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4. Which of the following fluids used for perioperative resuscitation has been associated with increased
complications?
A. Normal saline
B. Balanced crystalloids
C. Albumin
D. Synthetic colloids
CHAPTER 50
5. Perioperative fluid management using goal-directed
therapy seeks to achieve which of the following?
A. Minimal crystalloid use
B. Fixed fluid administration
C. Zero fluid balance
D. Normal cardiac output
Optimizing Perioperative Care: Enhanced Recovery and Chinese Medicine
6. Which of the following is associated with increased postoperative opioid requirements?
A. Intraoperative intravenous opioids
B. Intraoperative ketamine infusion
C. Neuraxial opioid analgesia
D. Peripheral nerve blocks
Answer: A
Normal saline can result in hyperchloremia and has been
associated with postoperative morbidity and mortality when
compared to balanced crystalloids in studies of cardiac and
other surgical patients. A 2013 Cochrane review did not show
any difference in outcomes when colloids were compared to
crystalloids for fluid resuscitation. Thus, balanced crystalloids tend to be utilized. (See Schwartz 11th ed., p. 2119.)
Answer: C
Goal-directed therapy aims to maintain zero fluid balance
coupled with minimal weight gain or loss. Normovolemia
is desired to maintain perfusion without volume overload.
Goal-directed therapy does not mean that there is minimal
fluid or fixed fluid administration. For some procedures,
fluid requirements may be more than anticipated and for others, fluid requirements may be less than anticipated. Goaldirected therapy aims to avoid the complications associated
with both hypo- and hypervolemia. (See Schwartz 11th ed.,
pp. 2118–2119.)
Answer: A
While opioid administration reduces pain immediately after
administration, they worsen pain scores after they wear off.
In fact, they can increase postoperative opioid requirements.
Alternatively, there are non-opioid adjuncts that can be used
in multimodal pain regimens to reduce opioid requirements
such as non-steroidal anti-inflammatory drugs (NSAIDs),
gabapentinoids, acetaminophen, local anesthetics, ketamine,
and lidocaine. Neuraxial opioid analgesia can reduce postoperative pain scores, and regional blocks can be opioid sparing.
(See Schwartz 11th ed., pp. 2119–2121.)
7. A 59-year-old woman who is planned for a total joint
replacement tells her anesthesiologist that she has a history of severe postoperative nausea and vomiting. Which
of the following would be associated with a decreased
risk of nausea and vomiting?
A. General anesthesia
B. Total intravenous anesthesia
C. Nitrous oxide and volatile agents
D. Intravenous fentanyl infusion
8. Which of the following strategies should be utilized to
reduce the incidence of postoperative ileus after a laparoscopic colon resection?
A. Placement of a nasogastric tube
B. Administration of a mu-opioid receptor antagonist
C. Maintenance of hypovolemia
D. Use of multimodal pain strategies
Answer: B
Strategies for avoiding postoperative nausea and vomiting
include the avoidance of general anesthesia, the use of totally
intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative
opioids, and adequate hydration. (See Schwartz 11th ed.,
p. 2121.)
Answer: D
Multimodal pain strategies and neuraxial blocks reduce opioid use and therefore minimize nausea and improve early
enteral nutrition. Routine use of nasogastric tubes is not recommended to prevent ileus; nasogastric tubes actually delay
return of gastrointestinal activity. Administration of a perioperative mu-opioid receptor antagonist (alvimopan) has been
associated with decreased ileus and length of stay in open
not laparoscopic surgeries. Maintenance of normovolemia is
desired as both fluid overload and dehydration are associated
with negative effects on bowel function. Early resumption
of enteral feeding is recommended. (See Schwartz 11th ed.,
pp. 2121–2122.)
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9. A surgical quality officer is tasked with setting up an
enhanced recovery after surgery (ERAS) program. Which
of the following should be her first step?
A. Engagement of stakeholders
B. Identification of current and goal states
C. Development of standardized order sets
D. Determination of facilitators and barriers
10. Traditional Chinese medicine techniques such as acupuncture can be used as an adjunct to Western medicine
in achieving the goals of enhanced recovery. Which of
the following is associated with the use of acupuncture?
A. Increased intravenous opioid use
B. Decreased anesthetic requirements
C. Decreased nausea and vomiting
D. Decreased fluid administration
Answer: B
The first step in setting up an ERAS program is to identify the
current state and the goal state of care. After that, stakeholders should be identified and engaged; the stakeholders should
work together to develop the protocol and identify facilitators
and barriers to implementation of the protocol. Ultimately,
development of standardized order sets and education of
frontline providers will be necessary to ensure appropriate
implementation. (See Schwartz 11th ed., p. 2124.)
