|WHAT IS ENHANCED RECOVERY?
|ENHANCED RECOVERY MEDICATIONS
|PREPARING FOR YOUR SURGERY
|AFTER YOUR SURGERY
|AFTER YOU LEAVE THE HOSPITAL
|ADDITIONAL INFORMATION AND NOTES
WHAT ARE THE BENEFITS OF ENHANCED RECOVERY?
- Fewer complications from surgery Less nausea after surgery
- Better pain control after surgery using non-narcotic (opioid) medications Less swelling after surgery
- Better glucose control after surgery
- A quicker recovery and return to normal activities
GET OUT OF BED AND WALK
Walking within hours after your surgery has many benefits, such as helping to prevent blood clots in your legs. The more you walk after surgery, the sooner you will feel ready to go home.
WEAR YOUR COMPRESSION STOCKINGS WHEN YOU’RE IN BED
These stockings or compression devices are used to prevent blood clots after surgery. When you’re in bed, you should have them on. You may also be given shots to help prevent blood clots in your legs.
EXERCISE YOUR LUNGS
Use your breathing machine (incentive spirometer) after surgery. Exercising your lungs will re-inflate the tiny airways that collapse during anesthesia. Ten deep breaths in a row every hour while awake will help your lungs recover from surgery and can prevent pneumonia.
DRINK YOUR FLUIDS
After bariatric surgery, you will not be able to drink much at one time. Frequent small sips are the best way to stay hydrated and you should start with small amounts the night of your operation. As your stomach heals, it gets easier to take a normal sized drink but for the first week or two, staying hydrated can be a full time job.
COMMUNICATE WITH YOUR TEAM
Let your team know if you have pain or nausea.
ENHANCED RECOVERY MEDICATIONS
LOCAL ANESTHETIC (BUPIVICAINE, LIDOCAINE)
Local anesthetic medications can be injected during your surgery to numb the nerves going to your incisions or can be given through your IV toimprove pain control. The use of local anesthetic medications are an important part of your overall pain control strategy and can decrease the amount of other pain medications you’ll need.
NARCOTIC PAIN MEDICATIONS/OPIOIDS (MORPHINE, DILAUDID, FENTANYL)
While these are powerful pain medications, they have many negative side effects including nausea, decreased bowel activity, and drowsiness.Narcotics will be used after surgery when needed for breakthrough pain but they should not be used as first-line pain medications. Strategies using non-narcotic pain medications and minimizing or eliminating opioid use is a key component of any enhanced recovery pathway.
Starts prior to surgery and used around the clock. It is a painkiller and works well together with other medications. Let your team know if you have any severe liver disease so that other pain medications can be used instead.
ANTI-INFLAMMATORY MEDICATION (CELECOXIB, KETOROLAC)
These medications decrease inflammation and pain after surgery and will be started either before surgery (celecoxib) or during the operation (ketorolac). These are an important part of your pain management and will be continued after surgery at the discretion of your surgeon. It is important to remember that, while these medications are safe for short-term use after surgery, you should not take any other anti-inflammatory medications by mouth after you are home. Medications like Ibuprofen (Motrin®), Naproxen (Aleve®) can lead to ulcers in your stomach, especially after gastric bypass surgery.
It is easier to prevent nausea than it is to treat it so your anti-nausea medication will be started when you arrive for surgery. A patch can be placed behind your ear to help prevent nausea after surgery and other medications will be given during your operation to minimize nausea when you wake up. Also, your anesthesia team will use techniques that are intended to minimize nausea and vomiting after surgery. Because narcotic pain medications (opioids) frequently cause nausea, limiting or eliminating their use after surgery will also decrease nausea.
One of the goals of Enhanced Recovery is to keep your blood sugar stable throughout the surgery and recovery period. This applies to patients with or without type 2 diabetes.
Enhanced Recovery pathways help minimize high glucose levels (and insulin resistance) after surgery by carbohydrate-loading. Although surgery increases blood sugar levels, evidence shows carbohydrate-loading helps manage blood sugar after surgery.
‘Carbohydrate-loading’ or ‘carb-loading’ involves consuming foods high in carbohydrates/sugars, such as juice or sports drinks. This is the same idea as carb-loading before an athletic event, except in this case the “race” is a surgical operation. While carb-loading is safe for the majority of patients, your surgeon will tell you if you should not drink the carbohydrate drinks prior to surgery.
Continue your exercise program or, if you haven’t been exercising, make time every day to walk as much as you’re able.
GET PLENTY OF SLEEP
Come to surgery mentally sharp and well rested.
FILL YOUR PRESCRIPTIONS
You will receive some prescriptions to take after your surgery at your preoperative visit or before you leave the hospital. Make sure you understand all of your medications before you leave the hospital. Pay special attention to diuretics (water pills) and diabetes medications that often need to be stopped or decreased after bariatric surgery.
FOLLOW YOUR DIET
If your team has recommended a special diet for preoperative weight loss, follow the plan. This will help you lose weight quickly before the operation. If you have diabetes, keep a close eye on your blood sugars. You will need to work with your team to manage your diabetes medications as you lose weight and decrease your calorie intake before surgery.
CPAP OR BIPAP MASK
Use your CPAP or BiPAP mask, if you have one, and bring your equipment with you to the hospital.
DRINK CLEAR LIQUIDS
- Decaffeinated tea or coffee (no cream)
DRINK ONE CARBOHYDRATE DRINK
|Drink One 20 ounce sports drink (not sugar free)
DO NOT SHAVE
Do not shave the area where you will be having surgery.
Take your medications as instructed
CLEAN YOUR SKIN
Clean your skin using the method indicated below:
If applicable, please clean skin with Chlorhexidine wipes provided.
