidence ERAS is a protocolized scientific halfway applied to boost the out & enhance the recovery phase after sx Multidisciplinary & several items/interventions and includes pt education and implimenting standardize protocols
41
Time frames: Preop
Decision for sx --> night before sx
42
Time frames: Intraop
Morning of sx --> intraop --> PACU
43
Time frames: Postop
Leaving PACU --> remainder of time in hospital --> post d/c
44
What are the ERAS Preop "Must Haves"? (2)
1. Formal, preop pt education - counseling 2. Risk assessment - intervention w/ standardized optimization
45
What are the ERAS Intraop "Must Haves"? (3)
1. Limited fasting 2. Carb rich drink up to 2 hrs before sx 3. Opioid sparing, multimodal analgesia that continues thru d/c
46
What are the ERAS Postop "Must Haves"? (2)
1. Ambulation w/i 8 hrs of sx stop 2. Formal d/c education that includes incision care & mobility recommendations
47
Implementing risk assessments with standardized interventions for optimization are done in the _______ phase for ERAS. What are some examples of risk assessments? (11)
Preop 1. Blood sugar 2. Smoking cessation/fasting 3. Nutritional screening (albumin) 4. Medications/polypharmacy 5. Narcotics/alcohol use 6. Anemia 7. Frailty/delirium 8. Physical activity/prehab 9. BMI/obesity 10. Risk assessment & prediction tool 11. OSA
48
What is the point of formal education in the preop phase? What are the recommendations of formal education? (4)
Well informed patients = better postop outcomes & realistic expectations 1. Consistent w/i the hospital 2. Offered to all patients 3. Does not vary from surgeon to surgeons 4. Encourages patient's participation
49
T/F: patient participation in formal education must be documented somewhere in the EMR
T
50
When you optimze a pt, what are the components of this? (3)
1. Physical 2. Mental 3. Functional
51
What are the ERAS intraop "suggestions"? (7)
1. Rare foley use -- dont place unless sx >4 hrs 2. Minimum blood loss -- MIS (consider TXA) 3. Normovolemia 4. Normothermia 5. Normoglycemia 6. Nausea prevention 7. **If foley placed --> d/c in PACU** if possible
52
What are the effects of surgical stress & NPO on metabolism? (8)
1. Increase immunosuppression 2. Increase insulin resistance 3. Decrease glucose uptake 4. Increase gluconeogenesis 5. Increase catecholamine surge 6. Increase cortisol, glucagon, GH 7. Increase IL-1, IL-6 8. Increase postop lean tissue loss --> affects strength, mobilization, wound healing, respiratory mechanics (This is why it's important to control stress & glycemic index on pts)
53
CHO loading =
Carbohydrate loading
54
What are the benefits of CHO loading? (3)
1. Significantly improved insulin resistance 2. Improved patient comfort --no aspiration events reported from systemic review
55
When to give meds: Gabapentin (1)
Preop holding
56
When to give meds: NSAIDs (5)
Preop holding --> Intraop --> PACU --> Floor --> Home
57
When to give meds: Opioids (5)
Preop holding --> Intraop --> PACU --> Floor --> Home
58
When to give meds: Tylenol (3)
PACU --> Floor --> Home
59
When to give meds: Bupivicaine
Intraop
60
When to give meds: Dexmethasome (3)
Intraop --> PACU --> Floor
61
When to give meds: Muscle relaxers (3)
PACU --> Floor --> Home
62
When to give meds: IV opioids (2)
PACU --> Floor
63
Medication ERAS (time/dose): Tylenol
Morning of sx = 1g PO Postop = 1g every 6hrs until d/c
64
Medication ERAS (time/dose): Gabapentin
Morning of sx = 300 - 600 mg PO
65
Medication ERAS (time/dose): Ketamine (2)
Pre-incision = 0.25mg/kg bolus During sx = 5mcg/kg/min
66
Medication ERAS (time/dose): Lidocaine
Pre-incision = 1.5mg/kg bolus During sx = 1.5 mg/kg/hr
67
Medication ERAS (time/dose): Ketorolac
After closure = 15 - 30 mg IV bolus Postop = <120 mg/day for 72 hrs
68
Medication ERAS (time/drug-2): Epidural
After closure 1. Fentanyl 2. Morphine
69
Medication ERAS (Percentage/time/dose/max): LA at incision - Lidocaine
Lidocaine 1% Pre-incision = 1ml/kg Max = 2.5 mg/kg
70
Medication ERAS (Percentage/time/dose/max): LA at incision - Bupivacaine
Bupivacaine 0.25% Pre-incision = 1ml/kg Max = 2.5 mg/kg
71
What are the ERAS postop "suggestions"? (4)
1. Early nutrition --back to baseline diet 2. Meals out out of bed -- in chair 3. Post d/c call w/ pt w/i 7 days 4. Post d/c clinic visit w/i 14 days
72
With fluid management, _________ has better outcomes than 4-2-1. What considerations should we have w/ this?
