Explore Orthopaedic Oncology Surgical Prep

Prep for Surgery

NARCOTIC MEDICATION

Given the current opioid crisis and new regulations (DEA, state, hospital) regarding these drugs, each patient is required to complete a narcotic contract prior to surgery since narcotics usually are prescribed upon discharge. This contract reviews the risks associated with narcotics and how to take them safely as prescribed. Here is an example of a narcotic contract.

MEDICATIONS

  • Continue your routine daily medications unless instructed to stop
  • Continue taking your daily ASPIRIN before surgery, including the day of surgery, unless instructed to do otherwise
  • STOP taking aspirin-containing products 7 days before surgery. For example, Alka-Seltzer, Bayer Arthritis, Fiorinal, Midol, Pepto-Bismol and Percodan
  • STOP Vitamin E, fish oil, and herbal supplements. For example, Chondroitin, Echinacea, Feverfew, Garlic, Ginkgo Biloba, Ginseng, Kava, Ma Huang, saw Palmetto, Valerian, St. John’s Wort
  • STOP Coumadin (warfarin) usually 4-5 days before surgery
  • You may need to start Lovenox injections, take as directed
  • STOP other anticoagulants (Plavix, Eloquis, Aggrenox) as directed (*see table below)
  • STOP taking anti-inflammatory drugs (NSAIDs) 3 days before surgery. For example, Motrin, Ibuprofen, Naprosyn, Naproxen, Advil, Aleve, Lodine, Daypro, Vicoprofen, Anaprox, Ansaid, Arthrotec, Celebrex, Cataflam, Diclofenac, Feldene, Indocin, Ketoprofen, Mobic, Toradol, Relafen, Voltaren
  • Take TYLENOL or continue with your current narcotic regimen, if it includes medications such as Ultram (tramadol), percocet/oxycodone, oxycontin, vicodin (hydrocodone), dilaudid, methadone or Fentanyl patch

*Anticoagulation Guide

Drug (Generic)

Common Trade Names

When to Stop

ASA

Aspirin

No significant risk when taken alone.

Apixaban

Eliquis

3 days (CrCl>50) 4 days (CrCl<50)

Clopidogrel

Plavix (75mg)

5-7 days

Dalteparin (Therapeutic)

Fragmin (5000 units BID or 120 units/kg BID or 175 units/kg QD)

24 hours

Dalteparin (prophylactic)

Fragmin (</= 5000 units QD)

12 hours

Enoxaparin (Theapeutic)

Lovenox (>60mg QD or 1mg/kg BID or 1.5mg/kg QD)

24 hours

Enoxaparin (prophylactic)

Lovenox (</=60mg QD)

12 hours

Fondapariunx

Arixtra (2.5mg)

4 days

Fondaparinus

Arixtra (5mg, 7.5mg, 10mg)

7 days

Rixaroxaban

Xarelto

2 days (CrCL > 50); 3 days (CrCl < 50)

Warfarin

Coumadin

3-5 days, INR </= 1.5

SMOKING

If you smoke, try to quit or decrease your smoking before surgery.

SHOWERING & HIBICLENS

  • Use Hibiclens solution before surgery. Shower three consecutive days before your surgery, using one small bottle per shower. You most likely will be given small bottles (4 fluid oz) at your preoperative appointment. If you do not receive the Hibiclens, you may purchase it at a pharmacy, over the counter.
  • At your preoperative appointment, you will undergo a nasal swab screening for Staphylococcus. This screening for bacteria is done for patients who will undergo any metal joint replacement or have extensive spine and pelvic instrumentation placed during surgery. If the nasal swab is positive, you must shower for 5 consecutive days before surgery with Hibiclens and may also need to use the medication mupirocin (see instruction below).


What I need to know about Hibiclens® before I shower:

  • Use Hibiclens® soap instead of your regular soap. Do not use both. If you do, the Hibiclens will not work correctly.
  • Do not use Hibiclens® if you have an allergy to chlorhexidine-containing products. If you do, you may use an antibacterial soap instead (like Dial antibacterial soap).
  • Do not use Hibiclens® on your head or face. If you get this soap in your eyes, flush with water right away.
  • Do not use Hibiclens® on the vaginal area.

