DAY CASE ANAESTHESIA

PRESENTER AYENI,F.B
REGISTRAR,DEPARTMENT OF
ANAESTHESIA,ABUTH,ZARIA
MODERATOR DR NWASOR
CONSULTANT ANAESTHETIST,
ABUTH,ZARIA

OBJECTIVES
To define some terms necessary in the
understanding of Day Case Anaesthesia(DCA)
To highlight the Rational way of selecting
appropriate patients and procedures for DCA
To discuss the various Anaesthetic options
available for DCA
To describe the objective ways of selecting
patient fit for discharge from Day Case Unit

OUTLINE
Introduction
History/Epidemiology
Definition of Terms

Types of Day Case Unit (DCU)

Benefits of DCA
Patient selection criteria
Procedure Requirement
Patient Requirement
Social Requirement

Contraindications

OUTLINE
Conduct of DCA
Pre Anaesthetic Evaluation
Choice of Anaesthesia
Post Anaesthetic Care/Recovery

Discharge
Follow up and Audit
Peculiarities in our environment
Summary
References

DEFINITION OF TERMS
DAY CASE SURGERY
Admitted for investigation or operation
Planned non resident basis
Requires facility for recovery

23HOUR SURGERY
Admitted for investigation or operation
Discharged the next day

Both are classified as Short stay surgery

DEFINITION OF TERMS
OUT PATIENT CASES :
Minor procedures performed under LA
which do not generally require post op
recovery time
DAY CASE ANAESTHESIA :
Tailored to meet the need of Day Case
Surgery so the patient can go home soon
after the operation

HISTORY
James Nicoll (1864-1921) Day case surgeries
on 900 children in Sick Childrens Hospital ,
Glasgow , Scotland
N2O and Ether Dental Extraction
Society for Ambulatory Anaesthesia - 1984

INTRODUCTION
Evolved due to ;
Availability of rapid and short acting anaesthetic
agents
Improved monitoring devices
Advances in minimally invasive surgery
Escalating health care costs

Accounts for 60-70% and 50% of Elective cases

in the USA and UK respectively
% grew from 20% in 1981 to 69% in the USA

TYPES OF DAY CASE UNIT

HOSPITAL INTEGRATED
Patients are managed in the same facility as in
patients but they may have different pre op
preparation and 2nd stage recovery area

HOSPITAL BASED
Separate day case facility within a hospital handling
only day cases

FREE STANDING
May be associated with a hospital but are housed in
separate building that share no space or patient care
function

FACILITIES AVAILABLE IN DCU

Reception area
Anaesthetic Room
Play Room ( Children )
Operating Room
Recovery Room
Discharge Area

BENEFITS OF DCA/DCS
TO PATIENTS :

Reduction in the cost of treatment

Minimal disruption in patients lifestyle
Early return to work and normal activities
Little risk of cancellation & Patients prefer it

TO THE HOSPITAL
Free in-patients beds for major and emergency
surgeries
Reduction of nosocomial infections
Reduce waiting list for elective surgery

PATIENT SELECTION CRITERIA

PROCEDURE REQUIREMENTS :
Absence of post op hemorrhage necessitating
blood transfusion
Duration of proposed procedure < 1hr
A minimal risk of post op airway compromise
Post op pain controllable by out-patient methods
A rapid return to normal fluid and food intake
Operative list organization to achieve early
commencement of procedures for which a long
recovery period is likely

PATIENT SELECTION CRITERIA

PATIENT REQUIREMENTS :
A willingness to have the procedure performed as
day case
Patients place of residence for post surgery care
being within 1hrs travelling time from the
hospital
Physical status 1 & 2 or medically stable 3 & 4
Normal term infant of > 6wks of age or expremature infants of >52wks PCA

PATIENT SELECTION CRITERIA

SOCIAL REQUIREMENTS :
A responsible person to accompany the patient home
and staying at least overnight following discharge
from the DCU
The patient remaining within 1hr of appropriate
medical attention until the morning following
discharge
The patient has ready access to a telephone in the
post op dwelling
The patient having advised as to when to resume
activities such as driving and making decisions