Goal directed therapy 1. Use improved technology/monitors --> Flotrak, Cheetah, Clearsight 2. Use crystalloids -- avoid NS 3. Have a greater role for colloids
73
What does literature say regarding bowel prep? (3) Is it even used anymore in all bowel cases?
If you dont use it the pt will have: 1. Earlier return of bowel function 2. Shorter hospital stays 3. No difference in rates of anastomatic leaks or wound infections Some people dont use bowel prep all the time. Subtract 2-3 liters from fluid deficit.
74
________ (3) are preferred over PRN opioids in pain management with ERAS
1. Neuraxial opioids 2. PCA 3. Regional
75
T/F: Opioids dont affect N/V
F They are a huge trigger -- even in spinal & epidurals
76
T/F: Pts should recieve around the clock regiments of COXIBs, NSAIDs, & tylenol according to ERAS
T
77
What types of pain management work at the cortex? (5)
1. Volatiles 2. Opioids 3. Alpha-2 agonist 4. Tylenol 5. N-methyl-D-aspartate (NMDA) antagonist
78
What types of pain management work at the spinal cord (transmission system)? (5)
1. LA 2. Opioids 3. Alpha-2 angonist 4. NMDA antagonist 5. COX-2 inhibitors
79
What types of pain management work at the periphery? (5)
1. LA infiltration 2. Tylenol 3. Anti-inflammatory agents 4. COX-2 inhibitors 5. LA via peripheral nerve catheters
80
__________ (3) reduce opioid requirements by ____%
1. COX-2 inhibitors 2. NSAIDs 3. Tylenol 20 - 30%
81
T/F: ketamine can treat opioid resistant pain
T
82
Alpha-2 agonists, which include _______(2) reduce _________ (2) requirements
1. Clonidine 2. Dexmedetomidine reduce: 1. Anesthesia 2. Opioid
83
Epidurals reduce _______ (2) responses, but there is a _____% failure rate in bowel cases.
1. Pain 2. Stress 30%
84
T/F: Peripheral nerve blocks always provide good pain relief in bowel cases
F They dont always work
85
What are the local techniques for the Thoracic region in bowel cases? (3)
1. Epidural 2. Erector spinae (ESP) 3. Transversus abdominis plane (TAP)
86
What are the local techniques for the Abdominal region in bowel cases? (3)
1. Epidural 2. Quadratus Lumborum 3. Transversus abdominis plane (TAP)
87
Where is a TAP block placed?
**Around T10** The LA is injected into a potentional space that is **inferior to the External oblique & Internal oblique** -- but is **superior to the transverse abdominis**
88
When do we start warming the patient for bowel sx?
We pre-warm them and begin warming them before they even get into the OR.
89
ERAS protocol encourages solids to be allowed until _______ before sx
6 hrs
90
1 - 2 PONV risk factors classifies the pt as a ________
Medium risk
91
What are the PONV risk factors for **children**? (5)
1. Sx >30mins 2. >3yo 3. Strabismus sx 4. Hx of PONV 5. Relative with PONV
92
How many interventions do you pick for low, medium, and high risk PONV?
Low - wait & see (0) Medium - 1/2 High - >2
93
What are all of the prophylaxis for PONV? (11)
1. Propofol anesthesia 2. Regional anesthesia 3. Droperidol/Haloperidol** 4. NK-1 receptor antagonist 5. Propofol sub hypnotic dose 6. Dimenhydrinate (Benadryl) 7. Perphenazine 8. Scopolamine 9. Non-pharmacological acupuncture 10. 5-HT3 antagonist 11. Dexamethasone
94
T/F: We should avoid NGT in bowel sx according to ERAS
T
95
What type of opioids should we avoid in bowel sx according to ERAS?
long acting opioids
96
What are the outcomes of ERAS? (3)
1. Reduced morphine 2. Improved pain scores 3. Decreased length of hospital stay
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