DAY CASE ANAESTHESIA Dr. Omar Mohamed DanfourSenior Lecturer –Specialist of Anesthesia & Intensive Care (MSU-IMS-Anesthesia Department)
Day Case Aneasthesia Another Name• Ambulatory surgery• Day-case surgery• Same-day surgery• Come and go surgeryPt. who is admitted for investigation or operation ona planned non-resident basis. The pt occupies a bedin a ward or unit set aside for this purpose.Outpatient surgery allows a person to return homeon the same day that a surgical procedure isperformed.
Day Case Aneasthesia During the last 30 years, there has been rapidexpansion in the use of day-case surgery. In the last 25 years, the percentage of pts goinghome the same day has increased from < 10% toapproximately 65% in the united states At the inception of day-case procedures, a case wasconsidered suitable if it took less than 90 min tocomplete (do not cause sever haemorrhage orproduce excessive amounts of postoperative pain).
Day Case Aneasthesia• because investigators have found that the operating and anesthetic time is a strong predictor of postoperative complications (e.g., pain, emesis)and delayed discharge, as well as unanticipated admission to the hospital after ambulatory surgery . With regard to the distance from the hospital to the pt’s home, and a responsible adult must be at home with the pt during first 24 h after surgery The growth in ambulatory surgery would have not been possible without the development of improved anesthetic and surgical techniques.
Day Case Aneasthesia The availability of rapid, shorter -acting anesthetic, analgesic, and muscle relaxant drugs has clearly facilitated the recovery process and allowed more extensive procedures to be performed on an ambulatory basis, irrespective of preexisting medical conditions. Surgical procedures suitable for ambulatory surgery should be accompanied by minimal postoperative physiologic disturbances and an uncomplicated recovery. Prolonged stay or unanticipated admission after day - case surgery are related to the surgical procedure (e.g., blood loss, pain, postoperative nausea and
Advantages of DCA• Significant reduction in medical costs• Increased availability of indoor beds• Better comfort and greater control over the patient’s business and personal lives• Some protection from hospital acquired infections and deep vein thrombosis• Less social disruption to patients and their families and minimal need for inpatient hospital resources• Particularly in children short separation from parents and family is very beneficial to the reduce separation-induced anxiety problems• Faster recovery, more rapid discharge and better pain relief for outpatients.• Less preoperative testing and postoperative medication
Surgical procedures commonly undertaken as day cases1. Gynaecology:- (Dilatation & curettage, Laparoscopy, Vaginal termination of pregnancy colposcopy & hysteroscopy.2. Plastic Surgery:- (Dupuytren’s contracture release, removal of small skin lesion, nerve decompression3. Ophthalmology:-(Strabismus correction, lacrimal duct probing, cataract surgery & examination under G.A).4. ENT:- (Adenoidectomy, tonsillectomy, Myringotomy, insertion of grommets, removal of foreign body, polyp removal & submucosal resection).5. Urology:- (Cystoscopy, Circumcision, Vasectomy)6. Orthopaedics:- (Arthroscopics, Carpal tunnel release, anal fissure, Ganglion removal, Lab Cholecystectomy & Haemorroidectomy )7. General Surgery:- (Breast lumps, Herniae, Varicose veins, Endoscopy8. Paediatrics:- (Circumcision, Orchidopexy, Squint, Dental extractions)
Guidelines for patient selection for day-case surgery under G.AA- Patients should normally be ASA I , ASA II, or medically sable ASA III only, i.e. normally healthy people & those with minor systemic disease not interfering with normal activities a pt with moderate to severe systemic disease & some functional limitation• Age: > 52 Weeks post-conception age• Weight: BMI < 30, (31-34 discuss with anaesthetic deparment)• Generally healthy i.e. can climb two flight of stairsB- Patients Exclusions:1- Cardiovascular• M.I/TIA/CVA within 6 months• Hypertension (persistent diastolic > 110mmhg)• Angina and low exercise tolerance• Arrhythmias & heart failure & symptomatic valve disease
2- Respiratory:• Acute respiratory tract infection• Asthma requiring regular β2-agonists or steroids3 Metabolic:• Alcoholism/narcotic addiction• Insulin-dependence diabetic• Renal failure & or Liver failure4- Neurological /Musculoskeletal 5- Drugs• Arthritis of jaw or neck, cervical spondylosis or Ankylosing Spondylosis • Steriods• Myopathies, muscular dystrophies or • Monoamine Myasthenia gravis oxidase inhibitors• Advanced multiple sclerosis • Antocoagulants• Epilepsy >3 fits per year • Antiarrhythmics • Insulin
Facilities AvailableThe hazards and risks of day-surgery general anesthesia are no less than those for in-patient surgery; indeed, in some respects they may be greater and the facilities provided must be comparableThere is always the possibility of a minor operation developing into a major operation and this demands that the theatre is well equipped to deal with this eventuality.1- An admission area:- Reception, treatment & examination rooms, a nurses station, lavatories, a playroom and a discharge area.2- An anesthetic room:- fully equipped, good lighting, scavenging, piped gases and suction equipment, anesthetic machine & monitoring equipment.
