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Day case surgery
- 1. DAY CASE SURGERY Dr.Alumona
- 2. OUTLINE • Introduction – Definition –Other forms of ambulatory surgery – Surgical importance – History • Models of care – Office based care – Stand alone day surgery facility – Self contained Integrated Day surgery facility – Integrated day and short stay surgery facility • Day Case Work Flow • Common Day case procedures
- 3. Outline cont… • SelectionCriteria – Patient/medical criteria – Social criteria – Surgical criteria • Pre-operative issues, assessment & management – Pre existing organ function – Nutritional status – Physical fitness – Pre operative fasting – Patients education and consent – Pre operative instruction form • Peri operative management & scheduling – The theater list – Pre medication
- 4. Outline cont… • Intraoperative issues and management – Anaesthetic technique – Maintenance of normothermia – Fluid management – Minimization of Incision and Mini Invasive Surgery • Post operative issues – Pain, PONV etc – Post op feeding – Mobilisation – Drains & catheters • Discharge • Follow up • Challenges in the developing world • Conclusion
- 5. INTRODUCTION • The plannedadmission and discharge of a patient for a specific surgical procedure within the 12-hour working day • Requires full sterile theater and recovery room facility • A patient pathway extending from first contact to final discharge • Success demands that each component of this pathway is safe, efficient and performed in sequence
- 6. Intro. Cont… • Otherforms of ambulatory surgery – Outpatient surgery: not admitted to a ward facility – Procedure room surgery: surgery not requiring full sterile theater facility – Overnight stay/ 23-hour stay: overnight admission with early morning discharge – Short stay surgery: admission up to 72 hours – Inpatient surgery: Requires more prolonged admission. Patients who are planned as inpatients but discharged home the same day of surgery counts as Inpatients with zero length of stay
- 7. Surgical Importance • Daycase surgery represents high-quality patient care with excellent patient satisfaction • Shorter hospital stay and early mobilization reduce rates of hospital-acquired infections and venous thromboembolism • Ensures smaller patient waiting times, less risks of cancellations, reduces demands on healthcare resources (human, non human and financial), less interruption to social life of patients
- 8. History – James Nicoll:20th century Glaswegian surgeon. 9000 paediatric day case procedures. Motivated by financial benefits, concerns over hospital acquired infections and lack of bed space – 1951: first Hospital based day surgery unit opened in the US, UK (1969) – 1989: formation of British association of Day case Surgery (BADS). International Association of Ambulatory surgery (1995)
- 9. Models of Care •Office based care – Diagnostic and ambulatory interventions are performed in consultation premises – Provides readily accessible health care to patients – Limited to procedure under local anaesthesia +/- conscious sedation
- 10. Stand Alone daysurgery facility – A free standing unit not geographically or administratively part of any other health care facility or – A hospital satellite unit which is located away from the parent hospital or within the campus – Cases limited to procedures under LA & RA, minor to intermediate procedures under GA
- 11. Self contained integrated facility/Hospitalautonomous unit – Structurally part of a hospital but functionally separate – Self sufficient: have own reception, ward, theater, and recovery areas – Do not take emergency admissions – Have access to parent hospital facility if required
- 12. Integrated day andShort stay surgery facilities • The hospital OT and recovery rooms are used for both day cases and inpatients • More challenging day case procedures can be carried out
- 13. Day case surgeryPathway Pt allowed home to await surgery 1-3 days before, team member calls each pt to access availability Pt is reviewed by surgeon and anaesthetic Fit pt sent to discharge process Unfit pt are admitted to the ward
- 14. Common Day caseprocedures (BASKET OF 25) • 1. ORCHIDOPEXY • 2. CIRCUMCISION • 3. INGUINAL HERNIA REPAIR • 4. EXCISION OF BREAST LUMP • 5. ANAL FISSURE DILATATION & SPHICHTEROTOMY • 6. HAEMORRHOIDECTOMY • 7. LAPAROSCOPIC CHOLECYSTECTOMY • 8. VARICOSE VEIN STRIPPING AND LIGATION • 9. TRANSURETHRAL RESECTION OF BLADDER TUMOUR • 10. EXCISION OF DUPUYTRENS CONTRACTURE • 11. CARPAL TUNNEL DECOMPRESSION • 12. GANGLION EXCISION • 13. HYDROCELE • 14. SURGERY FOR HALLUX VALGUS • 15. REMOVAL OF METALWARE • 16. EXTRACTION OF CATARACT • 17. CORRECTION OF SQUINT • 18. MYRINGOTOMY • 19. TONSILLECTOMY • 20. SUBMUCOUS RESECTION • 21. OPERATION FOR BAT EAR • 22. REDUCTION OF NASAL FRACTURE • 23. D&C HYSTEROSCOPY • 24. LAPAROSCOPY • 25. TERMINATION OF PREGNANCY
- 15. • TROLLEY ofprocedures: Recommended by the British Association Of Day Surgery (BADS) • Contains 50 procedures such as laparoscopic fundoplication, laser prostatectomy, arthroscopy of knee & shoulder, thoracic sympathectomy to be done on day case basis.
