Clinical Information

Before you come into Hospital

Your surgeon has asked a member of our practice to administer the anaesthetic for your planned operation.

An anaesthesiologist is a medical doctor who on completion of their basic medical degree have undertaken a minimum of a further 4 years of specialist training in the administration of anaesthesia, in the treatment of pain, in the care of very ill (intensive care) patients and in emergency care (resuscitation) and will be responsible for:

• administering your anaesthetic

• your well-being and safety throughout your surgery

• planning your post-operative pain control with you

• managing the transfusions of any blood products that you may need, and

• if necessary coordinating aspects of your post-operative care in the Intensive Care or High Care unit

Here are some things that you can do to prepare yourself for your operation to reduce the likelihood of difficulties with your anaesthetic.

If you smoke: you should consider giving up as long as possible before the operation. The longer you can give up beforehand, the better. Smoking reduces the amount of oxygen in your blood and increases the risk of breathing problems during and after an operation. If you cannot stop smoking completely, cutting down will help.

Health Check:

Prior to your anaesthetic we will require get some basic information about your general health and any chronic medication that you may be taking. This will allow us to tailor your anaesthetic specifically to your needs.

Your surgeon should ask you to attend the Pre-Assessment Clinic at the hospital where your surgery is planned. These clinics are staffed by trained nurses who will take you through a standardised questionnaire, record your vital signs and perform an ECG (heart tracing) if indicated.

Some of the questions you will be asked include:

• your general health and fitness

• any serious illnesses you have had

• any problems with previous anaesthetics

• whether you know of any family members who have had problems with anaesthetics

• whether you suffer from any pains in your chest

• whether you suffer from any shortness of breath

• do you suffer from heartburn

• any medicines you are taking, including herbal remedies and supplements you may have been prescribed or may have bought

• any allergies you have

• any loose teeth, caps, crowns or bridges

• whether you smoke

• whether you drink alcohol

Depending on the complexity of the surgical procedure or in the presence of certain underlying chronic disease, your surgeon may request that you also make an appointment for a consultation at our practice rooms. At this consultation, you will be seen by one of or anaesthesiologists. If you need specific blood tests, X-rays or any other tests or investigation, these will be arranged. This is a good time to ask questions and talk about any worries you may have regarding the procedure. Please note that the cost for this consultation ranges between R986 and R1508 (2020) depending on the duration and complexity and will need to be settled on the day of the consult and claimed back from your medical aid if applicable.

Occasionally the health check will happen in the ward after you are admitted to hospital.

Pre-operative preperation

A bath or shower before your operation will clean your skin and reduce the risk of infection. Ideally you should use the specific antiseptic soap that would have been given to you at the pre-admission clinic. Please avoid using make-up, body lotions or creams as they prevent heart monitor pads and dressings from sticking to your skin properly. Please remove nail varnish and ask for advice about false nails as these can interfere with oxygen monitoring. You can wear your glasses, hearing aids and dentures to go to the operating theatre. If you are having a general anaesthetic, you may need to remove them in the operating room to make sure they are not damaged or dislodged while you are anaesthetised. They will be returned to you as soon as you want them. Jewelry and decorative piercing should ideally be removed. Bare metal against your skin could get snagged as you are moved. If you cannot remove your jewelry, it will need to be covered with tape to prevent damage to it or to your skin.

Feeling unwell before surgery

If you feel unwell when you are due for your operation, your surgeon and anaesthetist need to know. Depending on the illness and how urgent the surgery is, your operation might be postponed until you are better.

On the Day of your Operation (What to Expect)

Please refer to the previous information pamphlet on what to do before you come to hospital (pre-admission visit, what to do with my medication, per operative fasting guidelines)

Pre-operative Fasting (‘Nothing to Eat or Drink’ or ‘Nil by Mouth’)

The general rule is that all patients (including children) should have no food or milk products from 6 hours prior to your admission, but may have clear fluids (water, black tea, clear apple juice or clear energy drinks) up to 2 hours before you report to the hospital on the day of your operation. Failure to adhere to these guidelines may result in any food or liquid in your stomach coming up into the back of your throat and then go into your lungs - causing choking or serious damage to your lungs.

