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Patient Surgery Pathway

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YOUR JOURNEY FOR FASTER RECOVERY

Mugis Congress 2022
  1. Targeted patient education
  2. Nutritional optimization
  3. Anemia optimization
  4. Smoking and alcohol cessation
  5. Shortened fasting
  6. Carbohydrate load
  7. DVT prophylaxis
 
 

  1. Short-acting anesthetics
  2. Multimodal analgesia
  3. Long protective ventilation
  4. Antifibrinolyrics
  5. Avoidance of hyperthermia
  6. Infection reduction bundle
  7. Goal-directed fluid therapy

 

  1. Multimodal analgesia
  2. Goal-directed fluid therapy
  3. Early exubation
  4. Early mobility
  5. Delirium management
  6. Glycemic control
  7. Avoidance of hypothermia
  8. Thromboprophylaxis
  9. Early drain and Foley removal

What is ERAS?

ERAS (Enhanced Recovery After Surgery) is a care pathway for a specific procedure that includes a set of pre-determined activities, rules, and guidance. The purpose of these ERAS pathways is to expedite and enhancing recovery after surgery

Below are the benefits

  1. Shorten your hospital stay
  2. Keep your pain level well control
  3. Help you get out of bed and walk within 24 hours
  4. Allow you to eat and drink as soon as it is safe for you
  5. Explains and listen to your concerns

However, ERAS does not only focus on what happens after the surgery but also before. Thus, it focuses on the whole perioperative care and puts patients in the center of their own experience.

This, again, means that ERAS aims to help run things as “normal” as possible before and after the procedure.

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About the surgery

Your surgery will involve removing the diseased tissue/organ. There is 2 methods surgery will be performed through and its is either:

• Open surgery or
• Keyhole abdominal surgery.

Types of procedure

Bowel surgery

Bowel surgery is the removal of the diseased section of your bowel.

Liver Surgery

Liver surgery is the removal of the diseased section of your liver

Stomach surgery

Stomach surgery is the removal of the diseased section of your stomach

Stoma

Your doctors may have advised you to bring a stoma bag for stool after surgery. Your stoma may be permanent or temporary. You should also see a stoma specialist to discuss how to take care of the stoma after your surgery.

Pain control

Reducing pain is very important for the rapid healing to return to normal activities. You should also be able to move around the ward area and eat without pain.

                Pain score

Your doctor and nurse will ask about your pain score. You should not feel pain more than a score of 4 out of 10.

If you are still in pain even with these steps, please talk to your nurse so you can get the help you need.

Pain control options

PainComforter is a system that delivers local anaesthetics continuously directly into or near your surgical wound to relief your pain after surgery. This will reduce narcotics usage and help you get better pain control than just taking narcotics alone.

The system works independently and does not require any action and the system will deliver the medication continuously over 2-5 days thru a small tubing. This tubing will be inserted by your anaesthetics or surgeons during your surgical procedure.

Patient Control Analgesia (PCA). You also need to press the pain relief button as often as possible to get optimal pain control. Any damage to the machine or running out of medicine should be reported to the nurse or doctor immediately.

If you have epidural anesthesia, you will continue to receive epidural pain relief in addition to oral relief using oral medications, usually paracetamol (Panadol) for the first few days. After the epidural is removed, stronger oral pain relief medications may be given.

You will be given oral medication and take the medication as per instruction from nurse or doctor. 

 

IMPORTANT!!!

Please bring along your appointment booklet with you during your appointment with the following sections:

• SFUC surgical division
• PAC Clinic (S2)
• Nutritionist
• Physiotherapy (with spirometry purchased in advance)
• Stoma Nurse (SFUC)
• On the day of surgery

2 days before admission day

  • You will receive a call from SFUC staff to confirm the date and commitment for surgery.
  • Prepare packets of chewing gum for postoperative use.
  • You may be reminded to prepare the intestines using 2 Fortrans packets

Bowel preparation

You may be reminded to do a bowel preparation using 2 packets of Fortrans

Bowel preparation guidelines

• Low residual diet (low in fibre) like white bread with jam,plain porridge, noodles, jelly, half or hard boiled eggs (NOT FRIED).
• Plain tea or coffee(without milk), filtered fruit juice, isotonic drinks(non-carbonated).  
• Patients are NOT allowed to eat or drink with milk products, oat, Milo, vegetables, fruits and meat.

• Plain soup, water with or without sugar, filtered fruit juice.
• Milk product is not allowed.  

• 1 sachet of FORTRANS + 1 litre of plain water (1000cc)
• Take a cup (250cc) every 15 minutes Continue to drink
during bowel preparation. 

• 1 sachet of FORTRANS + 1 litre of plain water (1000cc)
• Take a cup (250cc) every 15 minutes Continue to drink
during bowel preparation. 

Admission day

  • Bathrobe, slippers, pyjamas, loose comfortable clothing.
  • Toothbrush, toothpaste, hairbrush, deodorant, mouthwash, soap, tissues, shaving equipment, and perhaps earplugs.
  • If you wear glasses, contact lenses, a hearing aid or dentures, please bring the appropriate containers with your name on them.
  • If you use a cane, crutches or walker at home, please bring them to hospital.
  • Your medication in their original containers.
  • 2 packs of gum (any kind-your favourite). Sugarless
  • TED stocking and Incentive Spirometer.

       **Please leave all jewellery, credit cards and objects of value at home.

  • Take a shower or bath and put on freshly washed clothes.
  • Do not put on any creams, lotions or perfume.
  • Do not wear make-up or nail polish.
  • Remove all jewelry and leave it at home.