 

How to shower with Hibiclens®:
Do not follow the directions on the Hibiclens package. They are meant for surgeons. Follow the instructions below:

  • First, rinse your body very well with water.
  • Turn the water off.
  • Wash with the Hibiclens® from the neck downwards. Wash the part of your body (hip, knee, etc.) where you are having the surgery very well.
  • Wash your body gently for five minutes. Do not scrub your skin too hard. You can use a sponge to help with lathering. Hibiclens® does not lather as well as regular soap.
  • Turn the water back on and rinse well. Pat dry with a clean towel.

 

If you develop a rash or skin irritation, please call your doctor. If you get hives or have trouble breathing, call 911 or go to your nearest emergency department.

More instructions:

  • Do not shave for 24 hours before your surgery.
  • The day of your surgery, do not put on powder, lotion, deodorant or hair products.

 

If the test shows that you DO have staph, you will be asked to follow these instructions:

  • I need to fill my prescription for Mupirocin (nose medicine)
  • I need to get clean cotton swabs
  • I need to start using Mupirocin 5 days before my surgery

 

Nasal (nose) medicine:

  • Use this medicine for 5 days before your surgery and the day of your surgery for a total of 10 doses.
  • Apply your first dose in the evening 5 days before your surgery.
  • Then use twice a day, once in the morning and once at night for 4 days.
  • Apply your last dose the morning of your surgery.
  • Do not use this if you have an allergy to Mupirocin.
  • The instructions on the package will say not to apply to the nose. Please disregard this.

 

My Mupirocin schedule:

  • 5 days before my surgery: apply one dose in evening
  • 4 days before my surgery: apply one dose in morning and evening
  • 3 days before my surgery: apply one dose in morning and evening
  • 2 days before my surgery: apply one dose in morning and evening
  • 1 day before my surgery: apply one dose in morning and evening
  • My surgery day: apply one dose in morning

 

How to apply Mupirocin:

  • Wash your hands very well.
  • Put a pea-size amount of ointment onto a cotton swab. Insert the cotton swab about 1/4 inches into the nostril and apply the ointment.
  • Remove the cotton swab. Close the nostril by pressing the sides of the nose together and releasing. Massage the nostril in this way for one minute to spread the medicine evenly throughout the nostril.
  • Use a new cotton swab and do the same thing to the other nostril.
  • Wash the skin below your nose to remove any remaining medicine. Wash your hands.
  • Do not touch your eyes. If the medication gets into your eyes, it may cause burning and tearing. If this happens, rinse your eyes well and call your doctor.
  • If your surgery is postponed, stop your medication schedule above.
  • If your new surgery date is more than 2 weeks away, start the whole schedule again 5 days before your new surgery date.
  • If your new surgery date is less than 2 weeks away, continue your medication schedule where you left off. For example, if you took medication for 2 days before stopping, restart the medicine 3 days before your new surgery date.

DAY BEFORE SURGERY INSTRUCTIONS

Hospital admission the day before surgery: Report to the Admissions Department, 1st Floor, Gray Building, around Noon - 1pm.

  • This is applicable to patients with severe pain, immobility or advanced disease

 

Procedure before surgery: If you are scheduled for an Embolization, report as directed. Usually, you are admitted to the hospital after the procedure.Medication: Take your routine medications except for those mentioned above.

 

Diet: You will be instructed to follow one of these diets:

  • Normal diet
  • Clear liquid diet for bowel prep
  • Bowel prep
    • Surgeries involving the pelvis may require a cleansing of the bowel, or what is often called “bowel prep.” Most patients are given a prescription for Go-Lytely to drink the day before their surgical procedure beginning early in the morning. There are a few variations on bowel prep, and you will be given specifics by your doctor’s office.

NIGHT BEFORE SURGERY INSTRUCTIONS

Medication: Take your routine bedtime medications except for those mentioned above. You may take pain medication throughout the night.

 

Fasting Guidelines:

  • Adults and Children (7 years and older): NOTHING TO EAT OR DRINK after 10pm except for medications
  • Do not drink coffee, tea or orange juice after 10pm the night prior to your procedure
  • If your surgery is later in the day, you may have up to 1 cup (8 ounces) of clear liquids (water, apple juice or cranberry juice) up to 4 hours before the time of your procedure

MORNING OF YOUR SURGERY

Showering: use Hibiclens solution as instructed.

