Enhanced Recovery After Surgery (ERAS) Protocols — MCQs
Method followed to decrease post-op infection in cataract surgery:
During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
Postoperative third-space accumulation should be managed by intravenous fluid with
What is the primary aim of performing an abbreviated laparotomy in trauma surgery?
When do we have to start antibiotics to prevent post-operative infection?
On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :
Early movement following surgery for ankylosis is
What type of respiratory failure is most commonly observed in post-operative patients?
A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?
A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :
Enhanced Recovery After Surgery (ERAS) Protocols Indian Medical PG Practice Questions and MCQs
Question 1: Method followed to decrease post-op infection in cataract surgery:
- A. Topical antibiotics and sterile draping
- B. Topical antibiotics alone
- C. Topical antibiotics and sterile instruments
- D. Intracameral antibiotics and betadine wash (Correct Answer)
Explanation: ***Intracameral antibiotics and betadine wash*** - **Intracameral antibiotics** (e.g., cefuroxime, moxifloxacin) directly target the anterior chamber during surgery, effectively reducing the risk of **endophthalmitis**. - A **betadine (povidone-iodine) wash** of the ocular surface preoperatively significantly reduces bacterial load, preventing introduction of microbes into the surgical field. *Topical antibiotics and sterile draping* - While **topical antibiotics** are important, they may not achieve sufficient intraocular concentrations to prevent deep infection effectively. - **Sterile draping** is essential for maintaining a sterile field but does not address potential intrinsic bacterial flora on the conjunctiva or adnexa as thoroughly as a betadine wash. *Topical antibiotics alone* - **Topical antibiotics** alone are often insufficient to prevent **intraocular infections** because they may not penetrate the eye adequately to eradicate all pathogens. - This approach lacks the comprehensive germicidal action of a **betadine wash** on the ocular surface and the direct intraocular effect of intracameral antibiotics. *Topical antibiotics and sterile instruments* - **Sterile instruments** are a fundamental and non-negotiable part of any surgical procedure to prevent infection from external sources. - However, relying solely on **topical antibiotics** and sterile instruments overlooks the importance of reducing the patient's own **periocular bacterial flora** (addressed by betadine wash) and directly treating potential intraocular contamination (addressed by intracameral antibiotics).
Question 2: During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
- A. Liver
- B. Parietal peritoneum (Correct Answer)
- C. Intestines
- D. Visceral peritoneum
Explanation: ***Parietal peritoneum*** - The **parietal peritoneum** is richly innervated by somatic nerves (**spinal nerves**), making it highly sensitive to pain, pressure, and temperature. - When stimulated during surgery, even under local anesthesia which might not completely block deeper somatic nerves or if the local block is inadequate, it can cause the patient to suddenly feel **sharp, localized pain**. *Liver* - The liver itself has very few pain receptors in its parenchyma; pain from the liver typically arises from stretching of its fibrous capsule (**Glisson's capsule**). - This pain is usually dull and poorly localized, not the sudden, sharp pain typically experienced during surgical manipulation. *Intestines* - The intestines are primarily innervated by the **autonomic nervous system** and are sensitive to distension and ischemia, causing visceral pain, which is typically dull, crampy, and poorly localized. - They are generally not sensitive to cutting or burning, which are common surgical manipulations. *Visceral peritoneum* - The **visceral peritoneum** covers abdominal organs and is innervated by the autonomic nervous system, similar to the organs it covers. - Like the intestines, it is sensitive to stretch and ischemia, producing diffuse, poorly localized visceral pain rather than sharp, localized pain from surgical incision or manipulation.
