Enhanced Recovery After Surgery (ERAS) Practice Questions

Q: A 60-year-old diabetic patient scheduled for major abdominal surgery under ERAS protocol. Morning fasting blood sugar is 180 mg/dL. What is the most appropriate approach regarding preoperative carbohydrate loading?

Skip carbohydrate loading and maintain standard fasting. ***Skip carbohydrate loading and maintain standard fasting*** - In diabetic patients with elevated **fasting blood sugar (>180 mg/dL)**, preoperative **carbohydrate loading** is contraindicated due to the risk of worsening **perioperative hyperglycemia**. - While **ERAS protocols** are beneficial, the carbohydrate drink portion is typically omitted in diabetics to avoid unpredictable glycemic spikes and potential **gastroparesis-related** aspiration risks. *Proceed with standard carbohydrate loading as per protocol* - Standard loading involves high-maltodextrin drinks which can cause severe **hyperglycemic excursions** in a diabetic patient already at 180 mg/dL. - **Insulin resistance** is a hallmark of diabetes, making the physiological goal of the drink (reducing post-surgery insulin resistance) less effective compared to the risks of acute glucose elevation. *Postpone surgery until sugar is controlled below 120 mg/dL* - Routine major surgery does not usually require a fasting glucose **below 120 mg/dL**; targets are generally more lenient (e.g., <180 mg/dL) to avoid **hypoglycemia**. - Postponing surgery for a single reading of 180 mg/dL is unnecessary unless there is evidence of acute decompensation like **Diabetic Ketoacidosis (DKA)**. *Give half dose of carbohydrate loading with insulin coverage* - Attempting to "cover" a carbohydrate load with **bolus insulin** preoperatively increases the risk of **intraoperative hypoglycemia**, which is more dangerous than skipping the drink. - There is currently no standardized medical evidence or **ERAS guideline** supporting a "half-dose" strategy for diabetic patients with high baseline sugars.

Q: According to ERAS guidelines, what is the recommended timing for clear fluid intake before elective surgery?

2 hours. ***2 hours*** - **ERAS (Enhanced Recovery After Surgery)** guidelines allow consumption of **clear fluids** up to **2 hours** before the induction of anesthesia to reduce patient thirst and metabolic stress. - This practice helps minimize **postoperative insulin resistance** and does not increase the risk of pulmonary **aspiration** compared to strict fasting. *12 hours* - Traditional **"nil per os" (NPO)** orders from midnight resulted in prolonged fasting periods often exceeding 12 hours, which is now considered obsolete. - Excessive fasting causes **hypoglycemia**, dehydration, and a catabolic state that can delay **post-surgical recovery**. *8 hours* - An 8-hour window is much longer than the physiological requirements for **gastric emptying** of clear liquids, which is typically under 1 hour. - Maintaining an 8-hour fast for fluids leads to unnecessary **discomfort** and provides no additional safety benefit over the current guidelines. *6 hours* - The **6-hour** limit is the standard ERAS and ASA recommendation for a **light meal** or non-human milk, rather than clear liquids. - Restricting clear fluids for 6 hours is unnecessarily restrictive and can lead to **dehydration** and increased preoperative anxiety.

Question 1

A 45-year-old patient underwent laparoscopic cholecystectomy following ERAS protocol. Postoperatively, the patient received multimodal analgesia with paracetamol, NSAIDs, and local anesthetic infiltration but still reports pain score of 7/10. Opioid consumption has been minimal. Which aspect of ERAS multimodal analgesia was likely inadequate in this case?

Accepted Answer

Inadequate intraoperative local anesthetic infiltration at port sites

Answer

Non-administration of ketamine infusion

Answer

Excessive restriction of opioids leading to inadequate analgesia

Answer

Lack of preemptive analgesia with gabapentin

Question 2

A 60-year-old diabetic patient scheduled for major abdominal surgery under ERAS protocol. Morning fasting blood sugar is 180 mg/dL. What is the most appropriate approach regarding preoperative carbohydrate loading?

Accepted Answer

Skip carbohydrate loading and maintain standard fasting

Answer

Proceed with standard carbohydrate loading as per protocol

Answer

Postpone surgery until sugar is controlled below 120 mg/dL

Answer

Give half dose of carbohydrate loading with insulin coverage

Question 3

Why is goal-directed fluid therapy preferred over liberal fluid administration in ERAS protocols?

Accepted Answer

To prevent hypervolemia and tissue edema that delays recovery

Answer

To prevent electrolyte imbalance only

Answer

To reduce the cost of intravenous fluids

Answer

To avoid postoperative hypertension

Question 4

According to ERAS guidelines, what is the recommended timing for clear fluid intake before elective surgery?

Accepted Answer

2 hours

Answer

12 hours

Answer

8 hours

Answer

6 hours

Enhanced Recovery After Surgery (ERAS) — MCQs

Enhanced Recovery After Surgery (ERAS) — MCQs

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