CONTRAINDICATIONS TO DCA/DCS
Social factors e.g patient refusal , unwilling to
comply with instructions
Infants of PCA < 40 60wks with history of
prematurity
Unstable ASA 2 , 3 , & 4
Morbidly obese patient with other systemic
diseases e.g Severe obstructive sleep apnoea
Acute substance abuse & acute concurrent illness
Susceptibility to malignant hyperthermia

In all cases , the ultimate

decision as to the

suitability of a
patient for day case surgery is

attending
anaesthetist
that of the

IDEAL PROCESS

Pre operative management

Anaesthesia
Surgery
Recovery
Ward
Discharge
Follow up and Audit

PRE OPERATIVE MANAGEMENT

Pre operative assessmemt
Pre operative preparation
Premedication

PURPOSE OF PRE OP VISIT

History and physical examination

Risk assessment
Allay fear and anxiety
Give verbal and written instructions
Ability of patient to choose date
Obtain consent
Reduce pre op organisation on the day of
surgery

PRE ANAESTHETIC CLINIC

Before day of surgery ideally on day of
decision to treat 1-stop
Consultant Anaesthetist led
Nurse run
Protocol driven
Include investigation and medical review
Patient information

CHOICE OF ANAESTHESIA
The decision as to the type of Anaesthesia
must remain in the province of the Attending
Anaesthetist
Technique chosen will be based on :
Surgical requirement
Patient consideration
Experience of the Anaesthetist
Facilities and personnel of the DCU

ANAESTHETIC TECHNIQUE
There are 3 main anaesthetic options :

1) General Anaesthesia
2) Regional Anaesthesia
3) Monitored Anaesthesia Care
(MAC)

GENERAL ANAESTHESIA
Ideal Anaesthetic agent for day case surgery :
Smooth and rapid onset of action
Intra op amnesia and analgesia
Hemodynamic stability
Rapid recovery period without side effects
Cost effectiveness

To date , no ideal anaesthetic

agent/technique has been identified for day
case surgery

GENERAL ANAESTHESIA
INDUCTION AGENT IV/INHALATIONAL
IV- PROPOFOL

Smooth induction profile

Early and rapid recovery
Clear head and feeling of well being
Low incidence of PONV
Pain during injection

THIOPENTAL
Rapid onset and relatively short duration of action
Impairs fine motor skills for several hrs after surgery
Can produce hangover sensation

GENERAL ANAESTHESIA
KETAMINE
Prominent psychomimetic effect
Higher incidence of PONV

MIDAZOLAM
Slow onset of action
Prolonged recovery when compared to propofol

GENERAL ANAESTHESIA INHALATIONAL

SEVOFLURANE
Agent of choice
Non irritant to airway
Rapid induction in both adult and children
Quick termination of clinical effects
Minimal cardiovascular effects
Cause more PONV

GENERAL ANAESTHESIA INHALATIONAL

HALOTHANE :

GENERAL ANAESTHESIA MAINTAINANCE

SEVOFLURANE/DESFLURANE
Ideal agent for DCA
Volatile agents are associated with a higher
incidence of PONV

N2O
Reduce requirements for volatile agents & risk of
intra op awareness
Increase risk of PONV

GENERAL ANAESTHESIA MAINTAINANCE

HALOTHANE :
ISOFLURANE :

GENERAL ANAESTHESIA MAINTAINANCE

TARGET CONTROLLED INFUSION (TCI)(TIVA)
Propofol +/_ Remifentanil
Minimal risk of PONV
Short recovery time
High cost

GENERAL ANAESTHESIA - AIRWAY

LMA
Face mask
ETT

GA MUSCLE RELAXANT
Choice of muscle relaxant depends on
anticipated duration of surgery
SUCCINYLCHOLINE
Not ideal in Day case setting

SHORT ACTING NDMR

Allows reversal of neuromuscular blockade even
after brief surgical procedure
Atracurium , Mivacurium

GA - MONITORING
Standard
Monitoring awareness
Stability of BP & PR
Lack of movement in response to surgical
stimulation
Bispectral index ( BIS )

