guidlines

MEDICAL GUIDLINES

Before and after surgery consideration

Questions to Ask Before You Have Surgery

To answer that question, you need to clearly understand your diagnosis first, and then why it is that surgery is being considered. Start by asking your primary-care doctor and/or a surgeon these questions:

  • Is surgery the only way to treat my problem or are there nonsurgical approaches that could be tried?
  • Are there different kinds of surgeries to treat my condition and, if so, how do they compare?Back pain, for example, can be treated in various ways and by different specialists, for example, a neurosurgeon or an orthopedic surgeon.
  • Which surgical approaches are better for my particular condition and its severity, given my age and overall health status?

When considering surgery, it’s often a good idea to get a second opinion to learn about your treatment options. In fact, many insurance companies require a second opinion before they will approve a major procedure.

Make an appointment well in advance of any planned surgery to consult with the surgeon who will be performing the operation. The surgeon will explain the procedure in depth, discuss your particular medical needs and answer your questions.

Patients have different levels of curiosity about their surgeries. Not everyone wants to know all of the details, but some people do. You should learn as much about your surgery as you’re comfortable with knowing.

To help reduce your stress, consider asking a family member or friend to serve as your health-care advocate—someone who will look out for your best interests while you are preoccupied with your own thoughts or concerns. Your advocate can ask questions that you may not think of, help make sure that you get the right medicines and treatments, and enforce your health-care wishes in the rare case of an emergency.

 

Planning ahead for your hospital and at-home care can also help you feel more at ease. This might include organizing family and friends to be available on a rotating basis to give you a hand while you’re in the hospital or at home. You can also make sure that all the support services or supplies will be readily available when you arrive home. You do not want to be fussing with these details while you are not feeling your best.

If there are going to be special exercises, care practices or new patterns in your daily life as a result of the surgery, then learn about these ahead of time so that you can be prepared without surprises. For example, if you will have physical rehabilitation after surgery, take the opportunity beforehand to learn and practice the exercises, if you’re able to.

Talk to your doctor about how to get in the best physical shape as possible before your surgery. For example, if you have asthma, diabetes or heart problems, including high blood pressure, you’ll want to get those under control before surgery. If you smoke, cut back before surgery, and if possible, quit. Smoking restricts blood flow to the heart and increases the likelihood of life-threatening heart and lung abnormalities.

To help strengthen your immune system so that you tolerate the stress of surgery better, eat especially nutritiously for several weeks before your surgery. This can be particularly important for cancer patients and other chronically ill patients who need surgery.

Ask your surgeon about the likelihood that you’ll need a blood transfusion during surgery. If there’s a chance that you’ll need blood, ask whether you can donate your own blood beforehand. This service is now readily available in most communities. Your blood is the best blood to receive.

 

To reduce the chances of infection during surgery, avoid shaving the surgical site, since doing so can cause tiny skin nicks and open the skin to bacteria that can create infection. You’ll also be asked to remove all makeup, nail polish, contact lenses, false eyelashes and jewelry. Ask your surgeon’s office about all of these types of preparations.

Your medical team should follow The Joint Commission’s three-step protocol to reduce the chances of a surgical error, including:

  • verifying the procedure with you,
  • marking the surgical site
  • and taking a time-out to review the procedure with the entire medical team prior to surgery.

Expect many members of the medical team (and there may be a lot: surgical assistants, physician assistants, operating room nurses, an anesthesiologist and nurse anesthetist) to ask who you are, what surgery you’re having and what part of the body is being operated on. Doctors and nurses triple-check your identity to make sure that you’re the right patient before they even lift a scalpel. It’s a good idea to have a family member or friend with you to answer questions and prevent oversights and mistakes, in case you’re not able to do so.

If you’re having an inpatient procedure and will spend part of your recovery time at the hospital, make sure that every nurse checks your identity in two different ways, by checking your wrist band information and asking for your social security number, for example, to reduce the chances of medication mishaps.

All surgery patients should receive educational material from their hospital prior to surgery stating what they’re doing to prevent surgical errors.