As a guide

1. Morning surgery – No food or milk products after midnight. Clear fluids up to 5am.

2. Afternoon surgery – No food or milk products after an early light breakfast (before 7am.) Clear fluids up to 10am

Your Normal Medications

Unless your anaesthetist or surgeon has specifically asked you not to, then you should continue to take your normal medicines up to and including the day of surgery. (Medications that are usually taken in the morning can be taken with clear fluids.)

If you take drugs to thin your blood (such as Wafarin, Aspirin or Plavix) you should check with your surgeon whether and when you should be stopping these medications.

It is extremely important to bring all pills, medicines, herbal remedies or supplements that you might be taking with you. (A written list of everything you are taking, whether prescribed or bought over the counter, would be helpful for your anaesthetist and for restarting your chronic medication after surgery.)

Meeting your anaesthetist

You will meet your anaesthetist before your operation. He or she will make every effort to meet you in the ward before your surgery this is not always possible especially if the surgeon offers you an admission time after the start time of a list. Your anaesthetist will look at the results of your health check and any investigations that were performed and may ask you more detailed questions about your health. He or she will also perform some specific examinations including listen to your chest with a stethoscope, examine your neck and jaw movements, and look in your mouth.

Your anaesthetist will discuss with you which anaesthetic methods can be used. The choice of which depends on:

• your specific operation

• your answers to the questions you have been asked

• your physical condition, preferences and the reasons for them

• your anaesthetist’s recommendations and the reasons for them

• the equipment, staff and other resources at your hospital.

Having discussed the benefits, risks and your preferences, you can then decide together what would be best for you. Nothing will happen to you until you understand and agree with what has been planned. You have the right to refuse if you do not want the treatment suggested or if you want more information or more time to decide.

Premedication

Premedication (or ‘pre-med’) is the name for sedating drugs that are given before some anaesthetics. Modern anaesthetic practice has moved away from routine prescribing sedative drugs, but if you feel a pre-med would help you, please discuss this with your anaesthetist.

In general, a needle will be used to start your anaesthetic. If this worries you, you can ask to have a local anaesthetic cream put on your arm or hand to numb the skin but be aware that your medical aid may not pay for this cream.

The Timing of your Surgery

Although an operating list is scheduled to start at a particular time, only one patient can be anaesthetised and operated on at a time. This means that your surgery may be hours after the scheduled start time of the list. You will be given a rough estimate of the start time for your procedure.

Why does the anaesthetist postpone some operations?

Occasionally, your anaesthetist might find something about your general health that could increase the risks of your anaesthetic or operation. It might then be better to delay your operation until the problem has been reviewed or treated. The reasons for any delay would always be discussed with you at the time. Your anaesthetist’s main concern is your safety.

Blood transfusions

During most operations, you will lose a little blood. Your anaesthetist will usually make up for this blood loss by giving you other types of fluid into a vein through your cannula. If you lose a lot of blood, your anaesthetist will consider a blood transfusion. If your anaesthetist expects this he or she will discuss this with you beforehand. Occasionally, you might need blood unexpectedly. You have the right to refuse a blood transfusion, but you must make this clear to your anaesthetist and your surgeon before the operation.

The operating theatre

You will be collected by members of the theatre team generally 20 to 30 minutes before the anticipated start of your procedure.

The operating department includes a waiting area, operating theatres and a recovery room. Operating theatres are brightly lit and may have no natural light. The theatres may also be quite cool. As it is important for you to keep warm, a warm blanket will be provided if you feel cold.

Once in theatre, staff will check your identification bracelet, your name and date of birth, and will ask you about other details in your medical records as a final check that you are having the correct operation. You will then be taken into the operating theatre. Several people will be there, including your anaesthetist and the anaesthetic assistant.

If you are having a general anaesthetic, you will probably now need to remove your glasses, hearing aids and dentures to keep them safe. If you would prefer to leave your dentures in place, ask your anaesthetist if this would be okay.

