This document discusses day care or ambulatory surgery. It defines day care surgery as when a patient is admitted and discharged within a 12-hour period for a specific procedure. The document outlines the advantages of day care surgery such as reduced costs and stress. It discusses selection criteria for patients, including medical, social, and surgical factors. It also covers the preoperative, perioperative, and postoperative management of patients undergoing day care surgery. The key requirements for successful day care surgery are also summarized.

1. DAY CARE SURGERY
PRESENTED BY: DR SANISH MANANDHAR
1ST-YEAR RESIDENT (GENERAL SURGERY)
FACILITATOR: ASSOCIATE PROF. DR DEEPAK RAJ SINGH

2. DAY CARE SURGERY
•Day-case surgery / Ambulatory surgery / Outpatient surgery / Same-
day surgery / Come-and-go surgery
•Definition – Admission and discharge of a patient for a specific
procedure within the 12-hour working day.
•Patient pathway; NOT a surgical procedure.
•Extends from patient first contact to final discharge.

3. TERMS AND DEFINATIONS
•Outpatient surgery – not admitted to a ward facility
•Procedure room surgery – not requiring full sterile theatre facilities
•Same-day surgery – admitted and discharged within 12-hour
•Overnight stay – 23-hour stay with early morning discharge
•Short-stay surgery – admission of up to 72 hours

4. ADVANTAGES
•Reduction of stress
•Decreased medical costs – doesn’t need a hospital stay
•Increased availability of beds for patients who require hospitalization
•Protection of immunocompromised patients from hospital-acquired
infections
•Avoidance of disruption of the family unit by hospitalization.

5. ELECTIVE DAY SURGERY PATHWAY
•For Success
• Each component is required to be safe and efficient
• Performed in sequence

6. UNPLANNED OVERNIGHTADMISSION
•Minimized by:
• Patient fit for the procedure
• Procedure itself is achievable as a day case
• Procedure is scheduled early on the operating list to allow safe recovery
and discharge
• Home environment can support a post-operative ambulatory patient.

7. MODELS OF CARE
•Office-based care
•Stand-alone day surgery facilities
•Self-contained integrated day surgery facilities
•Integrated day and short-stay surgery facilities

8. SELECTION CRITERIA
•A. MEDICAL CRITERIA
• 1. Age
• No upper age limit
• Physiological status – better determinant of day-care surgery success
• 2. Comorbidity
• ASA classification – crude evaluation of chronic health
• ASA I and II – stand-alone unit
• ASA III and above – hospital integrated unit

9. SELECTION CRITERIA
•A. MEDICAL CRITERIA
• 3. Diabetes
• Well-controlled Type 1 and Type 2 DM – good candidates
• Associated with potentially severe comorbidities
• Success – ensuring these patients return to normal eating and drinking and
managing their own diabetes as quickly as possible postoperatively

10. SELECTION CRITERIA
•A. MEDICAL CRITERIA
• 4. Epilepsy
• Well-controlled epilepsy – managed as normal patients
• Regular medication should not be omitted
• Poorly controlled epilepsy – careful review and discussion with the medical
and anaesthetic teams
• Suitable home care = Suitable day surgery

11. SELECTION CRITERIA
•A. MEDICAL CRITERIA
• 5. Obesity
• Intraoperative and postoperative complications
• Common comorbidities associated with obesity
• Selected and optimized patients – BMI up to 40 (surface procedures) and 38
(laparoscopic procedures) are acceptable in advanced units
• 6. Anticoagulants
• For – atrial fibrillation, previous thromboembolism
• Should be discontinued before surgery
• Discussed with cardiologist and risk involved explained to the patients

12. SELECTION CRITERIA
•B. SOCIAL CRITERIA
• Safe and comfortable discharge – patient to be accompanied by a
responsible and physically able adult to remain with them overnight
• Home circumstances
• Toilet facility
• Means to contact the hospital
• Journey time to home ≤ 1 hour (the comfort of the journey - more relevant)

13. SELECTION CRITERIA
•C. SURGICAL CRITERIA
• Procedures up to 2 hours
• Recognized day surgery procedure
• Degree of surgical trauma – a procedure with abdominal and thoracic
cavity entry confined to minimal access technique
• Main requirement - Suitable control of pain and ability to drink and eat
in a reasonable time

14. PREOPERATIVE ASSESSMENT
•Evaluation and optimization of patient’s fitness for surgery
•Performed by specialist consultants and anaesthetists
•Basic health screening – BMI, BP, past medical history & current
medications
•Appropriate preoperative investigation
•Verbal and written information to patient and carer – admission,
operation and discharge
•Performed early – to allow time to optimize health problem

15. PERIOPERATIVE MANAGEMENT
•Scheduling
•Anesthesia and analgesia
•Postoperative complications

16. SCHEDULING
•Major surgery – scheduled early (allow maximum recovery time)
•General anaesthesia cases → regional and local anaesthesia cases
•Mixing day cases with inpatient cases – day cases should go first
•Mixing day cases with critical inpatient cases – not advisable

17. ANAESTHESIAAND ANALGESIA
•Successful day surgery anaesthesia – multimodal anaesthesia
•Preoperative period – full oral doses of PCM and NSAIDs
•Intraoperative period
• Inhalation agents
• TIVA using propofol – reduces PONV
• Short-acting opioids – Fentanyl [if Morphine used – small doses (under
0.1mg/kg)]
• Long acting LA- Bupivacaine

18. ANAESTHESIAAND ANALGESIA
•Postoperative
• Pain level routinely monitored
• Further dose of PCM, fentanyl, low dose morphine
• Patient should be comfortable prior to return to the ward

19. POSTOPERATIVE COMPLICATIONS
•Proactive monitoring before discharge
•Same as that of normal surgery (Haemorrhage, PONV, postoperative
pain)
•Most common anaesthetic-related cause of postoperative admission
• Inadequate recovery from anaesthesia
• Uncontrolled nausea and vomiting
• Inadequate pain control

20. ELECTIVE DAY SURGERY
•REQUIREMENTS FOR SUCCESSFUL DAY SURGERY
• Minimal access technique
• Good haemostasis
• Avoidance of unnecessary tissue handling and tension

22. EMERGENCY DAY SURGERY

23. EMERGENCY DAY SURGERY
•Traditional day surgery selection criteria are ignored
•Clinical judgement – whether the patients are appropriate for day
surgery
•Absolute contraindications – systemic sepsis, unstable diabetes,
major comorbidities

25. DISCHARGE
•Postoperative review by the surgical team
•Suitable supply of analgesics
•Discharge by trained day-surgery nurses using strict
discharge criteria

26. DISCHARGE CRITERIA
•Vital signs stable for at least 1 hour
•Correct orientation as to time, place and person
•Adequate pain control with the supply of oral analgesia
•Understands how to use oral analgesia supplied
•Ability to dress and walk, where appropriate
•Minimal nausea, vomiting or dizziness
•Has taken oral fluids

27. DISCHARGE CRITERIA
•Minimal bleeding or wound drainage
•Has passed urine
•Has a responsible adult take them home
•Has a carer at home for the next 24 hours
•Written and verbal instructions are given about postoperative care
•Knows when to come back for follow up
•Emergency contact number supplied

28. THANK YOU