Before and During The Operation
Scheduling Your Surgery
Once you have decided to proceed with surgery, there are a number of things that need to be taken care of before the day of the operation:
- Select the date and hospital for the surgery (see below)
- Start blood storage program
- Start taking iron and vitamin supplements
- Make an appointment to see the internist (see below)
- Have the necessary lab work done (see below)
- Stop taking certain medications in the days before surgery
- See Dr. Thomas for a final visit to make sure everything is in order (see Final Office Visit Before Surgery)
Selecting a Date For Surgery
Dr. Thomas’s surgery scheduler will schedule your surgery. Dr. Thomas is usually scheduled ahead for about four weeks. The surgery scheduler will also assist you with getting your blood storage program started, and with selecting an internist if you do not have one on staff at the hospital where you will have your surgery.
Appointment With The Internist
This is major surgery so medical evaluation by an internist is needed before we proceed with the operation. The internist will also see you daily while you are in the hospital to make sure that any medical complications which may develop are promptly recognized and treated.
It is best when your own internist is on staff at the hospital where you will have your surgery. If not, we will select an internist for you who is familiar with joint replacement patients, and who works with Dr. Thomas on a regular basis. An appointment with the internist is usually made 5 or 7 days before surgery, unless you have some serious medical problems that need more time to correct. If you have any infection (teeth, bladder, prostate, kidney, uterus, etc.), it should be treated and cleared up before undergoing joint replacement surgery.
Diseases such as diabetes and heart disease do not disqualify you from surgery, as long as they are under control. Some conditions may make the risk of joint replacement too great (chronic infection or a recent heart attack or stroke). The internist will help you weigh the risks of surgery against your age and general health.
Duties of The Internist:
- Dictate your complete medical history and physical examination into the hospital transcription system
- Order and evaluate necessary lab tests, including: complete blood count, chemistry and electrolyte panel, urine analysis, coagulation profile, electrocardiogram, chest x-ray and any other necessary tests needed to be sure that surgery is not too risky for you
- Prescribe any special medications (if any) before and after surgery including anticoagulants to prevent blood clots)
- Transmit the results of all your lab tests to Dr. Thomas’s office (Fax: 310- 206-0063) at least two days prior to your surgery date
- See you in the hospital after surgery on the day of surgery, and then daily thereafter while you are in the hospital
- Order and monitor (with blood tests) anticoagulant medications needed to help prevent deep vein thrombosis after surgery
- Continue to administer and monitor the anticoagulant medications for at least two weeks after the operation
Please show this section of this book to your internist to apprise him/her of these special needs, to take you safely through your hip operation.If your own internist (or an associate) is not able to see you every day while you are in hospital, then we recommend that you allow us to assign an internist to carryout all of the above duties for this operation. The internist we assign will consult with your own doctor both before and after the surgery, and will hand your care back after the operation. Please discuss this very important matter with your doctorwell ahead of time.
It must be clearly understood that you MUST BE SEEN DAILY BY THE INTERNIST WHILE YOU ARE IN THE HOSPITAL
Hip Surgery and Your Current Medications
Non-steroidal anti-inflammatory medications should be stopped three days prior to your hip surgery. These medications are. If you are taking aspirin or aspirin-containing drugs such as Percodan, Excedrin, or Anacin, these should be stopped 7 days prior to your surgery. Some of these drugs are. If you are on Coumadin it will have to be stopped, under the supervision of your internist, several days prior to your surgery.
The reason that these medications are discontinued is because they can increase bleeding at the time of surgery.
Extra strength Tylenol, Darvocet, Percocet and Tylenol with Codeine may be taken by mouth up to the night before your operation. Your internist may want you to take certain of your regular medicines (for high blood pressure, diabetes, etc.) with a sip of water on the morning of surgery, even though you are not supposed to eat or drink anything after midnight. You may do so.
Final Office Visit With Dr. Thomas Before Surgery
A day or two prior to your surgery, you will come to our office for a final preoperative visit to make sure everything is in order. Your vital signs will be checked, allergies and current medications will be reviewed, and you will be given papers to take with you to the hospital. You will also have a chance to ask Dr. Thomas any unanswered questions you may have. If your internist has not done all the necessary blood tests, we will send you to the hospital to do additional tests.
What to Bring to The Hospital
- Bring this manual with you
- The forms and papers given to you in the office to take to the hospital
- Make-up kit (women)
- A list of important phone numbers, including those of friends you might want to call while you are in the hospital
- Sturdy bedroom slippers with non-skid soles
- The hospital will provide you with a gown to wear in bed but you may bring your own if you wish
- A knee-length robe (a longer robe makes walking difficult)
- Do not bring your own medications - it causes confusion and the nurses prefer to dispense all medication (including vitamins) so that they know what you are getting
- Do not bring credit cards, jewelry or other valuable items, and no more
than $5 in cash
- Some people like to bring their favorite pillow
- Medical insurance card(s). (Medicare and/or other)
- Reading material
- Cassette recorder, headphones and tapes if you want music
- Crutches or walker: if you already have these have someone bring them to the hospital the day after surgery. If not, they will be provided for you to take home when you leave
The Night Before Surgery
You can spend the night before surgery at home or in a local hotel. Please be sure to arrive at the hospital on time. The night before surgery, you should take a long shower or bath.
On the night before surgery do not have anything to eat or drink after midnight. Food in the stomach can cause anesthetic complications. Do not smoke or drink alcohol for 48 hours before surgery. Smoking increases anesthetic risk. Alcohol delays emptying of the stomach.
Patients are admitted to the hospital the same day as the surgery. Most insurance companies insist that patients not be admitted the day before surgery because of the expense. If your surgery is the first one that day, the check-in time is 5:30 a. m. If your surgery is later, then you will check in around 8:00 a.m. Please be on time.
