Enhanced Recovery Protocols — MCQs

10 questions

A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

After a major oral surgery, the acute catabolic phase lasts for?

When do we have to start antibiotics to prevent post-operative infection?

What is the treatment of choice for a post-operative abscess?

In surgical stress all hormones are increased except:

Which of the following statements is NOT correct regarding total parenteral nutrition (TPN)?

In emergency caesarian section rapid induction of anaesthesia is done to –

On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

Which is not a feature of SIADH?

Q10

A hospital is implementing a protocol to reduce perioperative pulmonary complications in high-risk patients undergoing major abdominal surgery. Based on current evidence, which combination of interventions would provide the greatest benefit?

Enhanced Recovery Protocols Indian Medical PG Practice Questions and MCQs

Question 1: A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

A. Postoperative administration for 5 to 7 days of parenteral antibiotics effective against aerobes and anaerobes
B. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes may provide initial coverage. (Correct Answer)
C. Postoperative administration for 2 to 4 days of parenteral antibiotics effective against aerobes and anaerobes
D. Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile

Explanation: ***Single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes*** - For **elective colorectal surgery**, a single dose of a **broad-spectrum parenteral antibiotic** administered within 60 minutes prior to incision is the standard of care to reduce surgical site infections. - This approach ensures adequate drug levels in the tissues during the period of potential bacterial contamination and is a cornerstone of modern surgical prophylaxis. - Current guidelines (WHO, SCIP) recommend a single preoperative dose, which may be redosed intraoperatively if the procedure is prolonged beyond 3-4 hours. *Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile* - This is **incorrect**. **Oral antibiotics** (such as neomycin and metronidazole) are routinely used preoperatively in conjunction with mechanical bowel preparation for colorectal surgery to reduce intraluminal bacterial load. - The concern for *Clostridioides difficile* infection is generally low with short-term, targeted prophylactic antibiotic regimens compared to broad-spectrum, prolonged use. - The combination of oral and parenteral antibiotics has been shown to further reduce surgical site infections. *Postoperative administration for 5 to 7 days of parenteral antibiotics* - **Prolonged postoperative antibiotic administration** beyond 24 hours in uncomplicated cases is not recommended as it increases the risk of **antibiotic resistance**, *C. difficile* infection, and adverse drug reactions without additional benefit. - The goal of prophylactic antibiotics is to cover the period of contamination during surgery, not to treat presumed ongoing infection postoperatively. *Postoperative administration for 2 to 4 days of parenteral antibiotics* - While administration for up to 24 hours post-operatively may be considered in some high-risk cases, routine **prolonged postoperative antibiotics** (2-4 days) are unnecessary for most elective colorectal resections. - Evidence suggests that continuing antibiotics beyond the immediate perioperative period does not further reduce the incidence of **surgical site infections** in clean-contaminated surgeries.

Question 2: After a major oral surgery, the acute catabolic phase lasts for?

A. 1-2 days
B. 2-5 days (Correct Answer)
C. 4-7 days
D. 5-10 days

Explanation: ***2-5 days*** - The **acute catabolic phase** following major surgery, including oral surgery, typically lasts for **2 to 5 days**. - During this phase, the body mobilizes energy stores and protein to cope with surgical stress, leading to a net loss of lean body mass. *1-2 days* - This timeframe represents the **immediate post-operative period**, but the acute catabolic response often extends beyond 1-2 days. - While some catabolic changes begin immediately, the peak catabolic phase usually occurs slightly later. *4-7 days* - While some catabolic effects might still be present, the most intense **acute catabolic phase** usually starts to subside by day 4 or 5. - This period often marks the transition towards the **adaptive phase** of recovery. *5-10 days* - By this point, the patient is generally entering the **adaptive or anabolic phase** of recovery, where the body begins to rebuild tissues and restore energy reserves. - The most acute catabolic processes have significantly diminished.

Question 3: When do we have to start antibiotics to prevent post-operative infection?

A. 1 week before surgery
B. 2 days before surgery
C. After surgery
D. 30-60 minutes before incision (up to 24 hours post-op) (Correct Answer)

Explanation: ***30-60 minutes before incision (up to 24 hours post-op)*** - Surgical antibiotic prophylaxis (SAP) should be administered **30-60 minutes before surgical incision** to ensure adequate tissue and serum concentrations at the time of incision. - This timing allows optimal drug distribution to surgical tissues, which is crucial for preventing surgical site infections (SSIs). - For most clean and clean-contaminated surgeries, prophylaxis should be limited to a **single dose** or continued for **maximum 24 hours post-operatively** as per WHO and CDC guidelines. - Prolonged post-operative antibiotics beyond 24 hours do **not** reduce infection rates and increase the risk of **antibiotic resistance** and **adverse effects**. *1 week before surgery* - Administering antibiotics this far in advance is **unnecessary** and **ineffective** for surgical prophylaxis. - It increases the risk of **antibiotic resistance** and does not guarantee adequate drug levels at the time of incision. - Pre-operative antibiotic use should be avoided unless treating an active infection. *2 days before surgery* - This timeframe is too early to achieve prophylactic benefit during the surgical procedure. - Prolonged pre-operative use promotes **bacterial resistance** without providing additional protection. - Drug levels will not be optimal at the time of incision due to metabolism and excretion. *After surgery* - Starting antibiotics **after surgical incision** is **too late** for prophylaxis as contamination has already occurred. - Post-operative initiation is considered **therapeutic treatment** for established infection, not prevention. - The critical window for prophylaxis is the period from skin incision to wound closure.

