Patient preparation for surgery

By | April 2, 2017
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Proper preparation of a patient for surgery is as important as that procedure is important for that specific pathology. There are many steps which one should follow and should give the complete instruction about the surgery and anesthesia to the patient.

Patient Education

This is important first step and In many institutions, when a patient is scheduled for surgery, the patient is contacted before the procedure and given instructions as to how to prepare for the surgery. Clinicians can enhance patient preparation by reinforcing instructions on preoperative fasting, medications, anesthesia, and postoperative care.

Preoperative Fasting

While the overall risk of perioperative pulmonary aspiration of gastric contents that may result in morbidity or mortality may be relatively low, several factors may contribute to the possibility of this occurring, such as:

  • Anxiety;
  • Ascites;
  • Esophageal surgery;
  • Narcotic use;
  • Pain;
  • Hiatal hernia, gastroesophageal reflux disease;
  • Obstruction (bowel obstruction, pyloric stenosis);
  • Diabetes;
  • Neurologic problems (seizures, head injury);
  • Pregnancy; and
  • Full stomach.

Patients are often told not to eat after midnight. The reason why, however, is not always explained. Patients are not always compliant; they have reported they did “not realize it would be a big problem” and had liquids, gum, or candy just prior to entering the admission area. The reasons for fasting should be explained to the patient. When discussing fasting with the patient, it is also important to be very specific as to what “clear liquids” and a “light meal” means. Nonhuman milk is similar to a solid in gastric emptying time. A light meal typically consists of toast and clear liquids such as water, black coffee or tea, broth, or gelatin. Fried, fatty foods, or meat may also prolong gastric emptying time.

Medications

Usually we forget about telling this instruction to the patient. Patients should be told that they can take necessary medications such as antihypertensive, cardiac, seizure, and asthma medications with sips of water, preferably before they leave their home to come to the facility. People with diabetes should continue taking oral hypoglycemic agents until the evening before surgery. If the patient takes insulin, it is common to administer a fraction (one fourth to one half) of the usual morning dose.Aspirin and aspirin-containing products should be discontinued 1 week prior to surgery. Nonsteroidal anti-inflammatory drugs should be discontinued 4 days prior to surgery. If the patient is on warfarin, it is usually discontinued 3 days prior to surgery, if appropriate.The prescribing clinician may need to be consulted to be sure it is safe to discontinue these medications or switch to an alternative medication, especially if the patient has a recent heart valve replacement or other serious condition that may need to be taken into consideration.

Anesthesia

The patient may have many questions regarding types of anesthesia. Many anesthesia departments can provide literature preoperatively. The patient may be instructed to meet with someone from the anesthesia department prior to the date of surgery.

There are generally 3 different types of anesthesia. The type of anesthesia the patient will receive will depend upon the procedure and the patient’s medical condition. The anesthesia provider will discuss the appropriate anesthesia options with the patient during the anesthesia interview.

Local anesthesia. A local anesthetic agent can be injected near the surgical site to anesthetize the nerve endings and prevent the sensation of pain. This type of anesthesia produces a loss of sensation to a small specific area of the body. It is usually associated with numbness at the surgical site, and sometimes difficulty in moving an extremity, but few other effects. Sedation is often given to minimize the discomfort of the injection.

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Regional anesthesia. Local anesthetic is injected near one of the major nerves that provide sensation to a region of the body. This type of anesthesia prevents the transmission of the painful impulses for up to several hours. There may be loss of sensation and weakness of an entire arm or leg until it wears off. Spinal, epidural, or caudal anesthesia anesthetizes the major nerves in and around the spinal cord. It can be in the form of an injection at almost any level, from the sacral area to the upper back. It usually affects the entire body below the waist. The duration of the spinal block depends upon the drug used. When it begins to take effect, the patient will begin to feel warmth in the legs. The patient will feel changes that progress proximally, and when it wears off, it regresses from the highest dermatome in a caudad direction.

Regional anesthesia usually lasts for several hours but may be injected continuously through a small epidural catheter to provide pain relief for up to several days. It is often associated with numbness and weakness of the legs and lower body. The anesthesia department is responsible for medication administered through an epidural catheter. The medications that are used vary slightly from department to department. Often, a local anesthetic such as bupivacaine may be mixed with fentanyl in the pharmacy and then given continuously via special tubing and a pump. Additional narcotics may be given for “breakthrough” pain as well.

General anesthesia. This type of anesthesia interrupts the transmission of nerve impulses in the brain, causing unconsciousness. The brain does not receive or interpret any pain signals from the rest of the body. General anesthesia also interrupts other functions of the brain such as the control of movement and breathing. As the depth of anesthesia is increased, the patient may cease spontaneous respirations and will be assisted through mechanical ventilation. With a lesser depth of anesthesia and muscle relaxation, spontaneous respiration may continue, but the patient is still under general anesthesia and is not responsive to stimuli.

Endotracheal intubation is generally performed for any patient who needs more definitive airway protection. This may include patients who have predisposing risk factors for aspiration (as described earlier), a lengthy procedure, will be in a position that may make managing the airway difficult (prone), or any other factors that may compromise the airway without intubation.

Patients occasionally ask “Will my heart stop?” The patient can be assured that the heart continues to beat.

Monitored anesthesia care (sedation). This type of anesthesia, also referred to as “twilight sleep,” is becoming more widely used with the development of new medications. It is often used for procedures that are uncomfortable but not very painful, or along with local or regional anesthesia (eg, colonoscopy). The anesthesia provider administers sedation to provide pain relief and reduce anxiety. The patient will often sleep throughout the procedure while maintaining his or her own airway and awaken quickly at the end of the procedure.

Personal Items

Patients are usually reminded to leave valuables at home; however, they often forget to remove jewelry. It is becoming more common to have patients arrive in the surgery department with jewelry in tongue, belly, and genital piercings. These will need to be removed as well.

After Surgery

At the end of the procedure, the patient who has received sedation is awakened and will usually move onto the stretcher to leave the operating room and be transferred to the postanesthesia care unit (PACU). If the patient has received general anesthesia with intubation, the patient will be extubated and may require assistance to move onto the stretcher.

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source: medscape.com, medcyclopedia.net

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