Which of the following tips is especially useful when youre providing preoperative education?

Abstract

The umbrella of preoperative education covers a broad range of interventions including didactic information about the rheumatic disease diagnosis and symptoms, disease management strategies around self-management and pharmacologic treatments, and behavioral strategies such as physical activity and smoking cessation. Patients who elect to undergo surgery and their family caregivers will benefit from practical education about the surgical procedure, hospital experience, and perioperative care to facilitate recovery and alleviate anxiety. Patient education also extends to therapeutic strategies involving medication usage peri- and post-operatively and throughout the life course, including expected benefits, risks of adverse events, and interactions with concurrent medications. In a patient-centered care model, patients and families undertake a shared decision-making process with multidisciplinary care providers to promote a safe, successful surgical experience and positive long-term outcomes for quality of life and emotional well-being.

Surgeon

Despite the excellent and thorough preoperative evaluation and education of a patient by the multidisciplinary presurgical team, the surgeon bears equal responsibility for ensuring appropriate patient selection, education, and preoperative preparation. As documented in the American College of Surgeons Statement on Principles Underlying Perioperative Responsibility, the surgeon is responsible for the preoperative preparation of the patient.8 Minimizing the risks of operation while providing maximal opportunity for a satisfactory outcome requires a full appreciation by the surgeon of the patient's condition.

In our institution, the surgeon is initially consulted midway through the evaluation and only after the patient has been screened and identified as a potential candidate for a bariatric operation. This system of checks and balances protects the patient from the surgeon and vice versa. The surgeon's primary objective at the initial consultation is to ensure appropriate candidacy, educate the patient regarding surgical (and nonsurgical) options, describe the risks and potential short- and long-term complications, and reaffirm that the patient has realistic expectations. The possibility of future cosmetic surgery also merits discussion at this time.

Preoperative Rehabilitation

Before undergoing surgery, many patients attend a THA education class (if offered by the facility in which they are having surgery), which may include a physician and/or surgeon, nurse, rehabilitation clinicians, and a case worker, discharge planning nurse, or social worker. Patients are educated about preparing for surgery, the surgical procedure, the postoperative course, applicable precautions, early postoperative exercise, functional mobility with a walker and/or crutches, and discharge planning from hospital to home or to inpatient rehabilitation or extended care facility (ECF).73,74

One of the primary roles of preoperative education is the influence it can have on patient expectations regarding long-term outcome after surgery, course of hospitalization, and transition from the hospital into the postacute care phase.74,75 Evidence has shown that patients who receive preoperative education demonstrate improved achievement of preoperative expectations (such as symptom relief and improved function), significantly less preoperative anxiety, and decreased incidence of postoperative complications (such as hip dislocation).74–77 Education about hip dislocation precautions, the proper use of assistive devices, early postoperative exercise, and mobility may be more effective before surgery, when pain, the effects of anesthesia, and postoperative anxiety do not interfere with the patient’s ability to concentrate and process information. The textbox on the following page outlines a sample syllabus for a preoperative education class.

Sample Syllabus for Preoperative Education on Total Hip Replacement

Definition of items used during your hospital stay

Preparing your home before surgery and items to bring with you

Planning your discharge

Admission to the hospital

Operating room

Recovery room

What to expect each day in the hospital

Total hip replacement dislocation precautions

Prevention of dislocation after total hip replacement

Instructions for sitting and rising from a chair

Walker, crutches, and cane use

Gait training

How to climb stairs

How to get into and out of a car

How to get into and out of a stall shower or tub shower

Rehabilitation

Exercises

Sexual activity after hip replacement

Skin care

Wound care, signs of infection, signs of a blood clot

When to call your doctor and what to do in an emergency

How to contact your surgeon

How to contact the orthopedic nurse education coordinator

When to return for follow-up appointments

Antibiotic prophylaxis after a total hip replacement

Venous thromboembolism prophylaxis

The literature is conflicting on the effect of preoperative educational sessions on short- and long-term THA outcomes. In one study, patients who received preoperative education and therapy to increase strength and ROM performed transfer activities sooner postoperatively than those who did not receive preoperative training; however, no significant difference was seen in pain or in the Harris Hip Score (HHS).78 In another randomized, controlled prospective study, Giraudet-Le Quintrec et al.76 compared patients who had received a preoperative information leaflet (control group) with patients who had attended a collective, multidisciplinary information session 2 to 6 weeks before surgery. The patients who had attended the information session were significantly less anxious just before surgery than the patients in the control group. They also had less pain before surgery, and they were able to stand sooner; however, the trend toward lower anxiety scores was not statistically significant after surgery.75,76