Question 4: What is the treatment of choice for a post-operative abscess?

A. Hydration
B. IV antibiotics
C. Image guided aspiration (Correct Answer)
D. Reexploration

Explanation: ***Image-guided aspiration*** - This is often the **first-line treatment** for a post-operative abscess, especially if it is well-localized. - It involves **draining the pus** under imaging guidance, relieving pressure and removing the infectious material. *Hydration* - While important for overall patient management, especially in cases of infection or sepsis, **hydration alone does not treat an abscess**. - It is a supportive measure but does not address the **localized collection of pus**. *IV antibiotics* - Antibiotics are typically indicated as an **adjunct to drainage**, especially in cases of systemic infection or cellulitis. - However, **antibiotics alone are often insufficient** to resolve an abscess as they have difficulty penetrating the necrotic core and thick capsule. *Reexploration* - **Surgical reexploration** is a more invasive option usually reserved for abscesses that are **large, multiloculated, not amenable to percutaneous drainage**, or when initial drainage attempts fail. - It carries greater risks and is not the initial treatment of choice for every post-operative abscess.

Question 5: In surgical stress all hormones are increased except:

A. Insulin (Correct Answer)
B. Epinephrine
C. ACTH
D. Cortisol

Explanation: ***Insulin*** - While other **stress hormones** increase, **insulin** levels typically **decrease** or remain stable due to increased **insulin resistance** during surgical stress. - This physiological response aims to maintain **blood glucose** levels for energy during heightened metabolic demands. *Epinephrine* - **Epinephrine** (adrenaline) is a key **catecholamine** released during surgical stress, leading to a "fight or flight" response. - It increases **heart rate**, **blood pressure**, and promotes **gluconeogenesis** to supply quick energy. *ACTH* - **Adrenocorticotropic hormone (ACTH)** is released from the **pituitary gland** in response to surgical stress. - **ACTH** stimulates the adrenal cortex to produce **cortisol**, a critical stress hormone. *Cortisol* - **Cortisol** levels significantly rise during surgical stress, mediated by **ACTH** release. - It plays a crucial role in **modulating inflammation**, **glucose metabolism**, and maintaining **hemodynamic stability**.

Question 6: Which of the following statements is NOT correct regarding total parenteral nutrition (TPN)?

A. Lipids form 20-30% of energy source
B. Carbohydrates typically provide 40-60% of the energy source
C. In abdominal injury, early parenteral nutrition should be started after a minimum of 2 weeks of bowel rest (Correct Answer)
D. Proteins typically provide around 10-15% of the energy source

Explanation: ***In abdominal injury, early parenteral nutrition should be started after a minimum of 2 weeks of bowel rest*** - This statement is incorrect because, in cases of abdominal injury where enteral nutrition is not feasible, **early parenteral nutrition** (usually within 3-7 days) is often initiated to prevent **malnutrition** and improve patient outcomes. Prolonged bowel rest without nutritional support can lead to significant catabolism and poor healing. - While bowel rest may be necessary, it does not typically extend for two weeks before considering TPN if nutritional needs cannot be met enterally or peripherally. *Early nutritional support* is crucial, even if it requires TPN. *Carbohydrates typically provide 40-60% of the energy source.* - This statement is generally correct, as **carbohydrates** (dextrose) are the primary energy source in TPN formulations, typically providing **40-60% of total calories**. - This ensures adequate glucose supply to meet the body's metabolic demands, especially for obligate glucose users like the brain. *Lipids form 20-30% of energy source* - This statement is generally correct, as **lipids** ( intravenous fat emulsions) are included in TPN to provide essential fatty acids and a concentrated source of calories, typically contributing **20-30% of the total energy**. - Lipids also help to reduce the amount of dextrose required, potentially mitigating **hyperglycemia** and liver complications. *Proteins typically provide around 10-15% of the energy source.* - This statement is generally correct, as **proteins** (amino acids) are essential for tissue repair, immune function, and maintaining lean body mass, typically providing **10-15% of the total energy** in TPN. - The precise amount depends on the patient's individual protein requirements, which can be higher in critically ill or hypercatabolic states.

