Lecture notes for medical students

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2. Daycare Surgery

3. Daycare Surgery
• The patient undergoes surgery in the
morning and discharged on the same day in
less than 24 hours.
• Effective pre-operative preparation and
protocol-driven, nurse-led discharge are
fundamental to safe and effective day and
short stay surgery.

4. Types

5. Types
• Office procedures
• True Ambulatory Surgery -This is where
patients are admitted, operated on and
discharged during the time frame of one
working day (6 to 8 hours). There is no
overnight stay.
• Ambulatory Surgery with Extended
Recovery-This is where patients are
admitted, operated on and stay for one night
post-operatively in a hospital facility
(overall stay up to 23 hours).

6. Indications

7. Indications
• In recent years, the complexity of
procedures has increased with a wider range
of patients now considered suitable for day
surgery.

8. Selection of patients

9. Selection of patients
Factors Affecting-
• Social
• Medical
• surgical.

10. Social factors

11. Social factors
• The majority of patients are appropriate for
day surgery unless there is a valid reason
why an overnight stay would be beneficial.
• responsible adult should escort the patient
home;
• responsible adult should escort the patient
home;
• Presence of a carer for 24 h postoperatively

12. Medical factors

13. Medical factors
• Fitness for a procedure should relate to the
patient’s functional status as determined at
pre-anaesthetic assessment, and not by ASA
physical status, age or body mass index
• Patients with a stable chronic disease such
as diabetes are often better managed as day
cases because there is minimal disruption to
their daily routine.

14. Medical factors
• Obstructive sleep apnoea (OSA) is not an
absolute contraindication to day surgery in
adults,
• If postoperative pain can be managed
predominantly with non-opioid analgesic
techniques’

15. Surgical factors

16. Surgical factors
• The procedure should not carry a significant
risk of serious postoperative complications
requiring immediate medical attention, for
example, haemorrhage or cardiovascular
instability.
• Postoperative symptoms (such as pain and
nausea) must be controllable by the use of a
combination of oral medication and local
anaesthetic techniques

17. Surgical factors
• The procedure should not prohibit the
patient from resuming oral intake within a
few hours of the end of surgery.
• Patients should be able to mobilise before
discharge

18. Operations covered

19. Operations covered
The target is that 75% of elective surgery
should be performed as day cases
• .Excision of breast
lump
• Incision and
drainage of abscess
• Laparoscopic
appendicectomy
• laparoscopic
cholecystectomy
• Thyroidectomy
• Temporal artery
biopsy
• Eversion of hydrocele
sac
• Inguinal hernia repair
• Circumcision.
• Laparoscopic
sterilisation
• tonsillectomy
The list is endless

20. Management Aspects

21. Management Aspects
Components of an emergency day surgery
pathway are:
1. Identification of appropriate procedures
2. Identification of a theatre list that can reliably
accommodate the procedure (e.g. a dedicated day surgery
list or a flexibly run emergency theatre list)
3. Ensuring clear pathways are in place
4. Determining whether the condition is safe to be left
untreated for up to 24 h and manageable at home with
oral analgesia
5. Providing clear pre-operative patient information, ideally
in writing.

22. Facilities

23. Facilities
• Day surgery works best when it is provided
in a selfcontained unit that is functionally
and structurally separate from inpatient
wards and operating theatres.
• It should have its own reception, consulting
rooms, ward, theatres and recovery area,
together with administrative facilities.
• Stand alone day surgery units- not part of a
hospital have been started in several
developed countries.

24. Admission process

25. Admission process
• Patients should be admitted to the day
surgery unit as close as possible to the time
of their surgery.

26. Fasting

27. Fasting

28. Change
• Pre-operatively, patients should be allowed to stay
in their ‘street clothes’ for as long as possible in
order to maintain dignity, warmth and comfort.
• At a suitable time, they should change into theatre
gowns and wait in a single sex area.
• They should walk to theatre and ideally transfer
themselves onto the operating trolley in the
anaesthetic room.
• They can remain on this trolley throughout their
day surgery pathway until ready for transfer to a
chair in the postoperative ward.

29. Change
• Pre-operatively, patients should be allowed to stay
in their ‘street clothes’ for as long as possible in
order to maintain dignity, warmth and comfort.
• At a suitable time, they should change into theatre
gowns and wait in a single sex area.
• They should walk to theatre and ideally transfer
themselves onto the operating trolley in the
anaesthetic room.
• They can remain on this trolley throughout their
day surgery pathway until ready for transfer to a
chair in the postoperative ward.

30. Pre-operative preparation

31. Pre-operative preparation
1. To educate patients and carers regarding
day surgery pathways
2. To impart information regarding planned
procedures and postoperative care to help
patients make informed decisions;
important information should be provided
in writing.
3. To identify medical risk factors, promote
health and optimise the patient’s condition

32. Contraindications

33. Contraindications
• The only patients routinely not included in
day surgery are those with unstable medical
conditions.

34. Anaesthetic management

35. Anaesthetic management
• Dedicated anesthetist.
• Anaesthetic techniques should ensure minimum
stress and maximum comfort for the patient.
• Avoid Isoflurane.
• Analgesia is paramount and must be long acting,
but, as morbidity such as nausea and vomiting
must be minimised, the indiscriminate use of
opioids is discouraged
• Prophylactic oral analgesia with long-acting non-
steroidal anti-inflammatory drugs (NSAIDs)
should be given to all patients, unless
contraindicated.

