This document discusses day care surgery, also known as ambulatory or same-day surgery. It defines different types of day surgery based on admission and discharge times. The ideal patient for day surgery is ASA 1 or 2, with no major medical comorbidities and a BMI under 40. Common orthopedic surgeries done as day cases are listed. Discharge criteria include being able to walk, having stable vitals and pain controlled with oral medications. Regional anesthesia techniques are described. The document outlines medication instructions and follow up plans provided to patients at discharge.

1. DAY CARE SURGERY
Speaker : Dr. S. M. Sufi Shafi- Ul- Bashar
Assistant registrar (Surgery)
MMCH

2. DEFINITION USED IN AMBULATORY
SURGERY
 Outpatient surgery: not admitted to a ward
facility
 Procedure room surgery: surgery not
requiring full sterile theatre facilities
 Day or same-day surgery: admitted and
discharged within the 12-hour day

3. DEFINITION USED IN AMBULATORY
SURGERY CONTD.
 Overnight stay: 23-hour admission with early
morning discharge
 Short-stay surgery: admission of up to 72
hours

4. DAY-SURGERY PATHWAY.
┌ Referring doctor
↓
Method to return patients
unsuitable for surgical
or medical reasons ← Specialist Consultation ┐
↓
Diagnostics+Optimisation
└ Preoperative Assessment ┘
↓
Schedule & Admission
↓
Surgery
↓
Unplanned overnight ← Recovery → Successful Discha
admission

5. CRITERIA
 Medical:
-Age- No upper age limit
-Comorbidity- ASA 1, ASA 2
-Obesity- BMI up to 40 for surface
procedures and 38 for
laparoscopic
procedures are acceptable in
advanced units.

6.  Social:
-A responsible adult carer must be
available for first 24 hours
-Home conditions need to be suitable
-Ability to contact hospital in an
emergency
 Surgical:
-Operations up to 2 hours

7. ADVANTAGES
 Patient Comfort
 Reduced burden of Hospital
 Reduced burden of Operative list
 Psychological advantages for child
 Parental preference
 Efficient use of facilities
 Efficient use of staff
 Reduced risk of cross infection
 Cost efficient – up to 50% saving

8. DISADVANTAGES
 Expensive drugs
 Expensive equipments
 Requires good monitoring & assessment
 Communication skills
 Unplanned postoperative admissions
 Delayed treatment of post-op complications

9. OPERATION IN DAY CARE SURGERY
Orthopaedics Surgery:
 Dupuytren’s fasciotomy,
 Carpal tunnel release,
 Bunion operations,
 Removal of metalwork
 Therapeutic arthroscopy of knee or shoulder,
 Arthroscopic meniscectomy
 Arthroscopic shoulder decompression

10. ANESTHESIA
GA
 Isoflurane / Desflurane / sevoflurane
 Propofol
 Nitrous oxide LMA with spontaneous ventilatio
 Tracheal intubation & controlled ventilation
(short acting NMBA & adequate reversal
ensured)

11. ANESTHESIA
 LA
 Spinal anesthesia Low dose (5mg
bupivacaine + 10mcg fentanyl diluted to vol.
of 3ml)
 Wound infiltration 0.5% bupivacaine /
levobupivacaine in volume approp. to size of
wound
 Regional nerve blocks Extensive shoulder/
knee surgery

12. DISCHARGE CRITERIA
Post Anaesthesia Recovery Score modified for Day
Surgery (Aldrete ’95):
 Activity
- Able to move four extremities voluntarily or on
command 2
-Able to move two extremities voluntarily or on
command 1
-Unable to move extremities voluntarily or on
command 0
 Respiration
- Able to breathe deeply and cough freely 2
-Dyspnoea or limited breathing 1
-Apneic 0

13. DISCHARGE CRITERIA CONTD.
 Circulation
- BP ± 20% of preanaesthetic level 2
- BP ± 20 to 49% of preanaesthetic level
1
- BP ± 50% of preanaesthetic level 0
 Consciousness
-Fully awake 2
-Arousable on calling 1
-Not responding 0

14. DISCHARGE CRITERIA CONTD.
 Oxygen saturation
-Able to maintain saturation >92% on room air
2
-Needs oxygen to maintain saturation >90% 1
-SpO2 <90% even with oxygen 0
 Dressing
- Dry and clean 2
-Wet but stationary or marked 1
- Growing area of wetness 0

15. DISCHARGE CRITERIA CONTD.
 Pain
-Pain free 2
- Mild pain handled by oral medication 1
- Severe pain requiring parenteral medication
0
 Ambulation
-Able to stand up and walk straight 2
-Vertigo when erect 1
-Dizziness when supine 0

16. DISCHARGE CRITERIA CONTD.
 Fasting-feeding
-Able to drink fluids 2
- Nauseated 1
- Nausea and vomiting 0
 Urine output
-Has voided 2
-Unable to void but comfortable 1
-Unable to void and uncomfortable 0
SCORE ≥ 18 FIT FOR DISCHARGE

17. RECOVERY FROM REGIONAL
ANESTHESIA
 Assess Return of anal tone
 Passage of urine (bladder func.)
 Power of limbs
 Recovery of proprioception

18. MEDICATION AND ADVICE DURING
DISCHARGE
 Specific instructions regarding prescribed
analgesia, antiemetics or antibiotics &
Procedure specific information.
 Wound care & when patient is able bath or
shower
 Arrangements for dressing renewal and
suture removal (if appropriate)
 Resuming normal activities

19. MEDICATION AND ADVICE DURING
DISCHARGE CONTD.
 What ‘normal’ symptoms may be expected
and their duration.
 What would be abnormal symptoms and
what to do if they occur.
 Contact telephone numbers for information
or in an emergency Arrangements for follow -
up (telephone and out-patients).

20. FUTURE DEVELOPMENTS:
 Sending pts with catheter/ Drains in situ
 2 incision hip replacement
 Single compartment knee replacement

21. THANK YOU