When you arrive at the hospital on the morning of surgery, go directly to the admitting office. At both hospitals this is at the main entrance on the first floor. From there you will be taken to the pre-anesthesia area where you will change into a hospital gown, and an intravenous line will be started.
The anesthesiologist will see you there and discuss anesthetic options and risks. He will discuss the advantages of general anesthesia (in which you are unconscious) and spinal or epidural anesthesia in which the lower half of your body is completely numb and pain-free, and you will sleep lightly but not be unconscious.
Dr. Thomas prefers his patients to have spinal or epidural anesthesia, combined with a light general anesthetic or sedation. The incidence of blood clots is lower with epidural anesthesia. The recovery is also smoother, and you will have no pain for several hours after the operation.
With certain conditions (especially chronic lung disease), epidural anesthesia is considered safer. Most doctors having surgery themselves would probably elect to have an epidural over a general anesthetic.The final choice of anesthetic is made by you and the anesthesiologist. You will be given sedatives before being taken to the operating room.
In The Operating Room
First time hip replacements take 60 to 90 minutes of operating time. You will be in the operating room for about another 45 minutes (for anesthetic induction before, and recovery after, the operation). Revision operations can take up to 4 hours of operating time (or even more). When the operation is over, Dr. Thomas will meetwith relatives or friends in the surgical waiting area to give them a progress report. At Valley Presbyterian Hospital, the waiting area is next to the gift shop on the first floor. At Encino Hospital, it is next to the surgery suite in the basement.
What to Expect After Leaving The Operating Room
You will wake up in the recovery room. You will be comfortable and usually surprisingly free of pain. You will have “calf pumps” on your legs: pneumatic pumps which help to prevent blood clots. You cannot be visited in the recovery room, but can be visited as soon as you get to your room. You will be in the recovery room for about 2 hours. Patients at the Valley Presbyterian Hospital with orthopedic problems are then usually moved to the orthopedic floor, which is 3 West. At Encino Hospital, it is the whole third floor. Some patients are admitted to the Intensive Care Unit (ICU) for 24 hours before being transferred to the orthopedic floor. This does not mean that their condition is critical, but only that Dr. Thomas feels the need for closer monitoring because of their age or preoperative medical problems that increase risk.
Dr. Thomas is fanatical about pain control, and does everything possible to keep your pain to a minimum. You will be amazed at how little pain you will have. Amajor development has been the PCA Unit (Patient Controlled Analgesia): a computerized device that attaches to your intravenous line. It enables you to self-administer a small dose of narcotic at the press of a button whenever you feel the slightest pain, eliminating having to call a nurse. Since only small doses of narcotic are given at a time, you will not be as drowsy as with big-dose injections every 3 hours. The PCA is pre-programmed for your weight and age, so it is not possible for you to over-dose. Most patients also receive an anti-inflammatory medication by IV for 48 hours. After 2 days, the PCA unit will be disconnected because it is cumbersome and impedes your walking progress. If necessary, it may be continued for a few more days. After it is discontinued, pain injections are ordered, to be given every 3 hours if needed. Pain pills are ordered for milder pain
Most patients are surprised at how little pain they have after the operation.
Drugs are also ordered for nausea, constipation, and sleep. If you run a fever you will be given extra- strength Tylenol
Note that practically every patient runs a temperature up to 99.5 or even a hundred degrees in the first few days after hip replacement. It is so common as to be considered “normal”. If your temperature goes over 101 degrees it starts to be a source of concern.
All patients get stool softeners, but many patients still develop constipation and need a mild laxative on the second or third day after surgery. All patients are given antibiotics to prevent infection. starting just before the operation and for a few days after the surgery.
You must ask for sleeping pills, pain pills or pain injectionsbecause the nurses will not automatically give them. Do not restrict yourself from using the PCA machine or asking for pain medications. Dr. Thomas does not want you to be in pain. You need not fear that you will become addicted to the pain medication.
A blood “thinner” (Coumadin) is given after surgery to prevent blood clots from forming. The internist calculates the dose by daily blood tests. If the blood becomes too “thin”, bleeding problems can develop. If you do form blood clots, intra-venous Heparin will be started, you will be confined to bed for about three days, and then physical therapy will be resumed.
While you are in the hospital, please let the nurses or the internist know if you have calf pain, chest pain or shortness of breath. These may be signs of blood clots.
You will take Coumadin for about two weeks after your date of surgery, starting in the recovery room. You will be given a “take home” prescription for Coumadin. A fixed daily dose may be prescribed, or the visiting nurses may take your blood at home for testing, and notify the internist of the results. He/she will in turn will notify you as to the dose you should take. (After you run out of Coumadin at home, you should take a single regular Aspirin daily for a further 14 days).
Your blood count (Hemoglobin) will be monitored for a few days, and you will be given iron supplements, Epogen, and blood transfusions as necessary.
Suction drainage tubes are usually placed deep in the wound to remove blood which collects after surgery. The blood collected for the first 6 hours is usually filtered and given back to you through your intravenous tube. The drains are removed about 2 days after surgery. Removal is uncomfortable.
Many patients have difficulty passing urine right after surgery and catheterization is then necessary. For this reason, we insert urinary catheters in some of the men and all women during anesthesia, and remove them on the second postoperative day. Removal is not painful. We try to avoid catheters for longer than necessary because urinary infection can develop.
The Operative Wound
With the development of new instruments we can do the operation though a single “mini-incision” over the side of your thigh, or through two small incisions, one in front and one in the back of your thigh. The dressings are usually changed after the drainage tubes are removed, and as often as necessary after that. Dr. Thomas does a “plastic” closure to make the scar look as nice as possible