Getting ready for surgery: the checks before the day

The checks before a brain operation. These are blood tests, a heart trace, and the anesthesia visit. When to stop eating and drinking. And which of your medicines you keep taking.

The short version

Before a brain operation you have a set of checks. Blood tests, a visit with the doctor who puts you to sleep, and sometimes a heart trace or a chest x-ray. The checks are picked for you, so your list may be shorter than somebody else's. Two things here are worth reading today. Your hospital gives you its own times for stopping food and drink, and those are the ones to follow. Within that, you may not have to go all night without a drink of water, and it is worth asking. And you must not stop a blood thinner on your own.

What is it?

It is a set of checks that make sure it is safe to put you to sleep and operate on you.

Your team may call it your pre-op appointment, your pre-operative assessment, or your clearance. They all mean the same thing.

Most of it is talking. Somebody goes through your health history with you, looks at your notes, and examines you. The tests around that conversation are there to fill in the parts your history cannot answer.

The doctor at the middle of it is an anesthesiologist. That is the doctor who puts you to sleep for the operation and looks after you while you are under.

Why am I having all this?

An anesthetic and a brain operation both ask a lot of your heart and your lungs. Your team wants to know how yours are doing before the day rather than on it.

There is no fixed list of tests. They are chosen from your own health history and from the operation you are having. Somebody with a heart condition gets checks that somebody without one does not need. Your age on its own may not be a reason for a heart trace.

So if a friend had a test you have not been offered, that is usually not something going wrong. It is a fair thing to put to your team: why that one, and why not this one?

What happens, step by step

For an operation like this one, the anesthesia check is meant to happen before the day of surgery, not on the morning.

1. They read your notes. Your records go to the team before you get there.
2. They ask you questions. Your health, the operations you have had, your allergies, everything you take, and how you have been with anesthetics before.
3. They examine you. A short exam: the way into your lungs, your lungs themselves, your heart, and your blood pressure and pulse.
4. Blood tests, if there is a reason. These are rarely about the tumor. They may be done to check how well your liver, your kidneys and some other organs are working.
5. A heart trace, if there is a reason. Sticky sensors go on your arms, your legs and your chest, wired to a machine that records the signals your heart makes as it beats. It is called an electrocardiogram, and on your paperwork it may be written ECG or EKG. You may have one if your team has something about your heart they want to look at.
6. A chest x-ray, if there is a reason. It looks at your lungs, your heart and your chest wall. It is not automatic, and things like smoking, a recent cold or a long-term lung condition are among what your team weighs up. It uses a very small dose of radiation, which is the reason it is not given to everybody as a matter of course.
7. The talk about your medicines. This is the reason to bring your list, and it has its own section below.
8. Your instructions. You are given what to do and what not to do in the day or two before. Ask for it in writing.

Then, on the day itself, you change into a gown, take off jewelry and contact lenses, and have an IV line put into a vein for fluids and medicines. You meet the anesthesiologist, who goes through your worries and any allergies. You meet your surgeon, who goes through the plan and the risks, and answers any last-minute questions.

When does all of it happen?

Ask your own team about the dates, because this part depends on how your hospital runs. What follows is the shape of it.

• The pre-op appointment: a separate visit, before the day of surgery. Ask when yours is, and ask how long to allow for it.
• A heart trace: a few minutes.
• A chest x-ray: the whole visit is usually done inside about fifteen minutes.
• Your instructions: they cover roughly the day or two before the operation.
• The scan the surgeon navigates by: its own appointment. The scan just before surgery goes through it.

Hospitals do this differently, and the instructions you are given are the ones that count. If anything on this page does not match your sheet, follow your sheet and ask about the difference.

Will any of it hurt?

Almost none of it.

• Blood tests are a needle in your arm. Of the checks in the list above, that is the only needle.
• A heart trace does not hurt. The sensors stick to your skin and the machine only listens. No electricity goes into you. The skin may be a little sore where the stickers come off.
• A chest x-ray does not hurt either. You stand with your chest against a plate, hold still and hold your breath for a few seconds.

The hard parts, and what helps

Worrying that a test will stop the operation. That fear is a normal one, and it is worth saying out loud rather than carrying it home. Ask at the appointment what happens if a result needs looking at first, who calls you, and how quickly.

Telling your story more than once. You will be asked some of the same questions by different people, on different days. Bring your written list and your medicine list, so you are reading rather than remembering.

