Sunday, September 13, 2015

Getting ready for surgery - pet alert!

We have posted often on the "4 Ps" that contribute to the outcome of a shoulder surgery: the problem being treated, the characteristics of the patient having the procedure, the procedure itself and the physician performing the procedure.

Most shoulder surgery is elective; this means surgery should not be undertaken until everything is optimized. In this post we present the concept of "prehabilitation", that is, steps the patient can undertake before  surgery to make it safer and more effective.

Here is a 'risk calculator' which estimates the surgical risk related to some important characteristics of the patient. What is important to note is that the risk factors outlined here and elsewhere are, in many cases modifiable by the patient.

Here are some steps for the patient considering surgery that can reduce the risk of surgery. Consider it a 'pre flight check list'.

__Engage in three hours of aerobic exercise per week if your primary care physician deems it safe.

__Avoid smoking or use of any nicotine-containing products for three months prior to surgery.

__Avoid any narcotic medications stronger than hydrocodone for three months prior to surgery. If heavier narcotics have been used, detoxification under physician supervision should be accomplished three months before the surgery.

__For three months before surgery, restrict alcohol consumption to one drink per day for women and two drinks per day for men

__ A plan for patient care after discharge needs to be in place well in advance of surgery, recognizing that the shoulder may be less useful for a period after surgery than it was before. Understand the limitations on their activities after surgery, such as restrictions on driving, as well as the need for someone to be with you for days or weeks after the procedure. The need for a skilled nursing facility should be identified well in advance of the procedure.

__Identify a primary care physician who can manage non-surgical concerns and medications after surgery.

__Understand and plan for the rehabilitation program after surgery as well as the plan for followup with the surgeon.

Physical and emotional health
__Optimize dental hygiene, including gum care. Dental concerns need to be tended to at least 2 weeks before surgery.

__Identify any skin lesions anywhere on the body, especially on the arm of the intended surgery. These need to be completely healed at least two weeks before surgery. Be particularly careful to check the skin in the arm pit and under the breasts.

Cats and dogs may be a person's best friends, but look out. Here's the skin of a cat-scratched arm that led us to cancel an elective surgery on a patient from 1500 miles away.

__Assure that any infections are completely resolved and antibiotics discontinued at least 6 weeks prior to surgery.

__Optimize control of sleep apnea, anxiety, depression, diabetes, hypertension, heart conditions, as well as urinary tract function.

Communication with the surgical team
__Discuss the surgeon's personal experience with the problem and the procedure along with possible risks, alternatives and anticipated outcomes

__Notify the team if prior experience suggest that it will be difficult to establish an intravenous (IV) line for surgery or has been difficult for an anesthesiologist to establish an airway or if you have had any problems with prior anesthetics, or control of pain.

___Let the team know if you or any family member or blood relative ever had a serious problem with anesthesia, and if so, what was the problem?

__Discuss with the surgeon heart conditions, strokes, kidney disease, liver disease, lung disease, bleeding tendencies, prior surgical complications, reactions to anesthetics, seizures.

__Document and communicate all medical allergies, especially allergies to antibiotics and latex.

__Could you be pregnant? If so, we would recommend that you have a pregnancy test performed before coming for surgery, and if you are pregnant, that you not undergo elective surgery until after delivery.

__Compile and share complete list of all prescription and over-the-counter medications.

__Anti inflammatory medications and blood thinners ( for example, aspirin, Advil, Coumadin, Warfarin, Plavix, Ibuprofen) will increase the risk of bleeding and their use may need to be modified well in advance of surgery. If you are taking drugs to prevent blood clotting, you should consult with the pre-anesthesia clinic at least 10 days in advance to obtain instructions regarding when these medications need to be stopped, or modified.

__Identify and discuss any legal issues regarding the shoulder problem well in advance of surgery.

__Verify insurance coverage needs to be verified well in advance of surgery. This is especially important for patients living outside of Washington.
You may also be interested in the Strong for Surgery concept explained here.

Consultation for those who live a distance away from Seattle.

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