Here's a helpful guide to common questions our patients ask us. If you can't find an answer here please contact us, and we'll get back to you with an answer. You can also refer to the patient information section of the Australian Society of Anaesthesia website, ASA.org.au
Please understand the plan for your diabetic medication around anaesthesia and surgery will be personalised to you. It will be made utilising the general advice of the Diabetic Society of Australia, your GP, Endocrinologist, Surgeon and Anaesthetist. What follows is a general discussion and should be used by you to bring the important issues to those that will be caring for you.
The aim will always be to minimise the period without solid foods to between 6-8 hours. A longer fast than this is likely to require you to be provided with intravenous insulin and glucose to protect you from hypoglycaemia and/or acidosis.
Drinking clear glucose containing fluids (apple juice, lemonade) may be adequate to prevent hypoglycaemia. Eating a boiled lolly that dissolves in your mouth would also provide the required sugar with no residual solid material in your stomach.
Please speak with your Anaesthetist and Surgeon as use of insulin will depend on whether you are also on oral diabetic medications, the time of your surgery, and the nature of the procedure, as well as how quickly we are able to return you to a full diet. It is likely you will be asked to reduce or withhold your insulin medication on the day of surgery.
When these SGLT-2i are a combination tablet your GP will need to provide you with the other agents separately so they can continue until the day of your surgery.
Rarely, if the total period without food is limited to a period of less than 8 hours, you may be able to continue these medications, but do so only after consultation with your Anaesthetist.
All other Oral Hypoglycaemic Agents (OHG)
Should be continued normally with normal food intake on the day before surgery, OR the day before you begin a bowel prep for colonoscopy etc.
Do not take OHG medication on the day of your surgery (or while you use a bowel prep), they wil be recommenced once you have re-established a full diet the evening after or the following day.
If you are taking a bowel prep, watch your finger prick BSL every 1-2 hours and drink clear sugar filled fluids if it is <5.0mmol/L or sugar free clear fluids if it is >10mmol/L.
In the past, there has been advice to 'pump and dump' for 24 hours after surgery, and some women may continue to prefer to do this. However, there are implications of the interruption to breastfeeding both for the baby and maternal supply. Many patients are happy to hear that this advice is conservative and probably outdated. Commonsense approaches, such as breastfeeding the infant as close to the time of the procedure as practicable and staying well hydrated, would seem reasonable. 1
Once a mother is awake and alert after anaesthesia (or sedation) and able to safely hold her baby, it is safe to breastfeed again. Mothers may also choose to closely monitor their infants for any behavioural changes or increased sleepiness while breastfeeding in the period after surgery whilst they are still taking pain relief medications. 2
Some medications can be excreted in the breast milk and may have an effect on the infant, generally they can be easily avoided. These include diazepam, pethidine, hydromorphone, methadone, codeine, quinolones, sulphonamides, ciprofloxacin, metronidazole and pregabalin. Penicillins and cephalosporins are passed to breast milk but are safe for infants. Most agents used in anaesthesia for adults are the same as those used for infants and children and we know they are safe.
Parents and health care providers may check any medications using the LactMed database (National Institute of Health). 3
No matter what type of anaesthetic you are to receive (general, regional, local or sedation), your Anaesthetist will wish to monitor how well you are breathing and how much oxygen is getting to your blood and tissues. Generally, we do this by using a finger or toe probe that relies on measuring the colour of light that transmits through your finger tip.
Acrylic nails and nail polish, especially in the red to crimson colour range, can interfre with this reading, putting the reliability of the measurement at risk.
If possible, avoiding the deep red to crimson nail polishes, or leaving your manicure appointment until after your surgery, and arriving with your own unadorned nails will most commonly overcome the problem and allow your Anaesthetist to optimise your anaesthetic care.
Why do I have to fast from food and drink?
We ask patients to fast because of the higher risk of regurgitation and aspiration of stomach contents in to the airway and lungs. The effect on a patient's recovery, should aspiration occur, can be dramatic.