To monitor you during your operation, the theatre team will attach you to machines to allow the anesthetist to monitor:

• Your heart: ECG patches will be placed on your chest

• Your blood pressure: a BP cuff will be placed on your arm

• Your oxygen levels: a pulse oximeter will be placed on your finger

• In more complicated procedures advanced monitoring modalities may be applied at this time

Whilst the monitoring devices are being attached the anaesthesiologist will site your cannula (drip.) A needle will be used to put a thin plastic tube (‘cannula’) into a vein in the back of your hand or arm. This is then taped down to stop it slipping out. Sometimes, it can take multiple attempts to insert the cannula. This intravenous line is an essential part of the anaesthetic and allows for the delivery of antibiotics, anaesthetic drugs, fluids, blood products and emergency drugs (if needed)

General Anaesthesia

Anaesthetic drugs are generally given through the cannula. Induction happens very quickly, and you will become unconscious within a minute or so. People usually describe a slightly dizzy, light-headed feeling. Some anaesthetic drugs will result in some discomfort as the drugs are given through your cannula but this will pass quickly. Once you are unconscious, your anaesthetist will continue to give drugs into your vein or anaesthetic gases to breathe (or both) to keep you anaesthetised. Your anaesthetist will choose a way of making sure that you can breathe safely and easily while asleep. This may be a soft pipe placed in the breathing tube or an inflatable device placed in your airway. Keeping your airway open is essential for your safety. For some operations, muscle relaxants, which will stop you breathing, are necessary. Your anaesthetist will use a machine (a ventilator) to ‘breathe’ for you.

For the duration of the procedure the anaesthetist will stay with you and will be constantly monitoring your condition, adjusting the anaesthetic and giving you any fluids or drugs that you require.

Some of the drugs that you may be given during your anaesthetic include:

• anaesthetic drugs or gases to keep you anaesthetised

• pain-relieving drugs to keep you pain-free during and after your operation

• muscle relaxants to relax or temporarily paralyse the muscles of your body

• antibiotics to reduce the risk of infection

• anti-sickness drugs to stop you feeling sick

• other drugs depending on your condition as it changes.

At the end of the operation, your anaesthetist will stop giving anaesthetic drugs. If muscle relaxants have been used, a drug that reverses their effect will be given. When your anaesthetist is sure that you are recovering normally, you will be taken to the recovery room.

Local and regional anaesthetics

These anaesthetics are usually given to you while you are conscious

You can then:

• help your anaesthetist get you into the correct position

• tell your anaesthetist if the needle causes pain

• tell your anaesthetist when the anaesthetic is taking effect.

The type and place of a local or regional anaesthetic injection will depend on the operation you are having and the pain relief you will need afterwards.

Local anaesthetics

Local anaesthetics are injected close to the area of your operation. They can also be used to numb the skin before anything sharp is inserted, such as a cannula for a drip.

Regional anaesthetics

Spinals or epidurals (the most common regional anaesthetics) are used for operations on the lower half of your body. Spinals are single injections which take only a few minutes to work and last about two hours. They cannot be topped up to make them work longer. Epidurals can take up to half an hour to work but can be used to relieve pain for hours and sometimes days after your operation. They can be topped up by putting more local anaesthetic into the fine plastic tube. There are other nerve blocks that your anaesthetist may be able to offer for specific operations.

Starting a regional anaesthetic

Some local anaesthetic can be given to help the discomfort of the injection for the block. It can take more than one attempt to get the needle in the right place so that the area is properly numbed. Your anaesthetist will ask you to keep quite still so he or she can give you your local or regional anaesthetic block. When the needle is inserted, your anaesthetist will ask you if you feel any tingling or shocks. You may notice a warm tingling feeling as the anaesthetic begins to take effect. It is common to feel as though the part of your body which is anaesthetised does not belong to you. Your operation will only go ahead when you and your anaesthetist are sure that the area is numb. Once the local or regional block is working, your anaesthetist will continue with the plan you have agreed.

A cloth screen is used to shield the operating site, so you will not see the operation. Your anaesthetist is always near to you and you can speak to him or her at any time.

