2. Introduction
• 50% elective surgery in UK
• 60% elective surgery in USA / Canada
• 23 – 50% elective in India in selected centres
• NEED
• Long surgical waiting list
• Reduction in available beds
• High cost of in patients beds
• Improvement in anaesthesia and pain control
• Minimally invasive surgery
3. Definition
• “Planned investigations and procedures done on
patients who are admitted and discharged home
the same day as surgery and who require some
facilities and time for recovery.”
• Criteria of inclusion
• Patient who spend few hours in hospital but, do not stay
overnight.
• Patient who spend upto 23 hrs in hospital.
• Minor procedures in outpatient or accident in
emergency department not included
4. Historical aspect
• 1909 James Nicholl reported 9000 children operated as day
cases
• 1912 Ralph Waters founded anaesthesia clinic in same way as
today’s day surgery unit
• 1951 Eric Farquharson carried out hernia repair under local
anaesthesia
• 1960 hospital based DSU appeared in USA
• 1969 Walter Heed set up 1st DSU named Phoenix surgicentre….
….
5. Benefits of day surgery
• Reduced cost
• Low post-operative morbidity
• Reduced thrombo-embolism and hospital acquired
infections
• Minimal disruption to patients life
• Early return to work and normal activities
• Children prefer it
6. Contd…
• More efficient high volume turnover of patients
• Reduced waiting lists for elective surgery
• In patients bed freed for major and emergency surgery
• Fewer cancellation on day of surgery
7. Problems of day surgery
• Initial cost of setting up DSU
• Good organization and management needed
• Poor patient and procedure selection
• Trained and efficient staff needed
• Inadequate information given to patient
• Morbidity from anaesthesia and surgery
8. Contd…
• Burden of care passed to patient’s family
• Increased community health care workload
• Quality of care in day surgery should be of same high standard
as that expected for inpatient surgery
• Lead to emergence of DSU
9. Desirable features DSU
• Self contained: Reception , ward , theatres and
recovery area
• Adjacent parking
• Well planned patient flow
• Maintain as high standards as inpatient wards and
theatres
• Bed theatre ratios as prescribed
• Set protocols for selection , analgesia and discharge
to be followed
• Good record keeping
10. Contd…
• Support services readily available
• Trained , experienced staff
• Consultant led anaesthesia and surgery
• Organized training with closed supervision of trainees
• Clinical director in overall charge
• Team work between staff groups
• In tune with community services and GPs
11. Organization of DSU
• Nurses experienced with multi-skilling
specialized for children
• Ancillary staff portering and domestic duties
• Technicians record keeping, computer savvy
accurate and complete work-skills
high volume with fast turn over
12. Cont.…
• Medical staff ….
trainees are closely supervised …..
• Clinical director
• A consulant surgeon or anaesthetist
• Implement and audit good standards of care
• Regular multidisciplinary meetings required ….
13. Essentials of good day care surgery
• Selection of appropriate procedure and patients
• Pre-admission assessment and information
• Anaesthesia and surgery with minimal morbidity and
complication
• Post-operative and post-discharge analgesia
• Discharge criteria and postoperative instructions
• Follow-up and audit
14. Criteria for suitable procedures
• Minimal physiological alterations
• No excessive blood loss and fluid shifts
• Duration of 1-2 hrs maximum
• Oral analgesia after discharge
• Patient reasonably ambulant after discharge
• Avoid surgical drains
• Urinary catheters may be used
• Ensure minimal complications
16. Selection criteria for patients
• Social criteria
• Age
• Criteria for fitness of patients for general
anaesthesia
17. Social criteria
• Responsible adult escort patient home …
• Few stairs to climb
Good toilet facilities
Access to telephone
• Should live within 1 hr of hospital facilities
• Ready access to GPs on discharge …
• Concept of hospital hotels overnight
supervision at low cost in hotels …
• Concept of hospital at home ….
18. Developing countries due to long
distance and difficult travelling, day
surgery introduction has been slow
pick up.
19. Age
• Upper age limit 70 years
• Physiological age is more important than
actual age
• Lower age limit facilities available
• Experienced staff
• Procedures undertaken
20. Criteria for selection of anaesthesia
• Patient
• Fit and ambulant
• Not grossly obese ( BMI <30 )
• Able to climb one flight of stairs
• Do not book patients with cardiovascular
disease
• Poorly controlled hypertension (BP > 170/100)
• Angina , CCF or PVD
• MI ,CVA or TIA in last 6 mnths
• Symptomatic valvular disease
• Cadio-myopathy
21. Contd …
• Respiratory disease
• Severe asthma or COPD
• Others
• IDDM or poorly controlled NIDDM
• Renal, hepatic disease
• Alcoholic , narcotic addiction
• Multiple sclerosis , myasthenia gravis
• Severe psychiatry disease
22. Contd …
• Do not book patient taking
• Anticoagulants
• Monoamine oxidase inhibitors
• Digoxin
• Systemic steroids
• Anti-arrhythmics
• Oral contraceptives
• GTN
23. Assessment before admission
• Surgeons are not good in assessing patients ….
