Medical conditions

As a perioperative physician, I need to optimise and manage any other medical conditions you may have. Your questionnaire will allow me to arrange any further tests and organise any special facilities that may be needed.

If you have medical notes – for example letters from consultants, discharge summaries, imaging reports or blood results – please let me know and bring them with you.

Diabetes

If you are taking insulin it will be necessary to change the type and frequency depending on your operation. Patients having a day case operation are normally given the long acting element of their insulin on the morning of the operation. For larger operations we normally use a continuous infusion of short acting insulin. I will tell you what to do when I receive your questionnaire.

Patients who are on tablets for diabetes can normally continue to take them until their operation. I will advise you.

You should not have an operation if you are a newly diagnosed diabetic. Non urgent procedures should be delayed until you are established on either a diabetic diet or medication. Surgery should also be postponed if your diabetes is poorly controlled. Infections and other illnesses can destabilise diabetes and it is safer to deal with this before an elective operation.

Asthma

Anaesthetic drugs have a powerful anti asthma affect but the stress of the surgery can destabilise an asthmatic. If you are taking inhalers it is very important to continue to take them until your operation. Please bring all your inhalers and other drugs into hospital in their original containers and ensure you have an adequate supply for your hospital stay as there can be a difference between different manufacturers.

After an attack of asthma, the lungs are hypersensitive to further stimulation for two weeks. If you have had an asthma attack within two weeks please contact me before admission.

Hypertension

High blood pressure is a common disorder and anaesthesia does not normally cause any problems. You should continue to take your normal drugs on the day of surgery. You should delay any non-urgent operations if you are recently diagnosed, if your medication has been changed, or if your blood pressure is greater than 150 systolic or 100 diastolic.

If you are taking statins to lower your cholesterol, please do NOT stop them. Bring them into hospital with you.

Drugs and medicines

Please bring all your drugs into hospital with you. This includes any herbal medicine or over-the-counter vitamins. Please also bring the original containers if you have transferred the drugs into a dispenser. Please tell me if you are taking any recreational drugs, Chinese herbs or other chemicals.

I will prescribe any additional drugs that you need to go home. However, UK health insurers will not pay for these drugs and the costs can be quite high so if you are already on painkillers please ask your general practitioner to prescribe enough for a week after discharge. Most patients manage their pain with either paracetamol or non-steroidals such as ibuprofen. If you buy a box over the counter before admission it will reduce the cost of your take out drugs.

Preparing for your operation

Smoking

Smoking is not only the leading cause of premature death but also the leading cause of post operative complications. Nicotine is a highly addictive drug and it can be very difficult to give up especially if you live with somebody who also smokes. The NHS operates a nationwide stop smoking service which has one of the highest success rates in the world and I would urge you to consider contacting your local NHS hospital before your operation if you have time.

If you do smoke, stopping for just a few days dramatically reduces your risk. Whatever you do it is vital you do not smoke for 24 hours before the operation as the high levels of carbon monoxide cannot be distinguished from oxygen by our monitoring systems which means we cannot detect low levels of oxygen in your body.

Nicotine patches are considerably safer as long as I am aware that you are using them. E cigarettes are also far better than smoking.

Exercise and diet

We now know that the ability to cope with a major operation is related to muscle mass. Patients with a low muscle mass do not do as well and take longer to recover from major surgery. If you are having a big operation there are several things you can do. First consider an exercise regimen at your local gym. This does not need to be excessive and just 20 minutes exercise three times a week, ideally working against resistance will have a dramatic influence on the operation. A high-protein diet with lots of meat and fish or even high protein drinks are strongly recommended.

Dental care

Crowns and bridges at the front of the mouth can be at risk during operations. If your crowns are loose or damaged please see your dentist before your operation. If you have an abscess or any other infection in your mouth surgery should be postponed. Otherwise dental work should not be undertaken immediately before an operation due to the small risk of infection.

