• Most current insurance card
• Valid picture ID
• Advanced Directive paperwork if you have one
• Complete list of current medications
• If you take blood thinners, know the date and time that you took your last dose
• If you took medications the day of surgery, know which ones and when you took them
• A responsible adult, friend or family member who will drive you home and their phone number
• A plan for someone to be with you at home after surgery
• Notify pre-op about any implanted devices that you may have (pacemaker, defibrillator, insulin or pain pump, spinal cord or brain stimulator, etc.)
• Your hearing aids and a container for them if needed
• Your glasses and a case
• Comfortable and loose clothing that are easy to remove and put on again
• If you use a CPAP machine for apnea, bring it with you unless you are a pain, eye, or colonoscopy patient
• If your surgeon told you that your surgery would require an overnight stay in the hospital, please bring an overnight bag with person hygiene items

• What is your name?
• What is your date of birth?
• What procedure are you having done today?
• Do you have any allergies to medications, latex, iodine, or certain foods?
• What kind of reaction(s) do you have with each of these allergies?
• When is the last time you ate and what did you eat?
• When is the last time you drank and what did you drink?
• Do you smoke? How much do you smoke? How many years have you smoked? When did you last smoke?
• Do you drink alcohol? What alcoholic beverages do you drink? How often do you drink alcohol? When you drink alcohol, how many drinks do you have? When was the last time you drank alcohol?
• Do you take any non-prescribed drugs? What drugs do you use or take? When did you last use these drugs? For how many years have you used drugs? In what form do you use these drugs?
• Do you have hepatitis or HIV?
• Do you have cancer?
• Do you have heart disease? Have you ever had a heart attack, heart failure or a code arrest? When?
• Have you ever had a stroke? When?
• Do you have any neurologic or muscle disease?
• Do you have any seizure disorder? When was your last seizure? What kind of seizures do you have? When did you last take your seizure medication?
• Do you have any blood or bleeding diseases or disorders? What kind? Have you ever needed a transfusion?
• Will you consent to a blood or blood product transfusion/use if needed?
• Do you take any blood thinners including aspirin? When did you last take this medication?
• Are you on any supplements that can increase your risk of bleeding such as fish oils or large amounts of garlic?
• Do you have asthma? COPD or emphysema or any other condition that makes breathing difficult?
• Do you use oxygen? How much and when?
• Do you have sleep apnea? Do you use CPAP/BiPAP?
• Do you have diabetes? Do you take insulin? Do you have an insulin pump? When did you last take any medication for your diabetes?
• Did you check your blood sugar today? What was your blood sugar level when you last checked it today?
• Have you ever been admitted to the hospital for your diabetes? When?
• Do you have difficulty walking? Do you require assistance with ambulation?

1. Please review email for a list of routine medication that you are allowed to take prior to surgery
2. Please take any other medication as instructed by your PCP, surgeon or preop nurse
3. Remove jewelry and piercings
4. Remove fingernail polish, makeup and artificial nails
5. Shower thoroughly the night before surgery as instructed, possibly with special soap
6. Refrain from shaving the surgical area, but you may use clippers if desired
7. If you have been given any prescriptions to use after surgery, try to get them filled before surgery
8. Remember; no eating or drinking, including tobacco products, after midnight the evening before surgery or as instructed by the preop nurse
9. Bring your health profile folder with you to hospital
10. Upon arrival in pre-op, you will be placed in a body-warming gown. This plays an important role in infection prevention

Children and babies sometimes need surgery and we all need to work together to try and make their experience as pleasant as possible. The following are instructions that may apply to your child:

• 4 ounces of clear liquids may be allowed until two hours before surgery. This includes drinks like white grape, apple or cranberry juice, water, or pedialyte.
• Breast milk may be given up to four hours before surgery.
• Infant formula may be given up to six hours before surgery.
• Children may wear comfortable clothing like pajamas.
• Bring extra diapers, change of underwear and wipes.
• A stuffed toy is permitted.
• It is recommended to not bring any other children.
• As the parent or caretaker, you will be asked to stay with your child before surgery and then close by and not leave the hospital while they are in surgery.
• Please have two capable persons to drive home with the patient, one to drive and one to attend to the child.
• Consent for Surgery requires the legal parent/guardian to sign for all children <18 years old.
• Children under age 8 or weighing <80 lbs are required to ride in an approved car seat.