Question 7: In emergency caesarian section rapid induction of anaesthesia is done to –

A. Prevent gastric aspiration (Correct Answer)
B. Prevent fetal depression
C. All of the above
D. To decrease awareness

Explanation: ***Prevent gastric aspiration*** - Rapid sequence induction is crucial in emergency cesarean sections to minimize the risk of **pulmonary aspiration of gastric contents**. - Pregnant women are at increased risk due to **delayed gastric emptying**, increased intra-abdominal pressure, and a less competent gastroesophageal sphincter. *Prevent fetal depression* - While anesthetic agents can cross the placenta and cause fetal depression, rapid induction is primarily aimed at maternal safety through aspiration prevention, not solely preventing fetal effects. - The choice of anesthetic agents and their dosage is carefully managed to minimize fetal exposure and depression. *All of the above* - This option is incorrect because while preventing fetal depression is a concern, the primary and most immediate reason for rapid induction in an emergency C-section is to prevent **maternal gastric aspiration**. - Rapid induction techniques expedite intubation, limiting the time for regurgitation and aspiration. *To decrease awareness* - Preventing awareness during anesthesia is a goal in any surgical procedure, but standard induction methods are also effective for this. - Rapid induction's specific advantage in this context is the prevention of **aspiration**, not primarily to reduce awareness, which can be accomplished with slower inductions as well.

Question 8: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

A. Send for USG abdomen
B. Start treatments for peritonitis
C. IV fluids
D. Dressing of wound & observe for dehiscence (Correct Answer)

Explanation: ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.

Question 9: Which is not a feature of SIADH?

A. Urine Osmolality > 100 mosm/ kg
B. Treatment is fluid restriction
C. Low urine sodium (Correct Answer)
D. Euvolemia

Explanation: ***Low urine sodium*** - **SIADH** is characterized by excessive **ADH release**, leading to **water retention** and **dilutional hyponatremia** [1]. - In response to decreased effective circulating volume and concentrated urine, the kidneys excrete a relatively high amount of sodium, typically **urine sodium > 40 mEq/L**. *Urine Osmolality > 100 mosm/ kg* - In SIADH, the excess **ADH** causes the kidneys to retain water, leading to the production of **concentrated urine** despite plasma hypo-osmolality [1]. - A **urine osmolality > 100 mOsm/kg H2O** is a diagnostic criterion, reflecting this inappropriate water retention. *Treatment is fluid restriction* - The primary treatment for SIADH is **fluid restriction**, which helps to reduce water intake and correct the **dilutional hyponatremia**. - This intervention aims to achieve a negative water balance and gradually increase serum sodium concentration. *Euvolemia* - Despite significant water retention and hyponatremia, patients with SIADH are typically **euvolemic** (normal fluid volume status) [1]. - The excess water is primarily distributed intracellularly and interstitially, without causing overt edema or dehydration.

Question 10: A hospital is implementing a protocol to reduce perioperative pulmonary complications in high-risk patients undergoing major abdominal surgery. Based on current evidence, which combination of interventions would provide the greatest benefit?

A. Preoperative spirometry, postoperative incentive spirometry, early mobilization
B. Smoking cessation >8 weeks prior, lung expansion maneuvers, epidural analgesia (Correct Answer)
C. Prophylactic bronchodilators, routine chest physiotherapy, supplemental oxygen
D. Preoperative antibiotics, deep breathing exercises, prolonged mechanical ventilation

Explanation: ***Smoking cessation >8 weeks prior, lung expansion maneuvers, epidural analgesia*** - **Smoking cessation** must occur at least **8 weeks** before surgery to effectively reduce the risk of pulmonary complications to baseline levels; shorter periods may actually increase secretion production [1]. - **Epidural analgesia** provides superior pain control for abdominal surgery, which facilitates better **respiratory effort** and prevents the diaphragm dysfunction that leads to atelectasis. *Preoperative spirometry, postoperative incentive spirometry, early mobilization* - While early mobilization is beneficial, **preoperative spirometry** is a diagnostic tool used for **risk stratification** rather than an intervention that actively reduces postoperative complications. - **Incentive spirometry** alone is generally not superior to deep breathing exercises and must be part of a broader lung expansion protocol to be effective. *Prophylactic bronchodilators, routine chest physiotherapy, supplemental oxygen* - **Prophylactic bronchodilators** are not recommended for all patients and should only be used in patients with specific underlying conditions like **COPD** or **Asthma** [1]. - **Routine chest physiotherapy** has not consistently demonstrated a significant reduction in **postoperative pulmonary complications (PPCs)** for general high-risk abdominal surgery patients. *Preoperative antibiotics, deep breathing exercises, prolonged mechanical ventilation* - **Prolonged mechanical ventilation** is actually a risk factor for **ventilator-associated pneumonia** and other lung injuries, rather than a preventive strategy [2]. - While **deep breathing exercises** are helpful, they are outweighed here by the risks associated with unnecessary mechanical ventilation and the lack of systemic evidence for routine **preoperative antibiotics** specifically for PPC prevention [3].

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