A preoperative visit is usually scheduled with a member of the anesthesiology team who will be providing anesthesia during your surgery. This visit is to perform a focused physical assessment by the anesthesiologist and to review the options for anesthesia. Depending on the procedure, you may receive local anesthesia, which numbs just the area being treated; regional anesthesia, which numbs an entire area such as a spinal block or an extremity; or general anesthesia that causes complete sedation.

 

For some patients, the anesthesia administration is more important than the actual surgery in terms of having an optimal outcome. These can include patients with certain allergies, neurological conditions such as epilepsy or stroke, lung problems, immune function disorders, stomach problems or other conditions that may make complications more likely. If someone has significant lung, heart or kidney conditions, the anesthesiologist will make sure that the patient’s metabolic and physiologic functions are maintained in an optimal state throughout the entire length of the surgery to minimize complications. Make sure to ask about your options for anesthesia, the pros and cons and the potential complications.

The amount of pain a person experiences will vary with the type of procedure, the anesthesia methods and his or her tolerance to pain. Your surgeon, or a medical consultant working with your surgeon, orders your pain medications.

There are several types of pain medications, such as nonsteroidal anti-inflammatory drugs, opioids, and anesthetics. It may take a few tries to find the one that works well for you. The goal is to have you comfortable but not too drowsy, so that you can participate effectively in your postoperative care.

It’s the job of the nurses attending to your care to track your level of pain. Your nurse will often ask you to rate your pain on a scale from 1 to 10, with 1 indicating mild discomfort and 10 signifying severe pain. Be honest in your answers so that the nurses and doctors can provide you with the best pain control.

Complications vary depending on the procedure you’re having and your health status, so talk to your surgeon before the day of the operation to ask how you can minimize your risks. The majority of surgical patients receive antibiotics to reduce their chances of infection.

According to You: The Smart Patient, it can help to be proactive when it comes to oxygen and warmth. Because supplemental oxygen can reduce your chance of getting an infection, ask to have it during and after the operation. Cold patients develop more complications, so ask for a blanket to take with you into surgery and ask the anesthesiologist to keep you warm.

After surgery, make an effort to avoid complications related to heart, lung and kidney function. For example, to prevent lung problems, get out of your hospital bed and walk around and do deep breathing. Never be afraid to ask for assistance if you need it; you do not want to fall while trying to be mobile soon after surgery.

Your doctors and nurses will monitor your nutrition and fluid status to keep your heart, kidneys and intestines functioning as well as possible. Occasionally there will be a dip in the normal function of these organs, so don’t be afraid to ask how you are doing, or if there is more that you can do to improve your healing process.

Since hospitals are filled with sick patients, they are notorious for harboring germs. To minimize your chances of hospital-related infections, keep a container of hand sanitizer by your bed and ask health-care professionals and visitors to wash their hands. Also, beware of hidden harbingers of germs, such as the TV remote, your wedding band, dirty stethoscopes and toilet handles.

 

Before you return home, ask your surgeon and primary-care physician who you should call in the event that something unexpected happens and you need urgent care. You want someone who can respond quickly and you want to know how best to contact them.

Be sure to follow through with your rehabilitation or physical therapy.

Preoperative Procedures

Preoperative procedures are designed to improve the outcome of the surgery, decrease the risk for complications, and make the surgery as safe and effective as possible.

Patients who receive general anesthesia, which renders them unconscious, must refrain from eating or drinking for at least 8 hours before surgery. Most instructions indicate that nothing is to be taken by mouth after midnight, on the night before the procedure. It may seem harsh, not to be able to have a sip of water, but this precaution minimizes the risk for complications such as vomiting during surgery.

Discontinuing prescription and over-the-counter medications that “thin” the blood, such as aspirin is necessary prior to surgery. Whether a drug is held or administered is based on the patient’s medical condition, the type of drug, and the scheduled surgical procedure. Patients who take prescription medications on a regular basis must discuss this with the surgeon.