Your doctor, nurses and anesthesia providers will be working together to provide your child the least amount of discomfort, anxiety and stress.

In some cases, your child may receive anxiety medication before surgery that may be administered with spray in the nose.

When age appropriate and when your child is able to tolerate and cooperate, an IV may be started before surgery. When it would be less traumatic for the patient, the IV may be started in the operating room after breathing some anesthesia gas to relax and become sleepy.

Remember, when you have questions or concerns, always ask. We are happy to explain everything that we are doing and planning.

You are having surgery or a procedure, so it is reasonable to expect that you will have pain. In some cases, your pain will be very significant and will require strong pain medicine to help you tolerate your pain. You cannot expect to be pain free following surgery although there are things that you, your surgeon and your anesthesia provider can do to help.

First, you must expect pain and discomfort following surgery. Next, medication does not remove all pain but can be very helpful for you to tolerate the pain that you have after surgery.

Your surgeon will discuss with you the expectations regarding your pain following surgery. If you feel that you have special pain related issues, you must first address them with your surgeon and then later with your anesthesia provider on the day of surgery.

Your anesthesia provider will discuss the anesthesia plan with you on the day of surgery. Depending on your surgery and your surgeon, there may be anesthetic procedures that may be performed that will decrease the amount of surgical pain. Your anesthesia provider may recommend one of these procedures, often referred to as a “nerve block”. Other options offered by your anesthesia provider may include a spinal anesthetic which is a common way to numb the surgical area and dramatically decrease your post-operative pain. Your anesthesia provider will carefully consider your medical fitness, your medical history and allergies, your planned surgical procedure and your surgeon’s preferences to design an anesthetic plan to safely navigate you through your surgery day. And it is very high priority to also make you as comfortable as possible. But, unfortunately, it is impossible to prevent any and all pain and so you will experience pain and discomfort as a result of the surgery.

Having surgery is never a trivial matter and is to be taken seriously. In addition, surgery requires anesthesia which also carries risk. Below are listed known risks that are typically discussed with you in preparation for surgery and/or anesthesia. If you have any questions about any of the listed items, please ask your surgeon, anesthesia provider or nurse before surgery.

Death

Disability

Bleeding and need for transfusion of blood and/or blood products

Infection

Major Adverse Cardiac Events such as heart attack, heart failure, lethal arrhythmia

Stroke

Major Pulmonary Events such as respiratory failure, aspiration, pneumonia requiring prolonged endotracheal intubation and ventilator support in the ICU

Perioperative Nausea and Vomiting as a result of medications given or ‘nerves’. Vomiting is a major risk factor for pulmonary aspiration that can lead to respiratory failure and death.

Falling as a result of your particular surgery, effects of anesthesia or medications that make you unsteady.

Uncontrolled Pain as a result of medications that you are now taking, illicit drugs that you are using or previous history of alcohol or substance abuse.

Addiction to pain medicine following surgery is real and a discussion between you and your doctor must take place regarding any issues that you may have or expect to have with addictive pain medication. While your anesthesia provider will work very hard to address your severe surgery related pain during and immediately following surgery, you will experience ongoing pain for a while as part of the healing process.

Coughing and Shortness of Breath as a result of smoking or vaping of any kind which can lead to respiratory failure and death.

Smoking cigarettes, cigars or pipe smoking is a major cause of mortality in the US.

Smoking and vaping also places you at risk for major complications during surgery and anesthesia regardless of what you smoke/vape, how much you smoke or for how many years.

If you have ever considered stopping smoking/vaping, please contact your PCP or surgeon today for medical and clinical assistance. You can stop. But if you need help, there are lots of people and resources that are ready to assist you in this life-saving goal.

Obstructed Breathing/Stopped Breathing as a result of diagnosed/undiagnosed Sleep Apnea. If you have Sleep Apnea or have been told that you are at risk for sleep apnea because of snoring, obesity, daytime sleepiness or other reasons, PLEASE see your PCP or surgeon for a referral for Sleep Apnea evaluation and treatment. Sleep Apnea is a significant risk factor for major respiratory complications that can lead to death in surgical patients.

