Unless your child is being transferred directly from one of the in-patient hospital units, they, along with their caregivers, will be escorted to the St. Luke’s Pre-operative Holding Area (POHA). Here you will be introduced to your child’s POHA nurse. Your child’s nurse will obtain vital signs and information pertinent to your child’s care. You may also meet with one of St. Luke’s skilled child life specialists. These team members are pediatric health care professionals who work with children and families in hospitals and other settings to help them cope with the challenges of hospitalization, illness, and disability. The POHA unit has various audiovisuals, and a playroom to help calm children and to help distract them while information is gathered. Here you will meet your child’s anesthesiologist who is skilled in the care of pediatric patients.

The anesthesiologist’s primary concern is your child’s well being. This physician will help to ensure that your child is comfortable and safe before, during, and after any procedure. They obtain a medical history, do a physical exam, establish an anesthetic plan for your child’s procedure, answer questions, and discuss concerns that you or your child might have. Family input is very important during this process both in providing medical information and in determining what anxieties we need to address.

Depending on your child’s age and medical concerns, they may require an IV to be placed in the POHA, prior to the start of a procedure. An IV (intra-venous) line is a small, plastic catheter inserted beneath the skin into a vein, and provides a route to give fluids and medicines necessary for our patient’s safe anesthetic care. If placed in the POHA, this is typically done with family present for support and after the skin is “numbed” with local anesthetic medicine. After consultation with patient and family, the anesthesiologist may feel that oral, nasal, or IV pre-operative sedation may also be beneficial.

For endoscopic or imaging procedures, the POHA is in a different location than for surgical procedures, but the process is similar.

Not eating food or drinking liquids before surgery may seem unrealistic. However this is for your safety. The risk you may aspirate stomach acids or other contents increases when you haven't been able to fast properly before anesthesia. Obviously some surgeries are emergencies. In those cases, it's advisable to perform anesthesia and surgery as quick as possible. So what can I have, you say?

Basically you may drink clear liquids such as water, black coffee, non-pulp apple juice, and clear soda up until 2 hours before surgery. Meals need to be consumed prior to 8 hours before surgery. It is possible however to have something light and non-fatty such as toast up until 6 hours before your anesthetic. Your surgeon or the St. Luke's Pre-Admission Testing Clinic may advise you to take some medications on the day of surgery with a small sip of water. This is quite alright.

Minimum Fasting Guidelines for Elective Surgery (Pediatric & Adult):*

• 2 Hours for Clear Liquids (e.g. water, CLEAR juice without pulp, carbonated beverages, black coffee without cream, CLEAR sodas)
• 4 Hours for Breast Milk
• 6 Hours for Light Meal (e.g. infant formula, dry toast, jello)
• 8 Hours for Normal Meal* (e.g. dairy, orange juice, fried or fatty foods, meats, nuts, gastric tube feeds)

*Surgeon's offices may instruct you not to take anything after midnight except certain medications with a sip of water. Follow their instructions. It's possible they may be ready for your operation sooner than expected. If you have met the minimum fasting guidelines we may be able to accommodate an earlier surgical time than originally scheduled.

**Variables include meal fat content and food volume. We encourage light, low fat meals. When in doubt don't eat it!

What is herbal medicine?

Herbal medicine is an ancient disciple. Many prescription drugs we use today are derived from plant products. Herbal products are also known as dietary supplements, alternative therapies, complementary medicine, and homeopathic health care. Herbal products are available as teas, powders, tablets, liquids, or granules. In 1994 the Dietary Supplemental Health and Education Act classified herbal products as food or dietary supplements. As a result, these products are not regulated by the FDA and there are few instructions on proper use, dosage, possible side effects, toxicity, and interactions with other drugs.

Why should I be concerned about anesthetic implications and Herbal Medicines?

Many people believe that if something is natural, it must be safe. This may not actually be true. These products, when used properly, may have beneficial effects, but using them up until the day of surgery may impact the course of your anesthetic. It is essential that you inform your anesthesiologist and your surgeon about the herbal products you may be taking.

Some potential side effects are:

