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Health Protocols

Surgery - Preparation and Recovery

The Preoperative Period

In an ideal situation, patients undergoing surgery will have adequate time before the operation to prepare themselves emotionally and physically. The healthier patients are when they go into surgery, the healthier they are likely to be during the postoperative phase. The preoperative period is also a chance for patients to make sure they fully understand the goals and procedural steps of their surgery, as well as the preoperative instructions provided by their healthcare providers. During this period, anxiety about the surgery may be a problem for some people, but patients, along with their surgical teams, can take steps to alleviate this stress.

Risk Assessment

During the preoperative period, surgical teams assess patients for various risks, such as blood clots, malnutrition, and muscle weakness (Dinic 2018; Thiruvenkatarajan 2014; Akhtar 2013). These risks will depend, of course, on the patient's underlying disease, lifestyle, type of surgery, and other health complications the patient may have (Bihorac 2018). Risk assessment tests may include chest X-rays, electrocardiograms, urinalysis, and blood tests (Stanford Health Care 2017g). Once risks are assessed, the medical team can take steps to protect the patient.

Enhanced Recovery After Surgery (ERAS)

The concept of Enhanced Recovery After Surgery, or ERAS, was originally developed when a number of leading surgeons came together to evaluate ways to reduce the number of patients with postoperative complications (Dinic 2018; Xu, Zheng 2018). This group of experts has produced many guidelines for surgical teams and hospitals to improve patient care before, during, and after surgery (Sandrucci 2018; Melloul 2016; Beverly 2017).

The components of the ERAS guidelines are similar to those highlighted throughout this protocol and include measures such as improved preoperative nutrition, reduced preoperative fasting, and early movement after surgery (Dinic 2018). ERAS measures have been shown to reduce hospital stays and rates of complications by about 30% to 50% (Ljungqvist 2017; Eskicioglu 2009; Lassen 2009; Ahmed 2018).

Several hospitals and clinics all over the world have implemented some or all of the ERAS guidelines. For more information on the ERAS society, patient experiences with ERAS, and brochures on various procedures, see the society's website (ERAS Society 2016):

http://erassociety.org/patients/

For more information on ERAS guidelines for many types of surgery, see:

http://erassociety.org/guidelines/list-of-guidelines/

Nutrition

For many patients, the preoperative period is a time when many nutritional interventions can have a considerable effect. One overlooked statistic is that about 40% of acutely hospitalized patients are malnourished (Barker 2011). Patients with cancer or elderly patients are particularly at risk (Ocon Breton 2017; Favaro-Moreira 2016).

Malnutrition can lead to slow wound healing, suppression of the immune system, and muscle weakness (Stechmiller 2010; Bourke 2016; Lunardi 2012). ERAS guidelines recommend that nutritional status of all patients be evaluated before surgery and patients should be given enteral nutrition (tube feeding) not when they become malnourished, but when the risk of malnutrition becomes apparent (Weimann 2006).

A healthy diet and appropriate nutritional supplements can help prepare a patient for surgery by maximizing reserves of proteins, essential fatty acids, vitamins, and minerals. Specific nutrients and supplements can also help bolster the immune system, minimize oxidative damage, and keep inflammation under control. For more information on specific nutritional interventions, see the “Integrative Interventions” section of this protocol.

Preoperative Fasting

Practically since the inception of general anesthesia for surgery, doctors have worried about the effects of a full stomach during anesthesia. The chief risk is that patients will aspirate stomach contents into their lungs, which may cause severe inflammation, infection, or even death (Sarin 2017). Modern anesthesia practices, however, such as careful control of the patient's airways, close monitoring, and selective use of appropriate anesthetic drugs, have dramatically reduced this risk (Powers 2017; Michalek 2014). Because of delays and changes in operating room schedules, patients often end up fasting for 12 hours or more, and the metabolic response to fasting intensifies the response to the trauma caused by the surgery (Pimenta 2014).