Pregnancy, the oral contraceptive and breast feeding

If you are pregnant or think you might be pregnant please contact me before admission. Anaesthesia may induce a spontaneous abortion but there are other factors to consider such as the difficulty of using x-rays which may be essential to your operation.

We do not normally recommend stopping the oral contraceptive. However any operation no matter how small may stop the drug being absorbed. You must consider that you are not protected from pregnancy until you are over the operation, off all drugs, eating and drinking normally with normal bowel activity. A further two weeks on the pill is then necessary before you are protected and during this time you must take additional contraceptive measures

A number of anaesthetic drugs pass into human milk so if you are breastfeeding please contact me in advance so we can discuss whether this applies to your anaesthetic technique. I normally recommend mothers express milk before the operation so they have a supply for the post-operative period.

Alcohol

Alcohol increases the risk of some cancers but may also reduce the risk of heart failure. I am happy for you to drink moderately around the time of your operation with the exception of the night of surgery and also if you are on certain painkilling drugs. I will give you further advice when you are in hospital.

Heavy drinking can create a number of problems and I would recommend you attempt to moderate your intake leading up to the operation. Please be completely honest with me about how much you drink. It will remain confidential. If I am aware of the risks I can control them.

Make up and nail varnish

All make up must be removed before an operation. We use adhesive tape to protect your eyes and attach equipment. Make up stops the tape sticking and could result in the anaesthetic becoming disconnected. Please do not wear make up into hospital.

Hair spray should also be avoided because it is highly flammable

Nail varnish and acrylic shells bought or applied in the UK or Europe can be left on. All nail varnish sold in Europe is an enamel and the equipment that measures oxygen levels is not effected – very dark browns and blacks are occasionally a problem but we can remove this from a single finger if we need to. If you have bought the nail varnish in America then it does need to be removed from both hands before you arrive.

Eating and drinking on the day

We now have internationally agreed standards for eating and drinking before anaesthesia

• you can eat normally until six hours before your operation. Until this time there is no limitation whatsoever on what you eat
• you can drink until two hours before your operation. Some anaesthetists limit this to water but I am happy for you to drink anything except pure milk, or fruit juice with particles. Tea or coffee with some milk is acceptable as are fizzy drinks.
• within two hours of your operation you can sip water only. This will allow you to take any tablets and keep your mouth from feeling dry
• human breast milk is the only exception and this is allowed until four hours before anaesthesia

Please ask the hospital or your surgeon to tell you the time of the operation. It is normally 1 to 2 hours after admission. It is vital that you do not excessively starve or stop drinking as this can increase the amount of acid in your stomach and also affect your metabolism.

The only patients who may need to modify this regimen are those having surgery on the colon who are receiving bowel preparation

Many patients find these restrictions distressing but they are vital for a safe anaesthetic and if you eat and drink within the 2 and 6 hours your surgery will be postponed. If you are hungry you can drink apple juice which is full of carbohydrates until two hours before your operation

Coming into hospital

Please arrive in plenty of time to rest before your operation. You are not going to the airport! I need you to be relaxed and adequately prepared by the nursing staff for safe anaesthesia. This takes at least two hours.

I strongly recommend you travel light. Please bring your drugs, any medical notes or x-rays, and an iPad or book to read. Please wear loose clothes that can be washed if necessary. Do not bring jewellery or other valuables.

As soon as you arrive please get changed to avoid a rush at the last minute. It also allows us to examine you and take observations in plenty of time. If you have a cold you should still come into hospital as the symptoms rarely necessitates postponement. If you have an advanced directive (living will) please bring a copy and show it to me.

All anaesthetics require a cannula or plastic tube which is put into the vein with a needle. The needle is very small but if you have a needle phobia please tell the nurses as soon as you arrive and they will apply a local anaesthetic cream so that the injection is painless. The cream takes time to work and needs to be applied as soon as you are admitted.