 

Medication: Only take the medication you were instructed to take on the morning of your surgery. Please follow these guidelines, if not, your surgery may be cancelled:

  • YES, you may brush your teeth and rinse
  • NO food or drink
  • NO cough drops, breath mints, hard candy or chewing gum
  • NO vitamins, minerals, potassium or calcium supplements, or over-the- counter medications
  • NO oral diabetes medications (glipizide, glyburide, metformin, rosiglitazone, Actos, Glucotrol, Avandia, Glucophage, etc.)
  • Take your insulin as instructed by the anesthesiologist or your Primary Care Physician

Where to report the Morning of your Surgery (Adults)Wang Building, 3rd Floor, the Center for Perioperative Care.

 

Special Procedures on the Morning of Surgery:
Some patients have special procedures done the morning of their surgery. For example:

  • For a sentinel node injection for a lymph node biopsy, report to the White Building, 2nd Floor, Nuclear Medicine
  • For a needle localization, report to the Ellison Building, 2nd Floor, Radiology Reception Area
  • For a radiation treatment, report to Radiation Oncology (as specified by your physician)

 

After these special procedures, you will proceed to the Center for Perioperative Care, Wang Building, 3rd Floor.Where to report the Morning of your Surgery (Child)MassGeneral Hospital for Children (MGHfC) Surgery Admission and Family Waiting Area, 3rd floor, Ellison building. Whether you enter the hospital from the Main Entrance, the Wang Lobby or the Yawkey Building, head to the main corridor, follow the large blue "E" on the signs overhead to the Ellison elevators and go up to the 3rd floor. Once off the elevator, follow the blue line on the floor to a set of duck tracks. From there, the entrance to the reception area will be ahead of you on the right.

Refer to the Mass General Hospital for Children Preparing for Your Child's Surgery handout for more information.

Instructions for Family & Friends

If you are admitted to the hospital after surgery, family members and friends may wait in the Surgical Family Waiting Area, Gray Building, 1st floor. Your surgeon will meet them there following your surgery to give them information about your condition.

If you are going home the same day, or just staying overnight, your escort will be instructed to go to the appropriate Post-Anesthesia Care Unit (PACU) waiting area.

AFTER SURGERY

After surgery, you will go to one of the following nursing units, depending on the nature of your care:

  • Intensive Care Unit (Adult – Blake 12 or Ellison 4)
  • PACU (Post Anesthesia Care Unit) until stable, then go to a nursing unit
  • Ellison 6 or White 6 (Adult Orthopaedic Nursing Units)
  • Ellison 19 - if extensive thoracic surgery is done
  • Ellison 18 or 17 (MGH Hospital for Children)
  • Ellison 14 - if extensive plastic surgery is done
  • Another surgical/medical nursing unit – all depends on bed availability
  • Phillips House (private pay)
  • 23 hour observation (which means an overnight stay in PACU)

Some patients go home the same day as their surgery.Morning Patient RoundsEach morning the Orthopaedic Oncology Team will visit you. We call this our morning rounds. Usually one of our Residents, sometimes accompanied by a Medical Student, will visit you first. Then, one of our surgeons (Dr. Raskin, Dr. Lozano, Dr. Schwab or a fellow) will lead rounds.We work together as a team to provide comprehensive, cohesive patient care. Thus, we all know each patient and their individual plan of care. Morning rounds is a great time to have any of your or your family’s questions answered. If your care involves other services, you will have early morning visits by their team as well.

DISCHARGE INFORMATION

When you are discharged from Mass General, you will go to one of the following:

  • Home, with or without nursing and therapy services
  • Skilled Nursing Facility (SNF): If you are not independently mobile and do not have assistance at home, you may need an inpatient rehabilitation setting. To qualify for inpatient rehab in a SNF, you need to meet criteria for admission and have insurance coverage. SNFs are primarily nursing homes that provide short term rehabilitation in addition to long term care. They provide skilled nursing, physical and occupational therapy.
  • Acute Rehab Facility: If you have complex medical issues, you may qualify for intense medical management and rehabilitation.

A case manager will help you and your family determine the best facility for you, which is determined by your required level-of-care and insurance coverage.