Increasingly, anesthesiologists are recognizing both the biological and psychological value of permitting patients a reasonable oral intake. Modern recommendations have significantly reduced fasting periods (Sarin 2017; American Society of Anesthesiologists 2017). For instance, the American Society of Anesthesiologists guidelines state that for healthy patients undergoing elective procedures, a light meal such as toast and a clear liquid is acceptable until six hours before surgery (American Society of Anesthesiologists 2017). Clear liquids (tea, fruit juices without pulp, water) are acceptable until two hours before surgery. Patients should discuss preoperative fasting with their physicians well in advance of surgery.

Carbohydrate Treatment

As data have emerged supporting reduced preoperative fasting times, other studies have addressed whether a carbohydrate-rich supplement before surgery can improve patient outcomes (Weimann 2006; Jankowski 2017; Evans 2014). Surgery stresses the body and changes the patient's metabolism (Finnerty 2013), causing a catabolic state. In a catabolic state, the body starts breaking down proteins, leading to muscle wasting and suppression of the immune system. For some patients, a carbohydrate-rich drink two to three hours before surgery can prevent the body from entering this altered metabolic state (Jankowski 2017). Meta-analyses found that preoperative carbohydrates reduced surgery-induced insulin resistance and the length of time patients had to stay in the hospital (Awad 2013; Smith 2014).

Glucose Control

Both low and high glucose levels can be problematic during the perioperative period. Studies indicate that surgery-induced insulin resistance, leading to elevated glucose levels during surgery, occurs in up to 60% of surgery patients and raises the risk of complications and death (Galindo 2018; Duggan 2016). Intensive insulin therapy, a procedure in which glucose levels are closely monitored and maintained during surgery, can help reduce complications and lower the risk of death (Trussell 2008; van den Berghe 2001; Galindo 2018). However, this practice is not standard in hospitals and requires intensive monitoring by nurses and other members of the surgical team. Nevertheless, because of the benefits, patients may want to discuss intensive insulin therapy with their surgical team to see if it is warranted in their situation.

Oral Immunonutrition

Surgery and the underlying medical condition can suppress a patient's immune system just when optimal immune function is most important. Researchers are investigating ways to boost the immune system with various preoperative nutritional supplements collectively referred to as immunonutrition (Jankowski 2017; Gupta 2017). These formulas are flavored drinks or shakes produced by different companies and available without a prescription from stores such as Walmart and Amazon or directly from the manufacturers.

The purpose of immunonutrition shakes is to provide the proper nutrient mix to boost healthy immune function while suppressing exaggerated inflammatory responses (Song 2017; Hammad 2017). Each immunonutrition product contains a variety of ingredients. For example, two well-studied immunonutrition formulas called Oral Impact (Nestle Health Science) and Ensure Surgery (Abbott Nutrition) contain omega-3 fatty acids, protein and DNA building blocks, vitamins, and minerals. A study that used Oral Impact reported an increased activation of T cells and antigen presenting cells in the tissue of patients scheduled for surgery (Scarpa 2017). In one study of over 3,000 surgical patients, Oral Impact, taken before surgery, was associated with a lower chance of a prolonged hospital stay (Thornblade 2017).

For more information on components of immunonutrition formulas, see the “Integrative Interventions” section of this protocol.

Anxiety

Most people who will be undergoing a surgical procedure, no matter how minor, have some degree of anxiety about the procedure, its outcomes, and potential complications. A notable degree of anxiety can occur in up to 80% of patients (Sheen 2014). Patients report the fear of losing control during surgery, some are concerned that they will not be able to wake up, and some express their fear of pain (Hernandez-Palazon 2018). Psychological and emotional stress reduces the body's immune function and renders people more vulnerable to disease (Segerstrom 2004; Marshall 2011). Preoperative anxiety is also associated with high levels of pain after surgery (Thompson 2008; Ip 2009).