The anaesthetic

The commonest type of anaesthetic is a general anaesthetic which produces complete unconsciousness. We usually inject drugs intravenously into a small plastic tube in the back of your hand and you lose consciousness immediately. A general anaesthetic involves a number of different drugs which produce unconsciousness, pain relief and muscle relaxation. You also lose sense of time and will seem to wake up immediately you have lost consciousness.

An alternative to general anaesthesia is sedation where we give drugs intravenously to remove anxiety. The media often talks about conscious sedation or awake sedation which refers to drugs given by non-anaesthetists to facilitate procedures such as endoscopy. However, as an anaesthetist I am able to use these drugs over a much broader range to produce differing levels of consciousness. Please look at our blog on sedation for more information.

As well as sedation or a general anaesthetic I may recommend a spinal anaesthetic, an epidural or a nerve block. These involves injecting local anaesthetic around a nerve to stop it transmitting pain signals. These ‘blocks’ reduce the amount of painkillers we need to give during the operation and can dramatically reduce post-operative pain. I will discuss them with you at your consultation

Regardless of the technique a nurse will take you to an anaesthetic room. This is a small room adjacent to the operating theatre which is quiet and peaceful. We will play music and provide soothing videos on an overhead screen. We will warm you with a blower while you relax on the bed. This is an important time; if you are relaxed and comfortable I need to use less medicine and this provides a more pleasant recovery.

My assistant who is called an operating department practitioner will check you in. During your operation you will go through many checks although you will be unconscious for a lot of them. They are designed to eliminate the risk of errors.

Once you are checked in the ODP will attach monitors to measure the ECG, blood pressure and oxygen levels. This is mandatory before any anaesthetic. I also pre-warm my patients by blowing warm air under a blanket. This is not only very pleasant but also reduces wound infection. At the same time we insert a small cannula in the back of your hand and I will tell you when I inject drugs that will make you unconscious. The next thing you will know is when you are in recovery which is a special area staffed by recovery nurses and you will have your own nurse at this time.

After your anaesthetic

You will regain consciousness in the recovery area. You will be still be connected to the monitors and have your own nurse. You may have a clear plastic mask delivering oxygen, although we no longer use this for all patients. I will continue to supervise your care and be in the theatre suite until you are stable.

Pain

Most patients have little pain on waking. We give pain killers during the anaesthetic and often add local anaesthetic injections. If you do have pain the recovery nurse will give further drugs directly into your cannula under my supervision.

You may remain in recovery for an hour to ensure everything is stable, and there may be some discomfort. You should work with the nurse and agree the amount of pain relief you want, as this varies from patient to patient. The more medicine we give, the more drowsy you become, and you may be nauseous, so we aim to find the correct balance with your help.

We can manage pain in several ways as you move to the ward:

• If you have an epidural I will continue to inject local anaesthetic using a pump and this gives about 80% pain relief
• We often use a patient controlled analgesic pump (PCA) which is a small pump attached to your cannula. You have a button and you press the button when you want more pain relief. I programme the pump so you cant have too much.
• Modern anaesthesia uses multiple drugs to provide optimal pain relief with the least side effects. You may be given tablets, drips and injections which we will explain to you.

Nausea

Nausea remains common, occurring in about a third of cases. It is more common with certain operations (gynaecology), in women, and with day cases. I routinely give antiemetics and this significantly reduces the risk. If you suffer nausea, we will give further doses after your operation.

A small number of patients have nausea or vomiting with each and every anaesthetic. This is referred to as perioperative nausea and vomiting (PONV). It is more common in women, those that are fair haired and fair skinned, and from puberty to the menopause. Obviously the diagnosis can only be made if you have had a number of operations of differing types and always been sick. We now have a specific group of drugs which eliminates this problem in about 50% of sufferers. If PONV is a problem I will discuss this when I undertake your consultation

Preventing complications

We assess each and every patient for the risks associated with surgery. If there is a risk of infection I will give you antibiotics during your anaesthetic, although we rarely give more than a single dose because it is unnecessary and increases bacterial resistance and the risk of thrush.

