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By

Hala S. El-Ozairy,MD.Lecturer of anesthesia and

ICU,

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,

Definition.

Day case unit.

Advantages.

Disadvantages. Suitability for day case surgery.

Contraindications.

Patient preparation. Choice of anesthesia.

Postoperative management.

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A surgical day case is defined by the

Royal College of Surgeons of England as"a patient who is admitted forinvestigation or operation on a planned

non-resident basis and who nonethelessrequires facilities for recovery".

Day case surgery must be distinguished

from 'out-patient cases'. These are minorprocedures performed under a localanesthetic which do not generally require

postoperative recovery time.

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An outpatient is a patient who is nothospitalized overnight but who visits ahospital, clinic, or associated facility fordiagnosis or treatment. Treatment

provided in this fashion is calledambulatory care.

Ambulatory anesthesia is tailored to meet

the needs of ambulatory surgery so thepatient can go home soon after theoperation.

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Hospital integrated:The patients are managed in the same facility asinpatients but they may have separate preoperativepreparation and second stage recovery area.

Hospital based:Separate day case facility within a hospitalhandling only day cases.

Free standing:These surgical and diagnostic facilities may beassociated with hospitals but are housed in separatebuildings that share no space or patient carefunctions.

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Reception area.

Play room (pediatric).

Discharge area.Anesthetic room.

Operating room (fully equipped).

Recovery room.

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Day case surgery is advantageous to several

groups:patients: know when operation will be, little risk of cancellation.

minimal time away from home which is particularlybeneficial for pediatric patients.

Earlier ambulation. It decreases the risk of nosocomial infection especially in

children.

surgeons: less risk of cancellation permits better scheduling of

operating lists . greater turnover of cases.

less delay between cases, usually because less preparation isrequired.

release of in-patient beds that would have been occupied by

day case patients.

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Day case surgery is advantageous to

several groups:

Hospital management:

financial saving ranging from 19% to 70%

compared to in-patient treatment.

cost-effective treatment, still attainingclinical goals.

facilitates less demand for in-patientbeds.

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Disadvantages of day case surgeryinclude:the need for a responsible person to

oversee the day case patient at home for

the first 24-48 hours.the restriction of day case surgery to

experienced senior staff; littleopportunity for junior staff to practice.

extra work for the general practitionerin the postoperative period; patientsoften ring them for advice or treatment.

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It is done by:

Preoperative visit.

Telephone interview.Review of healthcare questionnaire

which can be done using the internet.

All are usually done by theanesthetist.

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Issues when assessing a patient'sappropriateness for day surgery include:

physical status - ASA I or II arepermitted.

Age.

type of surgery. length of anesthesia.

type of anesthesia.

recovery criteria. Transport.

postoperative pain relief.

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Although the acceptability of patients at theextremes of age (i.e., 70years) has been questioned, age alone should

not be considered a deterrent in the selectionof patients for ambulatory surgery. Manystudies have failed to demonstrate an age-related increase in recovery time or incidence

of complications after ambulatory anesthesia.Even the so called elderly patient (>100 years)should not be denied ambulatory surgerysolely on the basis of age.

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Operations for day case surgery vary betweenspecialties.Appropriateness may be expanded by the

facility for an overnight stay.

Generally operations should be:Short duration (

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Gynae: D&C, laparoscopy, VTOP, colposcopy.Plastics: removal of skin lesions, Dupuytrens

contracture release, nerve compressions.Ophtalmics: Strabismus correction, lacrimal duct

probing, EUA.

ENT: Adenoidectomy, Tonsillectomy,myringotomy, Grommets, Removal of FB, polypremoval.

Urology: Cystoscopy, circumcision, vasectomy.Orthopedics: arthroscopies, carpal tunnel

release, ganglion removal.General Surgery: Breast lumps, varicose veins,

herniae, endoscopy.Peds: Circumcision, orchiopexy, Squint, dental

extractions.

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MedicalConditions

Psychological Social

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Cardiovascular:

Prev MI.Hypertension, diast.>100 mmHg.Angina, at rest, low exercise tolerance.Arrhythmias.Cardiac failure.

Respiratory:Acute RTIs.Asthma requiring reg beta-2 agonists or steroids.COPD.

Metabolic:

Alcoholism.IDDM.Renal failure.Liver disease.

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Neurological, Musculoskeletal:Arthritis jaw, neck, cervical spondylosis,

ankylosing spondylitis.Myopathies, muscular dystrophies or

Myasthenia gravis.MS.

CVA or TIA.Epilepsy > 3 fits/year.

Drugs:Steroids.

MAO inhibitors.Anticoagulants.Antiarrhythmics.Insulin.

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psychologically unstable,e.g. psychosis.

concept of day surgery

unacceptable to patient.

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lives over one hour away from unit. no reliable person to drive patient

home after surgery and look after

them for the first 24-48 hourspostoperatively.

at home, no access to a lift,telephone or indoor toilet andbathroom.

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Full explanation.Pt should be given written instructions

incuding:Pre-op fasting: Nil by mouth from midnight (solids). Clear fluids until 3 hours pre-op.

Pts usual medication (i.e antihypertensivesshould be taken, oral hypoglycaemics shouldbe omitted). Pts should bring in their ownmedications.

Pt should stop smoking.The date and time of attendance.Complete registration is done.Informed consent is signed.List of the investigations required.

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Age range Men Women

75 Hemoglobin or

hematocrit level, ECG,serum urea nitrogen,

chest radiograph

Hemoglobin or hematocrit

level, ECG, serum ureanitrogen, chest radiograph

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The patient meets the anesthesiologist who willreview his medical and anesthesia history andthe results of any laboratory tests and willanswer any further questions.

Nurses give the patient the identifying braceletand record the vital signs, and theanesthesiologist and surgeon then visit tocomplete any evaluations and mark the site ofsurgery.

