MM Chapter 48

Question 1

What is the Enhanced Recovery Program (ERP)?

Answer 1

Utilizes evidence-based practices to ensure continuity of care, reduce clinical variations, decrease variation in clinical management, minimize organ dysfunction, decrease postoperative complications, and enhance recovery while minimizing complications and costs.

Question 2

What is the Perioperative Surgical Home (PSH)?

Answer 2

A team-based, interdisciplinary approach to managing surgical patients from initial diagnosis through full recovery, incorporating ERP elements tailored to local clinical environments.

Question 3

What is Persistent Postsurgical Pain?

Answer 3

Chronic pain lasting beyond 1–2 months post-surgery, which is a common and vexing problem.

Question 4

What factors contribute to the surgical stress response?

Answer 4

Surgical stimulus, hypothermia, and psychological factors.

Question 5

How can the surgical stress response be mitigated?

Answer 5

Through perioperative interventions such as neural blockade and reduction in invasiveness.

Question 6

What is Neuraxial Blockade?

Answer 6

Epidural and spinal anesthetics that blunt the metabolic, inflammatory, and neuroendocrine stress response to surgery.

Question 7

What is Epidural Analgesia?

Answer 7

A combination of local anesthetics and low-dose opioids that improves pain control for postoperative patients at rest and with movement.

Question 8

What are Peripheral Nerve Blocks (PNBs)?

Answer 8

Local anesthetics (single or continuous infusion) effective in blocking nociceptive pathways, reducing opioid use, and minimizing opioid-related side effects.

Question 9

What is Intravenous Lidocaine used for?

Answer 9

Has analgesic, antihyperalgesic, and anti-inflammatory effects, commonly used as a continuous infusion for pain management.

Question 10

What is Multimodal Analgesia?

Answer 10

Combines different pharmacologic classes for additive/synergistic pain relief while reducing opioid dependency and related side effects.

Question 11

How do NSAIDs contribute to pain management?

Answer 11

Effective in reducing postoperative pain, PONV, sedation, urinary retention, and opioid use but carry risks such as gastrointestinal bleeding, renal impairment, and delayed wound healing.

Question 12

What is Patient-Controlled Analgesia (PCA)?

Answer 12

Offers superior pain control and patient satisfaction compared to nurse-administered opioids.

Question 13

What is the role of Peripheral Nerve Blockade in Orthopedic Surgery?

Answer 13

Enhances pain management, accelerates recovery, and is widely used for ambulatory and inpatient orthopedic procedures.

Question 14

What is Postoperative Ileus?

Answer 14

Delays feeding and is one of the most common causes of prolonged hospital stays, often worsened by opioid use.

Question 15

What is the goal of Perioperative Fluid Management?

Answer 15

To optimize fluid therapy as both excessive and restricted fluid therapy contribute to postoperative ileus.

Question 16

What is the significance of Improved Surgical & Anesthetic Management?

Answer 16

Advances in perioperative care have significantly reduced mortality and morbidity, with ongoing progress depending on integrated, multidisciplinary approaches.

Question 17

What is Team-Based Perioperative Care?

Answer 17

Combining various evidence-based interventions into a coordinated effort leads to synergistic benefits.

Question 18

What are Enhanced Recovery Programs (ERPs)?

Answer 18

Focus on optimizing perioperative care to improve recovery, reduce complications, and lower costs.

Question 19

How does ERP effectiveness manifest?

Answer 19

A well-implemented ERP minimizes variations in clinical management, reduces organ dysfunction, decreases postoperative complications, and accelerates recovery.

Question 20

What is involved in Outcome Assessment for ERPs?

Answer 20

Tracking hospital length of stay, readmission rates, and perioperative complications.

Question 21

What role do anesthetic interventions play in recovery?

Answer 21

Effective anesthesia reduces pain, supports early mobilization, and enables quicker resumption of oral intake.

Question 22

How have Enhanced Recovery Programs evolved?

Answer 22

Originally designed for colorectal and cardiac surgeries, ERPs are now widely used across various major surgical procedures.