Question 3: Postoperative third-space accumulation should be managed by intravenous fluid with
- A. Albumin
- B. Normal saline (Correct Answer)
- C. Fluid restriction
- D. Dextrose in water
Explanation: ***Normal saline*** - **Third-space accumulation** leads to fluid shifts from the intravascular space to the interstitial space, commonly seen after trauma or surgery, resulting in **hypovolemia**. - **Isotonic solutions** like normal saline help replenish the lost intravascular volume and maintain blood pressure without shifting more fluid into the third space. *Albumin* - While albumin can increase oncotic pressure and draw fluid back into the intravascular space, it is typically reserved for cases of **severe hypoalbuminemia** or when crystalloids alone are insufficient. - Using albumin in the setting of acute third-space loss without clear indications of hypoalbuminemia may not be the initial or most appropriate intervention. *Fluid restriction* - **Fluid restriction** would worsen the patient's hypovolemia as third-space losses deplete the effective circulating volume of the patient. - This approach is appropriate for conditions like **heart failure** or **SIADH**, where there is true fluid excess or impaired excretion, not for hypovolemic states due to fluid shifts. *Dextrose in water* - Dextrose in water is a **hypotonic solution** that would rapidly distribute into the intracellular and interstitial compartments and may contribute to worsening edema in the third space. - It does not effectively expand intravascular volume and can lead to **hyponatremia** if administered in large quantities.
Question 4: What is the primary aim of performing an abbreviated laparotomy in trauma surgery?
- A. Definitive repair of all injuries
- B. Reduction of contamination
- C. Rapid stabilization of the patient
- D. Haemostasis (Correct Answer)
Explanation: ***Haemostasis*** - The primary aim of abbreviated laparotomy (damage control surgery) is to achieve **rapid control of life-threatening hemorrhage**. - This involves temporary measures to stop bleeding from major vessels and solid organ injuries, preventing exsanguination and further physiological deterioration. - **Damage control prioritizes hemorrhage control over definitive repair**, using techniques like packing, shunts, and temporary vessel ligation. *Definitive repair of all injuries* - This is specifically **NOT** the goal of abbreviated laparotomy. - Definitive repairs are **delayed** until the patient is physiologically stable (after resuscitation in ICU). - Attempting complete repair in an unstable patient leads to the "lethal triad" (hypothermia, acidosis, coagulopathy). *Reduction of contamination* - While contamination control is an **important component** of damage control surgery, it is typically **secondary to hemorrhage control**. - The sequence prioritizes stopping bleeding first, then controlling contamination from bowel injuries. *Rapid stabilization of the patient* - This is the **overall goal** of damage control surgery but not the specific primary aim of the laparotomy itself. - Stabilization is achieved **through** specific interventions during the abbreviated laparotomy, primarily haemostasis and contamination control.
Question 5: 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 6: 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 7: Early movement following surgery for ankylosis is
- A. Desirable (Correct Answer)
- B. Harmful
- C. Indicated only when ankylosis is one sided
- D. Unimportant
Explanation: ***Desirable*** - Early movement following surgery for **ankylosis** is crucial for preventing **re-ankylosis** and promoting the formation of a **neocartilage-like layer**. - It helps maintain joint mobility, reduce stiffness, and improves long-term functional outcomes after procedures like **arthroplasty**. *Harmful* - Delays in movement can lead to increased fibrous tissue formation, limiting the newly created joint's mobility and potentially causing **re-ankylosis**. - Prolonged immobilization after joint surgery can also lead to muscle atrophy, contractures, and impaired circulation, hindering recovery. *Indicated only when ankylosis is one sided* - The principle of early movement applies to both **unilateral** and **bilateral ankylosis** to prevent recurrence and improve range of motion in the affected joint(s). - Focusing solely on unilateral cases overlooks the functional benefits of early mobilization for all patients undergoing such surgery. *Unimportant* - Early movement is a **critical component** of postoperative recovery, as it directly impacts the success of the surgical intervention by maintaining joint space and flexibility. - Neglecting early motion can compromise the surgical outcome, increasing the risk of stiffness, pain, and the need for further interventions.
Question 8: What type of respiratory failure is most commonly observed in post-operative patients?