Surgery Related Complications are adverse outcomes that are well-known and related to your planned surgery. These are things that your surgeon discusses with you in the office while planning your surgery.

Weakness or Numbness can happen for a variety of reasons such as an IV placement to a nerve block for surgical pain. However, the most common reason is due to positioning of your arms and legs during surgery. Great care is given to this in properly placing and padding your extremities and body during surgery. Generally this is only temporary and will resolve on its own.

Allergic Reaction to medications, antibiotics, tape or bandage material, surgical supplies and materials

Dental Injury can happen in the course of surgery as a result of a procedure but more commonly as you wake up, sometimes patients clench their jaws tightly and can break or loosen teeth or dental implants/bridgework.

Eye Injury can occur during the course of your surgery during positioning or as a complication of the procedure that is happening in or around the face and neck. Most commonly this is due to the patient scratching their eyes unknowingly while emerging from anesthesia sedation. Great care is exercised during this phase of recovery but can still occur. These injuries are usually infrequent and minor and resolve spontaneously. However, they cause discomfort and concern and may require that an ophthalmologist evaluate the extent of the injury and for treatment.

Delirium is a distressing complication of the stresses of surgery and effects of anesthesia that can happen. The older you are, the more likely that you may experience delirium following surgery. This is usually brief and mild but may be more severe and debilitating and can last for weeks. In some rare and extreme cases, the patient may not recover their full preoperative level of cognition.

There is a link between known dementia preoperatively and a permanent loss of cognition following surgery.

There is also a link between some forms of mental illness, diagnosed or not, and post-operative delirium, combativeness, emotional lability, angry outbursts and personality changes. It is very likely that these changes are temporary but still can be very distressing for patients and their families/loved ones.

Wrong Site Surgery is when the operation expected and planned is not the surgery that was done as a result of a mistake or a series of mistakes made by all the personnel involved in your case including the surgeon. This is a terrible outcome that all surgery department personnel work hard to avoid. This explains why you, the patient are asked the same questions over and over again. This is the one thing that happens on the day of surgery that is proven to prevent such mistakes. However, these stories may still be found in the news from time to time.

Surgery Cancellation occurs when the surgeon determines that your surgery should be delayed or to not occur at all. This could happen for many different reasons. The most common is that you become ill right before your day of surgery. In the case of illness, your surgery should wait until you are well to avoid complications. Other reasons include things like eating food on the day of surgery, taking drugs or alcohol on the day of surgery, being on blood thinner medications before surgery, and finding out that you are pregnant.

If you have serious medical conditions involving your heart, lungs, brain, liver, blood or kidneys, then your primary care physician must determine that you are fit for surgery and anesthesia. This may involve blood testing, heart tests, Xrays and perhaps a specialist referral to evaluate you for surgery. Once this information is assembled, it is generally reviewed by an anesthesia provider for completeness.

After your surgery/procedure is done, your nurse and anesthesia provider will take you to the recovery room, what we call PACU (post anesthesia care unit). There, you will be cared for by a PACU specialty nurse who is trained to monitor your breathing, vital signs and pain. As you wake up, you will be asked many different questions like:

• “how are you feeling?”
• “are you having any pain?” “any nausea?”
• “do you have any numbness?” “can you move your arms and legs?”
• “are you cold?”
• “how is your breathing?”
• “would you like to eat some ice chips?”
  And you will be told by the PACU nurse to do several things like:
• “please take big breaths.”
• “take a big breath and cough.”
• “try to scoot up in bed.”
• “move your arms and legs.”
• “please don’t touch your face or scratch your eyes.”
• “please lay still for the blood pressure measurement.”

Once you are awake, able to have conversation and your pain has been addressed, you will be moved back to your room to see your family member or friend who will take you home. (Or you will be taken to a hospital room if you are staying overnight.) There, you will be greeted by another nurse who will work with you to coordinate your discharge home. For this, you will need to demonstrate that you will be able to go home by walking, eating and going to the bathroom with minimal or no assistance.