- 16. Selection Criteria • Medicalcriteria • Social criteria • Surgical criteria
- 17. Medical criteria • Age:no upper age limit • Comorbidity – ASA 1&2 for stand alone units, ASA 3 for integrated facilities – Diabetes: controlled Types 1&2 with HBA1c < 8.5% • Should be first on list • Morning list patients can skip morning dose of oral hypoglycemic meds or insulin • Afternoon list patients and patients on continuous sc infusion are managed closely with diabetic team – Hypertension: <180/110mmhg
- 18. – Epilepsy: Wellcontrolled pts continue routine meds in the pre operative period • Poorly controlled pts are reviewed with medical team. • Social support is very important – Obesity: not an absolute contraindication • BMI: 40 for surface procedures, 38 for laparoscopies • Reviewed for co-morbidities • At risk of sleep apnea post operatively – Anticoagulants: pts with atrial fibrillation, hx of PTE, or on a metal heart valve must be reviewed with a cardiologist if surgery requires discontinuation of anticoagulation
- 19. Social criteria • Consent:Patient/care giver must be willing to cooperate, able to understand, comply and cope with post-procedural instructions • Escort: a responsible and physically able adult • Transport: A journey time of 1hour or less – Comfortable transportation • Comfortable home facilities with appropriate toilet facilities • Communication: means of communication with hospital
- 20. Surgical Criteria • Simplesurgery up to 2hours. • Minimal risk of postoperative complications e.g. haemorrhage or airway compromise. • Minimal postoperative pain that can be controlled by simple analgesia. • No special postoperative nursing required post surgery. • Procedure must not require prolonged immobilization post operatively • Rapid return of normal food and fluid intake possible after the procedure • Venous thromboembolic risk assessment for prolonged procedures
- 21. Pre-operative assessment, issues& management • Evaluation and optimization of pt’s fitness for surgery • Should be performed early in the pathway • Past medical history and clinical examination • Basic health screen: BMI, Blood pressure • Appropriate investigations: FBC, EUCR, Clotting profile, and other specific investigations • Best performed by specialist nursing team suported by an anaesthetist with interest in DCS
- 22. Assessment and optimizationof nutritional status – Poor nutritional status is an independent risk factor for complications after surgery – Patients with Moderate and severe under- nutrition benefit from preoperative nutritional support preferably via enteral route for at least 7 days preoperatively
- 23. • Evidence supportsthat it may be beneficial to provide a drink containing 100g of carbohydrate on the evening before surgery and a second drink containing a further 50g upto 2-3hrs before surgery. – This measure improves • preoperative feelings of thirst, hunger, anxiety • reduces post operative insulin resistance and • reduces the catabolic stress response to surgery
- 24. IMPROVEMENT OF PHYSICALFITNESS – Patients with poor baseline exercise tolerance and physical conditioning are at increased risk of serious perioperative complications. – The strategy of augmenting physical capacity in anticipation of an upcoming stressor is termed as PREHABILITATION. • Observational data suggests that simply instructing the patient to walk for 30min daily in the preoperative period may be beneficial without the need for a formal individualized exercise program.
- 25. PRE-OPERATIVE FASTING • Currentpreoperative fasting guidelines recommend a 2 hour fasting for clear liquids and a 6 hour fast for solids. • Tailored to suit scheduled time for surgery
- 26. PATIENT EDUCATION andConsent • Patient should be provided information about – Benefits of day care program – Goals for daily nutrition intake – Early postoperative ambulation – Discharge criteria – Care at home and warning signs to seek medical care – Expected hospital stay in the event of common complications • A written informed consent is obtained
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- 29. Peri operative management& scheduling • The theater list – Dedicated DCS list – Mixed inpatient and DCS list • Pre medication – Benzodiazepins – Antiemetics eg ondasetron – Antacids and H2 antagonists – Analgesics (NSAIDS preferred over opiods)
- 30. Intra operative issuesand management • ANAESTHETIC TECHNIQUES – General anaesthesia • Propofol is the IV agent of choice for induction • For maintainance anaesthesia desflurane and sevoflurane are used as they fecilitate early recovery. • Short or intermediate acting non depolarizing muscle relaxants are used. Eg cisatracurium, mivacurium • Sugamadex is a new compound which has shown to provide faster reversal of non depolarising muscle relaxants
- 31. Anaesthetic techniques – RegionalAnaesthesia techniques – Spinal, epidural and peripheral nerve block have several advantages over general anaesthesia like • Improved pulmonary function, • decreased cardiovascular demand, • lower incidence of ileus and • good quality of analgesia at rest and onambulation. – For faster recovery, minidose lidocaine (10-30mg), bupivacaine (3.5-7mg) or ropivacaine (5-10mg) spinal anaesthetic techniques are combined with potent opoid analgesic like fentanyl (10-25mcg) or sufentanyl (5-10mcg)
- 32. Anaesthetic techniques • TIVAtechniques using propofol are popular and offer advantage of reduced post operative nausea and vomiting. • Caudal block is used to reduce pain in paediatric patients for circumcision, herniorraphy, orchidopexy. • Intra articular local anaesthetics are useful following arthroscopy. • Femoral and sciatic nerve block for knee surgery. • Nerve blocks using portable infusion pumps which the patient can continue at home.
