Anaesthesia at the Bronovo Hospital

Published: Bronovo-Nebo FoundationPrint run: 2.000 copies, March 2011Graphic Design: Mediaresponse - GorinchemBronovo has a strategic alliance with LUMC2

This brochure contains information about anaesthesia and pain relief duringand after your surgery or examination.The information is intended to supplement your conversation with theanaesthesiologist. If you still have questions, you may phone the pre-operativeoutpatients’ clinic, telephone number 070 – 312 44 56 on working daysfrom 08.00 - 16.30 hours3

TABLE OF CONTENTSAnaesthesia 5Forms of anaesthesia 5General anaesthesia 5Regional anaesthesia 6The anaesthesiologist 9The pre-operative outpatients’ clinic 9Changes in your health 10Preparation for the surgery or the examination 10A good night’s sleep 10Preparation at home 11Time of admission 11Coming with an empty stomach 11Medication use 11Jewellery, make-up etc. 12Admission to the nursing ward 12The patient’s room 12What to bring with you 13Contact person 13Visiting hours 13Shaving and clothing for the operation 13Premedication 14The operating complex 14The holding area 14The operating theatre 14After the anaesthesia/operation 15The recovery room 15Pain 15Your pain score 16Pain relief on a fixed schedule 17Side effects and complications of anaesthesia 17Back to the ward 18Information for patients who are having surgery as day patients 19Discharge 19Home again 19Problems and/or questions 20In conclusion 20Arrangements for the day of the surgery 214

ANAESTHESIAAnaesthesia is the collective name for all types of anaesthetics for surgery orexaminations. It means ‘numbness.’ In practice, however, anaesthesia is morethan just numbing. The objective of anaesthesia is to keep you in the bestpossible condition during the surgery.An anaesthesiologist is a medical doctor who has specialized in the variousforms of anaesthesia, pain control and other medical care concerned withthe operation.FORMS OF ANAESTHESIAThere are two forms of anaesthesia that are used in surgery, namely:• General anaesthesia• Regional anaesthesia (extensive localized numbness).A combination of both forms of anaesthesia is also often used, specifically formajor surgery. Which form of anaesthesia is the most suitable for you will bedetermined by your anaesthesiologist in consultation with you. This dependson various factors such as your age, your physical condition and the kind ofsurgery that you are having.General anaesthesiaWith general anaesthesia, your entire body is made numb. Because you aretemporarily unconscious, you will not be aware of anything during the surgeryand will also not remember anything about the operation. The drugs are generallyadministered via an intravenous line. In some cases, you will be given the medicationthrough a mask over your nose and mouth. This is generally the case withchildren.If necessary, a tube will be inserted into your throat for breathing as soon as youare under general anaesthesia.5

Regional anaesthesiaWith regional anaesthesia, the anaesthesiologist will only numb that area of thebody that is to be operated on. As long as the medication is working, you willnot be able to move that part of your body. For an operation on your knee, forexample, only the lower part of the body will be anaesthetized. It is sometimesalso possible to anaesthetize only the leg that is being operated on. This isdetermined by the anaesthesiologist who will be taking care of your anaesthesiaduring the operation.With this form of anaesthesia, you will, in principle, remain awake. The surgicalarea will be screened off so that you will not be able to see the operation takingplace. If you are worried about consciously experiencing the surgery, it is possibleto administer a short acting sleeping medication so that you will notice littleor nothing of what is happening. You may also ask the anaesthesiologist for thisduring the procedure.Some forms of regional anaesthesia have the advantage that after the surgery agood painkiller with localized pain medication can be given. This is administeredvia a catheter (a tube).A. Regional or plexus anaesthesia of shoulder, arm or handFor surgery on a shoulder, an arm or a hand, the network of nerves running tothe arm (brachial plexus) is blocked. The anaesthesiologist inserts a thin needleinto the neck or the armpit and stimulates the nerve with a minute electricalpulse. When the shoulder, arm or hand reacts appropriately, this needle is thenused to administer an anaesthetic. The amount and type of anaesthetic administereddepends on the surgical procedure to be performed and the pain levelexpected after the surgery. For surgery of less than an hour, the anaesthetic canalso be administered directly into a vein of the hand of the arm that will beoperated on (Bier’s block). An infusion needle is inserted into the hand andthen an inflatable cuff is wrapped around the upper arm. After inflating the cuffto fit snugly, the anaesthetic is injected through the infusion needle.The anaesthetic will only spread through the arm as the cuff stops it enteringthe rest of the body. The arm will appear spotty and pale and will becomenumb. After surgery, the cuff is removed and normal sensation returns.B. Regional anaesthesia of the lower bodyFor surgery of the lower body, such as the genitalia, groin, hips or legs, a nerveblock or a lumbar puncture can be used. A nerve block is applied as described6