FAQs

What time is my surgery?

You need to call the office (617-724-3700) the day before your surgery about 1-2 p.m. If your surgery is on Monday, please call the office on the Friday before your surgery because the office is closed for the weekend.

Will my doctor actually do my surgery?

YES. There will also be a surgical assistant, either the fellow or resident to assist your doctor. Your surgical team involves your surgeon, the fellow or resident, the anesthesiologist, and a scrub nurse who all remain sterile and at your side at all times. A circulating nurse is also pre-sent to circulate around the operating.room and help with the needs of the team.

What is a Bowel Prep and why do I need one?

Patients who are having major abdominal, pelvic, sacral or complicated pelvic and hip surgery need a 'bowel prep'. When the bowel is empty of stool, it is more manageable during the surgical procedure and the area being worked on is more visible. Severe infection and com-plications can arise if stool contaminates the surgical area. ·A bowel prep consists of a clear liq-uid diet the entire day before surgery which limits you to .broth, black tea or coffee, jello, pop-sides, apple/cranberry/ clear juices and gingerale. No cream, milk or juice with pulp. No solid food at all which includes gum, candy and crackers. Antibiotics taken by mouth will be ordered for you to take at 12 noon, 4 p.m., 8 p.m. and 10 p.m. on the day before surgery. 'Go-lytely' is a drink that you will take between 2 and 6 p.m. on the day before surgery which will cause you to have several bowel movements to empty or 'clean out' your bowel. A more gentle version of the bowel prep for less complicated surgery involves the clear liquid diet, one bottle of Magnesium Citrate (the size of a soda) and about 2 enemas on the afternoon and evening before surgery. Years ago ·insurance companies would pay for a one day preoperative stay in the hospital for the bowel prep. Now most preps are done at home and the patient arrives at the hospital on the same day as surgery.

Why will I be in the Intensive Care Unit (ICU) after surgery?

Patients who have complex surgery involving the pelvis, abdomen, sacrum or hip usually go to the ICU for closer observation by the medical and nursing staff until all of the major body systems are stable. Many times the endotracheal or 'breathing tube' is left in your throat for a few days. If you wake up with this tube, you will not be able to speak. The nurses will give you medication to relax you and prevent you from pulling at the tube or 'fighting' the tube. Your breathing and amount of circulating oxygen, hematology and chemistry blood values, heart function, and incision are closely monitored. The breathing tube will be removed as soon as the anesthesiologist or intensive care physician feels you can safely breathe on your own. As soon as all of your systems are stable, you will be transferred to the nursing floor. ICU visiting hours are limited, as is the number of visitors allowed per patient due to the severe surgical and medical conditions of all the patients in the ICU.

What type of pain control will I have postoperatively?

Most of our patients receive pain medication (narcotics) through the patient controlled anal-gesia (PCA) pump. The narcotic is morphine or dilaudid. The medication is placed in a syringe and locked into a pump. You are able to push a button to receive your pain medication. You can not overdose because the pump is calculated, set and locked at your correct dosage. If an epidural catheter was placed to administer your anesthesia during surgery, pain medicine will also be delivered through this catheter postoperatively. After a few days, you will be weaned off the intravenous pain medication and given pain medication pills. We usually dis-charge our patients with a small supply of Percocet or Tylenol with Codeine for children and instruct them to wean off this medication within a week or two. Eventually Tylenol Extra Strength or anti-inflammatories such as Advil, Motrin or Aleve can be taken for minor discomfort. Anti-inflammatories should not be taken if you are taking Coumadin.

Will I have a urinary catheter tube in place after surgery?

Patients with pelvic, hip and thigh surgery will have a catheter placed after they are asleep from anesthesia. The catheter remains in place for a few days postoperatively.

What does anticoagulation mean and what medications do I need to take after surgery?

Anticoagulation means preventing a blood clot, Deep Vein Thrombosis (DVT/VTE) or Pulmonary Embolism (PE) from forming. These involve the formation of a blood clot inside a vessel, usually in the legs but can occur in the arms (DVT) and sometimes in the lungs (PE).

Many people refer to anticoagulants as 'blood thinners'. They actually do not thin the blood, rather lengthen the time it takes for blood to clot. If you take an anticoagulant, it makes it harder for a clot to form in your blood vessel, or it keeps an existing clot in your vessel from getting bigger.