- 33. Anaesthetic techniques • INCISIONALLOCAL ANAESTHESIA – INFILTRATION of local anaesthetic is used for surgical procedures like hernia repair, anal surgery, breast procedures. • Long acting local anaesthetic like bupivacaine should be injected into the wound
- 34. Intra operative issuesand management • MAINTENANCE OF NORMOTHERMIA – Mild hypothermia elicits a stress response during recovery period. – Maintenance of intraoperative normothermia with the use of active and passive warming devices and – aggressive post operative management of shivering and residual hypothermia decreases incidence of wound infection, myocardial ischeamia and protein breakdown.
- 35. Intra operative issuesand management • FLUID MANAGEMENT – Strategies that avoid both hypovolemia and post operative overload are important in facilitating fast track recovery process. – Intraoperative oesophageal Doppler monitoring can facilitate goal directed fluid administration by targeting specific values for the cardiac index. – Soluset for paediatric patients
- 36. Intra operative issuesand management • MINIMIZATION OF INCISION AND MIS – The incision should be as small as possible while allowing adequate exposure – Laparoscopic techniques must be used whenever possible
- 37. Post operative issues MAJORMINOR Pulmonary embolism Pain Respiratory failure PONV MI Drowsiness Haemorrhage • Reactionary (usually 4-6hours post op) • Secondary (after 24hours post op) Minor bleeds Unrecognised damage to viscous Infection Headache
- 38. POSTOPERATIVE FEEDING • Commencementof oral feeding is tailored based on – the procedure and – patients tolerance. • For most abdominal surgeries: – liquids on the night following the operation with – light solids given on the morning of post op day 1 – normal diet initiated on post op day 2
- 39. MOBILISATION • Emphasis on‘OUT OF BED DAY 0’ strategy • POST OPERATIVE bed rest should be discouraged. • Structured post operative mobilization is an important component of fast track surgery protocols. • Patient should be given written instructions that include specific goals for each day. • Adequate pain control also helps in early mobilisation. • DRAINS and catheters impede independent mobilisation.
- 40. DISCHARGE CRITERIA • Stablevital signs for at least 1hour • Return to base line orientation • Ambulation without dizziness • Minimal pain and PONV • Minimal bleeding at the surgical site • Tolerate oral fluids • Has passed urine • Responsible adult to take pt home • Has received supply of oral analgesia, written and verbal instructions about post op care, follow up appointment and emergency contact number
- 41. POST ANAESTHESIA DISCHARGESCORING (A TOTAL PADSS SCORE >/= 9 IS CONSIDERED FIT FOR DISCHARGE)
- 42. POST DISCHARGE FOLLOWUP • PATIENT SHOULD BE ABLE TO Contact the team member of the day care surgery team should any problem like fever, wound redness, discharge arise. • A follow up telephone call should be made 24 to 36 hrs after the patient goes home. • Patient should visit the clinic between post operative day 7 and 10 and then seen again at 1 month after the operation • Patients are given specific written instructions about the recovery course.
- 43. Challenges of DCSin Developing countires • Lack of awareness in the patient population, • Poor communication and transport, • Poor facilities for proper training of doctors in day surgery specialty and • Sidelining the surgical specialties. • Health Ministries in favour of other programmes particularly those related to HIV/AIDS, Malaria and Tuberculosis as well as maternal and child health.
- 44. Conclusion • Day casesurgery is now an established practice with rates still increasing around the world due to advances in anaesthesia and surgical techniques • Efforts should be made to utilize evidence based care to push the frontlines in developing countries
- 45. Refrences • Daniel JQuemby, Mary E Stocker, Day Surgery Development and practice: key factors for a successful pathway, continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 6, December 2014, Pages 256-261, https://doi.org/10.1093/bjaceaccp/mkt066 • Normal S. Williams, P. Ronan O’Connell, Andrew W. McCaskie (2018) Bailey & Love Short Practice of Surgery 27th ed. • MANOJ VAIDYA, Ambulatory surgery, slideshare • Mukhtiar Ahmad, Anesthesia for Day Case Surgery, Slidshare
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