The waiting room of the pre-operative outpatient clinicabove for the arms or shoulder, the difference being that leg nerves are nowblocked. For a one-leg nerve block during knee surgery, both the groin and thehip nerves are blocked.For a spinal injection, the anaesthetic is injected at the base of the spine with afine needle. The effect is almost instantaneous.Patients for major abdominal and thorax surgery are injected in the epiduralspace. The anaesthetic agent is so administered via a thin tube which remainsin place, taped to the patient’s back where it can be used for further pain treatmentafter the operation.7

Anaesthesiologist team Bronovo.Standing from left to right:F. Kamerling, A.L. Molina, Mrs. K. Groenewoud-Muderlak and N. van der WilkSitting from left to right:R.L. van Leersum, Mrs. S.M. Mulder, W.J. Engelbrecht and Mrs. C.E. Kam-Endtz.8

THE ANAESTHESIOLOGISTYour body must keep functioning well during the surgery. The anaesthesiologistmakes sure that the bodily functions remain stable, so that you can comethrough the operation as well as possible. With the aid of special equipment,the anaesthesiologist monitors and regulates such functions as your bloodpressure, heart rate and breathing. If necessary, he/she can instantly adjust theanaesthesia.The pre-operative outpatients’ clinicThe specialist who is going to perform the surgery will give you a questionnaireform, that you must fill in before your appointment at the pre-operative outpatients’clinic. At this clinic of the Anaesthesiology Department, you will have aninitial consultation with a nurse. The nurse will measure your blood pressure,determine your height and weight and possibly make an ECG(Electrocardiogram), depending on your age and the state of your health.The nurse will also give you information about the procedures before andduring your admission.After this, you will have a consultation with the anaesthesiologist who will assessyour physical condition and make a risk-assessment for the operation. Based onyour answers to the questionnaire, the anaesthesiologist may ask you for moreinformation. Depending upon your personal situation, the anaesthesiologistmay decide to request additional testing, such as an X-ray or a blood test.If necessary, he/she will refer you to another specialist. All this is to ensure thatyou are in an optimal condition before the surgery. In discussion with you, theanaesthesiologist will decide what type of anaesthesia (general, regional or acombination) you will receive.There are eight doctors working in the Anaesthesiology Department. So youmay receive your anaesthesia from a different doctor than the one you saw atthe outpatients’ clinic. On the day of the surgery, you will meet the anaesthesiologistwho will be responsible for your anaesthesia. This anaesthesiologist willadhere to the agreements that were made concerning the anaesthesic techniqueto be used, unless there have been changes in your health, the proposedoperation has been changed or the anaesthesiologist is convinced that adifferent anaesthesic technique will be safer for you.The consulting anaesthesiologist will first discuss this with you.9

