Preoperative preparation of patient before surgery

Anxiety 

Emotional state characterized by subjective feelings of tension, apprehension, and/or worry. The autonomic nervous system is activated.

PAT 

Preadmission testing area where preoperative patients are assessed.

Presurgical holding area 

An area within the perioperative environment where the patient waits immediately before entering the OR.

Patient Education

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. This may be done by staff from the surgeon's office or staff at the institution where the surgery will be performed. Some institutions also send written instructions. Often the patient is anxious and may have difficulty understanding or remembering the instructions. 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,[1] 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. Not only is there an increased risk of nausea and vomiting postoperatively, there is the risk of regurgitation and pulmonary aspiration, which can have very serious consequences. Fasting criteria have become less strict over the past few years; however, the possibility of the procedure occurring earlier should be taken into consideration when instructing patients ( Table 3 ).[6]

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. The consumption of alcohol should be discussed at this time, as some patients have been known to consider certain alcoholic beverages as clear liquids. They should be advised not to consume alcohol for 24 hours prior to their procedure. Patients often do not understand that chewing gum and eating candy can also contribute to the stimulation of gastric acid secretion.[6]

Although a procedure may be scheduled for late in the morning, or even in the afternoon, most often the patient will still be asked to have nothing by mouth after midnight. This is done for a few reasons. Sometimes, due to scheduling changes, the procedure may be scheduled earlier. A set time also minimizes confusion for some people. Some institutions will allow people to have liquids until a specified time, which is communicated to the patient. Children are often allowed to consume liquids until the minimal allowable time ( Table 3 ).

Medications

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.[7] 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.[7] 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. For those with Internet access, Web sites are provided by The American Association of Nurse Anesthetists and The American Society of Anesthesiologists . Both Web sites provide excellent educational information for the public as well as brochures that can be obtained for the office.

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.[8] 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.

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.

Depending upon the type of surgery, length of procedure, and the patient's physical status, the airway may be maintained via mask ventilation, laryngeal mask airway (LMA), or endotracheal intubation. Mask ventilation uses the patient's natural airway and is usually used for shorter cases that do not put the patient at risk for aspiration, such as dilatation and curettage, myringotomy, and other minimally invasive procedures that may require general anesthesia.

LMA is a device placed in the hypopharynx, but it is not as invasive as endotracheal intubation. LMA may be used instead of mask ventilation to assist the anesthesia provider in maintaining a patent airway while freeing up his or her own hands to do other tasks.

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. Patients should be reminded that if they wear contact lenses, they should either leave them at home and wear their eyeglasses or bring a case and solution to store lenses. Contact lenses cannot be worn into the operating room. Dentures should also be removed and stored with personal belongings before coming into the operating room.

General Information

If the patient has any laboratory/diagnostic test results or medical clearance documentation from his or her healthcare provider, they should be brought to the surgery department to avoid having to repeat any procedures, saving time, money, and patient discomfort. (Ideally, this material should have already been faxed to the surgical department prior to the day of surgery, depending on institution policy.)

Patients should be instructed to contact their primary care provider's offices if they become ill shortly before the day of surgery. The presence of cold symptoms with a productive cough makes it inadvisable to proceed with elective procedures, especially if general anesthesia is planned. The patient's airways are more reactive, and he or she is at a greater risk for respiratory complications both during induction and postoperatively.

It is advisable to remind patients not to apply lotions, perfumes, or powders before surgery. Many offices now have signs requesting patients not wear perfume, because of staff and other patients' allergies. Lotions and powders applied to the skin can also interfere with monitoring equipment.

It is important to explain to the patient why he or she needs to arrive at the hospital or surgical center early. By having the patient arrive well before the scheduled time of surgery, paperwork can be completed and any last minute details can be managed. Patients often complain about the long wait. They may not realize that they have been asked to come in well before the procedure and assume that they will be entering the operating room within a few minutes of arrival. It can be suggested that they bring a book or magazine to read while they are waiting. If a delay arises, they need to be informed and given an explanation. This will usually relieve some of their anxiety.

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.

Patients who have been intubated or who have had an airway placed in the hypopharynx may experience a mild sore throat for a couple of days. There is also a potential for postoperative nausea, especially if the patient has a known history of postoperative nausea and vomiting. Medication can be given to minimize this problem. Nausea may be due to the anesthesia or the specific surgical procedure (eg, laparoscopic cholecystectomy, certain breast procedures).

Although every effort is made to make the patient comfortable, there may be some pain or soreness when the anesthetic reverses or wears off. Some patients believe they will wake up after surgery and have no pain, and if they are uncomfortable, they do not understand why. Each patient is different and reacts differently to anesthesia as well as the pain medication. Regional spinal anesthetic may wear off when the procedure is over or may last a couple of hours longer. Patients should be reassured that medication will be given when pain arises, and pain will be controlled. The surgeon will write a prescription for pain medication and leave it with written postoperative instructions for the patient and family. It is important to make sure the patient has these prior to discharge.

Most patients stay in the PACU for approximately 45 minutes. When a patient has met PACU criteria for discharge, the patient will be discharged to a room, a step-down area to prepare for discharge from the facility, or directly to home. It is required that the patient have someone available to transport him or her home (the patient is not allowed to drive home following the procedure). For certain procedures and general anesthesia, patients will be asked to have someone with them for at least the first 24 hours postoperatively.

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