PREPARING FOR ELECTIVE SURGERY 2

BLOOD TRANSFUSIONS AND BLOOD DONATION
Blood transfusions may be necessary during surgery. A blood transfusion is the delivery of whole blood or blood components to replace blood lost through trauma, surgery, or disease. About one in three hospitalized patients will require a blood transfusion. The surgeon can provide an estimate of how much blood the patient’s procedure may require.

To decrease the risk of infection and immunologic complications, some surgery centers offer a preoperative blood donation program. Autologous blood (from the patient) is the safest blood available for transfusion, since there is no risk of disease transmission.

Methods of autologous donation or collection include:
• Intraoperative blood collection: the blood lost during surgery is processed, and the red blood cells are re-infused during or immediately after surgery.
• Preoperative donation: the patient donates blood once a week for one to three weeks before surgery. The blood is separated and the blood components needed are reinfused during surgery.
• Immediate preoperative hemodilution: the patient donates blood immediately before surgery to decrease the loss of red blood cells during surgery. Immediately after donating, the patient receives fluids to compensate for the amount of blood removed. Since the blood is diluted, fewer red blood cells are lost from bleeding during surgery.
• Postoperative blood collection: blood lost from the surgical site right after surgery is collected and re-infused after the surgical site has been closed. The surgeon determines what type of blood collection process, if any, is appropriate.

MEDICATION GUIDELINES
Depending on the type of surgery scheduled, certain medications may be prescribed or restricted before the surgery. The health care team will provide specific guidelines. If certain medications need to be restricted before surgery, the patient will receive a complete list of the medications (including prescription, over-the-counter, and herbal medications) to avoid taking before the scheduled surgery. If the physician advises the patient to take prescribed medication within 12 hours before surgery, it should be taken with small sips of water. The patient should not bring any medications to the hospital; all necessary medications, as ordered by the doctor, will be provided in the hospital.

EATING AND DRINKING BEFORE SURGERY
Before most surgeries, the patient is advised not to eat or drink anything after midnight the evening before the surgery. This includes no smoking and no gum chewing. The patient should not drink any alcoholic beverages for at least 24 hours before surgery, unless instructed otherwise. If the patient has diabetes or if the surgery is to be performed on a child, the patient should ask the health care team for specific guidelines about eating and drinking before surgery.

Smoking cessation
Patients who will undergo any surgical procedure are encouraged to quit smoking and stop using tobacco products at least two weeks before the procedure, and to make a commitment to be a nonsmoker after the procedure. Ideally, the patient should quit smoking at least eight weeks prior to surgery. Quitting smoking before surgery helps the patient recover more quickly from surgery. There are several smoking cessation programs available in the community. The patient should ask a health care provider for more information if he or she needs help quitting smoking.

Activity before surgery
The patient should eat right, rest, and exercise as normal before surgery, unless given other instructions. The patient should try to get enough sleep to build up energy for the surgery. The health care team may advise the patient to scrub the planned surgical site with a special disinfecting soap the evening before the surgery.

MAKING PLANS FOR HOME AND WORK.
The patient should make arrangements ahead of time for someone to care for children and take care of any other necessary activities at home such as getting the mail or newspapers. The patient should inform family members about the scheduled surgery in advance, so they can provide help and support before, during, and after surgery. The patient should ask the health care team what supplies may be needed after surgery during recovery at home so these items can be purchased or rented ahead of time. Some supplies that may be needed include an adaptive chair for the toilet or bathtub, or supplies for changing the wound dressing at home. Ask the health care providers if home care assistance (in which a visiting nurse visits the home to provide medical care) will be needed after surgery.

Items to bring to the hospital
The patient should bring a list of current medications, allergies, and appropriate medical records upon admission to the surgery center. The patient should also bring a prepared list of questions to ask. The patient should not bring valuables such as jewelry, credit cards or other items. A small amount of cash (no more than $20) may be packed to purchase items such as newspapers or magazines.

Women should not wear nail polish or makeup the day of surgery. If a hospital stay is expected after surgery, the patient should only pack what is needed. Some essential items include a toothbrush, toothpaste, comb or brush, deodorant, razor, eyeglasses (if applicable), slippers, robe, pajamas, and one change of comfortable clothes to wear when going home. The patient should also bring a list of family members’ names and phone numbers to contact in an emergency.

Transportation
The patient should arrange for transportation home, since the effects of anesthesia and other medications given before surgery make it unsafe to drive.