There are several anticoagulation medications depending on your diagnosis and the type of procedure preformed. Your surgeon will determine what is appropriate for you.

Examples of anticoagulation medications:
- Aspirin: once or twince daily
- Lovenox: subcutaneous injection (usually daily in the evening)
- Coumodin: daily in the evening
- Xarelto: NEED TIMING
- Eliquis: NEED TIMING

Informed Consent

Patients with tumors, whether benign or malignant, are confronted with complex surgical procedures with serious risks and/or possible permanent alterations in bodily functions and mobility. It is important that the informed consent process provide knowledge of the procedure and options, risks and benefits of each option, and the extent and likelihood that these will happen. Informed consent is not merely to obtain a signature, rather it should be a continuous process of communication between a patient and his/her care team. Informed consent is not meant to overwhelm or scare patients, rather it is meant to educate patients about what will happen to their body in the aftermath of surgery and the impact the surgery can have on quality of life. It is a patient’s legal and ethical right, and this is the process of shared decision making.

Informed consent is a process to obtain permission from a patient before any healthcare intervention takes place. This includes any diagnostic procedures, chemotherapy, radiation treatment, surgery, research studies, and clinical trials. Patients 18 years and older sign this informed consent. Patients under 18 years of age have their parents sign, and for those patients deemed incompetent (mentally challenged), a guardian signs the form. It is a legal document that must be signed before any surgery.

An informed consent is a discussion that takes place between patient and provider, which explains the surgery or treatment in detail, including all the risks and benefits of the proposed procedure, so that a shared decision making process takes place.

All surgeries, no matter how small or complex, have associated risks such as:

  • Bleeding: Simple cases do not require blood transfusions. Larger cases may require a blood transfusion, so before surgery, a blood sample may be taken to determine your blood type. Many patients ask about blood donation before their surgery. For patients with cancer, it is not advised to donate blood to oneself. For patients that do not have cancer, if you want to donate blood, you should go through your local Red Cross. Patients who do require transfusions should feel comfortable with the blood from Mass General's blood bank. For more information about Mass General's blood bank, visit their website.
  • Infection: All patients receive a dose of antibiotics in surgery, and then if they remain in the hospital will receive two additional doses of antibiotics. Sometimes complex cases require prolonged use of intravenous antibiotics, such as those involving malignant tumors, plastic reconstructive surgery or a diagnosis involving infection (such as a prosthetic joint infection, post-operative wound infection, etc).
  • Blood Clots, Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE): These risks involve the formation of a blood clot inside a vessel, usually in the legs but can occur in the arms (DVT) and sometimes in the lungs (PE). Symptoms of a DVT can include pain and swelling in an extremity and fever. Symptoms of a PE vary but can include chest pain, shortness of breath, pain in the shoulders, pain with deep breathing and fever.

    During most operative procedures and post-operatively, SCDs are placed on the lower extremities to prevent blood clots and maintain adequate circulation. (picture of SCDs) Post-operatively, for simple surgeries, medication to prevent blood clots (anticoagulation) is not necessary unless mobility will be affected. In those cases, a daily aspirin may be prescribed. For more complex procedures involving benign and malignant tumors of the pelvis, hips and lower extremities, an anticoagulation medication will be prescribed; most often Lovenox, a subcutaneous injection. 

    Patients already taking one of the many oral anticoagulant medications for other medical issues such as placement of a cardiac stent, prior stroke or atrial fibrillation, will resume their home medication post-operatively and not receive additional anticoagulant medication from their physician.
  • Nerve/Vessel Injury: Depending upon the anatomical location of your surgical incision, there are always underlying nerves and vessels that can be injured during surgery. Usually, the injury is temporary and with time, symptoms lessen. Because nerves and vessels control motor and sensory function, symptoms are often numbness (sensory) and weakness (motor).
  • Delayed Healing of Surgical Incision: Some patients have a slower healing process than others, maybe due to medical issues (i.e. diabetes) or sometimes post-operative swelling and redness occur, which can represent a skin infection (superficial cellulitis) or a deeper infection. Other patients develop a fluid collection (seroma) or blood collection in the operative area (hematoma) or even extra drainage coming from their incision. All of these situations require a visit to your surgeon, where you may or may not need an antibiotic or wash-out (surgical cleaning of the incision).
  • Unforeseen Medical Issues: With any surgery, even the smallest procedure, there are inherit risks related to our body systems: cardiac, respiratory, gastrointestinal, genitalurital, neurological.