• Increased surgical bleeding,
• Heart and blood pressure effects,
• Reactions with sedatives,
• Changes in the body’s reactions to other medications.
• What should you do prior to having an anesthetic?
• STOP taking the herbal product at least two weeks prior to the scheduled procedure or surgery to prevent side effects.
• Inform your surgeon and anesthesia provider that you are taking an herbal product. Offer accurate information about any herbal products you are taking.
• When asked about your medication history, include ALL herbal products, over-the-counter drugs, dietary supplements, minerals, and teas.
• If you are not sure of the contents of an herbal product, then bring the product and the container it comes in with you for the preoperative anesthesia interview.
• Make sure that someone close to you is aware that you take an herbal product. In the event that you need emergency care, this person will need to share this information with your health care providers.
• Realize that herbal products need to be treated as medicine. Even if the product is natural, it still may be harmful when combined with anesthetics.
• Herbals & their potential side effects:
• Black Cohosh: Lowered Blood Pressure; Increased Surgical Bleeding
• Echinacea: Suppresses Your Immune System; Liver Inflammation
• Ephedra: Increased Blood Pressure and Heart Rate
• Feverfew: Migraines; Insomnia; Anxiety; Joint Stiffness; Increased Surgical Bleeding
• Garlic: Problematic Blood Pressure Control During Surgery & Bleeding
• Ginger: Increased Surgical Bleeding; Decreased Nausea and Vomiting!
• Ginkgo: Increased Surgical Bleeding
• Ginseng: Problematic Blood Pressure Control During Surgery
• Hoodia: Problematic Blood Pressure & Glycemic Control During Surgery
• Kava: Potential Liver Toxicity
• St. John’s Wort: Problematic Blood Pressure Control During Surgery & Prolonged Anesthesia
• Valerian: Increased Anesthetic Sedative Effects; Withdrawal; Taper Off Over Several Weeks Before Elective Surgery

Anesthesia Associates of Boise takes great pride in our opportunity and ability to care for you and your family members. Your satisfaction is a top priority. We encourage our patients to respond to our anonymous survey and let us know how we are doing. The survey will be delivered via email, text or by phone call and take just a few minutes to complete. By returning this valuable feedback, we can improve our processes and patient care.

You may wish to personally speak with us regarding your anesthesia experience. We welcome this dialogue and encourage patients to contact us to provide feedback. AAB has full time staff dedicated to quality and patient satisfaction. Our Anesthesia Quality Manager will be happy to address any concerns you may have. Whatever cannot be answered will be referred to one of our anesthesiologists. Sometimes you may have an urgent clinical question, perhaps regarding a peripheral nerve block or catheter you may have. In that case simply call the number below:

• Clinical Questions: (208) 489-6789
• Anesthesia Quality Manager: (208) 336-0895
• Billing & Other Concerns or Questions: (208) 336-0895

We appreciate the opportunity to serve and look forward to hearing from you!

Anesthesia Associates tailors each patient’s post-operative pain regime to your individual needs. We will take into account what procedure you have had, any drug allergies or intolerances, and come up with a “recipe” that is right for you. For the vast majority of our patients, IV and oral pain medications will be enough to keep your pain at a tolerable level after surgery. While it may be impossible to keep you completely pain free, we will do everything in our power to ensure that your pain is at a level that is acceptable to you.

Some patients that have extensive abdominal or chest surgery may benefit from an epidural catheter. An epidural is a small plastic catheter (tube) that is placed in your back before surgery to help you with pain when you wake up. Epidurals work by infusing numbing medication around the nerves in your back that cause you to feel numb in the abdomen or chest. Epidurals are used frequently for women to assist with pain control during child birth; so many of you are already familiar with this technique. Epidurals usually take about fifteen minutes to place. Those of you who have an epidural for post-operative pain management will have an anesthesiologist see you every day in the hospital. We want to make sure the epidural works as well as it can for your needs.

Patients that are undergoing orthopedic surgery usually have the option to have a regional nerve block. When we do a nerve block for you we use an ultrasound machine to find the nerves that control pain in your extremities. We inject numbing medication around the nerves while watching the location via ultrasound; this ensures that nerve blocks are very effective and safe. If you have a nerve block you can expect 12-24 hours of numbness and pain relief in the extremity. When we do this procedure we will go over specific instructions with you but it is very important to realize that your effected extremity will be numb and weak. Consequently you will not be able to walk without constant assistance while a lower extremity nerve block is in place. Patients with peripheral nerve blocks can expect to need less oral or IV pain medication than they would otherwise.

Therapeutic Options for Pain Relief:

• Spinal Narcotics: Commonly Used for Caesarian Sections
• Epidurals: Used for Thoracic, Abdominal & Lower Extremity Procedures; Laboring Patients
• Peripheral Nerve Blocks: Many Orthopedic Extremity Procedure
• Intravenous & Oral Medications: Used as Part of Multiple Different Therapeutic Options
• Other Modalities: Including Ice Therapy, Lamaze for Labor

For more information on epidurals and peripheral nerve blocks please visit this link to the American Society of Regional Anesthesia and Pain Medicine: http://www.asra.com/patient-info.php

You should keep taking your beta-blockers at your normally scheduled time. This medication may be taken with a small sip of water. There is evidence that abruptly stopping your beta-blocker increases your risk of having a cardiac event such as a heart attack. If you missed this medication, please remind your nurse or anesthesiologist during our pre-operative visit. Most likely we will have you take that medication prior to your procedure.

BLOOD PRESSURE MEDICINES YOU SHOULD TAKE

Take Your Beta-Blocker With a Sip of Water!

Examples TO Take Include: 

• Metoprolol
• Toprol
• Carvedilol
• Propranolol
• Bisoprolol

Now what about taking your other blood pressure medications? Most you can and should take. Having your blood pressure well controlled before surgery and anesthesia will lower your change of cardiac complications. However some medications work so well that it becomes very difficult to maintain an adequate blood pressure after initiating anesthesia.