• Anesthesiologists impractical ….time , cost ,
manpower-wise
• Alternative Filtering process
• Special nurses using planned questionnaire for
assessment
• Investigations done according to answers
• Anaesthesiologists review the case
24. Pre-admission information…
• On front page
• Time and date of operation with contact nos.
• Need for an escort or taxi to go home
• Females to notify DSU if pregnant or in menses
• Instructions not to drive for 48 hrs
• Fasting instructions
• Do not omit medication unless specified
• Instructions for clothing , valuables
25. Contd…
• Other information on day surgery
• Map , parking and how to find DSU
• Brief description of what will happen, PEMs
• Duration for stay and time for escort to come
• Post-anaesthetic restrictions on driving etc.
• Who to contact on discharge
26. Contd…
• Procedure specific information
• Procedure of operation
• Preoperative preparation
• Expected postoperative morbidity
• Rest duration
• Wound management , stitch removal and
follow up
27. Benefits of pre-admission clinic
• Problems sorted out before admission
• Unnecessary investigations reduced
• Cancellation on day of surgery reduced
• Patients better prepared and informed
• Non-attendance reduced
• Peri operative complications reduced
• Unplanned overnight admission reduced
28.
29.
30. Morbidity after day surgery
• Major
• Myocardial infarction
• Pulmonary embolus
• Respiratory failure
• Cerebrovascular accidents
• Major postoperative haemorrhage
• Unrecognised damage to viscus …..
31. Contd…
• Minor
• Pain
• Nausea and vomiting
• Dizziness and drowsiness
• Minor bleeding
• Infection
• Sore throat and headache ….
32. Anaesthesia
• Anaesthetic morbidity major reason for
unplanned readmission
• Two types
• Local /regional anaesthesia
• General anaesthesia
33. Local anaesthesia
• Ideal
• Excellent for elderly
• Economical
• BUT
• More time consuming
• Requires gentle hand
• Not preferred by patients
34. Contd…
• Types
• Spinal
• Caudal
• Epidural
• Disadvantage
• Time required to give and start action are more
• Delay in mobilization
• High incidence urinary retention
35. Contd …
• Drug used
• Long acting bupivacaine
• If increased speed of onset
lignocaine added
• Prilocaine , chloroprocaine Beir
block….
36. General anaesthesia
• Good for children
• Propofol drug of choice for IV induction
• Drug of choice for maintenance
• Good anaesthetic condition
• Rapid Problem-free recovery
• Incidence of post op nausea and vomiting is less
37. Contd…
• Inhalation induction
• Sevoflurane drug of choice for induction
• Has replaced halothane
• Maintenence volatile agent
• Isoflurane
• Enflurane
• Nitrous oxide in oxygen
38. Contd …
• Short acting opoid
• Alfentanyl or fentanyl
• Reduces dose
• Provide analgesia early post op
• Remifentanyl ultrashort acting opoid .
39. Analgesia
• Good pain control is essential to prevent
• Delay in discharge
• Unplanned overnight admission
• GP consultation after discharge
• Distress and dis-satisfaction
• Limitation to early mobilisation
• Prolongation of return to normal function
• Morphine
• Less used as sedative PONV
40. Contd…
• Multimodal analgesia
• NSAIDS
• Local anaesthetics
• Short acting opioid
• Oral analgesics 3-5 days post discharge
41. Discharge guidelines
• Oriented to time, place, person
• Tolerate oral fluids
• Can void
• Dress
• Walk without assistance
• Patient must not have
• Nausea and vomiting
• Excessive pain
• Bleeding or
• Fever
42. Follow-up audit and quality control
• Good day care surgery means reduction in:
• Nonattendance
• Cancellation
• Complication before and after discharge
• Overnight admission
• Readmission
• Are audited and improvement made
• Telephone call next day reassures patient
immediate feedback of analgesia and problems
43. Future
• It is not the Fastest surgery on the Fittest patient
• But has included older less fit patients with more major procedures
• And with advancement in medical science has good prospects