I will also assess the risk of deep vein thrombosis (DVT) or clots in the legs. We use compression stockings on all but the most minor procedures, and please leave these on as long as possible. I use inflating boots while you are anaesthetised and for higher risk operations I may give anticoagulant drugs. I rarely use injections as we have a new class of drugs given in tablet form which are equally effective. I will explain this to you during your admission if you need to take them.

Convalesence

The effects of the anaesthetic will have completely gone by the following day, although strong pain killers may make you feel woozy. I will visit you in hospital each day, examine you, review your results and explain to you your treatment for the following day. From an anaesthetic perspective there are no limitations when you leave hospital after an overnight stay but we will give you full instructions before you leave.

Day Case Anaesthesia

Advances in anaesthesia mean that many operations can now be undertaken as a day case where the patient leaves hospital on the same day as their operation. This is also known as ambulatory surgery although it is the anaesthesia that is ambulatory as opposed to the surgery!

Your surgeon will tell you if this is possible with your operation. If you are a day case there are a number of very strict regulations which we cannot change. Please make sure you can comply with them as otherwise your operation may be cancelled:

• you must have a responsible adult to take you home and to remain in your house overnight
• you must be able to return home or to the place it you are staying overnight by a short car or taxi ride. This can be a local hotel, and I have special arrangements with hotels. However please do not use a hotel simply because it is cheaper than staying in hospital. If your operation normally requires an overnight stay this is for a good reason and leaving early can put you at risk.
• you must not work, cook, care for children or have any other responsibilities that day

There is always a small possibility that you may need to remain in hospital overnight and you should make arrangements accordingly.

Complications of anaesthesia

Every patient undergoing an operation is asked to sign a national consent form which sets out the surgery as well as its benefits and the risks. A patient can only agree to an operation – in legal terms give informed consent – if they have all the information necessary to make that decision. In contrast it is normal to have no consent form for anaesthesia and to rely on an explanation from the anaesthetist. This is in stark contrast with the US where the consent form lists each and every risk and complication.

I do not believe it is acceptable to expect patients to undergo anaesthesia without a proper explanation of the anaesthetic management and risks involved. Simply telling a patient what they will experience omits many of the procedures and risks. However, at the same time it is very difficult to consult patients before admission with considerable pressure from insurers and others not to do so. Consequentially the anaesthetic consent process has to be careful not to unduly alarm patients just before their operation.

The Medical Protection Society has recently advised anaesthetists to obtain consent for local anaesthetic blocks and to explain all the risks. I think this should apply equally to the entire anaesthetic process.

I am now using a written consent form where I explain and agree with my patient which technique I recommend and why. The back of the form lists the general risks of anaesthesia and any specific risk is added to the form. I would welcome feedback from my patients about this form. Is it helpful? Does it reduce or increase anxiety? How should it be improved?

You can get a copy of the form here. The general complications are listed on this page. Please read them before your admission so we can discuss any questions or concerns when you are admitted.

Risks of Anaesthesia

A general anaesthetic is very safe. Universal monitoring, medical preassessment and good training have reduced the risk of general anaesthesia to about 1 in 100,000, the same as the risk of being knocked down by a car living in London for two years. However, for most patients an anaesthetic is an unusual and worrying event.

There are a number of relatively common self limiting side effects:

• Nausea, especially in women and day case procedures
• Shivering in recovery
• Small bruises from the cannula or tube in your hand
• Muzziness, malaise or headache. This tends to occur in specific patients & with dehydration

Some issues may arise with specific anaesthetic procedures:

• Sore throat if you are intubated (a breathing tube in your throat)
• Urinary retention especially with spinal surgery
• Retained chest secretions with larger operations

Major complications are very rare and include:

• Airway difficulties – I will examine you to assess if this is likely.
• Thromboembolism – clots in the legs or lungs. Minimised with stocking, boots and drugs
• Injury to the skin and joints – we will protect and pad your skin
• Allergies to drugs – minimised by taking an accurate history
• Damage to teeth – unlikely unless you have crowns or loose teeth
• Awareness – minimised by monitoring the brain where possible
• Confusion and delirium – mostly over 70 and minimised by EEG monitoring and certain drugs
• Heart attacks and strokes – normally restricted to patients with previous illnesses
• Injury to the lungs, windpipe and major vessels – very uncommon

Some patients are concerned about slow recovery and previous reports of low blood pressure but these are rarely a concern. I will discuss any specific risks with you, and only advise you have an anaesthetic where the benefits justify so doing.