Intravenous fluids will be started andpreoperative medications given.

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Benzodiazepines: if indicated. Temazepamprovides effective anxiolysis without delaysin recovery and discharge times.

Antiemetics: p.o preop or i.v. periop for high

risk pts (i.e. 5 HT-antagonists, dexamethasonein ped).

Antacids: if risk of acid reflux (H2-antagonists).

Analgesics: Paracetamol and NSAIDs.

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There are several types of anesthetictechniques available for day casesurgery ranging from local anesthesia

to general anesthesia.

The anesthetic technique recommended

depends on several factors. In somecases, the surgical procedure dictateswhat kind of anesthesia will be needed.

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Choice of agents depends on requirements of pt andpreference of anesthetist. Induction agent:

i.v. Propofol is used widely (easy &quick recovery,clear head, little PONV).

gas: Sevoflurane is non-irritant to airway, rapid

induction, minimal side-effects, but more PONV.Maintainance: N2O: higher incidence PONV, but lower

requirements for volatiles. TIVA: Propofol +/- Remifentanilhigh cost. VIMA: Sevoflurane (more PONV).

Airway: GA mask, LMA, COPA or even ETT.Muscle-relaxants:

Succinylcholinemuscle pains. NDMRshort-acting, Atracurium, Mivacurium,

Vecuronium, Cisatracurium.

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Standard.Monitoring Awareness:

Stability of blood pressure and heart

rate. Lack of patient movement in response

to surgical stimulation.

The bispectral index : BIS has beenshown to be a reliable indicator toprevent awareness and facilitaterapid emergence from anesthesia.

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Advantagesto patient

avoidance of general anesthetic with its related complications. minimal incidence of nausea and vomiting.

improved post-operative pain relief. shortened recovery room time (can by-pass first-stage recovery). ability to communicate with staff during surgery. ability to observe the procedure (arthroscopy). earlier mobilization including immediate physiotherapy.

Advantagesto surgeon

enables accurate assessment of function before end of surgery. allows discussion of operative findings and treatment options at surgery.

Advantagesfor institution

options of direct transfer to second-stage recovery. shortens patients time in recovery room. reduces post-operative nursing requirements. fewer hospital admissions overall reduction in facility costs.

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Takes longer because of: discussion with patient.

block procedure.

onset time.

gentle tissue handling. incomplete block necessitating supplementation

or conversion to general anesthetic.

Requires surgeon and patient co-operation.

Risk of post-spinal headache.Prolonged regional block may result in

urinary retention and delayed discharge(central blocks).

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A number of regional anesthetic techniques can be usedfor day-case surgery:

At completion of surgery, infiltration of the woundusing a long-acting local anesthetic (e.g. 0.25%bupivacaine) provides prolonged postoperativeanalgesia.

For ocular surgery, peribulbar, retrobulbar or topical

blocks can be performed safely, effectively and withfew complications.

Caudal block is easy to perform and providesexcellent analgesia for perineal or inguinal surgery.

Blocks may be performed on the ilioinguinal nerve,

iliohypogastric nerve, the brachial plexus, femoralnerve or digital nerves.

Ring blocks of the wrist or ankle and local infiltrationare simple and effective.

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IVRA is most suitable for short duration (

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Peripheral nerve blocks provideexcellent analgesia over a limited fieldand with minimal systemic effects.

Peripheral nerve blocks have extendedthe indications for day-case surgicalprocedures such as major shouldersurgery and knee reconstruction.

Avoid techniques that may beassociated with occult complications,e.g: supraclavicular approach

(pneumothrax).

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It was previously called conscioussedation.

It is a combination of local anesthesia

with intravenous sedation andanalgesic drugs under monitor by theanesthetist.

Up to 50% of all day case procedures canbe performed with a MAC technique.

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Postoperative complications.

Discharge criteria.

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Anestheticcomplications

PONV Pain Others:

prolongedsomnolence,headache,urinaryretention,muscle pain,

sore throat,hoarseness,croup, IV siteproblems.

Medicalcomplications

CVS: hyper orhypotension,arrhythmias,

CHF,.. Pulmonary:

bronchospasm,atelectasis,aspiration,.

Surgicalcomplications

Bleeding Unsuccessful

procedures

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Age.Gender.

Pre-existing disease (e.g.: Diabetes)History of motion sickness.History of PONV.SmokingLevel of anxiety

Patientrelatedfactors

Premedication.Opioid analgesia. Induction and maintenance drugs.Reversal drugs.Gastric distention. Inadequate hydration.

Anesthesiarelatedfactors

Operative procedure: Strabismus, orchiopexy,..Length of surgery.Blood in the GIT: tonsillectomy,Forcing oral intake.Premature ambulation (postural hypotension).Pain.

Surgeryrelatedfactors

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Should start pre- or intraoperative by:Opioids:Short-acting opioids (Fentanyl,Alfentanil), avoid Morphine if possible if highrisk of PONV.

LA/regional blocks (i.e. Caudal block in kids;Ropivacaine more selective sensory blockthan Bupiv.).

Ketorolac: 0.5-1 mg/kg Iv or IM. It does notcause nausea or vomiting or respiratorydepression.

Acetaminophen: 25-40 mg/Kg orally orrectally.

Cox-2 inhibitors: Parecoxib 20-100 mg Iv orIM. No GIT side effects of other NSAIDs.

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Prior to discharge from the day case unit patients

should: Have stable vital signs. Be alert and orientated. Be comfortable / pain free. Be able to walk.

Be able to tolerate oral fluids. Have minimal nausea and vomiting.

Adequate follow-up arrangements should bemade.

Patients should be provided with informationsheets.

Should be provided with contact telephonenumbers.

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Thanks