Question 23

What is the role of anesthesiologists in the Perioperative Surgical Home?

Answer 23

Anesthesiologists play a key coordinating role, necessitating expanded training in perioperative medicine, pain management, and surgical care integration.

Question 24

What is Persistent Postsurgical Pain (PPSP)?

Answer 24

Chronic pain lasting beyond 1–2 months post-surgery, affecting over 30% of patients after certain procedures.

Question 25

What is recommended as a preventive strategy for PPSP?

Answer 25

Multimodal perioperative pain control.

Question 26

What is the importance of Patient Education in ERPs?

Answer 26

Active participation and clear communication are crucial for effectiveness.

Question 27

What is the benefit of preoperative risk assessment?

Answer 27

Optimizing patient health preoperatively improves surgical recovery.

Question 28

How does smoking cessation impact postoperative outcomes?

Answer 28

Reduces postoperative complications by 41%, especially for wound healing and lung function.

Question 29

What are the guidelines for food and fluid intake before surgery?

Answer 29

Clear fluids allowed up to 2 hours before anesthesia for low-risk patients.

Question 30

What is Antithrombotic Prophylaxis?

Answer 30

Reduces perioperative venous thromboembolism risk and associated mortality.

Question 31

What is the purpose of Antibiotic Prophylaxis?

Answer 31

Preoperative antibiotics reduce surgical site infections (SSIs).

Question 32

What strategies minimize the surgical stress response?

Answer 32

Minimally invasive surgery, maintaining normothermia, neural blockade, and reducing procedural invasiveness.

Question 33

What are the benefits of Minimally Invasive Surgery (MIS)?

Answer 33

Lower stress response, fewer SSIs & surgical complications, less postoperative pain, and better respiratory function.

Question 34

What is the role of Regional Anesthesia/Analgesia Techniques?

Answer 34

Epidural analgesia is effective in major open surgery but may delay recovery in MIS.

Question 35

What are the benefits of Intravenous Lidocaine Infusion?

Answer 35

Analgesic, anti-inflammatory, and opioid-sparing properties.

Question 36

What is β-Blockade Therapy?

Answer 36

Blunts sympathetic stress response during intubation and surgery.

Question 37

What is the effect of α2-Agonist Therapy?

Answer 37

Reduces pain, opioid use, and extends local anesthetic effect.

Question 38

What are the advantages of using short-acting intravenous & inhalation agents?

Answer 38

Preferred for high PONV-risk patients and can reduce recovery costs.

Question 39

What is the significance of maintaining normothermia?

Answer 39

Prevents complications associated with hypothermia.

Question 40

How does oxygen therapy impact surgical stress?

Answer 40

High intraoperative & postoperative oxygen may reduce wound infections and PONV.

Question 41

What is the importance of postoperative nausea and vomiting (PONV) prophylaxis?

Answer 41

Delays recovery and impairs early feeding & postoperative mobilization.

Question 42

What is Goal-Directed Fluid & Hemodynamic Therapy (GDFT)?

Answer 42

Uses noninvasive cardiac output monitoring to guide fluid administration.

Question 43

What strategies minimize postoperative shivering?

Answer 43

Maintaining normothermia is the best strategy.

Question 44

What is the goal of multimodal analgesia?

Answer 44

To use multiple pharmacological mechanisms to reduce opioid use and minimize side effects.

Question 45

What are the risks associated with NSAIDs?

Answer 45

GI & wound bleeding, kidney impairment, and possible anastomotic leaks.

Question 46

What is the role of Acetaminophen in pain management?

Answer 46

Reduces pain & opioid use, and is a safer alternative to NSAIDs.

Question 47

What are Gabapentinoids used for?

Answer 47

Pre-op single dose may reduce postoperative pain.

Question 48

What are the risks associated with certain analgesics?

Answer 48

Risks include GI & wound bleeding, kidney impairment, and possible anastomotic leaks.

Question 49

What are COX-2 inhibitors and their risks?

Answer 49

COX-2 inhibitors (e.g., celecoxib) have fewer GI effects but pose uncertain kidney & cardiovascular risks.