In principle, the visit to the pre-operative outpatients’ clinic is valid for sixmonths. If the waiting time for your operation is longer, you will be contactedby the pre-operative outpatients’ clinic before your admission. Depending uponyour physical condition, it will be determined whether or not you must visit theoutpatients’ clinic again or if a few questions over the telephone are sufficient.CHANGES IN YOUR HEALTHThere may be some time between your visit to the outpatients’ clinic and themoment that you are called in for your surgery. If, during this time, there havebeen any changes in your general health, you must report this to the consultinganaesthesiologist in the pre-operative outpatients’ clinic so that this can betaken into account (telephone pre-operative outpatients’ clinic: 070 - 312 44 56).This could include any of the following:• If you have been treated by a different medical specialist;• If changes have been made in your medication;• If your blood pressure is higher;• If you have any wounds or infections on your skin in the area that is to beoperated on;• If you have been admitted to a hospital, in Bronovo Hospital or elsewhere• If you have had surgery• For women: if you are pregnant or think that you might be.If, on the day preceding or the day of your surgery, you develop a fever (38.5°Cor higher) or a serious cold, it is important to pass on this information immediately,by phone to the specialist who is going to do the surgery. In that case, itwill be decided, in consultation with the anaesthesiologist, whether or not thesurgery can take place.PREPARATION FOR THE SURGERY OR THE EXAMINATIONA good night’s sleepIt is important that you are well rested on the day of the surgery. Perhaps youare a bit nervous or the strange hospital environment (if you have already beenadmitted) is keeping you awake. In that case, you may ask the nursing staff fora sleeping pill.10

PREPARATION AT HOMETime of admissionIf you are being admitted to the hospital on the day of the surgery, you mustcall the Admissions Office telephone number: (070 - 312 46 82) between14.00 and 16.00 hours one working day before the planned surgery in order toinquire about the time that you are expected at the hospital. The actual time ofthe operation itself cannot be given. You will hear about this once you areadmitted.Patients who are to be admitted one or more days before the surgery willreceive a phone call about this from the relevant outpatients’ clinic or via theAdmissions Office.Coming with an empty stomachThe operation can only be done if you have fasted in the hours beforehand.This is to prevent severe complications.From five hours before the agreed admittance time, you may not eat ordrink anything except clear liquids like:• water;• coffee and tea without milk or creamer;• fruit cordial diluted with water;• apple juice.These drinks may be drunk until one hour before the admittance time.It is not allowed to smoke on the day of the operation.Medication useIn most cases, you should continue to take your own medication up until thesurgery. The anaesthesiologist will determine what you may or may not take.If you are taking diuretics, you may not take them on the morning of theoperation.The use of aspirin and blood thinning medication (Sintrommitis,Fenprocoumon, Acenocoumarol, Marcoumar, Ascal, Plavix or Persantin) mustbe stopped at least 5 days -- but generally 10 days -- before the operation,unless the anaesthesiologist or your specialist has decided differently in your11

case. This is in connection with the effect of these medicines on the clotting ofthe blood.The use of painkillers such as Brufen, Voltaren and others must be stopped1 day before the surgery. If you are in pain, you may use paracetamol up to theday of the procedure. You may also continue to use e.g. COX-II inhibitors,Arcoxia and Celebrex.Women who are taking birth control pills may continue to take them. After thesurgery, complete protection can, however, not be guaranteed for the remainderof the cycle.Jewellery, make-up etc.Before the procedure, you must remove all your jewellery. This also applies topiercings in all body parts.Make-up must be removed. This also applies to nail (finger/toe) varnish:the anaesthesiologist will want to be able to see the natural colour of your skinand nails.If your procedure is going to be done under general anaesthesia, you must alsoleave your glasses, contact lenses and dentures -- if applicable -- behind in theward. This is not necessary with regional anaesthesia.A hearing aid may generally be taken into the operating complex if, for example,you would not be able to hear the anaesthesiologist without it and hewould not be able to communicate with you.ADMISSION TO THE NURSING WARDOn the day of your procedure, you must report to the nursing ward at theagreed time. This is generally two hours before the procedure and never before07.00 hours.The patient’s roomOn the ward, you will be given a bed and a bedside cupboard. There is also alockable wardrobe available for storing your possessions. You can lock thiswardrobe after depositing a 2 euro coin. When you return the key, you will getyour coin back.12