REGIONAL ANAESTHESIA ADVANTAGES

TO PATIENT
Avoidance of GA with its complications
Minimal incidence of PONV
Improved post op pain relief
Short recovery room time
Ability to communicate with staff during surgery
Earlier mobilization including physiotherapy

REGIONAL ANAESTHESIA ADVANTAGES

TO SURGEON
Enable accurate assessment of function before end of
surgery
Allows discussion of operative findings and treatment
options at surgery

FOR INSTITUTION :

Option of direct transfer to 2nd stage recovery

Shortens patient recovery time in recovery room
Reduces post op nursing requirement
Fewer hospital admission
Overall reduction in facility cost

REGIONAL ANAESTHESIA DISADVANTAGES

Takes longer time

Discussion with patient

Block procedure
Onset of action
Gentle tissue handling
Incomplete block necessitating supplementation or
conversion to GA

Requires patient and surgeon cooperation

Risk of post spinal puncture headache
Prolonged regional block may result in urinary
retention and delayed discharge (central block)

REGIONAL ANAESTHETIC TECHNIQUE

SPINAL :
Should ideally be the 1st patient on the list
Acceptable in reduced dose
Post-dural puncture headache , motor weakness ,
dizziness , urinary retention , impaired balance
Use 25/26G pencil point needle
5-10mg of 0.5% Heavy Bupivacaine + 10microg of
Fentanyl diluted to a volume of 3mls
British Association of Day Surgery Recommendation

REGIONAL ANAESTHETIC TECHNIQUE

EPIDURAL :

Technically more difficult to perform

Slower onset of action
Potential for IV or intrathecal injection exist
Associated with a greater chance of incomplete
sensory block

CAUDAL :
Easier to perform
Produces excellent relieve of pain post op especially in
children
Use dilute solution 0.125% Bupivacaine

REGIONAL ANAESTHETIC TECHNIQUE

PERIPHERAL NERVE BLOCK :
Facilitate recovery process by minimizing the need
for post op analgesics
Excellent analgesia over a limited field thereby
minimizing systemic effects
Avoid techniques that may be associated with
occult complications ( e.g supraclavicular
approach pneumothorax )

REGIONAL ANAESTHETIC TECHNIQUE

BIERS BLOCK :
For short superficial hand,forearm,foot and ankle
procedures limited to a single extremity
Procedure < 60mins in duration
0.5% Lidocaine
Quick onset of action & recovery is fast after the
release of tourniquet
Published success rate 94-100%
Main problems related to requirement for tourniquet
and systemic toxicity due to incidental release of
tourniquet

MONITORED ANAESTHETIC CARE

(MAC)
Local Anaesthetics + IV Sedation and
Analgesics + Monitoring by
Anaesthetist
Up to 50% of all Day case procedures
can be performed with a MAC
technique

ANALGESICS
NSAIDS
?OPIODS

DISCHARGE
Responsibility of :
Attending Anaesthetist
Surgeon
Nursing officer in charge of the DCU

Verbal and written instructions must be given

to the patient and/or guardian with particular
attention to ;
Immediate action in the event of complication
Whom to contact ( with telephone no )

DISCHARGE
Patient must be escorted home by a responsible
adult and ideally , by private transport
Patient must be advised verbally and in written
,that, in the 1st 24hrs post op, he/she must not ;

Drive or operate machinery

Cook
Work of make any decision
Drink alcohol
Take any medication not prescribed by the DCU

DISCHARGE CRITERIA

Stable vital signs for at least 1hr post op

Oriented in TPP
Adequate pain control
Minimal nausea, vomiting or dizziness
Adequate hydration
Minimal bleeding or wound drainage

DISCHARGE CRITERIA
Patients at significant risk of urinary retention
must have passed urine
A responsible adult to take the patient home
Resumption of oral intake is encouraged
though no longer required to be
demonstrated prior to discharge