Spine & Pelvic Tumor Surgeries

These surgeries have more risks due to the anatomical location of the tumor(s). Patients usually require a two-staged approach (anterior and posterior approaches) to remove such tumors, meaning that the surgeries take place a few days apart. Complex reconstruction may require even more surgeries and most of these patients are hospitalized for a minimum of two weeks, sometimes up to a month.

The common risks include bleeding, infections and blood clots, as previously described above. The more specific risks due to anatomical location include:

  • Facial Abrasion & Blindness: While in the prone position (face-down), patients are at risk for pressure sores on their forehead, under their eyes and on their chin. Anesthesia works diligently to protect a patient’s skin using an assortment of facial pads. It is extremely rare to develop blindness. One of the reasons we stage these procedures is to decrease the amount of time a patient remains in a prone position.
  • Infection: In addition to the information on infections listed above, for these complex procedures, antibiotics usually are continued throughout the patient’s hospital stay.
  • Blood clots: In addition to the information on blood clots listed above, in between the stages of complex procedures, an Inferior Vena Cava (IVC) filter is placed to prevent blood clots from entering the lungs, causing pulmonary emboli. These filters are retrievable and stay in place for an average of 3-6 months after these major surgeries. They eventually will be removed. Some form of anticoagulation medication usually is prescribed (aspirin, Lovenox) after all stages of the procedure are complete.
  • Nerve/Blood Vessel Injury: Patients may have bowel, bladder and sexual dysfunction with pelvic and sacral surgeries, even lower level lumbar spine surgeries. Surgeries involving the spine run the risk for paralysis, foot drop, bilateral lower extremity edema and weakness.
  • Dural Tear/Leak: Removing tumors in the spine may damage the dura, which is the covering of the spinal cord. This is common with these complex surgeries. Treatment for a dural tear involves lying flat for 24+ hours with the hope of spontaneous healing of the leak. Some patients experience headaches or sensitivity to light from the dural tear. Caffeine and medication are prescribed for the headache and dimming the lights for comfort. Sometimes with a persistent leak, the patient returns to the operating room where your surgeon will “patch” the leak.
  • Delayed Healing due to preoperative radiation and chemotherapy treatment: Sutures or staples are not removed for a minimum of four weeks usually longer, to allow adequate tissue healing.
  • Seroma (Fluid Collection), Hematoma (Collection of Blood), Wound Dehiscence (Opening of Incision) and/or Wound Infection: When a tumor is removed in the pelvis or spine, a dead space is left behind. This space tends to fill-up with fluid, which is a normal occurrence. However, if the fluid becomes infected, or the patient is experiencing significant pain/other symptoms, the patient will return to surgery for a washout. This procedure involves opening the incision and draining the fluid, washing the operative site and/or any involved instrumentation. Unfortunately, this is a common recurrence due to the preoperative radiation and complexity of the procedure. Many times this will lead to a prolonged intravenous or oral antibiotic course or a consultation with our plastic surgery team to fill the dead space with muscle/skin graft.
  • Problems with Instrumentation: Patients with extensive pelvic or spinal instrumentation (hardware), run the risk of loosening or fracture of the instrumentation. Some patients continue to function well with fractured hardware, but when pain worsens and mobility decreases, the patient will return to surgery for hardware revision.
  • Stress Fractures due to Radiation: Patients usually receive pre-and-post operative radiation therapy to prevent recurrent tumor. Unfortunately, radiation weakens the bone and can cause tiny stress fractures to occur in the radiation field where the bone received the treatment. These fractures cause pain and most are treated non-operatively with pain medication and limiting physical activity.
  • Unforeseen Medical Issues: Patients who have complex past medical history including atrial fibrillation, history of heart attack, stroke, cardiac stents, emphysema, diabetes and obesity, run the risk of having post-operative problems associated to their medical history. In addition, many patients develop issues that were unforeseen, like deep vein thrombosis, pulmonary emboli, pneumonia, gastrointestinal bleed due to medication or even acute renal failure and/or allergic reaction due to medication. If these problems occur, physicians in all specialists are consulted to address these problems.
  • Prolonged Intubation: Patients with cervical and thoracic spine tumors sometimes endure prolonged intubation (breathing tube placed during surgery). Because of the removal of tumor and reconstruction of the spine in these areas, it is normal for patients to have a prolonged intubation. However, the surgeon and intensive care unit staff monitor how long the tube is in. If the tube is in place too long, a tracheostomy is placed after a lengthy discussion with the patient’s family. This tracheostomy usually is temporary until the patient can breathe on his/her own.
  • Poor Nutritional Intake: Patients who are unable to eat solid food, such as those with a tracheostomy or signification swelling that occurs after cervical procedures, will be fed by a Nasal Gastric Tube (NG Tube) or a Gastric Tube (G Tube). Tissue healing requires a high caloric intake. Patients will have a consult with our nutritionist.
  • Bowel & Bladder Dysfunction: Some patients will have permanent dysfunction, while others have a temporary pause with bowel and bladder function associated with most pelvic and lower lumbar spine surgeries. If the nerves that provide this function are not removed with the tumor, then normal function or semi-normal function should return. In the meantime, for bladder function, both male and female are taught how to self-catheterize. The same principles hold true for bowel function. Patients with permanent bowel dysfunction, sometimes decide to have a colostomy. Many patients through trial-and-error, find a bowel regimen that suits their lifestyle, meaning some patients use chronic laxative, suppositories, time their bowel movements (planned visit to the bathroom), even digital evacuation.
  • Altered Mental Status: Most pelvic and spine surgeries require a stay in the intensive care unit. Normal sleep/wake cycles are disrupted due to the intensive nursing care required around-the-clock. In addition to interrupted sleep, anesthetic and narcotics contribute to confusion. The surgical team relies heavily on family members to inform us if patients are acting confused. Infection or reaction to medications can cause confusion, even something as simple as a urinary tract infection.
  • Death: During the informed consent process, most complex surgical procedures mention the risk of death due to those unforeseen medical complications.