In our hospital, it is possible that men and women share one room. If you havefundamental objections to this, you should make this known to the AdmissionsOffice.What to bring with you?Do not forget to bring the following things with you:• Your registration card with the bar code and appointment card.• The medication that you use at home and/or a list of the medication and thedosages that you take.• Toilet articles, underwear, nightclothes, a bathrobe and slippers.• Dietary requirements, if applicable.• If desired, magazines, a book or other reading material.• Some small change.• With a regional or local anesthesia you can bring a MP3 player to listen tomusic during the operationWe advise you to leave jewellery and other valuables at home!Contact personMake sure that there is a contact person who can be reached by phone duringthe time that you are in our hospital. Together with the nursing staff, it will bedecided when the contact person can call to ask about your condition andwhen you can be taken home again. It is not possible for your contact person/companionto stay in the nursing department during your hospitalization.Visiting hoursThe visiting hours are daily from 15.30 - 16.30 hours and from 18.30 - 19.30hours. On Saturdays and Sundays, there is an extra visiting hour from 11.15 -12.15 hours. There are different visiting hours for the Pediatric Department andthe Intensive Care Unit.Shaving and clothing for the operationIt is sometimes necessary to shave the area where you will have the surgery.This will be done in the operating complex.13

PremedicationBefore you are taken to the operating theatre, you will generally be given thepremedication by the nurse as instructed by the anaesthesiologist. This includesmedication that will sedate you and can make you sleepy, as well as a numberof tablets that are intended to act as painkillers immediately after the operation.THE OPERATING COMPLEXThe operating complex consists of three centres: the holding area where you arereceived, the operating theatre where your procedure will be performed and therecovery room where you will be intensively monitored after the surgery.The holding areaYou will be brought to the operating complex in your bed. Here, you will bereceived in the holding area by an anesthesiology assistant or a nurse. In thisarea, there will be other patients who are waiting for surgery.Generally, one of the staff members in the holding area will insert an intravenousline into your hand or arm and you will be attached to equipment that willmeasure, among other things, your heart rate and blood pressure. If it has beendecided, in consultation with you, that you are to receive a regional anaesthesic,this will be administered in the holding area.After this, you will be brought to the operating theatre in your bed. There youwill be transferred to the operation table.The operating theatreIf you are given general anaesthesia you will be put to sleep in the operatingtheatre. Because it is cold in the operating theatre, you will be covered with awarm flannel blanket. In the operating theatre, you will see various kinds ofequipment. A large surgical lamp hangs above you. Once you are there, youwill again be attached to the monitoring equipment. After the procedure isover, you will be woken up in the operating theatre. You will then be takenback to the recovery room in bed. After an operation with regional anesthesiayou will also go to the recovery room.14

The recovery roomAFTER THE ANAESTHESIAThe recovery roomIn the recovery room, you are attended to by specialist nurses. As in the operatingtheatre, your heart and respiration rates and your blood pressure are measuredand recorded frequently. Here too, a special effort is made to prevent not onlythe pain that might occur after surgery (and alleviate it if it occurs) but alsopossible nausea or vomiting after the operation.As soon as your physical condition allows, you will be taken back to the ward,where the unit nurse will receive all your personal information. Occasionally,you might have to be monitored for a little longer, in which case you will betransferred to the Intensive Care unit usually for one night.PainIrrespective of the scope of the surgery, everyone hopes for a quick recovery. Tothat end, effective pain relief can be very helpful. For instance, after surgery it isimportant that you continue inhaling and exhaling deeply and are able to coughup and move. Post-surgical pain keeps you from doing so and stops you15