DRINK ONE CARBOHYDRATE DRINK
Drink one 20 ounce sports drink (not sugar free) 2 hours before you are scheduled to arrive to the hospital.
Stop drinking ALL fluids 2 hours before surgery.
Remove jewelry, nail polish, contact lenses, and wigs.
CHECK IN AT THE HOSPITAL(DETAILS BELOW)
Use the restroom and empty your bladder before going into the operating room.
WHILE YOU ARE IN THE HOSPITAL
You will have some pain after surgery, but the goal is to manage the pain so that you are reasonably comfortable (severity of 4 or less out of 10 most of the time) and can walk and take deep breaths effectively. Your surgeon or anesthesia team will perform a “block” or administer a local anesthetic medication through your IV to help reduce the pain when you wake up from surgery. The goal is to use as little narcotic medication (opioids) as possible to manage your pain. This will keep you from feeling so nauseated after anesthesia and will help your bowels wake up faster. On the post-operative nursing unit, you will continue to take the Tylenol and anti-inflammatory medication by mouth or IV around the clock.
If you need stronger pain medicine for breakthrough pain, it's OK. Ask your nurse and you will have an order written for a narcotic pain medication to help get your pain under control.
NAUSEA AFTER SURGERY
It is common to feel nauseated after surgery, especially surgery on the stomach and intestines. You will be given anti-nausea medications during your operation to prevent nausea after surgery. By reducing the amount of narcotic pain medication (opioids) needed after surgery we can significantly reduce the amount of nausea you experience. On the post-operative nursing unit, you will receive regular doses of anti-nausea medication. It’s easier to prevent nausea than it is to treat it. If you need more medicine for nausea after surgery, please tell your nurse.
NOSE TUBES, CATHETERS, AND DRAINS
The use of tubes and drains can slow down your recovery and ability to move around after surgery. We want to minimize or eliminate using them, if possible. There may be times when these are necessary based on your surgery or medical conditions, but in general these will not be used as part of the pathway.
WALKING AFTER SURGERY
You will be expected to get out of bed within hours of arriving to the post-operative nursing unit. You will have help to move at first because you will be sore and tired, but it is important that you get moving soon after surgery. Standing and moving to a chair is a good start. This is good for your lungs and helps prevent blood clots in your legs. The morning after surgery you will take walks out in the hall at least three times during the day. More is better and will get you ready to go home sooner.
SIP CLEAR LIQUIDS
Drink clear liquids (such as water, decaffeinated tea or coffee without cream, or broth) slowly.
GET OUT OF BED
Get out of bed (with help) within a few hours of arriving to the post-operative nursing unit.
Begin to increase the amount you are drinking.
MAKE A MEDICATION PLAN WITH MEDICAL TEAM SCHEDULE FOLLOW-UPS
Make sure you have your initial postoperative follow-up appointment scheduled before you leave the hospital.
GET CONTACT INFORMATION
Get your program’s contact information and the phone numbers to call if you have a question or concerns.
The Johns Hopkins Bayview Bariatric Surgery team can be reached at:
410-550-0409. For after hours, call the operator and ask for the on call surgery team:
The Sibley Center for Weight Loss Management team can be reached at:
202-370-6565. For after hours, call the operator and ask for the on call surgery team:
RECEIVE DIET PLAN FROM CARE TEAM
Talk to your care team about your diet after surgery. You will receive a plan to follow (take notes below):
Your doctor, nurse and/or dietitian will discuss your hospital fluid goal.
Fluid goal after leaving hospital is at least 64 ounces per day.
Please refer to the handouts previously reviewed with you by your dietitian for the recommended diet advancement at home.
You will keep your regular follow-up appointments with your surgery team. Expect a call from the surgery program after surgery to ask you about your recovery. Questions will be related to how your activity is progressing and your overall experience after surgery. You will be asked to complete a survey to assess your recovery. The survey and phone calls are not substitutes for your postoperative clinic visits.
Resume your essential medications as prescribed by your regular doctor. Talk to your surgeon and care team about all of your medications before you leave the hospital. If you’re not sure about what to take, ask again or call when you get home. Avoid or minimize the use of diuretics (water pills) like Lasix, Bumex, or HCTZ. If needed, use them under close supervision by your doctor to avoid severe dehydration.
Diabetes medicines will need to be reduced or discontinued after surgery. If you have diabetes, check your blood glucose levels and communicate regularly with the doctor that manages your diabetes to avoid high or low blood glucose levels. Blood thinners like Coumadin, Plavix, or one of the many new medications (Eliquis, Pradaxa, etc.) should be restarted according to your doctor’s instructions.
Coumadin can be difficult to manage in the first few weeks after surgery and close follow-up with your Coumadin clinic should be arranged before you leave the hospital.
It’s OK to wait a week or two before resuming all of your bariatric vitamins, especially if they cause nausea or stomach upset.
PAIN AND NAUSEA MEDICATION AT HOME
It’s normal to continue to have incisional pain for several days after going home from the hospital. It should improve from day to day and be managed with the least amount of medication needed. Start with Tylenol and limit the amount of narcotic pain medication (opioids) used as much as possible. Nausea medication can be taken as needed after discharge to help you maintain your fluid and protein intake.
Continue walking regularly and increase the duration and intensity of your activity as tolerated. It’s normal to feel tired for several weeks after surgery so listen to your body. Your surgeon will let you know when it’s safe to do heavy lifting or more vigorous exercise.
ADVANCING YOUR DIET
You should have a clear plan about your diet progression after bariatric surgery. Follow your program’s plan. Enhanced Recovery will not affect the normal diet progression after surgery.
Please refer to the discharge instructions for additional information.
This booklet is supplied courtesy of the Johns Hopkins Center for Bariatric Surgery.