Unless told otherwise by the Pre-admission Testing Clinic, do not take the following classes ((angiotensin converting enzyme inhibitors (ACEI) & angiotensin receptor blockers (ARB)).

BLOOD PRESSURE MEDICINES YOU PROBABLY SHOULD NOT TAKE

Examples NOT to Take Include:

ACEI: 

• Accupril (Quinapril)
• Altace (Ramipril)
• Lotensin (Benazepril)
• Capoten (Captopril)
• Vasotec (Enalopril)
• Monopril (Fosinopril)
• Prinivil (Lisinopril)
• Zestril (Lisinopril)
• Tarka (Trandolapril combined with Verapamil)
• Univasc (Moexipril)

ARB: 

• Atacand (Candesartan)
• Avapro (Irbsartan)
• Benicar (Olmesartan)
• Cozaar (Losartan)
• Diovan (Valsartan)
• Exforge (Amlodipine combined with Valsartan)
• Micardis (Telmisartan)
• Tevetan (Eprosartan)

References:

PERIOPERATIVE MANAGEMENT OF MEDICATION, Cleveland Clinic: Current Clinical Medicine, 2nd ed. Am J Health Syst Pharm. 2004;61(9)

Many patients will have an appointment with the Pre-Admission Testing Clinic. Their phone number is (208) 381-2570. Bring your insurance information, photo identification, any orders your doctor may have given you, a copy of your Living Will or Durable Power of Attorney for Health if you have one and wish to have it on file at St. Luke’s, a list of your medications with dosages and frequency, a list of allergies and a list of previous surgeries.

The Pre-Surgery Clinic visit may take place at St. Luke’s or may be done over the phone, depending on your surgery and underlying medical conditions. During the visit a nurse will review with you, any current medical issues, your past medical and surgical history as well as your medications and allergies. Various medical tests and laboratory studies may be done at this visit as well.

Based on the information and test results obtained, some patients may be referred for further medical evaluation prior to their surgery. The clinic now has Internal Medicine Physician appointments available for that purpose. The goal is to have each patient medically optimized before undergoing anesthesia and surgery helping to ensure a good outcome.

Finally, the nurse will give you a list of instructions in preparation to the upcoming surgery. We want patients to be well informed and comfortable with the process leading up to their surgery.

This is a state of unconsciousness occurring when your anesthesia provider administers medication rendering you, the patient, asleep for procedures. Unlike your normal anesthetized sleeping state, you lose your natural airway protective reflexes. Consequently placing a breathing tube is routine in most cases. Your anesthesia provider will make every effort to safely monitor your course and adjust the anesthetic depth as needed during the procedure. We also make every effort to minimize unwanted side effects such as nausea and delirium after you awake. Additionally any anesthetic management includes some provision for post-operative pain relief. Even if you've had a general anesthetic we may balance that with IV narcotics or some form of a nerve block or epidural to help you wake up comfortably.

Monitored anesthesia care (M.A.C.) is the term anesthesia providers use to describe the sedation we administer to our patients. Really general anesthesia is simply an extension of the depth of sedation or M.A.C. Once a patient is sedated to the extent they no longer maintain their natural protective airway reflexes or respond purposefully to painful stimulation, they are under general anesthesia.

You can be under general anesthesia if your anesthesia provider administers enough of the same IV medications used for sedations. One doesn't have to have anesthesia "gas" or "agent" administered then to have a general anesthetic. Usually we do administer the inhaled anesthetic agent however. Sometimes, though, this is not possible and we must give you only IV medications. Examples may include complex spine surgery or certain airway procedures.

It's important to note that sedations or M.A.C's may not completely take away your awareness of a procedure. You may "wax and wain" somewhat with your level of consciousness during monitored anesthesia care, but most patients, by far, don't care, especially when they find themselves in recovery comfortably numb from your surgeon's local anesthetic or your anesthesia providers regional block.

If your anesthesia provider hasn't combined a regional technique with a general anesthetic (for instance having a shoulder and arm block combined with general anesthesia for a shoulder replacement), you probably will be sedated. This isn't the same as having a general anesthetic, but you should be comfortable. Depending on how much sedation any given patient's condition may tolerate, you might wax and wain a bit with your level of consciousness. It's very likely you won't care at all. In fact probably you will be happy to wake up from sedation with some pretty good pain relief!

How about sedation for the regional anesthetic placement? Good question. Unless clinical circumstances are unique such as pediatric surgery, it is safer to place nerve blocks, spinals, and epidurals with patients nicely sedated but not completely asleep. The reward of a good safe block is well worth some minimal discomfort while administering the regional anesthetic.

If you have a question that wasn't answered at the hospital before going home, just contact us on the clinical questions line. We will answer as soon as we can. If you are having an emergency please dial 911.