Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery (ERAS) Indian Medical PG 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

Enhanced Recovery After Surgery (ERAS) 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.

Enhanced Recovery After Surgery (ERAS) Indian Medical PG Question 2: Match List-I with List-II and select the correct answer using the code given below the Lists:

• A. A→1 B→2 C→4 D→3
• B. A→3 B→2 C→4 D→1
• C. A→3 B→4 C→2 D→1 (Correct Answer)
• D. A→1 B→4 C→2 D→3

Enhanced Recovery After Surgery (ERAS) Explanation: ***Correct Answer: A→3, B→4, C→2, D→1*** **Understanding Health Education Methods:** **A. Symposium → 3. Series of speeches** - A symposium is a formal meeting where multiple experts deliver **sequential speeches** on different aspects of a selected subject - Each speaker presents their perspective, typically without much interaction between speakers during the presentation **B. Panel Discussion → 4. Discussion among the speakers** - A panel involves **interactive discussion among panelists** (experts) on a particular topic - Characterized by dialogue and exchange of views between speakers, often followed by audience questions **C. Workshop → 2. Arriving at a plan of action** - A workshop is a **participatory, problem-solving session** designed to achieve practical outcomes - Participants actively engage in exercises and activities to develop concrete action plans or solutions **D. Role-play → 1. Dramatizing a situation** - Role-play involves **acting out scenarios** to experience different perspectives - Participants assume roles and dramatize situations to understand behaviors, emotions, and decision-making processes *Key Differentiation:* - Symposium = One-way presentations (speakers → audience) - Panel = Two-way discussion (speakers ↔ speakers) - Workshop = Participatory action planning - Role-play = Experiential learning through dramatization

Enhanced Recovery After Surgery (ERAS) Indian Medical PG Question 3: Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?

• A. Green
• B. Yellow (Correct Answer)
• C. Blue
• D. Black

Enhanced Recovery After Surgery (ERAS) Explanation: ***Yellow*** - Patients in the **yellow category** are those who require **significant medical attention** and intervention, such as surgery, but whose condition is stable enough to withstand a delay of a few hours up to 24 hours without immediate threat to life or limb. - This category indicates a **delayed but urgent need** for treatment, distinguishing them from immediate (red) or minor (green) cases. *Blue* - The color **blue** is generally **not a standard triage category** in most commonly used disaster protocols (e.g., START, JumpSTART). - Triage systems typically use red, yellow, green, and black to prioritize patients based on immediate medical need and prognosis. *Green* - The **green category** is for patients with **minor injuries** who are considered "walking wounded" and can often wait for treatment for several hours, sometimes up to a few days. - These individuals are **stable** and do not require immediate intervention to preserve life or limb. *Black* - The **black category** is reserved for individuals who are **deceased** or have injuries so severe that survival is unlikely given the available resources, often implying **palliative care** rather than active life-saving interventions in a mass casualty event. - This category signifies that resources would be better allocated to patients with a higher chance of survival.

Enhanced Recovery After Surgery (ERAS) Indian Medical PG Question 4: Which among the following is not used in post laryngectomy rehabilitation?

• A. Tracheostomy tube (Correct Answer)
• B. Esophageal speech
• C. Tracheoesophageal puncture
• D. Electrolarynx

Enhanced Recovery After Surgery (ERAS) Explanation: ***Tracheostomy tube*** - Following total laryngectomy, the **trachea is permanently diverted** to form a permanent stoma in the neck for breathing. - In the context of **post-laryngectomy rehabilitation**, the focus is on **voice restoration** methods rather than airway management devices. - While laryngectomy tubes or stoma buttons may be used temporarily for **stoma care** (preventing stenosis, maintaining patency), traditional **tracheostomy tubes are not part of voice rehabilitation** protocols. - The patient breathes directly through the permanent stoma, and rehabilitation centers on restoring communication ability. *Esophageal speech* - **Esophageal speech** is a voice rehabilitation method where air is injected into the esophagus and then expelled, vibrating the pharyngoesophageal segment to produce sound. - It requires no external devices, only extensive training, and can provide functional voice for communication. - This is one of the **three main voice restoration options** after laryngectomy. *Tracheoesophageal puncture* - **Tracheoesophageal puncture (TEP)** with voice prosthesis is the **gold standard** for voice rehabilitation post-laryngectomy. - A small fistula is created between trachea and esophagus, and a one-way valve (voice prosthesis) is inserted. - Air from the lungs is diverted through the prosthesis into the esophagus, vibrating the pharyngoesophageal segment to produce speech. - Provides the **most natural-sounding voice** among rehabilitation options. *Electrolarynx* - An **electrolarynx** is an external, battery-operated device held against the neck or placed intraorally that generates vibrations. - The vibrations are articulated by the mouth and tongue to produce speech. - Provides **immediate communication** post-laryngectomy, though the voice quality is mechanical or robotic.

Enhanced Recovery After Surgery (ERAS) Indian Medical PG Question 5: What is the treatment of choice for a post-operative abscess?

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

Enhanced Recovery After Surgery (ERAS) 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.

Enhanced Recovery After Surgery (ERAS) Flashcard 1 of 4

Question: A patient in sepsis, DIC, ARDS would be classified under ASA _____

Answer: IV

Enhanced Recovery After Surgery (ERAS) Flashcard 2 of 4

Question: _____ lowers IOP to levels lower than those achieved with other agents.

Answer: Sevoflurane (general anesthetic)

Enhanced Recovery After Surgery (ERAS) Flashcard 3 of 4

Question: A patient undergoing regular scheduled dialysis would be classified under ASA _____

Answer: III

Enhanced Recovery After Surgery (ERAS) Flashcard 4 of 4

Question: A patient who is not expected to survive without the operation would be classified under ASA _____

Answer: V