At a minimum, there may be an unplanned stay in hospital at least overnight. There can also be a prolonged period (potentially 4 to 6 weeks) of an uncomfortable cough that can be worse with exercise. A significant aspiration can result in a patient's need to receive assistance with their breathing and can include admission to High Dependency or Intensive Care Units.
Please refer to the following for additional information:
What do I fast from?
There can be specific fasting instructions for specific procedures, and patients with specific underlying conditions or at particular hospitals, which you will be informed of by your Surgeon, Anaesthetist, or the hospital prior to your procedure. However, the following are the general guidelines accepted by NAPS Anaesthetists for patients having an elective procedure, as listed on the ANZCA website.
For adults and children over the age of 2 years
For infants and children over 6 months and under 2 years
For infants under 6 months of age
Medications that are needed (you will be informed if there are medications you are to stop before surgery) can be taken as required with a sip (<30mL) of water less than 2 hours before surgery.
What is a clear fluid?
What is not clear fluid?
There is no simple answer to this question.
No Anaesthetist wishes to give an anaesthetic to a patient with an acute illness or an unstable chronic illness, especially if this involves the airway and breathing system. Even if you feel your child is improving or your GP said in the previous few days that they were alright, your Anaesthetist on the day may choose a more conservative treatment plan and postpone your child's surgery.
An otherwise healthy child will need to have no symptoms of illness for 1 to 2 weeks after a significant head cold or respiratory illness, for their risk of adverse respiratory event to return to normal. If your child suffers from an underlying respiratory illness, eg Asthma or Cystic Fibrosis, this symptom free period may increase to 4 to 6 weeks.
Significant respiratory illness would include, but not limited to, the child having a temperature, a sore throat, an ear ache, a blocked nose (which may be seen as the child is breathing with an open mouth), or a runny nose (the colour is not relevant to the illness or fitness for anaesthesia), a cough (whether dry or moist), loss of appetite, a change in their level of energy and interest in play, a desire to sleep or sit quietly with a parent and not engage in their usual activities, perhaps crying more and being less tolerant of things generally, restless sleeping, perhaps waking often and needing attention throughout the night.
Despite all this, an isolated runny nose may not have any real consequence to your child's anaesthetic. We understand infants and pre-school aged children often have runny noses for reasons that are not due to viral or bacterial infections. Teething, hay fever, or allergies, having enlarged tonsils and adenoids, being transferred from a warm bed to a cold car and in to an air conditioned hospital can all be associated with a runny nose, and may not alter their risks.
Your Anaesthetist will balance the risks of postponing your child's surgery with the risk associated with them having a compromised airway and the likelihood that this will create a medically critical situation or a prolonged period of respiratory illness or other adverse event in the recovery period.
If after reading this you are confident that your child's runny nose falls in to the significant illness or are worreid that it may, then we encourage you to speak directly with your Anaesthetist and/or Surgeon, and consider the implications to you and your family should the surgery be postponed on the day of surgery.
Clinically, your Anaesthetist will have assisted the Surgeon in ensuring your regular medications are recommenced in a timely fashion, and will have organised appropriate pain relief for the procedure you have had. Some will arrange for a follow up review with you, and if needed, will share information with your GP should some medical situation require further investigation or have some ongoing impact on your health care.
In the ensuring 2-4 weeks your anaesthetist will provide the NAPS staff with the details of your anaesthetic care and an invoice will be created and sent to you, when there are amounts to be paid direclty by you, or to your Private Health Insurer (PHI) group if there is no out of pocket cost. You will receive no further notification from NAPS if the latter is the situation.
It will depend on your PHI if you need to pay the invoice in full, and then claim your reimbursement from them and Medicare, or if you are able to pay just the gap and your Anaesthetist will bill the rest directly to your PHI and Medicare.
Your invoice will contain bpay details for payment. Alternatively, payments can be made by credit card over the phone, or in person with cash, cheque or credit card in our Rooms.
An Anaesthetist's fee is calculated based on the number of units (RVG units) which are calculated from:
Each Anaesthetist sets their own RVG unit price from which the total invoice is then calculated. At times, they will choose to utilise the amount that is offered by the private insurance funds (the no-gap or known gap rate) and as such the patient will have no out of pocket costs. At other times, they will have reasons where they feel it is appropriate to charge above the insurance fund fees and this will create an out of pocket cost to the patient.
