Day-Case Anaesthesia

Published on 27/02/2015 by admin

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Day-Case Anaesthesia

A day-case patient is one who is admitted for investigation or operation on a planned non-resident basis. Patients are usually discharged from the hospital or unit later on the day of the procedure. The procedure may require general, regional or local anaesthesia, sedative techniques or a combination of these.

The NHS plan predicts that 75% of all elective operations will be carried out as day cases. According to the British Association of Day Surgery (BADS), patients support day surgery because it provides timely treatment, less risk of cancellation, a lower incidence of hospital-acquired infection and an earlier return to normal activities. Procedures commonly selected for day-case care are those which take < 60 min to complete and which do not cause severe haemorrhage or produce excessive amounts of postoperative pain (Table 26.1). Increasingly complex cases are now performed as day-case procedures, including laparoscopic cholecystectomy and tonsillectomy. By extending day surgery opening hours and using staggered admission times, patients who would normally require hospital admission may be treated as day cases. The British Association of Day Surgery (BADS) publishes guidelines and protocols for the management of specific issues: for example, day surgery for patients with diabetes. BADS has also published a list of 25 procedures which should normally be undertaken as day cases. The NHS Modernisation Agency audited current day surgery rates for these procedures and set target rates for individual hospitals.

TABLE 26.1

A Selection of Surgical Procedures Commonly Undertaken as Day Cases

Gynaecology

Dilatation & curettage, laparoscopy, vaginal termination of pregnancy, colposcopy, hysteroscopy

Plastic Surgery

Dupuytren’s contracture release, removal of small skin lesions, nerve decompression

Ophthalmology

Strabismus correction, cataract surgery, lacrimal duct probing, examination under anaesthesia

ENT

Adenoidectomy, tonsillectomy, myringotomy, insertion of grommets, removal of foreign body, polyp removal, submucous resection

Urology

Cystoscopy, circumcision, vasectomy, transurethral bladder resection

Orthopaedics

Arthroscopies, carpal tunnel release, ganglion removal, bunion operation, removal of metalwork

General Surgery

Breast lumps, herniae, varicose veins, endoscopy, laparoscopic cholecystectomy, haemorrhoidectomy, anal fissure dilatation

Paediatrics

Circumcision, orchidopexy, squint, dental extractions

Achievement of a pain-free ambulant patient requires skilful patient selection and experienced anaesthetists and surgeons working within a day surgery unit. Large-scale reports have indicated that day surgery represents a safe, cost-effective and efficient practice. Advantages include decreased risks of nosocomial infection and deep venous thrombosis, less social disruption to patients and their families and minimal need for inpatient hospital resources. Therefore we now face the challenge of providing faster recovery, more rapid discharge and better pain relief for these patients.

PATIENT SELECTION

The selection of patients for day-case surgery is of vital importance if maximum use is to be made of the resources in the day-case unit and also to facilitate smooth running of the unit. The selection of patients must take into account two separate aspects: firstly, the patient’s state of health, and secondly, his or her social circumstances. Patients should normally be ASA I or II, or medically stable ASA III. Recent reviews have shown that patients with a body mass index of > 35 kg m⁻² do not have an increase in unplanned admission rates or postoperative complications. The Association of Anaesthetists of Great Britain and Ireland has recommended that obese patients should not be excluded from day surgery based on their BMI measurement alone. There is no evidence of significant morbidity in the immediate postoperative period when treating morbidly obese patients as day-cases. Although an increased risk of adverse events occurring intraoperatively and in the immediate recovery period in obese patients has been reported, these have not been shown to increase the incidence of unplanned admission significantly.

Evidence has shown that many elderly patients cope better at home. Careful preoperative assessment should highlight patients who will require an extended time in hospital. Elderly patients are more likely to have comorbidities and these patients should be assessed according to their physiological rather than their chronological age. Careful medical and social preoperative assessment is required to help elderly patients to benefit from shorter hospital stays with less risk of postoperative confusion. The patient should stay a minimum of a 1-h drive from the hospital on the night following surgery and they should have an adult escort available for the first 24 h. An example of guidelines used for patient selection for day-case anaesthesia is shown in Table 26.2.

