This document discusses day case or ambulatory surgery. It notes that over the last 30 years, there has been rapid expansion in the use of day-case surgery, with the percentage of patients going home the same day increasing from less than 10% to approximately 65%. Suitable procedures are those that take less than 90 minutes, do not cause excessive bleeding or pain, and are accompanied by minimal postoperative disturbances. The growth of ambulatory surgery has been facilitated by improved anesthetic techniques and drugs that allow for faster recovery. Regional anesthesia and nerve blocks can also benefit recovery. Guidelines for safe discharge include stable vital signs and adequate pain control and mobility.

1. Prep by Mukhtiar Ahmad
Lecturer anesthesia
IPMS-KMU Peshawar

2. Another Name
 Ambulatory surgery
 Day-case surgery
 Same-day surgery
 Come and go surgery
 Day Case Anesthesia
 Pt. who is admitted for operation on a planned non-
resident basis. The pt occupies a bed in a ward or unit
set aside for this purpose.
 Outpatient surgery allows a person to return home on
the same day that a surgical procedure is performed.

3.  During the last 30 years, there has been rapid
expansion in the use of day-case surgery.
 In the last 25 years, the percentage of pts going home
the same day has increased from < 10% to
approximately 65%
 At the inception of day-case procedures, a case was
considered suitable if it took less than 90 min to
complete (do not cause sever hemorrhage or
produce excessive amounts of postoperative pain).

4.  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.

5.  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 vomiting
(PONV).

6.  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
 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

7.  Gynaecology Dilatation & curettage, Laparoscopy, Vaginal termination
of pregnancy colposcopy & hysteroscopy.
 Plastic Surgery contracture release, removal of small skin lesion, nerve
decompression
 Ophthalmology Strabismus correction, Lacrimal duct probing, cataract
surgery & examination under G.A
 ENT Adenoidectomy, tonsillectomy, Myringotomy, insertion of
grommets, removal of foreign body, polyp removal
 Urology Cystoscopy, Circumcision, Vasectomy)
 Orthopaedics Arthroscopics, Carpal tunnel release. Reductions Ganglion
removal,
 General Surgery Breast lumps, Herniae, Varicose veins, Endoscopy, anal
fissure, Lap Cholecystectomy & Haemorroidectomy
 Paediatrics Circumcision, Orchidopexy, Squint, Dental extractions
polypectomy

8.  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
 Age: >50
 Weight: BMI < 30, (31-34 discuss with anaesthetic
deparment)
 Generally healthy i.e. can climb two flight of stairs

9. 1: Cardiovascular
 M.I/TIA/CVA within 6 months
 Hypertension (persistent diastolic > 110mmhg)
 Angina and low exercise tolerance
 Arrhythmias & heart failure & symptomatic valve
disease

10. 2: Respiratory:
 Acute respiratory tract infection
 Asthma requiring regular β2-agonists or steroids
3: Metabolic:
 Alcoholism/narcotic addiction
 Insulin-dependence diabetic
 Renal failure & or Liver failure
4: Neurological /Musculoskeletal
 Arthritis of jaw or neck, cervical spondylosis or Ankylosing
Spondylosis
 Myopathies, muscular dystrophies or Myasthenia gravis
 Advanced multiple sclerosis
 Epilepsy >3 fits per year

11. 5- Drugs
 Steriods
 Monoamine oxidase inhibitors
 Antocoagulants
 Antiarrhythmics
 Insulin

12.  An anesthetic room:- fully equipped, good
lighting, scavenging, piped gases and suction
equipment, anesthetic machine & monitoring
equipment.
 An operating theater:- Should be of the same
specification as the in –patient equivalent
 A fully equipped recovery room

13.  Equipments:
 –Anaesthetic machine & monitors
 –Airway and intubation adjuncts
 –Suction apparatus
 –IV device
 –Drugs
 –Warming devices
 –Trolley – Spinal, CVP
 –Trained assistance

14. Equipments:
 –SPO2
 –BP & ECG
 –ETCO2
 –Temperature
 –Invasive IABP, CVP
 –Nerve stimulator
 –Gas analysis

16.  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

17.  Pre-operative Assessment.
 Pre-operative Preparation.
 Premedication.
 The purposes of pre-operative visit.
 History taking.
 Physical Examination
 Investigation
 Risk Assessment.
 Common causes for postponing Surgery.

20.  Not routinely prescribed for day cases, as it is
usually unnecessary. Drug that may be used
include the following
A- Benzodiazepines
B- Antiemetic
C- Antacids
D- H2-antagonist (If there is a risk of acid reflux)
E- Analgesics
 Routine use of narcotic (Opioids) analgesics for
premedication is not recommended unless the
patient is experiencing acute pain (Oral NSAIDs
are used)

22.  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.

23. For many ambulatory procedures,
general anesthesia remains the most
popular technique with both
patients and surgeons.

24. Any induction agents used in day-case anesthesia
should ensure a smooth induction, good immediate
recovery and a rapid return to street fitness.
 Propofal 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

25. 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
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

26.  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

27. Sevoflurane & 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 or TIVA of propofol
with or without the ultra-rapid-acting opioid
remifentanil are techniques which have minimal
risk of PONV & short recovery time.

28.  Opioids fentanyl, sufentanil, alfentanil, and
remifentanil) are used due to ultra short time effect
 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
DCA 18% with an LMA
45% with a tracheal tube and
3% with a face mask.
 RSI Patient at risk of aspiration still require a
rapid- sequence induction technique with tracheal
intubation

29.  Many superficial outpatient surgical procedures do
not require the use of neuromuscular relaxants
 When Remifentanil is used in combination with
propofal for induction of anesthesia, tracheal
intubation can be performed without any muscle
relaxants
 Succinylcholine is associated with muscle pains,
especially in ambulant patients and it is not ideal in
the day-case setting.

30. 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
 Atracurium are used during day case anesthesia

31.  Neostigmine
Antagonists may also produce unwanted side
effects (e.g., dizziness, headaches, PONV) that
should be considered before routinely using these
drugs.
 Naloxone
 Flumazenil

32.  Regional 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.

33.  Epidural anesthesia 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

34. 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
Peripheral nerve blocks facilitate the recovery
process by minimizing the need for postoperative
opioid analgesics.
L.A blocks(infiltration) e.g. ilioinguinal Nerve
Block for inguinal hernia repair, Brachial plexus
block for hand & arm

35.  Female gender,
 Advanced age,
 Longer operations,
 Large fluid or blood loss
 Opioids use
 Nondepolarizing muscle relaxants
 Postoperative pain and PONV
 Spinal anesthesia

36.  Guidelines for safe discharge from an ambulatory
surgical facility include
 Stable vital signs
 Return to baseline orientation,
 Ambulation without dizziness,
 Minimal pain and PONV,
 Minimal bleeding at the surgical site.

38.  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.

39. THANK YOU