Preoperative anxiety can be alleviated in several ways. The most important is patient education and counseling. When doctors educate patients about their medical conditions, surgical procedures, and recovery, patients feel less anxiety (Wongkietkachorn 2018; Lee 2017). A face-to-face meeting or phone call with the anesthesiologist can be particularly helpful. Printed materials, online materials, or personal counseling have all been shown to be effective, as long as patients get the information they need (Jankowski 2017; Ayyadhah Alanazi 2014). For example, in a randomized clinical trial of 100 patients scheduled for surgery, watching an educational video on anesthesia was associated with a significant reduction in patient-reported anxiety and an increase in patient satisfaction (Lin 2016). Many patients effectively alleviate their own anxiety by searching for information on the internet, although it is important that the sources of information be reputable and reliable (Tulgar 2017).

Another way to reduce anxiety is to keep the preoperative period reasonably short. The preoperative period should be just long enough to optimize the patient's health before going into the procedure. Excessively long preoperative periods, however, may be associated with increased amounts of worrying, anxiety, and stress; these factors can have a negative impact on surgical outcomes (Shoar 2016). Similarly, keeping the preoperative hospital stay as short as possible can also reduce anxiety (D'Andrilli 2018).

Integrative medicine strategies for reducing preoperative anxiety and stress have been shown to be helpful in varying degrees (Attias 2016). Hypnosis has been found to be effective in reducing both preoperative and postoperative anxiety (Kendrick 2016; Akgul 2016). A related technique called guided imagery, in which a skilled therapist works with the patient to envision low-stress and positive concepts, has also been documented to reduce anxiety, safely lower pulse and blood pressure, and shorten hospital stays (Hadjibalassi 2018; Halpin 2002; Norred 2000). Relaxing music or aromatherapy with essential oils may also be helpful (Ayik 2018; Wotman 2017; Franco 2016; Millett 2018). Some studies are even exploring virtual reality to help surgery patients relax (Ganry 2018).

Premedication

Patients undergoing surgery are at increased risk of blood clots during and after the procedure. Depending on the type of procedure and the patient's medical history, doctors may recommend medications to help reduce the risk of blood clots (Childers 2018; Bell 2015; Moffatt-Bruce 2017). For instance, in patients undergoing surgery to repair a broken bone, only one of 39 (2.6%) patients treated with the anti-clotting drug rivaroxaban (Xarelto) had a type of blood clot called a deep vein thrombosis after surgery, compared with eight of 41 (19.5%) who did not take the drug (Li 2017).

Aspirin is well-known for reducing blood clots. Some studies suggest low-dose aspirin may benefit certain patients, such as those undergoing coronary artery bypass surgery, when taken within 24 hours before surgery (Deng 2015). However, because aspirin's effect on clotting may increase the risk of bleeding, patients should not begin aspirin therapy unless under the direct supervision of their surgical team. Lower doses (less than 100 mg per day) may not increase the risk of bleeding based on some research, but additional studies are required (Ma 2014).

Some patients may also be treated with antibiotics before surgery to reduce the risk of infection (Chang 2012; Holubar 2017). Certain procedures, such as surgeries on the gastrointestinal or respiratory tract, are associated with a higher risk of infection. The type of antibiotic prescribed will depend upon the bacterial strains present at the site of surgery (D'Andrilli 2018). When developing guidelines for the use of antibiotics before surgery, doctors are careful to balance the risk of infection with the risks associated with antibiotic use, such as adverse effects or antibiotic resistance (Bryson 2016).

Lifestyle

Patients who smoke do not fare as well during and after surgery (Turan 2011; Musallam 2013). Doctors recommend that smokers stop smoking at least eight weeks before their surgery if possible, and there is strong evidence that smoking cessation reduces the risk of complications and death after surgery (Thomsen 2014; Sorensen 2012; Rodrigo 2000; Singh 2013).

Some patients may also benefit from efforts to improve physical functioning prior to surgery. For patients who will undergo lung surgery, preoperative breathing exercises may help maximize lung function prior to surgery (Kendall 2017). Frailty prior to surgery is associated with poor patient outcomes (Mosquera 2016; Arya 2015). Thus, an exercise program with aerobic exercise and strength training may be helpful to some patients if they are healthy enough to exercise (Mainini 2016).

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