Going without food and water for longer than you needed to. It happens a lot, it is worth asking about, and the next section is about it.

Feeling like paperwork while you are frightened. Getting ready for surgery turns something enormous into a list of appointments, and that can be a strange and lonely few weeks. If it is sitting on you, there are people you can say it to today. Get help now has the numbers.

When do I stop eating and drinking?

Your hospital gives you your own times, and those are the ones to follow. Nothing here replaces them.

But it is worth asking about them, because the times people are given are often longer than the guideline asks for.

The guideline anesthesia teams work to says clear drinks can go up to two hours before you are put to sleep. Food needs longer, about six hours. Clear drinks means water, and other drinks you can see through, with no milk in them and no alcohol.

The reason for the difference is simple. A clear drink leaves the stomach fast, and about nine tenths of one is gone from the stomach inside the first hour. Food has to be broken up first, so it sits there much longer.

That guideline is written for a planned operation, in people whose stomachs empty normally. Some conditions and some medicines slow that down, and the weight-loss and diabetes injections a lot of people are on now are the ones most talked about. If any of that is you, your own time may genuinely be longer, and it is not your hospital being careless. Say what you take and let them decide.

What happens in practice is a long way from the guideline. In a study across forty-six centers in twelve European countries, the middle patient had gone twelve hours without a clear drink before their anesthetic, and fewer than one in a hundred had a drink in the last two hours.

Going that long dry is not harmless. It leaves people thirsty, dry-mouthed, hungry, restless and anxious, and if you drink coffee you can get a withdrawal headache on top of it.

So ask, plainly: how late can I drink water? If the answer is nothing after midnight, it is fair to ask whether that is the time for you or the one they give everybody. Get the answer in writing, and then follow it exactly.

Which of my medicines do I keep taking?

Some of what you take will carry on, and some of it will stop. Which is which is the whole point of this conversation, so do not assume either way about any of it until somebody has told you.

Bring the whole list. Prescriptions, anything you buy for yourself, vitamins and herbal things, with the doses. The things people leave off a list are usually the ones bought off a shelf, and those count too.

Your seizure medicine. For somebody who has seizures, the usual plan is to keep the medicine as close to normal as it can be around the operation, and to get back onto it as soon as possible afterwards. On the morning you may be told to take your dose with a sip of water. Ask whether that is your plan, because there are reasons a team sometimes wants it done differently. Anti-seizure medicines covers the rest, including what it can do to mood and temper, and how to ask whether your course has an end date.

Your steroid. If you are on dexamethasonedexamethasone: A steroid medicine given to bring down swelling around a tumor. It is not chemotherapy. It has its own side effects, so your team lowers the dose when they can. See the glossary or another steroid, this is not a medicine to stop on your own. A steroid is normally brought down in steps rather than stopped, and stopping one suddenly can make you seriously ill. Your team tells you what to do with it around the operation. Steroids is the page for the rest of it. A craniotomy, step by step covers what happens to it afterwards.

Blood thinners: do not stop one on your own

If you take a medicine that makes it harder for your blood to clot, that decision is not yours to make alone, and it is not one to make off anything you read, including this page. People call these medicines blood thinners. Aspirin is one, and there are several others.

It is usually settled between the doctor who prescribed it and your surgeon, with the anesthesiologist in the conversation and with you in it too. Ask who is deciding, because each of them can assume somebody else has done it.

Some of these medicines are stopped some days before an operation. It is not the same number of days for every one, and for some of them it is around a week. That is why this conversation needs to happen early rather than the night before.

Some people are told to carry on taking theirs. Aspirin is the clearest example: whether it stops depends on why you are on it in the first place. Somebody taking it after a heart attack or a stroke, or because they have a stent, may well be told to keep going. That is a decision about that person, not a rule you can apply to yourself.

What to do with all of that:

• Ask for the exact date you stop each one, and get it in writing.
• Ask who is deciding, and get a name.
• If nobody has raised it and your operation is close, phone and ask. It is a normal thing to chase.

What to bring, and what to leave at home

The operation page has the list for the day you are admitted. This is the shorter one, for the appointment before it.

To the pre-op appointment, bring:

• Your medicine list, with the doses.
• Anything you have been given in writing already, including the letter with your operation date on it.
• Your advance directive, if you have one. That is a living will, or the form naming the person who speaks for you if you cannot speak for yourself.