Preparation for surgery may begin days before the procedure. Surgeries involving the digestive system require special drinks, laxatives, and an altered diet. The digestive tract must be as empty as possible before surgery to prevent leakage of its contents into the abdominal cavity.

If surgery is being done on an outpatient basis, the patient must arrange for someone to be with them upon discharge. Even though the anesthesia has worn off, grogginess can last several hours and it is unsafe to drive. Also, the patient may need assistance when they get home.

 

If surgery is being done on an inpatient basis, the patient checks into a room. Most patients return to their room after surgery, but those undergoing complex surgical procedures and those who have complications may go to the intensive care unit (ICU). Outpatients usually go to an area designated for same day surgery.

After arrival, time is needed to prepare the patient for the procedure and sometimes, the time of surgery is changed due to cancellations or emergencies.

All patients must sign an informed consent form acknowledging that they are aware of risks and complications, that they know they will be receiving anesthesia, and that the surgeon has explained the operation to them. The surgery will not proceed unless the consent form is signed.

Patients are usually asked to remove personal items (e.g., jewelry, eyeglasses, hairpieces, contact lenses, dentures) before surgery. This policy protects the patient and prevents the items from being lost or damaged. Depending on the procedure, eyeglasses or hearing aids may be worn.

Different staff members may ask the same questions. The clerk who checks the patient in asks several questions, as does the admitting nurse and the anesthesiologist. These questions may be the same or similar and this may seem tedious, but the information must be checked and double-checked to avoid errors and omissions.

The doctor who administers the anesthesia (anesthesiologist) performs a brief physical examination; takes a patient history; and obtains information regarding medication used on a regular basis, drug allergies, and prior adverse reactions to anesthesia. This information helps the anesthesiologist select the most suitable anesthetic agents and dosages to avoid complications.

 

Patients are usually taken to a preoperative or holding area before surgery. An intravenous line (IV) is started here if the patient does not already have one. A sedative may be given by injection, through the IV, or occasionally, orally, to help the patient relax.

Fasting Before Surgery

If you’ve ever undergone surgery, you probably received the traditional pre-op order: Don’t eat or drink anything after midnight prior to the day of surgery. Some experts agree that the length of the recommended fast is needlessly long.

 

Fasting guidelines have been relaxed in recent years, but it’s not uncommon for patients to be given the traditional after-midnight order. While it’s always best to follow your doctor’s advice, it’s perfectly reasonable to ask about relaxing the fasting requirements—especially if you’re scheduled for an afternoon procedure. In that case, you might be asked to go without food for more than 12 hours! Doctors and anesthesiologists are often willing to accommodate your wishes.

The after-midnight order has been the norm for decades. It’s a precautionary measure to prevent pulmonary aspiration, which occurs when stomach contents enter the lungs, potentially blocking airflow and putting patients at risk for serious infections like pneumonia. However, modern anesthesia techniques make pulmonary aspiration much less likely. And when it does happen, it almost never results in long-term complications or death.

What’s more, research has demonstrated that the stomach empties much faster than previously believed, and a long fasting period probably won’t reduce aspiration any better than a short fast.

A long fast may add to discomfort during recovery. Fasting can lead to headaches, nausea, dizziness and dehydration. Dehydration can be serious and makes it difficult for nurses to draw blood for necessary tests.

In its preoperative fasting guidelines, the American Society of Anesthesiologists says it’s safe for healthy people of all ages who undergo elective surgery to consume:

  • Clear liquids, including water, clear tea, black coffee, carbonated beverages and fruit juice without pulp, up to two hours before surgery
  • Very light meals, like toast and tea with milk, up to six hours before surgery
  • Heavy meals, including fried or fatty foods and meat, up to eight hours before surgery

Despite these guidelines, don’t be surprised if you schedule an elective procedure and are given after-midnight instructions. Many surgeons and hospitals continue to recommend the traditional after-midnight order on the assumption that it’s easier to give everyone the same instructions. Therefore, patients don’t need to count down the hours before surgery when making decisions about what to eat or drink, and health care professionals don’t need to sort out which patients should have different fasting times.