After a local or regional anaesthetic

• After surgery you may have problems passing urine. A thin soft tube (catheter) may need to be inserted temporarily into the bladder to drain it. This is more likely after a spinal or epidural anaesthetic, as you will not be able to feel when your bladder is full.

• It will take some hours for feeling to return to the area of your body that was numb. This ranges from one hour to about 18 hours depending on the type of anaesthetic injection.

• You can expect to feel tingling as feeling returns, but this soon passes. At this point it is important to let staff know if you are feeling pain.

Post-Operative Recovery

After a general anaesthetic you will regain consciousness in the recovery room. Specially trained recovery staff will be with you at all times and will continue to monitor your blood pressure, oxygen levels and pulse rate during your emergence.

• Oxygen may be given through a lightweight clear-plastic mask that covers your mouth and nose.

• You will receive pain-relieving drugs before you regain consciousness, but if you are in pain, please tell the staff.

• If you feel sick, you will be given drugs that will help with this.

• You may shiver after your operation. If you are cold you will be warmed with a warming blanket.

• You may have a urine catheter in place - a soft tube put into the bladder to drain it.

• Once you are fully alert, dentures, hearing aids and glasses can be returned to you

Intensive Care Unit (ICU)

After some major operations, you may be taken to the ICU. If this is planned, it will be discussed with you beforehand. If you are going to one of these areas, you can ask your surgeon, anaesthetist or ward nurse what to expect.

After your Operation

Back to the ward

The recovery staff must be totally satisfied that you have safely recovered from your anaesthetic, and all your observations (such as blood pressure and pulse) are stable before you are taken back to the ward. The type of operation will affect how long it will be before you can drink or eat. After minor surgery, this may be as soon as you feel ready. Even after quite major surgery you may feel like sitting up and having something to eat or drink within an hour of regaining consciousness.

What will I feel like afterwards?

How you feel will depend on the type of anaesthetic and operation you have had, how much pain-relieving medicine you need and your general health. Most people feel fine after their operation. However, you may suffer from side effects of some sort. You may feel sick, dizzy or shivery, or have general aches and pains. Some people have blurred vision, drowsiness, a sore throat, a headache and breathing difficulties. You may have fewer of these side effects after a local or regional anaesthetic block. Until the block wears off, you will usually feel fine. However, when it has worn off, you may need painrelieving medicines and you may then suffer from their side effects.

Pain relief

Good pain relief is important as it prevents suffering and it helps you recover more quickly. Your anaesthetist will probably discuss different pain-relief methods with you before your surgery so you can make an in- formed decision about which you would prefer. Some people need more pain relief than others. Pain relief can be increased, given more often, or given in different combinations. Occasionally, pain is a warning sign that all is not well, so the nursing staff should always be told about pain.

Good pain relief helps prevent complications because if you can breathe deeply and cough easily after your operation, you are less likely to develop a chest infection. If you can move around freely, you are less likely to get blood clots in your legs. It is much easier to relieve pain if it is dealt with before it becomes severe. Consequently, you should ask for help as soon as you feel pain, and continue the treatment regularly.

Ways of giving pain relief:

• Pills, tablets or liquids to swallow: These take at least 20 minutes to work and should be taken regularly. You need to be able to eat, drink and not feel nauseous for these drugs to work.

• Injections: If needed, these may be given through your cannula into a vein (in ICU) or into your shoulder, leg or buttock muscle (in the ward). If they are given into your muscle, they may take 20 minutes or longer to work.

• Suppositories: These waxy pellets are placed in your anus (rectum). The pellet dissolves and the drug passes easily into the body. They are useful if you cannot swallow or if you are likely to vomit.

It is important to ask for help:

• when you first get out of bed (although you may feel fine lying in the bed, you may feel faint or sick when you first get up).

• if you have had a spinal or epidural, as your legs may still be weak or numb for some hours. They may not regain their full strength for about 12 hours. This will help prevent you from falling over.

How did it all go?

For most people, the part that the anaesthetist plays in their care is over within an hour or two of day surgery, or a day or two for more major surgery. If there have been any problems during the anaesthetic that have affected you or your treatment, you should be told about them as you have a right to know and so that you can warn anaesthetists who may care for you in the future.