Health Care Proxy

Prior to surgery, a Health Care Proxy must be completed. This is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions. It is an important document, however, because it concerns not only the choices you make about your health care, but also the relationships you have with your physician, family, and others who may be involved with your care.

Refer to the Massachusetts Health Care Proxy form.

If you have any of the following and want it to be part of your medical record, bring a copy with you to our office:

  • Living will
  • Do not resuscitate (DNR)
  • Medical Order for Life Sustaining Treatment (MOLST)
  • Physician Order for Life Sustaining Treatment (POLST)

A heath care proxy and/or an advanced directive/living will is used to describe a patient’s preference about life sustaining treatment that are to be honored after the patient loses decision making capacity.

A MOLST/POLST is the actual order the patient and physician have decided upon and is signed by both the patient and her/his physician.

For patients who have MOLST/POLST and will undergo a surgery to help quality of life in their advanced stage of disease, the MOLST/POLST is reversed during the surgery and then resumed in the post-operative period.

Anesthesia

You will meet an anesthesiologist during your pre-admission testing workup or the morning of surgery to discuss the specifics of anesthesia and sign the anesthesia consent form. For most of our major surgeries, general anesthesia is given. There are five types of anesthesia:

  1. General Anesthesia: Your anesthesiologist uses medications (given through your intravenous (IV) line and/or through a mask) to put you into a controlled state of unconsciousness. Surgery takes place while you are unconscious and you are awakened when the procedure has been completed.
  2. Regional Anesthesia: Your anesthesiologist will numb a region or part of your body by injecting a local anesthetic in the appropriate area. This technique includes spinal, epidural, and several types of nerve blocks. You may also receive medication to sedate you during the procedure.
  3. Monitored Anesthesia Care: Your anesthesiologist will monitor your vital body functions and administer medicine through an IV to make you drowsy. Your surgeon will inject local anesthesia to numb the area of the.operation.
  4. IV Sedation: Your surgeon injects local anesthesia without an anesthesiologist in attendance. There is a nurse with you who may provide sedation.
  5. Local: The surgeon injects local anesthesia without an anesthesiologist in attendance.