Facilities Available3- An operating theater:- Should be of the same specification as the in –patient equivalent. A good operating lighting light, air-conditioning, scrub-up and autoclave facilities4- A fully equipped recovery room:- must always be equipped and staffed for the safe recovery of patient after G.A. Piped gas supplies and resuscitation equipment are mandatory and the full range of monitoring and ventilation equipment must be readily availableOther facilities that should be available include office space, equipment store, staff room, a panty to make drink and lavatories for patients, parents and staff.
O.T PreparationOutpatient surgery Equipments: requires the same basic – SPO2 equipment as inpatient – BP & ECG surgery – ETCO2Equipments: – Temperature – Anaesthetic machine – Invasive IABP, CVP, PA & monitors – Nerve stimulator – Airway and intubation – BIS (Bispectral Index adjuncts monitor) – Suction apparatus – Gas analysis – IVD – Drugs – Warming devices – Trolley – Spinal, CVP – Trained assistance
Monitor LaryngoscopeO2 Anc. MachineIV line Stethoscope Defibrillator Suction
• The role of anesthetists for out pt surgery is enormous particularly regarding pt selection, preoperative evaluation & preparation, intra-operative anesthesia management, post operative care and safe discharge from out pt clinic. In Unexpected adverse situations, the pt may need hospitalization as per advice of the anesthetist concerned.• There should be adequate number of house officers , nurses,& other personnel & at least one senior anesthetist.
Admission• Pts should be admitted to the ward in adequate time for history-taking and examination• Any investigation requested as an out pts should be available and noted.• The surgeon should ensure the indication for surgery is still present• The consent form should be signed if not already done.• The operation site should be marked• A pregnancy test in women of fertile age• Staggering patient admission decreases waiting times and improve the efficiency of the unit.
Pre-operative Management• Pre-operative Assessment.• Pre-operative Preparation.• Premedication.The purposes of pre-operative visit.• History taking.• Physical Examination.• Risk Assessment.• Common causes for postponing Surgery.
premedicationNot routinely prescribed for day cases, as it is usually unnecessary. Drug that may be used include the following:A- Benzodiazepines:• Temazepam 10-20 mg is effective anxiolytic for day cases, no delay in recovery times as measured by memory test cards and all pts were discharged from the day unit 3 h after administration of GA.• Oral Midazolam has been used, but it associated with delay in immediate and late recovery compared with TemazepamB- Antiemetic:• Oral or & I.V, antiemetic may administered before operation or rectal antiemetic perioperatively if pts are at high risk of postoperative nausea and vomiting (PONV).
C- Antacids:• If there is a risk of acid reflux, H2-antagonist are commonly prescribed as a premedication in day surgery.D- Analgesics:• Routine use of narcotic (opioid) analgesics for premedication is not recommended unless the patient is experiencing acute pain• Oral NSAIDs and paracetamol may be given preoperatively if declines rectal route perioperatively• Oral COX II inhibitors have better GIT side effect profiles than NSAIDs and less antiplatelet effects• Pt satisfaction with self- administration of rectal Diclofenac preoperatively has been reported• Dermal application of tetracaine over a vein has a useful role for children & nervous adults or those with a neddle phobia.
Optimal Anesthetic Techniques• The optimal anesthetic technique in the ambulatory setting would provide for excellent operating conditions, rapid "fast-track" recovery without postoperative side effects or complications, and a high degree of patient satisfaction.• General, local, & regional anesthesia may be administered safely to day-case pt. The choice of technique should be determined by surgical requirements, anesthetic consideration, and patient’s physical status and preference.