TABLE 26.2

Guidelines for Patient Selection for Day-Case Surgery Under General Anaesthesia

ASA 1 or 2 and medically stable ASA 3

Age: > 52 weeks post-conceptual age

Weight: body mass index = weight/height² (kg m⁻²)

≤ 35: acceptable

> 35: discuss with anaesthetic department

Generally healthy, i.e. can climb two flights of stairs

Exclusions

Cardiovascular

MI/TIA/CVA within 6 months

Hypertension: persistent diastolic pressure > 110 mmHg

Unstable angina

Arrhythmias

Heart failure

Poor exercise tolerance

Symptomatic valve disease

Respiratory

Acute respiratory tract infection

Asthma requiring regular β₂-agonists or steroids

Metabolic

Alcoholism /narcotic addiction

Insulin-dependent diabetes

Renal failure

Liver disease

Neurological/musculoskeletal

Severe arthritis of jaw or neck

Cervical spondylosis/ankylosing spondylitis

Myopathies/muscular dystrophies/ myasthenia gravis

Advanced multiple sclerosis

Epilepsy > 3 fits per year

Drugs

Steroids

Monoamine oxidase inhibitors

Anticoagulants

Antiarrhythmics

Insulin

The selection of patients for day-case surgery is made at the time of outpatient consultation and routine measurement of pulse rate and blood pressure, urine analysis and other relevant investigations (e.g. ECG, full blood count and sickle cell testing) are performed; performance of these routine tests minimizes the number of problems when patients are admitted on the day of surgery. A standardized patient health/anaesthesia questionnaire and preliminary nurse assessment with appropriate referral for anaesthetic consultation minimize difficulties encountered on the day of surgery. Pre-assessment clinics provide an opportunity to educate patients and have been shown to reduce both cancellations by patients and unnecessary preoperative investigations. Children should be treated as day cases if possible and children scheduled for day-case procedures should be healthy and usually ASA I or II. Premature babies who have not reached 52 weeks post-conceptual age should not be considered for day-case surgery because of the risk of postoperative apnoea, and special consideration should be given to babies who have been receiving ventilatory support. The parent must be able to cope with the pre-procedure instructions and with the care of the child following treatment. The parent must agree to day treatment and be available to stay throughout the day although there may be exceptions for older children who attend regularly. Home facilities and travelling conditions should be taken into account. Following a general anaesthetic, the use of public transport is inappropriate.

Following selection of a patient for day-case surgery, the nature of the operation and the routine of management are explained fully to the patient and the consent form may be signed. Many units issue the patient with explanatory leaflets, CDs/DVDs or even podcasts explaining the procedure. A date for surgery can then be arranged and registration completed, as for an in-patient admission. It is wise to book any pathological or radiological investigations which are required well in advance of the day of admission.

The patient should be given written instructions detailing the date and time of attendance at the day unit, with written instructions relating to preoperative starvation and the patient’s regular medication, e.g. antihypertensives, should be taken as usual but oral hypoglycaemics must be omitted on the morning of surgery. These instructions should be written clearly in plain English (or another appropriate language). The patient is usually advised not to eat anything from midnight for a morning operating list.

Recent clinical studies suggest that overnight fasting may not be required in adults or children. Pulmonary aspiration occurs usually in emergency abdominal and obstetric procedures where there may be complicating factors such as recent food and fluid intake, trauma or administration of opioid analgesics. These factors do not normally apply to healthy elective day-case patients. The universal order of nil by mouth from midnight should apply only to solids. Clear fluids should be allowed until 3 h before the scheduled time of surgery. The effect of giving patients 150 mL of clear fluid 2 h before general anaesthesia for termination of pregnancy has been studied; the results showed that clear fluids do not increase the incidence of regurgitation or vomiting during anaesthesia and the postoperative period and that preoperative thirst was decreased in the clear fluid group. It is advisable to ask patients who smoke to refrain from smoking for 4–6 weeks before the operation. Patients should be asked to bring with them all tablets and medicines which they take regularly.

ORGANIZATION OF THE DAY-CASE UNIT

Types Of Unit

In order to help improve the number of day-case operations, BADS has produced a directory of 160 procedures. Attached to each of these procedures are four possible management options.

Procedure room; an operation which can be performed in a suitable clean environment outside the operating theatre.

Day surgery; traditional day surgery.