Regional anaesthesia:

This includes epidurals, spinals and caudals. These injections are very effective at controlling pain and may have significant benefits including reducing bleeding, infection, deep vein thrombosis and the need for other drugs.

Risks include bleeding, infection and nerve damage. The blood pressure may fall but I will correct it.

Blocks may also make it difficult to pass urine and make your legs weak until the block wears off. If you are having a daycase procedure this may delay your discharge. Prolonged blockade is very rare.

If opiates are added to the epidural you may get itching and nausea. You breathing will need to be regularly checked as it can be suppressed

Some doctors claim patients can get backache but this is disputed and these injections are used for the treatment of back pain

Local anaesthetic blocks:

These involve injecting local anaesthetic around a nerve, and are normally undertaken under sedation or general anaesthetic. Using ultrasound and specially designed needles makes it very safe, with a small risk of bleeding or nerve injury. I will inform you of any specific risks if they apply.

Air travel before and after surgery

Any operation carries a small risk of clots developing in the leg called deep vein thrombosis or DVT. The risk is greater with longer operations, in smokers, in women, and in patients with chronic infection. Operations on the pelvis and legs carry a higher incidence.

Air travel carries a risk of DVT due to depressurisation and inactivity. The risk is greater in economy and increases with the length of the flight.

You should not fly immediately before or after an operation as each operation and each flight are accumulative. If you live abroad it may be impossible to avoid flying to arrive in London but I would recommend you arrive a few days before the operation and do not fly immediately afterwards. Some patients have operations in between flights. This is an unacceptable level of risk.

If you are flying please let me know at the consultation so I can assess your risk and decide whether to give you anticoagulants.

Our fees

Many patients are understandably confused about fees. Please read this section before your anaesthetic and if you do not understand please ask for clarification.

You may be sponsored, self pay or insured:

Sponsored

If you are sponsored by an overseas government, company or solicitor you will be provided with a letter of guarantee. Please email this to us at [email protected] at least 48 hours before admission so we can confirm cover. In the absence of confirmation we will ask you to pay on admission and reclaim

Self pay

If you are paying for your own treatment, we ask you to pay at the time of treatment as this reduces costs. You will have received a quotation by email or been informed of our fees by the surgeon. You may either pay by BACS using the bank details on our quotation or we are happy to accept credit or debit cards on admission. Quotes assume a normal length of stay and the absence of any complications and are subject to revision at our normal rate of £400 per hour if the treatment is greater than predicted.

Insured

We cannot accept authorisation from overseas insurance companies and will ask you to pay on admission. Your insurer will reimburse you against our receipt.

If you are insured with a UK insurance company we will send you an invoice. You should send this to your insurance company for assessment. If your insurance company pays Anaesthesia Ltd directly they will inform you. They may also pay you or the policyholder requiring you to settle with Anaesthesia Ltd. If our invoice is unpaid after 30 days we ask you to pay and reclaim.

The level of benefit paid by some insurance companies may be less than our fees and we recommend you check the amount of benefit you have purchased. We cannot deal directly with your insurer.

A health insurance policy is a contract between the policyholder and their insurance company and not between the doctor and the insurer. Anaesthesia Ltd submits our own invoices and we are not contracted to nor employed by any hospital, doctor or insurance company. Quotations given by surgeons and other third parties cannot be relied upon. An insurance policy may not pay for all or part of our invoice and we strongly advise you to contact us for a quotation and compare it with the amount of benefit you have purchased before you are admitted.