If the discharge criteria are not met ,

the patient must then be admitted

DISCHARGE CRITERIA
Short stay surgical patient should have a
protocol based discharge from 1st stage to the
ward ( 2nd stage ) and from the ward to home
Two commonly used discharge criteria after
GA and MAC are :
1) Aldrete Discharge Criteria
2) Post Anaesthetic Discharge Scoring System
(PADSS)

ALDRETE DISCHARGE CRITERIA

ACTIVITY ( can move voluntarily on demand)
4 Extremities (2), 2(1) , 1(0)

BREATHING
Able to deep breath and cough freely (2), Dyspnoea,
shallow or limited breathing (1), Apnoea (0)

OXYGEN SATURATION
Maintains oxygen saturation of >92%on room air (2)
Needs oxygen supplement to maintain SPO2 >90% (1)
Oxygen saturation < 90% (0)

ALDRETE DISCHARGE CRITERIA

CIRCULATION(BP compares with pre anaesthetic
level)
+/_ <20mmHg
+/_ 20 50mmHg +/_ >50mmHg
-

2
1
0

CONSCIOUSNESS
Fully awake
Rousable to speech Not responding
-

2
1
0

If score >/= 9 ,patient can be discharged to the

ward

POST ANAETHETIC DISCHARGE

SCORING SYSTEM (PADSS)
ACTIVITY
Steady gait/no dizziness/meet pre op level 2
Requires assistance to ambulate
-1
Unable to ambulate
-0

VITAL SIGNS
BP & PR within 20% of pre op baseline - 2
BP & PR within 20-40% of pre op baseline 1
BP & PR > 40% of pre op baseline
-0

PAIN
Acceptable to patient
Not acceptable to patient
Not acceptable to patient or nurse -

2
1
0

POST ANAETHETIC DISCHARGE

SCORING SYSTEM (PADSS)
NAUSEA & VOMITTING
Minimal, successfully treated with oral anti emetics - 2
Moderate, successfully treated with IV anti emetics - 1
Severe & Persistent - 0

POST OP SURGICAL BLEEDING

Minimal, does not require dressing change
2
Moderate , up to 2 dressing changes required - 1
Severe, >3 dressing changes and surgical review required
- 0

If score is >/= 9 , patient may be discharged from

ward to home

DISCHARGE AFTER REGIONAL

ANAESTHESIA
Before ambulation :
Normal perianal (S2-S4) sensation
Ability to plantar flex the foot
Proprioception of the big toe

Discharge criteria should include :

Return of normal sensation
Return of muscle strength
Proprioception
Return of sympathetic nervous system

UNPLANNED ADMISSION
ANAESTHETICS :
PONV ,Complications , Delayed Recovery

SURGICAL :
Pain , Complications , Extensive Surgery

MEDICAL :
Undiagnosed medical conditions

SOCIAL :
Late surgery ,

FOLLOW UP AND AUDIT

QUALITY INDICATORS :
Unplanned admissions
Post operative morbidity
Patient/Parental Satisfaction

PECULIARITIES IN OUR
ENVIRONMENT

PATIENT
PROCEDURE
ANAESTHETIST
FACILITY

SUMMARY
Only broad guidelines for patient and
procedure selection
Multidisciplinary team work and effective
communication form the cornerstone of DCA
Post op Analgesia and prevention of PONV is
vitalIF THERE IS A NERVE TO BLOCK , LET US
BLOCK IT
Continuous process evaluation is mandatory

REFERENCES
Day Case and Short Stay Surgery : Published by
The Association of Anaesthetists of Great Britain
& Ireland , May 2011
Australian and New Zealand College of
Anaesthetist Recommendation for the peri op
care of patient selected for Day Case Surgery
Reviewed 2010
The Hong Kong College of Anaesthesiologist
Guidelines for Day Case Surgery Reviewed Feb.
2002

REFERENCES
Anaesthesiology by Atuso Ambulatory
Surgery ; Chapter 60
British Journal of Anaesthesia 87(1):Pg 7387(2001) Analgesia for Day Case Surgery
Day Surgery and 23Hr Surgery at UCH, London
Guidelines and Protocol; May 2008
Questions and Answers in Anaesthesia &
Intensive Care : Page 140-142

Thank
you for
your
Attention