elaxing. In a situation like this, pain actually impedes your recovery and,consequently, needs to be relieved. To do so, several possibilities exist: it can betreated with pills, suppositories, injections or other methods prescribed by theanaesthiologist.Your pain scoreFor good pain relief, it is important for us to know how much pain you areexperiencing. Your input is important for this. You are the one feeling the painand only you can say how bad it really is.For that reason, pain registration is used. For you, this means that after yoursurgery, nurses and doctors will frequently ask you for a pain score. In order todo so, a ‘pain index’ has been developed which is a sort of ’pain thermometer’.In the first days after surgery, you will be asked 3 or 4 times daily to indicatethe level of pain you are experiencing. You will be asked to ’score’ your pain ona scale between 0 (no pain) and 10 (the most excruciating pain).• If you are pain-free, your score would be 0.• If you are experiencing little pain, a number between 1 and 4 would beappropriate. The number 4 is for the most pain that is acceptable: remember,surgery is never totally painless. Up to and including, 4, the pain is considered“bearable”. Moving, coughing, inhaling and exhaling should not be affected.• Pain scores above 4 are a reason to intervene. You need to report this to yournurse immediately so extra medication can be given.• A pain score of 10 is for the most excruciating pain you can imagine.This really should not ever happen to you.Pain is a personal experience. If, for instance, you think your pain score is 5,then give it a 5 even though you might think somebody else might give it a 3or a 7. You can never choose a wrong score. After all, it is the pain YOU areexperiencing!ImportantIt is important that you inform the nurse and the doctor about the pain you areexperiencing and whether the painkillers are working well. If needed, they cangive you different painkillers or adjust the dose. The longer you wait beforereporting the uncomfortable pain, the harder it will be to treat it. So, please donot try to be ‘brave’!16

Pain relief on a fixed scheduleImmediately after surgery you will receive painkillers at set times. Administeringpainkillers this way has a continuous soothing effect and is the basic principle ofpain treatment.Depending on your situation, different kinds of painkillers can be given:• Paracetamol (acetaminophen) has painkilling and fever-reducing effects but doesnot act as an anti-inflammatory drug.• Diclofenac not only relieves pain but is also a fever-reducing and anti-inflammatoryagent and is therefore not only prescribed for pain relief. This drug can begiven in combination with gastro-protective medication.• Morphine is a potent painkiller and is not addictive if it is prescribed for shortperiods. There is no reason to be afraid of receiving an overdose.The duration of pain depends on the kind of surgery received. After administrationof a painkiller, it is important to determine in which way you, the patient, react tothe medication received. Is the medication received sufficient or is a higher doserequired? A check is made to see whether the medication received is doing its job.Side effects and complications of anaesthesiaNo surgery is entirely risk-free. With proper monitoring devices and a qualifiedstaff, we do our best to ensure your safety and wellbeing before and aftersurgery. Nevertheless, we want to draw your attention to potential side effectsand complications:During general anaesthesia• allergic reactions to the medication• damage to teeth or throat caused by insertion of the breathing tube• calamities caused by the physical condition of the patient.After recovery from general anaesthesia• drowsiness• pain in the part of the body that was operated on.• nausea and/or vomiting• dry throat or sore throat because of insertion of the breathing tube.This irritation will disappear within a few days.17

During spinal or epidural anaesthesia• insufficient pain relief• low blood pressure• the level of numbness may ascend in the body, resulting in a feeling ofbreathlessness• difficulty in urinating.After spinal or epidural anaesthesia has lost its effect:• back pain (complaints decrease within a few days)• headaches (complaints decrease by lying flat). If these are very intense orpersist for a long time, you can ask the nurse to contact the AnaesthesiologyDepartment.During the plexus anaesthesia:• insufficient pain relief• allergic reaction to the anaesthetic.After the plexus anaesthesia:• tingling sensations or impaired feeling in arm and/or hand (usually disappearsafter a few days).Fortunately, serious complications are rare. These are almost always the consequenceof a very rare calamity or are related to the state of health you were inbefore the surgery. Do not hesitate to ask your anaesthesiologist about the risksin your particular case.BACK TO THE WARDWhen you are sufficiently recovered from the anaesthesia, you will be takenback to the ward. If, after the surgery, you need extra monitoring and/or treatment,you will be admitted to the Intensive Care Unit. You will have been toldabout this beforehand by the anaesthesiologist or the surgeon.After surgery, it might take a while for your physical condition to recover completely.You might tire or feel breathless more easily. This is quite normal:because of the surgery, your body has suffered quite a bit. Complaints like lossof concentration and memory will disappear the moment you regain your18