Answer: C
Acupuncture can be used to both prevent and treat postoperative nausea and vomiting, and it is associated with
improved gastrointestinal function and decreased ileus. It can
also be used for perioperative pain management, and there is
evidence that it reduces opioid use. There is no evidence to
suggest that acupuncture has an effect on anesthetic requirements, fluid administration, or other complications. (See
Schwartz 11th ed., pp. 2124–2128.)
CHAPTER 50
Optimizing Perioperative Care: Enhanced Recovery and Chinese Medicine
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CHAPTER 51
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Understanding, Evaluating, and
Using Evidence for Surgical Practice
1. Of the study designs listed below, which is generally
considered to be the strongest level of evidence?
A. Systematic review
B. Cross-sectional study
C. Case-control study
D. Animal studies
E. Case series
Answer: A
Randomized controlled trials (RCTs) are often considered
the “gold standard” of evidence; however, RCTs are relatively
rare in the surgical literature. In the absence of RCTs, a metaanalysis will likely provide the highest level of evidence for
a given subject. Meta-analyses use a standardized method
to search for, appraise, and pool published data in order to
increase the overall statistical power compared to individual
studies. New statistical conclusions can then be made using
quantitative methods based on a larger sample size. Similar
to meta-analyses, systematic reviews use standardized methods to search for and appraise studies; however, they do not
utilize standardized quantitative methods to summarize the
results. Therefore, they are generally considered lower quality
evidence compared to a meta-analysis.
Although the hierarchy of evidence remains largely intact
(Fig. 51-1), many newer frameworks of evidence evaluation
allow for movement of studies up or down based upon study
design and potential unaddressed biases. (See Schwartz
11th ed., pp. 2139–2140.)
RCT
Cohort study
Case control study
Case series
Case reports
Animal research
In-vitro research
Expert experience/opinion
FIG. 51-1. Evidence-based hierarchy.
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2. A type II error occurs when:
A. The null hypothesis is rejected but is actually true.
B. The null hypothesis is not rejected when it is actually
false.
C. The null hypothesis is not rejected when it is actually
false.
D. The incorrect statistical test was performed.
CHAPTER 51
3. Which of the following is a properly constructed patient/
population, intervention, comparison and outcome
(PICO) question?
A. Does [surgery] provide a [good recovery] in [adults]
Understanding, Evaluating, and Using Evidence for Surgical Practice
with [acute appendicitis]?
B. In [patients > 18 years old with uncomplicated
acute appendicitis] do [antibiotics] compared to
[laparoscopic appendectomy] result in fewer [major
complications]?
C. In [patients] do [antibiotics] work better than [surgery]
for [appendicitis]?
D. In [adult patients] are [antibiotics] superior for treat-
ing [acute appendicitis]?
Answer: B
A type II error is the failure to reject the null hypothesis when
the null hypothesis is false. This error may also be referred to
as a false negative. Alternatively, a type I error occurs when
the null hypothesis is rejected but is actually true. The type II
error is related to the power of the study and may also be
referred to as the significance level, often a value of 0.05. This
error may also be referred to as a false positive. The type of
statistical test is unrelated to type I or II errors. (See Schwartz
11th ed., p. 2147.)
Answer: B
Effective and efficient use of search engines is enhanced by
framing the clinical question in a format designed to improve
the relevancy of search results. PICO is one such format and
stands for:
• Patient or population is the specific group of individuals
for which the questions is being asked.
• Intervention is the treatment or technique of interest for
the defined patient or population. Intervention might be
a procedure, such as “laparoscopic appendectomy” or
be defined as an exposure of interest, such as “smoking.”
• Comparison is the alternative treatment or technique
to which you are comparing the intervention. Terms
might include, for example, “open appendectomy” or
“observation.”
• Outcome of interest is the final step of the PICO format.
Examples include “mortality,” “operative time,” and “wound
infection.”
4. A trauma surgeon at your hospital examines data from
motor vehicle collisions and determines that there is an
association between blood alcohol content and fatalities.
This kind of study is an example of a:
A. Randomized controlled trial.
B. Case series.
C. Case-control study.
D. Cross-sectional study.
Option B is written in the correct order with a well-defined
population, intervention, comparison, and outcome. The
remaining answers are either out of order, nonspecific, or
missing a component of the PICO question. (See Schwartz
11th ed., p. 2139.)
Answer: C
In a case-control study, cohorts are determined by the presence or absence of a particular outcome of interest, in this
case motor vehicle collision fatality. Case-control studies are
considered to be a lower level of evidence for risk factors,
given that they are more susceptible to multiple types of bias
than cohort studies. However, well-designed and properly
analyzed case-control studies can provide solid evidence, for
instance on risk factors for specific conditions. This is in contrast to a cross-sectional study where cohorts are determined
by presence or absence of an exposure. A case series involves
reporting on a group of patients that share specified clinical features, but generally does not include a control group.
