Anaesthetic and ICU Care

• Stopping smoking at any point, but ideally 6 weeks prior to your surgery, will improve your lung and heart functioning and reduce the risk of breathing problems during and after your anaesthetic.
• Optimizing your nutritional state and improving your physical fitness may reduce your operative risks and improve your ability to recover from surgery.
• If you are obese, reducing your weight may improve your lung, heart and liver functioning.
• If you have obstructive sleep apnoea, the nightly use of your CPAP machine pre-op will reduce your risk for peri-operative lung and heart problems.
• If you have significant or poorly controlled heart, lung or other medical problems, it may be advisable to have a checkup with your GP or your specialist (eg cardiologist) before your procedure. If you have specific concerns about your medical problem and anaesthetic risks and would like to see your anaesthetist pre-op, an appointment can be made at our rooms. Contact details can be found on the Contact us page.

• The omission of alcohol is advised the night before and the day of your surgery.
• Stopping smoking for even a few hours may reduce the risk of post-operative lung complications.
• Bring all your medications (or a list of your medications), including herbal or over-the-counter medications to the hospital so that they may be examined by your anaesthesiologist.
• If you use a CPAP machine at home, bring it to the hospital. It is likely to be required postoperatively.
• Fasting: All patients need to have an empty stomach before surgery, otherwise the stomach contents and acid may regurgitate up and enter the lungs. All patients coming for anaesthesia (including for sedation, regional and local anaesthesia) need to thus adhere to the fasting guidelines. Do not eat any food or drink any milky/cloudy liquids for 6 hours before admission for your surgery. You may drink “clear liquids” (eg water, tea/coffee without milk, apple juice without pulp, soft drinks) up until 2 hours before the procedure. Therefore for morning surgery, omit food from midnight and stop clear fluids after 05h00. For afternoon surgery, you may be allowed a light breakfast (before 06h00) and then clear fluid until 10h00.
• Most routine medication (including asthma, thyroid, cholesterol, acid reflux and HIV medication) should be taken on the morning of your surgery, with a sip of water if necessary. Hypertensive medications should be continued with the exception of ACE-inhibitors and angiotensin-receptor blockers (eg enalapril, perindopril, valsartan, etc). Diabetic medications should be omitted until after your surgery and when you are eating normally again. Blood-thinning agents/anticoagulants (Ecotrin/Aspirin/Warfarin/Xarelto/Plavix/Clopiwin, etc) may need to be stopped before your surgery (some may need to be stopped a week beforehand). Please consult with your surgeon/anaesthetist if you are on any of these.
• If you are going to be admitted to the High Care after your surgery, bringing along earplugs, earphones or eye patches as this may enable you to have a better night’s sleep.

Your anaesthesiologist will do his best to see you in the ward on the day before or the day of your surgery. However if your surgeon offers you admission after the start of the theatre list or if you are coming in for an emergency procedure, this may not be possible and you may therefore only be seen in the waiting room of the theatre complex.

Your anaesthesiologist will use the pre-op visit to assess your fitness to undergo the planned surgery and to optimize any facet of your health which can be improved in the short term. He will then plan the best and safest anaesthetic for you.

He will take a medical history, including any past anaesthetics and allergies to medication. Please let him know about any significant medical co-morbidity you have as this will lead to a safer anaesthetic for you. He will then conduct a relevant clinical examination and possibly order special investigations, including blood tests, an ECG, heart ultrasound (Echocardiogram) and X-rays or other specialized tests.

Sedative premedications are not routinely prescribed in modern adult anaesthetic practice but can certainly be provided on request or if your anaesthetist deems it worthwhile.

Your anaesthetist will stay with you throughout the procedure and will serve as your safety officer during the surgery. On arrival at the operating theatre, monitors will be placed to assess your ECG, oxygen saturation and blood pressure and additional monitors may be needed depending on your medical condition or the planned surgery.

A drip will be inserted through which the anaesthetic agents will be administered after a short period of supplemental oxygenation given via a facemask. For paediatric anaesthesia, it is commonplace to induce anaesthesia via inhaled anaesthetic vapours (also via a facemask). Additional lines or nerve blocks may be placed while you are asleep. Please see the section on specialised procedures and surgeries for more information.

While the surgery takes place, your anaesthetist will be monitoring all your vital signs and constantly re-adjusting the anaesthetic as well as making alterations to parameters such as your breathing, blood flow and oxygen delivery, metabolic state, fluid balance and blood requirements to ensure you are as safe as possible while aiding in the successful completion of your surgery.

Your anaesthetist will be responsible for managing your pain during and immediately after your operation and will prescribe medication for nausea if required.

Immediately after your operation, you will be transferred to the recovery room, where you will usually stay for around 30 minutes to make sure you are awake enough, are breathing well by yourself and have no anaesthetic or surgical problems that require further therapy. You will then be taken to the ward or the ICU/High Care for further care.

For those patients undergoing day case procedures, you are likely to be discharged a few hours after the surgery. You will, however not be allowed to drive yourself home, even after light sedation, as the anaesthesia may impair your ability to safely operate a car or other dangerous machinery. Please make alternative transport arrangements before your surgery.

Some patients will require admission to ICU or to High care after their surgery. This is usually a planned stay based on the surgery you have undergone or your medical co-morbidities but it may also be required if complications have arisen in theatre and a higher level of monitoring and care is required. On arrival to the ICU, a full handover of your medical and surgical problems will be given to our colleague on duty in the ICU who will take over responsibility for your further care while in the unit.