Preoperative preparation
Upon arriving at the hospital or surgery center, the patient will be required to complete paperwork and show an insurance identification card, if insured. An identification bracelet that includes the patient’s name and doctor’s name will be placed on the patient’s wrist.

INFORMED CONSENT
The health care provider will review the informed consent form and ask the patient to sign it. Informed consent is an educational process between health care providers and patients. Before any procedure is performed, the patient is asked to sign a consent form. Before signing the form, the patient should understand the nature and purpose of the procedure or treatment, the risks and benefits of the procedure, and alternatives, including the option of not proceeding with the procedure. Signing the informed consent form indicates that the patient permits the surgery or procedure to be performed. During the discussion about the procedure, the health care providers are available to answer the patient’s questions about the consent form or procedure.

ADVANCED DIRECTIVES
The health care provider will ask the patient if he or she has any advance directives to be included in the patient’s file. Advance directives are legal documents that increase a patient’s control over medical decisions. A patient may decide medical treatment in advance, in the event that he or she becomes physically or mentally unable to communicate his or her wishes. Advance directives either state what kind of treatment the patient wants to receive (living will), or authorize another person to make medical decisions for the patient when he or she is unable to do so (durable power of attorney).

Advance directives are not required and may be changed or canceled at any time. Any change should be written, signed and dated in accordance with state law, and copies should be given to the physician and to others who received original copies. Advance directives can be revoked either in writing or by destroying the document. Advance directives are not do-not-resuscitate (DNR) orders. A DNR order indicates that a person— usually with a terminal illness or other serious medical condition—has decided not to have cardiopulmonary resuscitation (CPR) performed in the event that his or her heart or breathing stops.

TESTS AND PREOPERATIVE EVALUATION
Some routine tests will be performed, including blood pressure, temperature, pulse, and weight checks; blood tests; urinalysis; chest x ray; and electrocardiogram (ECG). A brief physical exam will be performed. In some cases, an enema may be required. The health care team will ask several questions to evaluate the patient’s condition and to complete the final preparations for surgery. The patient should inform the health care team if he or she drinks alcohol on a daily basis so precautions can be taken to avoid complications during and after surgery.

FINAL SURGICAL PREPARATION
Preoperative preparation generally includes these steps:
• The patient changes into a hospital gown.
• The patient removes (as applicable) contact lenses and glasses, dentures, hearing aids, nail polish, and jewelry.
• The patient empties his or her bladder.
• The health-care providers clean and possibly shave the area on the body where the surgery will be performed.
• The patient may receive medication to aid relaxation.
• An intravenous catheter will be placed in a vein in the patient’s arm to deliver fluids, medications, or blood during surgery.
• In some hospitals, the patient may wait in an area called a holding area until the operating room and surgical team are ready. Depending on the hospital’s policy, one or two of the patient’s family members may wait with the patient.
• The patient is taken to the operating room in a wheelchair or on a bed (also called a gurney) where monitors are placed to evaluate the patient’s condition during surgery.
• Anesthesia is administered; the type of anesthesia administered will depend upon the procedure, the patient’s general health, and medications.
• A catheter may be placed in the patient’s bladder to drain urine.
• The patient’s vital signs, including the blood oxygen level, electrical activity of the heart, blood pressure, pulse, temperature, breathing, mental status, and level of consciousness, are continuously monitored during and after the surgery.

Information for families
While the patient is in surgery, the family members wait in a designated waiting area. Some hospitals or surgery centers offer a pager to the patient’s family so they can be contacted for updates about the progress of the surgery. It may be helpful for the patient to select a spokesperson from the family to communicate with the health care providers. This may improve communication with the health care providers as well as to other family members. The patient should also communicate his or her wishes regarding the spokesperson’s telephone communications to other family members.

Educational classes may be available for family members to learn more about the patient’s surgery and what to expect during the recovery. When the surgery is complete, the surgeon usually contacts the family members to provide information about the surgery. If a problem or complication occurs during surgery, the family members are notified immediately.

Patients who receive proper preparation for surgery, including physical and psychological preparation, experience less anxiety and are more likely to make a quicker recovery at home, with fewer complications. Patients who perceive their surgical and postoperative experiences as positive report that they had minimal pain and nausea, were relaxed, had confidence in the skills of their health care team, felt they had some control over their care, and returned to their normal activities within the expected timeframe.