Question 50

What is the role of Acetaminophen (Paracetamol) in pain management?

Answer 50

Acetaminophen reduces pain & opioid use but is less effective than NSAIDs. It is a safer alternative to NSAIDs and can be used routinely in ERPs.

Question 51

How do Gabapentinoids affect post-operative pain?

Answer 51

Pre-op single dose of Gabapentinoids (Gabapentin & Pregabalin) may reduce post-op pain & opioid needs, especially in the first 24 hours. ## Footnote Risks include sedation, dizziness, and increased fall risk, especially in elderly patients.

Question 52

What is the effect of NMDA Receptor Antagonists like Ketamine and Magnesium?

Answer 52

Ketamine reduces pain, opioid needs, and PONV, especially useful for chronic opioid users. Magnesium may reduce post-op pain and opioid use but has uncertain optimal dosing. ## Footnote Risks include hypotension & neuromuscular blockade potentiation.

Question 53

What are the benefits of Intravenous Lidocaine Infusion?

Answer 53

It is effective for multimodal analgesia, especially in major abdominal surgery, leading to faster return of bowel function & shorter hospital stay. ## Footnote Requires monitoring, but newer protocols allow safe use in surgical wards.

Question 54

What is the role of Opioids in pain management?

Answer 54

Opioids are essential for severe pain, but efforts are made to reduce use. Patient-Controlled Analgesia (PCA) is preferred over PRN Opioids for better pain control and fewer side effects.

Question 55

What is the advantage of Epidural Analgesia?

Answer 55

Epidural Analgesia is best for open abdominal & thoracic surgery as it blunts stress response and reduces complications. ## Footnote It is less useful for minimally invasive surgery and thoracic epidurals are preferred over lumbar epidurals.

Question 56

What are Paravertebral & Truncal Nerve Blocks?

Answer 56

They are effective alternatives to epidural anesthesia and lower the risk of epidural-related complications.

Question 57

How does Peripheral Nerve Blockade assist in recovery?

Answer 57

It is frequently used in orthopedic surgery for fast-track recovery and has an opioid-sparing effect that helps reduce PONV and respiratory depression.

Question 58

What is the purpose of Local Anesthetic Wound Infiltration & Infusion?

Answer 58

Used in total joint replacement surgery as an alternative to nerve blocks, it reduces opioid needs, especially in open abdominal surgery.

Question 59

What is the effect of Intraperitoneal Local Anesthetic Instillation & Nebulization?

Answer 59

It reduces pain & opioid use in abdominal and laparoscopic surgery.

Question 60

What strategies facilitate recovery on the surgical unit?

Answer 60

Standardized, procedure-specific protocols should involve a multidisciplinary team including surgeons, anesthesiologists, nurses, physiotherapists, nutritionists, pharmacists, and case managers.

Question 61

What is encouraged for early mobilization post-surgery?

Answer 61

Provide chairs and walkers near beds, avoid routine bed rest, and encourage sitting & walking within 24 hours post-op.

Question 62

What is the goal of optimizing analgesia for functional recovery?

Answer 62

The goal is to keep patients comfortable for mobilization and physiotherapy with minimal side effects, as opioid-related PONV & ileus are leading causes of prolonged hospital stay.

Question 63

What are the causes of post-operative ileus?

Answer 63

Causes include sympathetic inhibitory reflexes, local inflammation from surgery, systemic opioid use, and bowel edema from excessive IV fluids.

Question 64

What are the prevention & treatment strategies for post-op ileus?

Answer 64

Avoid Nasogastric Tubes, use Minimally Invasive Surgery, Thoracic Epidural Analgesia, Laxatives, and consider Opioid μ-Receptor Antagonists. ## Footnote Opioid μ-Receptor Antagonists reduce opioid-related bowel dysfunction and are more effective for open surgery than minimally invasive surgery.

Question 65

What is Goal-Directed Fluid Therapy (GDFT)?

Answer 65

GDFT avoids excessive or restricted fluid therapy, maintaining optimal tissue perfusion and reducing bowel edema & ileus risk.