General Anesthesia 2For many ambulatory procedures, general anesthesia remains the most popular technique with both patients and surgeons. 3
General AnesthesiaAny induction agents used in day-case anesthesia should ensure a smooth induction, good immediate recovery and a rapid return to street fitness.• Propofol is now used widely as the primary induction agent which has advantage of rapid recovery & low incidence of PONV.• Thiopental (3 to 6 mg/kg) is the prototypical intravenous induction drug with a rapid onset and a relatively short duration of action as a result of redistribution of the drug . However, thiopental impairs fine motor skills for several hours after surgery and can produce a "hangover“ sensation
• ketamine compares unfavorably with both the barbiturates and propofol for minor gynecologic procedures because of its prominent psychomimetic effects and higher incidence of PONV during the early postoperative period• Although midazolam (0.2 to 0.4 mg/kg IV) has been used for induction of anesthesia in outpatients, its onset of action is slower and recovery is prolonged in comparison to the barbiturate compounds and propofol.• Sevoflurane is the agent of choice for inhalational induction with advantage of Non irritant to the airways, rapid induction in both children & adults, minimal cardiovascular side effects. However, sevoflurane causes more PONV than propofol.
Maintenance of anesthesia:• Both sevofurane & desflurane are ideal agents for day- case anesthesia• Volatile anesthetics are associated with a higher incidence of vomiting in the early recovery period than propofol based anesthetic techniques• Nitrous oxide increase the risk of PONV, but it reduce the requirements for volatile agents & risk of intraoperative awareness.• Target-controlled infusion (TCI) of propofol with or without the ultra-rapid-acting opioid remifentanil are techniques which have minimal risk of PONV & short recovery time.
• Morphine, hydromorphone, oxymorphone, and meperidine have all been used in outpatient anesthesia However, these opioid compounds are less popular than the more potent, rapid, and shorter-acting opioid analgesics (e.g., fentanyl, sufentanil, alfentanil, and remifentanil).• The laryngeal mask airway (LMA) is used widely & avoids for intubation & extubation, which improves turnaround time between cases.• The incidence of postoperative sore throat after ambulatory surgery was 18% with an LMA versus 45% with a tracheal tube and 3% with a face mask.• Patient at risk of aspiration still require a rapid- sequence induction technique with tracheal intubation or in these situations to minimize the risk of gastric distention and ensure adequate ventilation in the Trendelenbmg posinduction .
• Many superficial outpatient surgical procedures do not require the use of neuromuscular relaxants.• When remifentanil is used in combination with propofol for induction of anesthesia, tracheal intubation can be performed without any muscle relaxants .• The choice of MR depends on the anticipated duration of surgery. Succinylcholine is associated with muscle pains, especially in ambulant patients and it is not ideal in the day-case setting.• NDMRs: Use of the short- and intermediate-acting nondepolarizing muscle relaxants (e.g., cisatracurium, mivacurium) allows reversal of neuromuscular blockade even after brief surgical procedures• Mivacurium may be advantageous for use during the maintenance period because reversal is seldom required if the drug is properly titrated
Antagonist (Reversal) Drugs• Antagonists may also produce unwanted side effects (e.g., dizziness, headaches, PONV) that should be considered before routinely using these drugs.• In addition, because their duration of action is often shorter than the agonist (e.g., naloxone, flumazenil), a "rebound“ of the agonist effect may occur.
Regional AnesthesiaRegional anesthesia can offer many advantages for the ambulatory patient population . Spinal anesthesia has been used for day-case anesthesia, but the side effects of post-dural puncture headache & motor weakness, dizziness, urinary retention, and impaired balance may delay ambulation & discharge. Smaller-gauge pencil spinal needles have reduced the incidence of PDPH• Shorter-acting local anesthetics may increase the use of day-cases. Prilocaine, Mepivacaine with or without opioid (pethidine, fentanyl), have also been used for out patient.• Bupivacaine (3ml 0.17%) + 10μ Fentanyl has been used successfully for knee arthroscopy
Epidural anesthesia is technically more difficult to perform, it has a slower onset of action, the potential for intravascular or intra-thecal injection exists, and it is associated with a greater chance of an incomplete sensory block than spinal anesthesia.Caudal block is used to reduce pain in paediatric pts for circumcision, herinorraphy, hypospadias or orchidopexy using 0.25% plain bupivacaine; this provides excellent post operative analgesia.Local anesthetic block are an excellent choice for day-case pts because of the low incidence of PONV & good post operative analgesia
Peripheral nerve blocks facilitate the recovery process by minimizing the need for postoperative opioid analgesics.Therefore, an increasing number of ambulatory cases are being performed with a combination of local anesthetic nerve blocks and intravenous sedation (so-called monitored anesthesia care [MAC])• Femoral & sciatic N B give superior analgesia after complex knee surgery• L.A blocks e.g. ilioinguinal Nerve Block for inguinal hernia repair, Brachial plexus block for hand & armIntra-articular local anesthetics are useful following arthroscopy of the knee or shoulder.intravenous regional anesthesia (Bier’s block) For short superficial surgical hand & forearm procedures «60 minutes) limited to a single extremity, technique with 0.5% Lidocaine is a simple and reliable technique
Monitored Anesthesia Care Cerebral Monitoring• Monitoring patient vital signs remains the most common method for determining the "depth of anesthesia" during surgery.• Recent studies have suggested that the use of cerebral monitoring improves early recovery after general anesthesia in the ambulatory setting because of its ability to minimize both "overdosing" and "underdosing “ with both intravenous (e.g., propofol) and inhaled anesthetic (e.g., sevoflurane and desflurane) drugs during the maintenance period.