The purpose of anaesthetics is to ensure that you are comfortable and pain-free during surgery. Anaesthetics make the surgery easier for the surgeon and in most cases surgery will not be possible without it. Unfortunately, an anaesthetic isn’t risk-free. Some common complications are shivering, sore throat, constipation, difficulty to empty your bladder, confusion, nausea, and vomiting. These complications are not serious but can be very distressing. More serious complications like heart attacks and strokes are very uncommon and death from anaesthetics is extremely uncommon. Some people fear that they may wake-up during surgery but will be unable to talk or move. This is extremely rare and has only happened in extraordinary circumstances. Nowadays we also have special monitors that will tell us your depth of anaesthesia and level of consciousness.

Modern anaesthetics are considered much safer than car travel. In poor countries without specialist anaesthetic services up to 1 in 300 people will die as a consequence of the anaesthetic. In countries with more resources and specialist anaesthetic services, 1 in 185 000 (United Kingdom) to 1 in 300 000 (Sweden) will die from anaesthetics.

It is important to distinguish anaesthetic deaths from procedure-related deaths. An anaesthetic death is a death considered purely as a result of the anaesthetic given. Procedure-related deaths could be as a result of surgical complications (e.g. bleeding or infection) or worsening of a pre-existing medical condition (e.g. heart failure or lung disease) during or after surgery. Procedure-related deaths are more common with 2 - 4 deaths per 100 patients. Your risk will depend on the type of surgery you are having and the condition of your health.

Your anaesthetist is a specially trained perioperative physician that will care for you during and after your surgery. Any specific questions or concerns will be addressed during the meeting you will have with your anaesthetist before the surgery.

Further information on anaesthetic types, terminology and need to know information can be found at the online resource patient.info.

You or a loved one may be admitted to ICU as an emergency if there is a sudden, severe deterioration in health due to illness or because of serious trauma.

You may also have a planned admission to ICU after an operation, because the specific surgery is associated with a high risk of complications and/or because it puts a huge strain on your body during the recovery phase. Furthermore, you may be admitted for medical reasons after even minor to moderate surgery, if you have a pre-existing illness or concern (e.g. diabetes, heart disease or old age) that poses an additional risk to your health during and after surgery.

Intensive care involves closely monitoring and supporting your different organ systems (e.g. lungs and respiration, heart and blood pressure) which might either be failing or be at risk of failing (ie when the organ is no longer working as it should). It also involves diagnosing and then treating the cause of the organ failure (e.g. infection causing respiratory failure).

Sometimes intensive care involves taking over an organ's work altogether and giving it time to recover.  For instance, when you have a lung infection, you will struggle to breathe.  If the infection is so severe that you are unable to maintain an adequate balance of oxygen and carbon dioxide in the blood, then your lungs are said to be failing and we can use a machine called a ventilator to breathe for you. Similarly, if your kidneys fail then a dialysis machine can be used to take over the kidney’s function and remove water and toxins from your body.

As the intensive care physicians, we will be in charge of initiating, titrating and weaning these organ support systems as is required by your physiological state and your illness or injury.

Looking after someone in ICU is usually very labour intensive. There are a lot of things that need to happen during the day including basic nursing (e.g. cleaning, feeding), treatment, examination, tests, different therapies (physiotherapy, speech therapy) and the patient also requires a lot of time to rest.

It is for this reason that visiting time is limited to 2 one-hour periods during the day. It is also better that only those people close to the patient (immediate family and special friends) visit as it can be very tiring for the patient to interact with many different people.

If you are traveling from far or have transport difficulties, visits outside of the scheduled times can be arranged with the ICU nurses.

Even during visiting times, patients remain vulnerable and need close monitoring. A crowded ward can distract nursing staff from keeping a watchful eye on your loved one. For this reason, only two visitors at a time are allowed at the bedside.

Seriously ill patients in the ICU are very susceptible to infections. It is thus very important to spray your hands with alcohol when entering and leaving the ICU. For the same reason, children under 12 years are only allowed in the ICU under exceptional circumstances. Some gifts like flowers and soft toys are also not allowed because of the risk of carrying germs.

If your loved one is unconscious or sedated in ICU then he/she will not be able to give their permission for treatment. In these cases, a shared decision-making between the doctors and the family will occur for a few reasons:

Family will have a better understanding of the wishes of their loved one - this will be taken into account in any decision-making;

Secondly, the doctors will know which treatment options will be helpful and which will be futile and they will have a better picture of your loved one's chances for full recovery.

It is natural to feel that you want to do anything possible to keep your family member alive but it is important to consider things from your loved one's perspective as well. Questions like:

What will their quality of life be?

What are their wishes?

Would they want to be alive but remain bedridden or in a persistent vegetative state?

Everyone - doctors, nurses and family members want your loved one to regain full function and recover entirely. Sadly, this is not always possible. Sometimes it is more appropriate to allow for a loved one to die in comfort and in dignity rather than prolong their suffering.

The intensive care team will keep relatives informed of progress or any problems that might arise. Doctors are not always immediately available during the time that you are visiting, as they have many patients to attend to, but an appointment can be arranged by speaking to the nursing staff in the ICU. It is important to nominate one or two representatives that can be contacted. Other family members or friends can then contact the representatives for an update on the patient’s condition.