Your IV will be taken out before you are discharged. You may have other tubes, drains or catheters that you will need to care for and manage at home. You may have residual discoloration of the skin at the surgical site. This is from the surgical scrub used in the operating room. This is normal and will wash off in 2-3 days. You surgeon and nurse will give you these instructions.

When you are ready, you may be discharged home.

You should know:

• what activities are you to do OR not do
• when and what you can eat or drink
• when and how you are able to bathe
• how and when are you to care for your surgical wound
• what to look for regarding your wound that may indicate a problem
• when are you to go see your surgeon at the office
• what medications you have been given and how to use/take them
• when you should call your doctor or go to the ER for further evaluation and care
• exactly what surgery or procedure was performed and whether there were any issues/complications
• what you can do about your pain like specific medications to take, elevation, cool packs, warm packs, compression wrap, etc.

You will be given papers with instructions and information regarding your surgery on them. Please take them and read them.

If you are not ready to go home when asked, please make sure that your discharge nursing staff are aware of your concerns so that they can address any issues. It is true that you may have pain that is significant following surgery and we all will do everything we can to safely manage your pain. Most people, if they are uncomfortable, prefer to be uncomfortable at home rather than the hospital. All patients seem to do better at home in familiar surroundings and with the care of their loved ones. However, if there is any doubt about your ability to thrive at home, your nurse or doctor will speak to you about staying in the hospital where you can receive close observation and care.

Following anesthesia, it is illegal to drive. Please make sure that you have someone that is able to drive you home and to assist you into your home if needed.

Evening Before Surgery

Oral Diabetes medications or non-insulin injections: 

• If daily dosing, take usual dose
• If weekly dosing, stop 1 week prior

Rapid acting insulins:

• Take usual dose

Intermediate and insulin combinations:

• Take 50% (half) of your usual dose

Long lasting insulins:

• Take 75% (3/4) of your usual dose

Combination products with long acting insulin & GLP-1 Analogs

• Take 75% (3/4) of your usual dose

SGLT-2 inhibitors

• Consider the main ingredient, if it involves combination drugs follow directions for the SGLT-2 ingredient

Morning of Surgery

Oral Diabetes medications or non-insulin injections: 

• If daily dosing, do not take morning dose
• If weekly dosing, stop 1 week prior

Rapid acting insulins:

• Do not take morning dose

Intermediate and insulin combinations:

• Do not take morning dose

Long lasting insulins:

• Do not take morning dose

Combination products with long acting insulin & GLP-1 Analogs

• Do not take morning dose

SGLT-2 inhibitors

• Hold 3 days prior to surgery: Canagliflozin, Dapagliflozin, Empagliflozin
• Hold 4 days prior to surgery: Ertugliflozin
• Monitor glucose closely once medications are discontinued

When to check blood sugar

Check glucose as usual. If glucose greater than 150 on morning of surgery, cover with usual correction insulin dose (sliding scale).

If you become hypoglycemic

1. If glucose is less than 80 (hypoglycemia) or
2. If you are having symptoms, you may drink 4 ounces (1/2 cup) of clear liquids
   • apple juice
   • fruit punch
   • soda
   • sweet tea

Do not drink fluids with pulp. Do not drink milk. Do not eat any food.

Recheck blood sugar every 20 minutes or sooner if symptoms persist. Continue to treat until you arrive at the hospital.

Instructions for monitoring glucose once SGLT-2 medication held:

Stopping these medications for such a short time should not cause a dramatic change in glucose (blood sugar).

• Please check your glucose (blood sugar) a minimum of 2 times daily
• If you see an increase of 50 points or greater, contact your primary care provider (PCP) for treatment advice
• If glucose is greater than 200 more than once, contact PCP

Insulin pump

Keep your insulin pump running at the usual rate. Do not allow early morning higher rate.

If your surgery is after 1 pm

Check blood glucose at 12 pm: If greater than 150, cover with usual sliding scale.

Before your scheduled procedure

No solid food after midnight before your surgery. You may continue to drink clear liquids up to 3 hours before your procedure. Clear liquids include water, juice without pulp, carbonated beverages, Gatorade/Powerade, clear tea, black coffee without milk or creamer.

• Do not drink fluids with pulp or milk
• Do not drink alcohol or broth or have gelatin