 

Some patients do need to follow the after-midnight rule. These include people who have gastroesophageal reflux disease (GERD) and people with gastric paresis (paralysis of the stomach that can occur in people who have diabetes). These individuals have an increased risk of vomiting and aspiration during surgery and should be instructed to fast for a longer period—as should people undergoing gastric or intestinal surgeries. A blanket after-midnight order protects people who might have undiagnosed GERD or diabetes.

Surgery & Medications

Before undergoing surgery, it’s important to make your health care provider and surgical team aware of all over-the-counter (OTC) and prescription medications and herbal or dietary supplements you’re taking. Some medications can promote excessive bleeding and must be avoided for a period of time—prior to surgery and/or after the procedure—and other drugs can cause an adverse interaction with anesthesia.

 

Below is a list of medications that may be of concern before (and/or after) surgery. Please note: This is not a complete list and it is not meant to be a substitute for professional medical advice. Talk to your health care provider and do not discontinue the use of any prescription medication without permission from your physician.

4-Way Cold Tablets

A

  • Ascriptin
  • Ascriptin with Codeine
  • Advil
  • Aleve
  • Alka-Seltzer
  • Anacin
  • Anaprox
  • Arthopan Liquid
  • ASA and Codeine
  • Aspirin
  • Ascriptin
  • Aspergum

B

  • Bayer
  • BC Tablets and powder
  • Bromo-Seltzer
  • Bufferin
  • Bufferin with Codeine #3

C

  • Cama Arthritis Pain Reliever
  • Clinoril
  • Congesprin Chewable Tablets
  • Cope Tablets
  • Coricidin “D” Congestant Tablets
  • Coricidin
  • Coumadin

D

  • Darvon with ASA (removed from the U.S. market)
  • Darvon Compound (removed from the U.S. market)
  • Disalcid
  • Doan’s Pills
  • Dolobid
  • Dristan
  • Duragesic

E

  • Easprin
  • ECOTRIN
  • Empirin
  • Empirin with Codeine
  • Equagesic
  • Excedrin

F

  • Feldene
  • Fenoprofen
  • Florinal Tablets
  • Florinal with Codeine

I

  • Ibuprofen
  • Indocin
  • Indomethasin

L

  • Lodine

M

  • Micrainin
  • Midol
  • Motrin

N

  • Nalfon
  • Naprosyn (Naproxen)
  • Norgesic and Norgesic Forte
  • Nuprin
  • Nyquil
  • Nytol

O

  • Orudis
  • Oxycodone

P

  • Pamprin
  • Percodan
  • Persantine
  • Phenaphene
  • Propoxyphene

R

  • Robaxisal

S

  • Synalgos – DC Capsules

T

  • Talwin
  • Trilisate

Z

  • Zorpin

Postoperative Care

Most patients experience discomfort after the anesthesia wears off. Some experience pain and nausea and others have minimal soreness. Patients may be asked to rate their pain on a 1–10 scale to determine their level of discomfort. Slight pain is 1–2; annoying pain, 3–4; significant pain, 5–6; severe pain, 7–8; and excruciating pain, 9–10. The pain scale helps nurses and physicians determine the proper pain medication. After receiving the medication, patients may be asked again to rate their pain to evaluate the medication’s effectiveness.

If an agent was used to control bleeding during surgery—for example, Raplixa, which was approved by the FDA in April 2015—the spray-dried sealant may increase post-surgical pain and also can cause nausea, constipation, fever, and low blood pressure after surgery.

Family members are usually allowed to see patients once the anesthesia has worn off and they have been transferred to their room. There are usually areas where the family can wait while the surgery is in progress.

How soon the patient can get up, shower, and eat depends on the type of surgery, recovery, and the treatment plan. Most patients can get out of bed the day after surgery.

The surgeon determines when a patient is discharged from the hospital. In most cases, the patient must be able to walk, eat, drink, and urinate, and must no longer need IV fluids or medication.

The ability to return to work or school, drive, climb stairs, and lift heavy objects depends on the type of surgery, recovery, and the patient’s overall health and age.

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