      **Please leave all jewellery, credit cards and objects of value at home.

  • You will be reminded to enter the ward at noon.
  • You are still allowed to eat lightly up to 6 hours before surgery.
  • Continue to drink fluids (with or without sugar) for 2-3 hours before surgery.
  • Glucose drinks will be given before midnight and 2-3 hours before surgery.
  • Doctors will confirm you the time when you need to start fasting.

Day of surgery

  • Wear anti-embolism stockings (TED) in the morning after bathing.
  • You may get the option for a Paincomforter- ‘Continuous infiltration of local anesthetic’ or Regional Block/Patient Control Analgesia (PCA) and the doctors will confirm with you again.
  • Upon reaching the operating room, the anesthesiologist may give an epidural anesthetic through a plastic tube placed on your back outside the spinal cord to reduce pain during and after surgery (If no Paincomforter or PCA) . You will then be given a general anesthetisia and will not feel or remember what happened during the surgery

After surgery

After the surgery, you will wake up in the Post Anesthesia Care Unit (PACU)  and then be transferred to the ward. You will be connected to a drip and may wear a urinary catheter.

  • You will be recommended to get out of bed and sit for 2 hours after surgery today.
  • You can drink it a few hours after surgery. ONS will be served.
  • You can supplement your diet, starting with drinking more fluids and nutritious drinks, then moving on to regular meals.
  • Chew chewing gum as often and as much as you want.

This starts as early as the day after surgery to meet your nutritional needs. If you experience any nausea or vomiting or abdominal pain, inform your nurse or doctor.

  • You are encouraged to get out of bed, sit for  2 hours daily after the day of surgery and sit/walk for at least 6 hours a day for the next few days. Your nurse or physiotherapist will be with you to help.
  • Physiotherapist may want you to do leg exercise if you have trouble walking, it will help blood circulation in the right and left of your legs. Repeat these 4-5 times every half hour while you are awake. 
  • You should also use your spirometer 10x/hour daily every time you wake up, to prevent lung infections. Eating and doing physical activity after surgery helps increase healing and reduce the risk of complications after your surgery. If necessary, you can also seek advice from a dietitian on nutritious food and drink (ONS) before you leave the hospital.
  • Chew your chewing gums as much and as frequent this has proven to improve your digestive systems

If you have a stoma after surgery, our stoma nurse will teach you and your caregiver how to manage your stoma.

  • You should feel confident managing your stoma before going home.

When you get satisfactory pain control using oral pain medications, you will be able to get out of the hospital. Most patients can leave the hospital 2-5 days after surgery.

If you have been recommended for rehabilitation by a physiotherapist, you can be transferred to a community care center before returning home.

  • A follow-up appointment will be arranged with your doctor.
  • Date of removing stitching will also be provided if necessary.
  • You also have the option of removing the Paincomforter catheter yourself if you go out before day 4, the doctor will show you how to do it. It is very easy.

 

Leg exercises

1. Rotate your feet to the right and left.

2. Wiggle your toes and bend your feet up and down.

3. Stretch your legs out straight.

Incentive Spirometry exercise

It may seem difficult at first to use your spirometer, but following these steps will help you quickly catch on:

 
  1. To use the incentive spirometer, sit upright in a comfortable chair or on the edge of your bed.
  2. Hold the incentive spirometer upright with both hands. Slide the indicator (located on the left when you are facing the spirometer) to the desired target level. Your doctor or respiratory therapist should tell you where to start, but 1250 millimeters (mm) is a good ballpark. (You may need to increase or decrease this depending on your needs.)
  3. Place the mouthpiece into your mouth and tightly seal your lips around it. Try not to block the mouthpiece with your tongue.
  4. Breathe in slowly and as deeply as possible. The piston that is resting below the indicator should now rise up inside the column.
  5. When you’ve reached your full inhale capacity, remove the mouthpiece and hold your breath for at least three seconds or as long as possible to allow the piston to fall back to the bottom of the column. If you start to feel dizzy or lightheaded, take a break.
  6. Exhale normally, then rest for a moment and cough to clear your airway of mucus if needed.
  7. Reposition the indicator at the level you obtained during your best effort.

Repeat these steps 10 to 12 times every hour you are awake, or as often as your doctor or respiratory therapist recommends. Aim to meet or beat the level you reached during your previous use.

 

If you do not reach your goal, do not get discouraged. You will improve with practice and as you heal.

At home

You are expected to be at home 3-4 days after your surgery.

  • You can supplement your diet, starting with low residue foods for 2 weeks and drinking more fluids and nutritious drinks, then after 2 weeks only start moving on to regular meals.
  • Chew chewing gum as often and as much as you want.

This starts as early as the day after surgery to meet your nutritional needs. If you experience any nausea or vomiting or abdominal pain, inform your nurse or doctor.

  • You should continue to stay active at home by taking walks, for example. You will feel increased fatigue from exercise, which could last a several weeks after the operation.
  • Avoid heavy load lifting (more than half of your body weight) for about 6 weeks after your surgery.

You will be given two(2) pain medications to manage your pain at home.

  1. Panadol (Paracetamol) for mild pain (take as instructed) 
  2. Another type for moderate pain (only when necessary) 

If the pain persists and increase over the time, please contact your doctor/nurse and inform them on your condition. 

You will receive a telephone call from your nurse (ward or SFUC) to check on your well being 2-3 days after discharge.

If you feel unwell, have a fever, worsening abdominal pain, bloatedness or vomiting, please inform the doctor/nurse. 

Please go the Accident & Emergency Department (A&E) if you unable to reach the doctor/nurse.

Contact

If you have any questions, please contact us at the following numbers:

Colorectal Services Nurse Coordinator:
Mrs. Hidaryati
019-7348667

SFUC General Number:
07-2257000 Ext 2371

Ward W4
07-2257000 Ext 2409/2774

Ward E2
07-2257000 Ext 2111/2110

Wad OW
07-2257000 Ext 3530

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