Discussions and decisions about discharge planning and destination (i.e., home or rehabilitation facility) should begin preoperatively via formalized screening. Studies have shown that factors available to providers before surgery, such as age, gender, presence of co-morbidities, living situation, and presurgical function, are all factors in the recommendation for discharge destination.79,80 Since 1999, use of formalized preoperative screening tools has also assisted in anticipating likely discharge destination after the hospital stay. Oldmeadow et al. developed the Risk Assessment and Prediction Tool (RAPT) for total joint arthroplasty patients (Figure 19-3).81 Information such as age, gender, preoperative walking ability, preoperative use of assistive walking aids, and available social supports are collected by the multidisciplinary team. This information is entered into a formula that generates a prediction score for likely discharge destination (i.e., home versus inpatient rehabilitation). This tool has been validated in multiple studies to aid early discharge planning.82,83 Early planning to arrange alternative short-term living arrangements or support may allow patients who live alone to avoid discharge to an inpatient rehabilitation setting.81

PREVENTION

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Consider the developmental level of the patient.

Allay parental anxiety with preoperative education before the day of surgery.

Assess the child's level of preoperative anxiety on the day of surgery.

Administer preanesthetic sedation to high-risk pediatric age groups (1to 6 years) and children with high levels of preoperative anxiety.

Implement a multimodal analgesia plan and maintain a high degree of suspicion for the inadequacy of postoperative analgesia.

Avoid overly rapid emergence from low-solubility volatile inhalation anesthetics.

Consider administering IV opioids, midazolam, propofol, dexmedetomidine, or clonidine before emergence in patients who have received low-solubility volatile anesthetics.

Rapidly reunite the child with his or her parents in the PACU.

Preanesthetic Medications

Appropriate preanesthetic management of pediatric patients has been an area of much interest for quite a few years. Preoperative education, parental presence, and pharmacologic agents have all been used and all have a place in providing a smoother and safer induction. These are considered in Chapter 9 (Preoperative Preparation) and only cardiac effects of pharmacologic agents will be considered here. Although numerous oral, intramuscular, and intranasal drugs have been proposed as pediatric premedicants, the current most popular agent is oral midazolam. Intravenous midazolam can decrease cardiac output when it is combined with intravenous morphine (Shekerdemian et al., 1997). Midazolam in routine oral doses of 0.5 to 1.0 mg/kg is well tolerated hemodynamically, even in children with cardiac disease. In a study by Masue and colleagues (2003), larger doses of 1.5 mg/kg did not cause any overall decrease in blood pressure, heart rate, or oxygen saturation, although a small number of patients did have a decrease in blood pressure or saturation (6% and 4%, respectively). This was likely related to baseline agitation or underlying cyanotic heart disease confounding the measurements (Masue et al., 2003). If used for sedation in the intensive care unit, abrupt cessation after several days of use can result in cardiovascular withdrawal phenomena. Audenaert et al. (1995) used Doppler echocardiography to compare three premedication regimens in children. They compared oral premedication (meperidine, 3 mg/kg + pentobarbital 4 mg/kg), nasal premedication (ketamine, 5 mg/kg + midazolam, 0.2 mg/kg), and rectal premedication (methohexital, 30 mg/kg). All had relatively modest effects if any. Meperidine + pentobarbital decreased heart rate, mean arterial pressure, and cardiac index. Ketamine + midazolam had no significant cardiovascular effects, and methohexital increased heart rate with a consequent decrease in stroke volume, but without additional effects.