Recovery and Post operative care• The recovery area should be provided with the same range of monitoring equipment and resuscitation facilities as available in an inpatient facilities.• Post operative pain control should be started pre-or intra- operatively by IV or inhalational anesthesia with combination of NSAIDs, Paracetamol, shorter acting opioid and local/regional block• For routine antiemetic prophylaxis, the most cost-effective combination consists of low dose droperidol (0.5 to 1 mg) and dexamethasone (4 to 8 mg).• PONV may be treated with IV 5HT3 antagonist, dexamethasone, or cyclizine & IM prochloroperazine as well as adequate analgesia & hydration.
Recovery• The three stages of recovery after ambulatory surgery are the early, intermediate, and late recovery periods .• The early and intermediate recovery stages occur in the ambulatory surgical facility, whereas• The late recovery refers to the resumption of normal daily activities and occurs after discharge home
Early recovery• The time interval during which patients emerge from anesthesia, recover control of their protective reflexes, and resume early motor activity.• During this phase of recovery, patients are cared for in the post anesthetic care unit PACU, where their vital signs and oxygen saturation are carefully monitored and supplemental oxygen, analgesics, or anti emetics can be readily administered.
Intermediate recovery• During the intermediate recovery period, patients are usually cared in a reclining chair and progressively begin to ambulate, drink fluids, void, and prepare for discharge.• Most ambulatory surgical facilities have a separate area for the intermediate recovery of outpatients to a home-ready state
late recovery• The late recovery period starts when the patient is discharged home and continues until functional recovery is achieved and the patient is able to resume normal activities of daily living.• The anesthetics, analgesics, and anti emetics can also have an effect on the patients recovery during the post-discharge period.• However, the surgical procedure itself has the highest impact on the patients full functional recovery.
Factors that predict a more prolonged stay in the day-surgery unit include female gender, advanced age, longer operations, large fluid or blood loss and opioid use, nondepolarizing muscle relaxants, postoperative pain and PONV, and spinal anesthesia.
DISCHARGE CRITERIADischarge after General Anesthesiaand Monitored Anesthesia CareGuidelines for safe discharge from an ambulatory surgical facility include stable vital signs, return to baseline orientation, ambulation without dizziness, minimal pain and PONV, and minimal bleeding at the surgical site.
Patients who achieve a score of 9 or greater and have anadult escort are considered fit for discharge (or home ready).
Discharge After Regional AnesthesiaWith spinal or epidural anesthesia,• It is generally accepted that motor and sensory function returns before sympathetic nerve function.• Residual blockade of the sympathetic nerve supply to the bladder and urethra may cause urinary retention.• Before ambulation, these patients should have normal perianal (S4-5) sensation, the ability to plantar-reflex the foot, and proprioception of the big toe.• Thus, discharge criteria after spinal and epidural anesthesia should include the return of normal sensation, muscle strength, and proprioception, as well as the return of sympathetic nervous function.
General Advises• Pts should be advised against driving, Operating power tools, making important decisions, and ingesting alcohol for at least 24 hrs after the procedure.• Pts should be advised that they may experience pain, headache, nausea, vomiting, dizziness, and skeletal muscle aches and pains that can’t be attributed to the surgical incision• It must be confirmed that a responsible adult will accompany (drive) the pt home and if appropriate remain with the pt for some period of time• At some facilities, staff members telephone the pt the next day to determine the progress of recovery.