strength. Generally, after more extensive and sustained surgery, these complaintslast longer.INFORMATION FOR PATIENTS WHO ARE RECEIVING SURGERY ASDAY PATIENTSA DAY SURGERY admittance means that you will be admitted,operated on and sent home all in the same day.In addition to the information already presented in this brochure, the followingapplies to your situation:DischargeIn the course of the day, it will be decided if you have sufficiently recovered fromthe procedure. After your consulting physician or the ward doctor has seen you,it will be decided in consultation with the nurse when you may be taken home.The nurse will make an appointment for you for the first check-up at the outpatients’clinic.The specialist will give you a letter for your family doctor (G.P.) and, if necessary,a prescription for medication.You must not leave the hospital unacccompied nor may you drive yourself.Home again• For the first 24 hours after the procedure, you may not drive a vehicle or ridea bicycle. This means that you must organize transportation to go home fromthe hospital.• We advise you to make sure that you are not alone at home for the first 24hours.• It is also not permitted to operate machinery (drills, electric saws, etc.) for thefirst 24 hours.• We advise you not to make any important decisions and/or undertake any(business) transactions during this period.• You must not use any alcohol or drugs during the first 24 hours after theoperation19

If regional anaesthesia of the arm was used during your surgery, you will haveto be extra careful with your arm during the first day as the sensation takestime to return completely (At least 12 hours). Carry your arm in a sling.If you had surgery while anaesthetised by a lumbar puncture and, after returninghome, you notice that your leg muscles feel weak or that parts of yourlegs feel numb again, you must immediately contact the anaesthesiologistwhose phone number is listed below.We recommend you to keep a stock of paracetamol 500 mg (acetaminophen)tablets and diclofenac (50 mg) or suppositories at home, just in case you startexperiencing pain again. The doctor treating you will inform you about dosageand frequency of useProblems and/or questions:After returning home from surgery, you might have problems or questions concerningthe anaesthesia, such as pain relief, complaints about serious headachesafter a spinal anaesthesia and the occurrence, and control, of nausea and vomiting.If so, please contact the Anaesthesiology Outpatient Department: weekdaysbetween 07.30 and 16.30 hrs, phone number 070 - 312 44 56.After hours, contact the anaesthesiologist on duty through the central hospitalphone number: 070 - 312 41 41.IN CONCLUSIONWe hope that, after the operation, you will be satisfied with the treatment thatyou have received from the doctors in the Anesthesiology Department. If youhave any suggestions concerning improvement to the care that you receivedand/or the contents of this brochure, we would be glad to hear them.Bronovo HospitalBronovolaan 52597 AX The HagueTel. 070 - 312 41 41www.bronovo.nl20Published: March 2011

ARRANGEMENTS FOR THE DAY OF THE PROCEDUREPlease bring with you all medication that you are taking when you are admitted.On the day of the procedure, you must only take the medication listed below:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do not take any other medication.You use as blood thinning medicationMarcoumar (Fenprocoumon)Sintrom(itis) (Acenocoumarol)AscalPlavixother ………….……………..........You must stop taking this ….. days before the operation.21

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24Bronovo HospitalBronovolaan 52597 AX The HagueTel. 070 - 312 41 41www.bronovo.nl

In this brochure, you can read everything about the anaesthesia that youwill be given during your operation or diagnostic procedure.If you still have questions, you may phone the pre-operative outpatientclinic, telephone number 070 - 312 44 56 on weekdays from08:00 - 16.30 hours.Health Centre Wassenaar, Bronovo Hospital and Nebo Nursing Home together make upthe Bronovo-Nebo FoundationBBronovoBronovolaan 52597 AX DEN HAAGPhone: 070 - 312 41 41www.bronovo.nl