Preoperative Education and Management

The multidisciplinary preoperative evaluation that leads to the decision to offer surgical treatment is followed by considerable patient and family preoperative education. It is important that this process is organized and not rushed because patients must comprehend a great deal of information about the anatomic and physiologic changes that occur after surgery that impact success and the risks for the short- and long-term complications. Detailed information about the options for various surgical procedure(s), nursing care, dietary strategies, physical activity, and behavioral approaches to support adherence to the postoperative regimen is provided. Patients may also benefit from discussion with others who have undergone surgical treatment. In the weeks before the operation, a final outpatient visit for anesthesiology consultation, final informed permission (consent) discussion, and final review of the postoperative regimen is scheduled. At the conclusion of this visit, some programs require the patient to take a written test, which is scored and reviewed with the patient, as further documentation of his or her level of understanding of the procedure and known and potential adverse and beneficial consequences.

During the evaluation of a potential surgical patient, studies include serum chemistry and liver profiles, lipid profile, complete blood cell count, hemoglobin A1C level, fasting blood glucose value, thyroid-stimulating hormone level, and Helicobacter pylori titers. If these titers are positive, a breath test is done to confirm or exclude active H. pylori infection. An electrocardiogram is obtained to screen for cardiac problems and dysrhythmias. For instance, prolonged QT syndrome does exist in morbidly obese adolescent patients and may be previously unrecognized. Because unrecognized sleep disorders are relatively prevalent in the severely obese, a complete sleep history is sought, including a history of snoring, irregular breathing, and increased daytime somnolence. A history suggestive of sleep apnea should prompt formal polysomnography. If the fasting glucose concentration is elevated, or if other symptoms of diabetes exist, patients should undergo a 2-hour glucose tolerance test to determine if more significant abnormalities of carbohydrate metabolism exist, including impaired glucose tolerance and type 2 diabetes.

On the day before the operation, the patients are limited to clear liquids. Preoperative medications include low-molecular-weight heparin (40 mg injected subcutaneously and continued twice daily postoperatively). A second-generation cephalosporin antibiotic is administered within 1 hour of surgery. Sequential compression boots also are used intraoperatively and postoperatively. Most patients are candidates for laparoscopic procedures, although some of the heavier and centrally obese patients may present challenges, particularly in the early portion of a surgeon’s learning curve.

Recommendations in the immediate postoperative period

LSG is a perfect fit for enhanced recovery after surgery (ERAS) programs. Obese patients are usually well committed to self-care after the whole process of preoperative education carried on by the multidisciplinary team; the operative time is usually short (less than an hour), and complications are not frequent if the surgery is performed by well-trained surgical teams. The ERAS protocol consists of goal-directed patient education, specific pre- and postoperative multimodal medication regimen, early ambulation, and early oral intake. If everything goes according to plan, the LSG patient could be discharged in the first or second postoperative day [6].

The same day of the surgery, the patient can try with small intakes of clear liquid diet (usually 4–6 h after surgery, if there are not contraindications in relation to intraoperative complications or anesthetic issues); and we must insist on early mobility (the patient should go to a comfortable chair, stand, and walk a few steps the same day of surgery). The ERAS protocol includes prophylaxis of nausea and vomiting and a reduction in the use of morphics to facilitate the early intake of liquids.

In the following day, we will recommend increasing the fluids in several intakes of 80–100 ml each; and we can add some soluble protein (10 g/8 h). we could also use some commercial preparations with proteins as OptiSource or similar.

If the patient can tolerate the oral intake with some soluble protein, the patient is capable to walk and stand; there are not any signs or symptoms that suggest any postoperative complications, there is a caregiver available at home and they do not live very far from the hospital; the patient could be discharged in the first or second postoperative day. It is crucial that the patient and the caregiver understand all the precautions, the warning signs indicating complications and the nutritional recommendations before being discharged. It is better to give all of this information before the operation and make a reminder at discharge.

PREOPERATIVE CONSIDERATIONS

Selection of a treatment modality for localized prostate cancer is multifactorial and requires extensive discussion between the surgeon and the patient. Preoperative expectations on the part of the patient are a critical determinant of postoperative satisfaction. The process of preoperative education mandates a careful and comprehensive review of the therapeutic options and their potential complications and relative outcomes.