23-h stay; patient admitted and discharged within 24 h.

Under 72-h stay; patient admitted and discharged within 72 h.

There are three common types of day-case unit.

A unit within a hospital complex, but with separate staff, wards and operating theatre; this is functionally the most flexible type as it may be adapted to the varying requirements of day-case patients.

A unit with a separate ward, but using the hospital’s main operating theatre complex.

Outside the UK, it is common for a separate centre to have its own operating theatres and wards remote from a conventional hospital. This type of unit has now been introduced into the UK.

Ideally, day surgical units should not be freestanding but situated on in-patient hospital sites. The ward area should be close to the operating theatre to reduce portering time, particularly when short operations are performed. This arrangement also enables parents to accompany their children to the anaesthetic room if this is desirable.

Preferably, the unit should be near a car park and well signposted to facilitate the prompt arrival of patients and to avoid unnecessary delays.

Facilities Available

The accommodation should ideally include the following.

An admission area, which includes reception, treatment and examination rooms, a nurses’ station, lavatories, a playroom and a discharge area.

An anaesthetic room, fully equipped and large enough to allow free access around the patient’s trolley to permit the use of local or general anaesthesia. There should be good lighting, scavenging, piped gases and suction equipment, anaesthetic machine and monitoring equipment. The hazards and risks of general anaesthesia for day surgery are no less than those associated with elective in-patient surgery; indeed, in some respects they may be greater and the facilities provided must be at least comparable.

An operating theatre, which should be of the same specification as the in-patient equivalent. A good operating light, air conditioning and piped services are required, in addition to the usual scrub-up and autoclave facilities. There is always the possibility of a minor operation developing unexpectedly into a major operation and this demands that the theatre is equipped to deal with that eventuality.

A fully equipped recovery room, which must always be equipped and staffed for the safe recovery of patients following general anaesthesia. Piped gas supplies and resuscitation equipment are mandatory and the full range of monitoring and ventilation equipment must be readily available.

Other facilities which should be available include office space, an equipment store, staff changing and locker rooms, a staff room, a pantry to make drinks and lavatories for patients, parents and staff.

Admission

Patients should be admitted to the day ward in adequate time for history-taking and examination. The results of any investigation requested as an outpatient should be available and noted. Patients should receive an identity bracelet and their name should be entered into the nursing record. The surgeon should ensure that the indication for surgery is still present, e.g. presence or absence of lumps to be removed, because it may be several weeks since the clinic appointment. The consent form should be signed if not already done during the outpatient appointment, and the operation site clearly marked.

Venous thromboembolism prophylaxis should be provided according to local hospital policy based on the risk factors which are present. It is also important that careful attention is paid to WHO checklists and procedures, to maximize patient safety in the day-case environment.

A pregnancy test in women of fertile age may need to be performed if there is any risk of pregnancy. Staggering patient admissions decreases waiting times and improves the efficiency of the unit. Using dedicated paediatric day-case lists ensures an appropriate staffing mix for these patients. The use of separate operating lists for local anaesthesia and general anaesthesia may improve throughput, as does the introduction of day-surgery operating trolleys.

ANAESTHESIA

Premedication

Most anaesthetists do not routinely prescribe premedication for day-case surgery because it is usually unnecessary and for fear of delaying recovery and discharge. Premedicant drugs that may be used if required include the following.

Benzodiazepines

It is thought that sedative premedication may prolong the recovery time and delay the patient’s discharge from hospital. However, a double-blind study of temazepam premedication for day surgery found effective anxiolysis in the patients who received temazepam 10 or 20 mg; there was no delay in recovery times as measured by memory test cards and all patients were discharged from the day unit within 3 h after administration of general anaesthesia. Oral midazolam has been used as a premedicant in day surgery, but it was found that it produced a delay in immediate and late recovery compared with temazepam.

Antiemetics

If patients are at high risk of postoperative nausea and vomiting (PONV), antiemetics may be administered orally before operation, or via the intravenous or rectal routes perioperatively. Apfel et al (2002) developed a simplified PONV risk score and suggested the use of prophylactic antiemetics for any patient with two or more of the following: female gender; past history of motion sickness or PONV; non-smoker; and use of postoperative opioids. However, risk scores such as this have no more than a 70% chance of predicting PONV.