Part I: Medical optimization aka getting as healthy and strong as possible before surgery
In the setting of COVID-19, in many regions of the US, hospitals have cancelled or postponed elective surgeries and other hospital-based procedures to increase capacity for people suffering from COVID-19 and other emergencies. Capacity has many domains: physical space, protective equipment, healthy health care workers and medical equipment to treat the ill. Indeed, there has been a radical transformation in all these elements: nonpatient areas have been seized and converted to accommodate COVID cases, personal protective equipment improvised, retired physicians and nurses called back from retirement and nonmedical specialties deployed, and various medical and nonmedical machines adapted or repurposed to serve as substitute ventilators.
As the pandemic surge wanes, and hospital resources become less needed for COVID management, some areas of the country have begun to schedule elective (planned as opposed to emergency) surgery cases. This will be an economic boon for health systems, surgical equipment suppliers and sidelined surgeons and OR staff in addition to potentially life-saving, health-enhancing and quality of life improvements for those individuals who had eagerly awaited their planned, but quasi- or non-urgent surgery. Among others, cancer surgery, hip and knee replacements, gall bladder removal, and even serious heart operations such as coronary artery bypass and valve repairs and replacements will re-start. It is unknown when precisely planned surgeries will be again widespread; it will vary with the need to care for COVID patients in each locality, the ability to reconfigure spaces, and how quickly new protocols and prevention can be instituted to protect against potential COVID infections. Whether this occurs in two or three months from the present or longer, there is time to prepare for a planned surgery.
Remember: the decision to undergo surgery must be arbitrated with the surgeon and patient (or surrogate) as full partners. This approach is termed shared decision-making. Think carefully about what results you wish to obtain from the operation and if the expectations are reasonable. Surgery always comes with risks, which must be taken into account prior to the decision to move forward.
Start with the surgeon’s office for pre-op counseling
It is important to work closely with your surgeon, nurses and other office staff to get the full picture of how to get ready and what to expect: learn about the procedure and its duration, projected time as a patient in the hospital, expected recovery time, realistic results to anticipate, type of anesthesia, pain relief and other medications you may need, before, during and after surgery. Often some medications will need to be stopped for a period of time prior to surgery, particularly those medications that increase bleeding, such as blood thinners, NSAIDs and aspirin. Although minimizing bleeding during and after surgery is desired, postoperative blood clots are a known risk for certain types of surgeries, therefore it will be important to know if you will require blood thinners or aspirin after surgery. Will you need to take an antibiotic before surgery to prevent infection? Will there be any special equipment needed for home? If there will be physical therapy will it be at home or at an outpatient office? Is inpatient rehab a possibility? A visiting nurse? The surgeon’s office may have other specific directions for you, particular to your current medical conditions and the surgical procedure that is planned.
If the doctor and staff are not forthcoming or you are not getting answers to your questions, you may have to work closely with them to elicit guidance. If you are in the early stages of choosing a surgeon or getting a second opinion, perhaps you will find a better fit in another surgeon or other practice. It’s part of the job to help prepare people for surgery and to inform about what to expect.
Prehabilitation and medical optimization
Surgery and anesthesia are stressful on the body and the mind. How can patients better withstand the rigors of an operation and its aftereffects such that they emerge as physically and cognitively strong and functional as possible? Many research studies suggest that programs to enhance wellness before surgery result in better outcomes afterwards.
Certain conditions such as obesity, diabetes and hypertension have been associated with increased possibility of complications and poor outcomes, as has smoking. Importantly this is an area in which you, the patient, can have some control by making changes. Controlling these conditions has the potential to reduce the likelihood that you will be sicker or have a longer, more complicated or painful length of stay. As people prepare for a surgery, there is a window of opportunity to change health behaviors with the right encouragement and support. Other conditions that put people at risk during and after surgery, such as anemia (low amount of red blood cells), can be treated with medications to correct deficiencies. Your surgeon and your other doctors can provide resources for support to get you on the right track. Do not hesitate to ask for this help; preoperative counseling is an important part of the surgery process.
Prehabilitation was initially focused on physical therapy exercises prior to surgery to prepare the muscles and joints for the rigors of surgery and the recovery. The concept of prehab has evolved to include a whole body and mind approach. Physical therapy, respiratory exercises, psychological and nutritional support are examples of disciplines that comprise this approach.
What does a prehab regimen look like?
Depending on the patient’s characteristics, medical conditions and type of surgery, a prehab regimen can be personalized. Components might include strengthening exercises, mindfulness meditation and a special diet. Ideally, these components work together synergistically to provide overall benefits.
Getting in shape is always a good idea, but especially so before an operation. Getting out of bed and moving as soon as possible after surgery is the new normal. Bedrest is a thing of the past. Strong muscles, good balance, and increased cardiopulmonary function will support recovery. The earlier patients can move around (whether independently or with the support of devices and assistance) the sooner the body’s organ systems will return to normal. What this means in practical terms is decreased need for urinary catheters, a better functioning digestive tract, and reduced risk of blood clots. Mostly importantly, the lungs must be exercised as well to prevent postoperative infection (pneumonia).
Nutrition before surgery
Just as it is important to get fit and be in the best health before surgery, the body needs the proper building blocks to heal. Eating a healthful diet in the time leading up to surgery will ensure that the stress of surgery will not add further strain on the system. Many prehab programs include a nutritional support program. For some people, this will mean focusing on foods with high nutritional content. For others, the support and guidance will be tied to weight loss. Some people will need to gain weight before surgery and may even require supplements. A person’s nutritional status can be determined by looking at the albumin level in the blood. People with low albumin are at higher risk of complications after surgery.
A visit to the dentist several weeks before surgery is a good idea, as is rigorous oral hygiene in the time leading up to the day of surgery. If you will have anesthesia by endotracheal intubation, loose or broken teeth can be a problem. The mouth harbors many bacteria that could potentially be harmful and a cause of infection so it is advisable to take particularly good care of the teeth and gums before surgery.
Special considerations for older adults
The media is filled with advertisements for hospitals boasting about surgical successes for older and older people. Yet, we must take stock of how success is defined. Organs can be restored to function, bones and cartilage mended, heart vessels refurbished and joints replaced with prosthetics but these are isolated pieces of the whole cloth that makes up the human body and mind. As people age, the body is less able to bounce back; muscles, digestion and the brain will take on extra burden. Surgery, principally the anesthesia required to enable its occurrence, poses cognitive risks which increase with age. For older adults, the decision to undergo surgery must be made with a realistic assessment of all the possible outcomes, positive and negative, including the potential for a decline in function postoperatively which may be temporary or permanent. It is advisable to consult with your geriatrician or primary care provider to help in the decision-making process.
Resource: The American College of Surgeons (ACS) has developed a comprehensive program for patients to prepare for surgery: Strong For Surgery. I am particularly impressed that a discussion of delirium is included. (Delirium is a common postoperative complication and can lead to serious problems. Therefore recognizing people at risk beforehand and putting prevention and management strategies in place is important.)
Pro tip: you might ask your surgeon and office staff about their thoughts on the ACS program; the response will give you insight into how seriously they consider prehab and optimization.
You CAN prepare physically, psychologically and practically for an elective surgery. You will come out ahead of the game if you approach your operation methodically and with a plan. Next time, Part II: Logistics of Preparing for Surgery.