In general, candidates for radical prostatectomy should be in good health. In contemporary prostatectomy series, the risk of myocardial infarction, pneumonia, cerebrovascular accident, and death from these causes is exceedingly low,3-5 likely because of proper patient selection in addition to improved anesthesia techniques.6 Selection of healthy surgical candidates is important not only from the standpoint of avoiding anesthesia-related morbidity but also because the relative advantage of surgical resection over radiation-based therapies lies in the duration of therapeutic response.

Individuals with expected longevity >10 years are ideal for the procedure and are likely to benefit the most from it. In assessing a patient's longevity, the urologist must carefully weigh the aggressiveness of the disease against the patient's health. Higher-grade cancers, which are more likely to result in disease-related morbidity in the short term, may require aggressive therapy in patients with relatively short longevity, whereas radiation-based therapies or watchful waiting may be more important in individuals with moderately differentiated disease and relatively poor health.

In this regard, Albertsen and colleagues7 described the risk of cancer-related death in ≤15 years of diagnosis for individuals with various grades of prostate cancer. The estimated risk of death was 4% to 7% in patients with Gleason score 2 to 4, 6% to 11% in patients with Gleason score 5, 18% to 30% in patients with Gleason score 6, 42% to 70% in patients with Gleason score 7, and 60% to 87% in patients with Gleason score 8 to 10. Clearly, individuals with higher-grade disease have worse outcomes with radical prostatectomy than do patients with low-grade disease, but prediction of outcome must be balanced against disease-related risk of death.

In selecting candidates for radical prostatectomy, the presence of voiding dysfunction should be carefully elucidated. Individuals with significant preoperative obstructive voiding symptoms may actually experience relief of such symptoms following radical prostatectomy.8 Conversely, such individuals, particularly those with large prostates, may experience a worsening of voiding symptoms or progression to urinary retention following radiation-based treatments. The improvement in quality of life resulting from the relief in voiding symptoms following radical prostatectomy may actually outweigh the detriment causes by mild degrees of stress incontinence in the view of the patient.9

A careful assessment of the patient's daily activities and profession may aid in determining the potential impact of stress urinary incontinence on the individual surgical candidate. Although rates of significant incontinence have drastically improved, the patient should be made well aware of the nature and potential impact of stress urinary incontinence. Similarly, the risk of impotence despite nerve-sparing procedures should be carefully delineated. Although the pharmacologic advancements in the field of erectile dysfunction have lessened the impact of postoperative impotence following radical prostatectomy, the presence of a regular sexual partner, the stability of current relationships, and cultural attitudes regarding erectile dysfunction should be carefully evaluated before the surgical procedure.

The overall impact of complications of radical prostatectomy on quality of life is a topic of intense study in many centers and is covered comprehensively in Chapter 45. Future focus will lie in preoperative identification of poor candidates for surgery on the basis of potential impact of surgical complications on quality of life.

Operating Room Environment

Ventilation and OR traffic likely affect SSI rates. Laminar-flow ORs and high-efficiency particulate air (HEPA) filters have been shown to reduce SSIs and wound contamination when compared with conventional airflow systems.123–125

Personnel are the major source of contamination in the OR.126 The number of personnel as well as traffic flow rates in the OR positively correlate with the degree of airborne contamination.127 Education, preoperative planning, communication, and limiting surgical time are the most effective measures to decrease traffic flow.

There are many potential sources of contamination from equipment within the OR (i.e., light handles, fluoroscopic C-arm, ultrasound probe; Fig. 86.2). The contamination of sterile light handles has been reported to be as high as 14.5%; therefore, the handling of OR lights should be minimized.126,128 Biswas et al. evaluated the sterility of 25 C-arm drapes placed with aseptic technique after their use during spine surgery.129 All locations were contaminated at the end of the surgical case. The front, top half and the superior end of the image intensifier were associated with higher contamination rates. All OR personnel should avoid contact with the C-arm.