It is important to remember that there are over 30 individual Anaesthetists within the NAPS cooperative, and we each decide how we will approach our billing and which cases will attract an out of pocket cost. Across the entire practice however, close to 60% of our accounts are billed so as to leave no out of pocket costs. And the majority of the others are billed within the known gap levels.
At NAPS, we take every possible step to ensure patients undergoing procedures that will attract an out of pocket cost are notified with an Informed Financial Agreement. We attempt to obtain lists from the surgeons rooms with your contact information as soon as they are placed on a list. We find that we need this information at least 72 hours before the day of surgery. Surgeons are not always aware of all of their cases on any particular list until inside that time, however we have staff dedicated to coordinating this process and attempt to send an email within 48 hours of receiving a patient's name/email address, or to post the information when no email address is provided.
As doctors, we have no control over what proportion of our fees are covered or not covered by the various insurance bodies responsible for the reimbursement of money to patients.
Anaesthetists decide what our time and experience is worth, while we care for our patients with our surgical and procedural medical colleagues. We base this decision on the fact that we are working in a first world medical environment and that we have studied and trained for between 5 - 6 years beyond our undergraduate medical degree, to provide some of the safest and technologically advanced anaesthetic care in the world.
Any invoice is partly covered by the Medicare rebate, at a rate defined by the Federal Government in its Medical Benefits Schedule (MBS) of fees. Between 2013 - 2018 there was a freeze placed on these MBS rebates and even now some services have not been released from this freeze. These Medicare rebates are currently under review, but they are often set based more on what is possible for Governments to gain Parliamentary support for rather than the real costs of medical care.
Private insurance funds then pay for an amount above this Medicare rebate as defined by their own benefit scheme, and each fund, while often being aligned, gives differing amounts for each item attracting a rebate. Furthermore, there are some procedures which are not included in the MBS and these may or may not be available for reimbursement by a fund. Finally, it can depend on the level of insurance (gold, silver or bronze) a client chooese to hold, and which fund a client chooses to insure with.
Some funds keep their premiums to clients low, but then have a different lower rebate system should the doctor choose to charge above the fee that the fund has set, this will force the client to pay a larger out of pocket cost. It should be taken in to consideration that it is to the benefit of shareholders within a for-profit health insurance fund to keep outgoing payments low.
Consequently, given there is a benefit to government and insurance companies to undervalue and limit payment for the services of doctors, and more specifically, Anaesthetists, then there will be an amount of our invoices that remains uncovered and will need to be met by the patient themselves.
Private Health Insurers (PHI) have their own schedules, they define what level of cost they are prepared to reimburse the patient for and these schedules fall in to the general definition of being either:
No Gap: No out-of-pocket cost
The insurer sets an upper limit for how much they will pay over the MBS fee. If your doctor charges above the MBS but under, or up to, the insurer's 'no gap' threshold, you will be covered and have no out-of-pocket cost. If they charge more than the 'no gap' threshold, you may be able to take advantage of your insurer's 'known gap' scheme (see next point).
(PHI's that have no 'known gap' scheme may reduce the amount reimbursed to the patient back to the MBS amount if a doctor charges above their no gap amount.)
Known Gap: Known out-of-pocket cost
This gives you a bit of leeway if your doctor charges above the 'no gap' threshold, but not all health funds offer a known gap option in their scheme. The insurer sets a known gap amount, which is often exactly the same amount as the no gap amount. Usually, if the doctor charges up to $500 more than the known gap amount, you pay the difference between the known gap amount and the doctor's charge. The health fund and Medicare pay the rest. This usually limits your out-of-pocket costs to a maximum of $500.
But be aware, if your doctor charges only a few dollars above the known gap amount, you will no longer be eligible to claim anything under the gap scheme, and you will be back to paying the difference between the MBS-set fee and what the doctor or surgeon charges.
Health funds have agreements with particular doctors who have agreed to charge up to the threshold for some or all of their patients. But even if a doctor has a gap agreement with your health fund, it is up to them if they choose to use it for you.