(See Schwartz 11th ed., p. 2139.)
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5. Which of the following would increase the external
validity of a study?
A. Surgical interventions in the study are performed by
a single surgeon.
B. The study has strict inclusion criteria.
C. Involvement of multiple institutions across a number
of cities.
D. Increasing the sample size.
E. Performing the study at a single center.
Answer: C
External validity or generalizability refers to how results of a
study translate to “real-world” situations with greater heterogeneity within the potential target population. Involvement
of multiple institutions across multiple cities would help
increase the chances that a study could be generalized to the
population of interest as compared to a study performed at
a single institution. In general, external validity is related to
the representativeness of the sample population, environment,
and procedures to the target population at large. Alternatively,
Internal validity describes the degree to which a study’s causal
conclusion is warranted. Factors such as randomization, blinding, completeness of follow-up, equivalence among groups,
and accuracy of analysis affect the internal validity of a study.
(See Schwartz 11th ed., p. 2146.)
CHAPTER 51
Understanding, Evaluating, and Using Evidence for Surgical Practice
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CHAPTER 52
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Ambulatory Surgery
1. Based on the Centers of Medicare and Medicaid Services
(CMS), ambulatory surgery centers (ASCs) are:
A. Any Center that provides same day medical service
with minor procedures.
B. Any distinct entity that operates exclusively for the
purpose of providing surgical services to patients not
requiring hospitalization and which services will not
exceed 24 hours following admission.
C. Any office outside a hospital that provides invasive
procedures to patients outside hospital setting.
D. Does not need referral from a primary care physician.
2. The top five procedures performed at ambulatory surgery centers (ASCs) are:
A. Cataract surgery, esophagogastroduodenoscopy with
biopsy, colonoscopy with biopsy, and spine epidural
injection foraminal.
B. Laparoscopic cholecystectomy, inguinal hernia
repair, epidural injection, diagnostic colonoscopy.
C. Laparoscopic cholecystectomy, inguinal hernia repair,
abdominal wall hernia repair, debridement of skin
ulcers, skin lesion removal.
D. Injection paravertebral facet joint, insertion of tem-
porary bladder catheter, diagnostic colonoscopy,
abdominal wall hernia repair, inguinal hernia repair.
Answer: B
ASCs are independent health care facilities that offer patients
the convenience of having surgery performed safely without
admission to a hospital. According to the Centers for Medicare and Medicaid Services (CMS), effective May 18, 2009,
ASCs are any distinct entity that operates exclusively for the
purpose providing surgical services to patients not requiring
hospitalization and which the expected duration of services
would not exceed 24 hours following an admission. ASCs
should not be confused with office-based surgery practices or
with other outpatient centers that provide diagnostic services
or primary health care, such as urgent care centers, community health centers, mobile diagnostic units, or rural health
clinics. ASCs are distinguished from other health care facilities by (a) there use of a referral system for accepting patients
and (b) their maintenance of a dedicated operating room.
(See Schwartz 11th ed., p. 2153.)
Answer: A
The top five in procedures they have formed at ASCs are
cataract surgery with intraocular lens, esophagogastroduodenoscopy with biopsy, colonoscopy and biopsy, colonoscopy
with lesion removal, and spine epidural injection foraminal.
In contrast, the top five procedures performed at the hospital outpatient departments by volume are: Subcutaneous tissue debridement, esophagogastroduodenoscopy with biopsy,
aspiration/injection of joint, cataract surgery with intra ocular lens implant, and colonoscopy and biopsy. (See Schwartz
11th ed., p. 2155.)
3. Cost of performing procedures at ambulatory surgery
centers (ASCs) are lower than those performed in hospitals due to which of the following factors?
A. Avoiding emergency procedures
B. Fewer diagnostic tests and fewer medications
C. Less staffing and less expensive instruments
D. All of the above
Answer: D
In many cases an outpatient procedure performed in an ASC
is between 1/2 and 1/3 of their costs as the same procedure
performed in a hospital. In large part, ASCs affect cost savings
by eliminating overnight hospitalizations and emergency procedures. ASCs perform fewer extensive diagnostic tests and
dispense fewer medications. These facilities are not staffed
around the clock and are not encumbered by the need for
expensive and highly specialized equipment as are hospitals.
(See Schwartz 11th ed., p. 2157.)
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4. Requirements to open an ambulatory surgery center
(ASC) in any state include which of the following?