On the day of the operation, you will be asked to take off jewelry and contact lenses, so leave the jewelry at home and bring your glasses and a lens case. A craniotomy, step by step covers the rest of what to pack.

For the person going with them

If you are the one driving to the appointments, keeping track of the pills, and lying awake at night worrying about them, this part is for you.

You are allowed to ask questions. In one study, families said they were afraid of annoying the doctor by asking too much. One of them was told by a doctor to stop playing doctor. Ask anyway. Write your questions down before you go, and bring a notepad. Two people in the room hear more than one.

Ask who your first call is. Care comes from a lot of people at once, and it is easy to end up as the only one holding it together. Ask the team: who do I call first? Some teams have one person whose job this is, often a nurse. Get the name and the number.

Get two numbers, and know which one to use. One for work hours, one for nights and weekends. Then ask what counts as "call us today" and what counts as "call an ambulance" for this tumor, and write the answer down where you can see it. If you are not sure which it is, call. Nobody on that team will mind.

If they have seizures, read about them before you need to. What to do when someone has a seizure is the one to know by heart. Living with seizures is about the rest of the time: what is safe, what to change, and driving.

Ask to be shown anything you are sent home to do. In that same study, families were sent home to change dressings and give medicines with no training at all. That is not fair to you. Before you leave the hospital, ask someone to show you. Then do it once while they watch.

Say what you notice. You may see a change before they do. Changes in thinking, mood and behavior can show up to the people close by first. Telling the team is not going behind their back. It is something the team cannot learn any other way.

Look after yourself, and let people help. Eat, sleep, and keep your own appointments. Take a little of the day back for yourself. When someone asks what they can do, give them a real job: a meal, a ride, an hour with the kids. Most people want to help and do not know how to offer.

You can talk to somebody about all of this today. See where to get help.

Before the operation, there are four jobs here that are genuinely yours, and none of them are the ones people expect.

The medicine list. Write it out before the appointment. Everything, with doses, including whatever they buy for themselves. This is the single most useful piece of paper either of you will bring, and it is much easier to do at the kitchen table than from memory in a clinic.

The blood thinner, if there is one. Make sure it has actually been settled, and not just mentioned. Ask for the date they stop it and who decided, and ask in front of them so you both hear the same answer. Do not let anybody stop one on the strength of something they read. That includes this page.

The eating and drinking times. Get them in writing and put them somewhere you can both see them. Then ask the question in the section above: how late can they drink water? Somebody has to ask it, and it is easier for you than for them.

Ask what to do if they get ill before the day. A cold or a temperature in the week before is a normal thing to happen and a normal thing to ask about. Find out now who you would call.

What you are not doing yet is the aftercare. That is a different and much bigger job, and it starts on the other side. A craniotomy, step by step has the section for it, and it is worth reading before the day rather than in the hospital.

Who reads all of this, and what if something is not right?

The results go to the anesthesiologist. That is the doctor whose job it is to check that an anesthetic is safe for you, and it is the reason the appointment exists at all. Your surgeon sees them too.

Timings vary from hospital to hospital, so the honest answer to when will I hear is to ask before you leave. Ask it as two questions: who calls me if something needs following up, and what number do I call if I think of something before the day?

Hearing nothing is not a signal on its own. Ask whether you should expect to hear anything before the day, so you know what silence means and are not sitting at home reading something into it.

What to ask your team

• When exactly do I stop eating, and when do I stop drinking?
• Can I have water closer to the time than the sheet says?
• What do I do if I eat or drink something by mistake?
• Which of my medicines do I stop, and on which date exactly?
• Do I keep taking my seizure medicine and my steroid?
• Who decides about my blood thinner, you or the doctor who prescribed it?
• Do I need a heart trace or a chest x-ray, and why?
• Which blood tests am I having?
• When is my pre-op appointment, and how long should I allow for it?
• What time do I arrive on the day, and who can stay with me?
• What happens if a result needs following up first?
• What do I do if I get a cold or a fever in the days before?

Where to go next

• A craniotomy, step by step for the operation these checks are for, and everything after it.
• Biopsy: how tissue is taken if what you are having is a needle biopsystereotactic biopsy: Taking a small sample through a narrow opening in the skull, guided by a scan. A full opening is not made. It is used when the area to be sampled is hard or risky to reach. See the glossary rather than an operation to remove the tumor.
• Your MRI scan for the scan the surgeon navigates by.
• Get help now if you need to talk to a person today.