- A. Hypercapnic respiratory failure
- B. Mixed respiratory failure
- C. Perioperative respiratory failure
- D. Hypoxemic respiratory failure (Correct Answer)
Explanation: ***Hypoxemic respiratory failure*** - **Hypoxemic respiratory failure** (Type I) is characterized by a **PaO2 less than 60 mmHg** with a normal or low PaCO2, often due to **V/Q mismatch** and **shunt**. - Post-operative patients frequently develop **atelectasis**, **pneumonia**, or **pulmonary edema**, leading to impaired gas exchange and reduced oxygenation. - This is the **most commonly observed type** in the immediate post-operative period. *Hypercapnic respiratory failure* - **Hypercapnic respiratory failure** (Type II) is primarily due to **alveolar hypoventilation**, resulting in a **PaCO2 greater than 50 mmHg**. - While it can occur post-operatively, it is less common than hypoxemic failure and is typically seen with significant **sedation**, **neuromuscular blockade**, or severe **obstructive lung disease**. *Mixed respiratory failure* - **Mixed respiratory failure** involves both **hypoxemia** and **hypercapnia**, indicating severe impairment in both oxygenation and ventilation. - Although it can occur in severe post-operative complications, it is not the *most commonly observed initial presentation* compared to isolated hypoxemia. *Perioperative respiratory failure* - **Perioperative respiratory failure** (Type III) occurs specifically in the surgical setting and involves atelectasis from changes in chest wall mechanics. - While this occurs in the post-operative context, the term is less commonly used, and the **underlying mechanism is primarily hypoxemic** in nature.
Question 9: A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?
- A. Pulmonary embolism (Correct Answer)
- B. Cardiac tamponade
- C. Acute MI
- D. Hypotensive shock
Explanation: ***Pulmonary embolism*** - Postoperative state, sudden onset of **breathlessness**, and **chest pain** are classic symptoms of pulmonary embolism (PE). - **Right ventricular dilatation** and **tricuspid regurgitation** on echocardiography are strong indicators of acute right heart strain due to increased pulmonary artery pressure caused by the embolus. *Cardiac tamponade* - Characterized by muffled heart sounds, **pulsus paradoxus**, and **hypotension**, often due to fluid accumulation in the pericardial sac. - While it can cause breathlessness, the echocardiographic findings of **right ventricular dilatation** and **tricuspid regurgitation** are not typical of tamponade. *Acute MI* - Myocardial infarction typically presents with ischemic chest pain, often radiating, and is primarily diagnosed by **ECG changes** and **cardiac enzymes**. - While acute MI can cause breathlessness, the combination of a postoperative setting and the specific echocardiographic findings of **right heart strain** points away from an initial diagnosis of MI. *Hypotensive shock* - Hypotensive shock is a state of severe low blood pressure leading to organ hypoperfusion, with various underlying causes. - While PE can *lead to* hypotensive shock due to hemodynamic compromise, the question describes the specific pathology (right heart strain) rather than just the resultant shock state.
Question 10: A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :
- A. Myocardial failure due to fluid overload
- B. Deep vein thrombosis (Correct Answer)
- C. Oedema of renal failure
- D. Hypoproteinaemia
Explanation: ***Deep vein thrombosis*** - Postoperative patients, especially those undergoing **abdominal surgery** and those with **malnutrition**, are at high risk for **deep vein thrombosis (DVT)** due to Virchow's triad (venous stasis, endothelial injury, hypercoagulability). - A **painful calf swelling** is a classic symptom of DVT, indicating clot formation within the deep veins of the leg. *Myocardial failure due to fluid overload* - While fluid overload can occur post-surgery, it typically leads to **generalized edema**, shortness of breath, and signs of cardiac dysfunction, not isolated painful calf swelling. - The primary presentation here is a localized, painful swelling, which is less consistent with systemic cardiac issues. *Oedema of renal failure* - **Renal failure** can cause **edema**, but it tends to be **pitting, bilateral, and generalized**, often affecting the ankles and sacral areas. - It would not typically present as a painful, unilateral calf swelling without other signs of kidney dysfunction. *Hypoproteinaemia* - **Hypoproteinaemia**, common in **malnourished** individuals, can cause **generalized non-pitting edema** due to decreased oncotic pressure, not specifically a painful calf swelling. - It would manifest as widespread edema rather than a localized, painful swelling indicative of a thrombotic event.
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