A. Accreditation by regulating state bodies
B. Certificate of need
C. Accreditation by JCAHO
D. None of the above
CHAPTER 52
Ambulatory Surgery
5. Unplanned admission to a hospital after a procedure in
ambulatory surgery centers (ASCs) occur in 0.5% to 2%
of cases with highest odds in the following EXCEPT:
A. Medicaid patients.
B. Patients with private insurance.
C. Lower median household income.
D. Greater preoperative comorbidity burden.
Answer: D
Health care facilities in the United States are highly regulated by federal and state entities. ASCs are included in this
oversight. Independent observers evaluate the safety and
quality of care provided in ASC through three processes:
Medicare certification, state licensure, and voluntary accreditation. To obtain Medicare certification, ASCs must meet the
Medicare certification requirements, known as the conditions
for coverage of these conditions include specifying standards
for administration of anesthesia, quality evaluation, operating and recovery rooms, medical staff, nursing services, and
other aspects of care. An ASC must have an inspection conducted by a state official or a representative of an organization authorized by the government. Each state determines
the specific requirements ASCs must meet for licensure. An
ASC does not have to be certified by Medicare in order to
be accredited by JCAHO, but if they will be reimbursed by
the Medicare they should meet their requirements.
In 37 states, any party looking to open an ASC must demonstrate the need for ASC to exist. State licensure requirements
generally exist for both health care facilities and health care
professionals. (See Schwartz 11th ed., p. 2158.)
Answer: B
Safe use of ASC is based on identification of patients who are
unlikely to require admission to a hospital after their procedure. Thus far, ASCs do very well in this aspect. Unplanned
admissions after ambulatory surgery occurring approximately 0.5% to 2.0% of cases. In the future, ASCs will be challenged to reduce this unplanned admissions rate even further.
Patients with Medicaid insurance, lower median household
income, and greater preoperative comorbidity burden have
the highest odds of unplanned acute care use. These patients
may benefit from interventions that enhance and streamline
possible to follow-up. Additionally, the potential costs associated with postoperative acute care following procedures
performed in ASCs are not insignificant. Patient-specific predictors of unplanned hospital admissions include age 65 years
or older, anticipated operating time longer than 120 minutes,
cardiac comorbidities, peripheral vascular disease, cerebral
vascular disease, malignancy, positive for human immunodeficiency virus (HIV) and regional or general anesthesia
use. The strongest predictor for unplanned inpatient hospital
admission was the individual patient’s own history of previous hospitalizations, particularly among older adults. African
American and Hispanic individuals also have had a markedly elevated risk of inpatient hospital admission, possible
related to cultural or socioeconomic issues for access to care.
(See Schwartz 11th ed., pp. 2159–2160.)
CHAPTER 53
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Skills and Simulation
1. Virtual reality (VR) simulation has been used for training
in laparoscopy, flexible endoscopy, sinuscopic surgery,
and endovascular interventions. Which of the following
is an advantage of VR simulator–based training as compared to physical laparoscopic video trainers?
A. Significantly improved operative performance
B. Ability to perform proficiency-based training
C. Automated performance measurement
D. Lower upfront costs for development
2. Which of the following is a nontechnical skill that can be
taught using simulation training?
A. Situational awareness
B. Instrument selection
C. Economy of movement
D. Respect for tissue
Answer: C
VR simulators allow for automated performance measurement such as time, instrument motion, and electrosurgery
use measurements as well as a tally of the occurrence of
predefined errors. These measurements are not only automated but also free of observer bias. Both virtual reality and
physical laparoscopic video trainers (“box” trainers) allow
for proficiency-based training. Good training results can be
obtained with proficiency-based training within a larger curriculum, regardless of training platform. Although there may
be some advantage with the virtual reality trainer, no significant difference has been identified. (See Schwartz 11th ed.,
pp. 2169–2171.)
Answer: A
Nontechnical skills refer to the cognitive knowledge and
teamwork-related abilities that must be integrated with psychomotor skills and abilities. Examples of nontechnical skills
include situational awareness, communication, and teamwork. Examples of technical skills include respect for tissue,
time and motion, instrument handling, and knowledge of
instruments; these skills, for example, can be evaluated using
a global ratings scale such as in the objective structured assessment of technical skills (OSATS). (See Schwartz 11th ed.,
pp. 2166–2167, 2175–2177.)
3. Which of the following strategies for simulation-based
error training allows the instructor to engage in a broad
assessment of learning needs?
A. Error-enabled approach
B. Forced-error approach
C. Error-centric skills assessments
D. Graduated autonomy approach
Answer: A
The error-enabled approach is where the learner can make
any of a variety of errors during the course of a task. This
allows for a broad assessment of learning needs. The forcederror approach is where the learner experiences a specific,
usually unexpected error and demonstrates error management as well as options for correction. This approach allows
instructors to engage in specific error management skills and
metrics. Error-centric assessments allow for evaluation and
categorization of errors; these types of assessments allow for
focused error training and feedback. While gradual increases
in patient autonomy and autonomous decision-making are
an important component of resident training, this is not
a specific simulation-based strategy. (See Schwartz 11th ed.,
pp. 2177–2178.)
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