36. Regional anaesthesia

37. Regional anaesthesia
• Local infiltration and nerve blocks can provide
excellent anaesthesia and pain relief after day
surgery.
• Patients may safely be discharged home with
residual motor or sensory blockade, provided the
limb is protected and appropriate support is
available for the patient at home.
• Infusions of local anaesthetics may also have a
role
• Use of a ‘block room’ improves efficiency and
allows confirmation of adequate nerve blockade
before surgery commences

38. Spinal anaesthesia

39. Spinal anaesthesia
• Concerns regarding post-dural puncture headache
have previously limited the use of spinal
anaesthesia in day surgery patients, but the use of
smaller gauge (25 G) and pencil-point needles has
reduced the incidence to < 1%.
• Low-dose local anaesthetic techniques and newer
shorter acting local anaesthetics such as
hyperbaric prilocaine 2% and 2- chloroprocaine
• Appropriate spinal anaesthetic dosing targeted to
surgical site, for example, lateral for a unilateral
knee arthroscopy or sitting for peri-anal
procedures, can minimise side-effects such as
hypotension and prolonged motor blockade

40. Spinal anaesthesia

41. Spinal anaesthesia
• Restricting i.v. fluids to no more than 500 ml
should reduce the incidence of urinary retention.
Patients should be encouraged to drink
postoperatively in order to allow their own body
to correct fluid balance.

42. Safe mobilisation after spinal
anaesthesia

43. Safe mobilisation after spinal
anaesthesia
• Return of sensation to the peri-anal area
(S4–5)
• Plantar flexion of the foot at pre-operative
levels of strength
• Return of proprioception in the big toe.

44. Post op management

45. Post op management
• Venous thromboembolism risk assessment and
prophylaxis should be followed..
• management of postoperative nausea and
vomiting (PONV)
– Prophylactic anti-emetics are recommended in patients
with a history of PONV,
– motion sickness and those undergoing certain
procedures such as laparoscopic
sterilisation/cholecystectomy or tonsillectomy..
– Routine use of intravenous (i.v.) fluids and
maintenance of body temperature can enhance the
patient’s feeling of wellbeing and further reduce
PONV

46. Post op complications

47. Post op complications
• Common postoperative problems
– PONV (Postoperative Nausea And
Vomiting)
– Pain
• Emergencies
– Haemorrhage
– Cardiovascular events

48. Discharge: Assessment

49. Discharge: Assessment
Who should assess fitness for discharge?
• Surgeon and/ or anaesthetist
• Senior nurse against a medical approved
printed protocol.
• Surgeon and/ or anaesthetist only involved
in cases of doubt or when there is a
problem

50. Discharge Process and Criteria

51. Discharge Process and Criteria
• There are 3 phases of recovery following
anaesthesia:
1. Early recovery - awakening and recovery of
vital reflexes.
2. Intermediate recovery - recovery to point of
'home readiness‘
3. Late recovery - recovery to point of 'street
fitness'.
• Patients are fit for discharge from the day unit
when they have completed the intermediate phase
of recovery .

52. Discharge:
Essential invariable criteria

53. Discharge:
Essential invariable criteria
• Stable vital signs
• Orientated to preop. stage
• Minimal nausea and vomiting
• Controllablel pain by oral drugs.
• No significant bleeding from operative site.

54. Discharge: Variable criteria

55. Discharge: Variable criteria
• Micturition prior to discharge. Essential
following epidural or spinal anaesthesia.
May be deemed essential following certain
surgical procedures.
• Fixed length of stay in day unit following
surgery plays no part in the generality of
surgical procedures. May be deemed
necessary after certain procedures to
minimise the risk of reactionary
haemorrhage at home eg: tonsillectomy,
thyroidectomy.

56. Discharge: Disputed criteria

57. Discharge: Disputed criteria
• The ability to take and retain oral fluids
prior to discharge is increasingly disputed.
It may in fact provoke nausea and vomiting.

58. Discharge: Non-medical criteria
Non-medical criteria to be met prior to
discharge from the day unit.
• An adult to accompany the patient home
and to be with them at home for the first 24-
hours following surgery .
• Access to a functioning telephone at home.

59. Discharge: Patient to be given

60. Discharge: Patient to be given
• Printed post-operative instructions
• Printed information on whom to contact in
case of emergency .
• Appropriate discharge drugs
• Follow-up information.
• A summary of the treatment they have
received.

61. Post-operative instructions

62. Post-operative instructions
• Not to drink alcohol, operate machinery or
drive for 24 h after a general anaesthetic.
• Patients should not drive until the pain or
immobility from their operation allows
them to control their car safely and perform
an emergency stop
• Recent guidance for driving following
isoflurane anaesthesia recommends
refraining from driving for four days after
its use.

63. Patient satisfaction

64. Patient satisfaction
• Good post-operative pain control is achieved
• There is no post-operative nausea and vomiting
• Good pre and post-operative information is
delivered ;
• Increased surgery availability and short waiting
time before surgery are achieved;
• A courtesy and a friendliness environment are
given by the operating and day surgery staff;
• Patients do not feel that they are being discharged
too early or in a rushed way;
• A telephone follow-up contact on the next day is
established.

65. Advantages

66. Advantages
• Quicker recovery
• Less disruption to patients and family life
• Cost effective
• Reduces the risk of hospital-acquired
infections and
• venous thromboembolism

67. Disdvantages
• .

68. Disdvantages
• Low acceptance
• Need for a responsible caregiver at home.
• Anxiety
• Readmission
• Stand alone units must collaborate with a
regular hospital to manage complications.

69. Day surgery for children

70. Day surgery for children
Lower age limit and medical comorbidities of
children
• Lower age limit of 44 weeks ‘post-
menstrual age’ (defined as gestational age
plus chronological age).
• Ex-premature infants (those born at less
than 37 weeks gestational age) not accepted
for day surgery < 60 weeks postmenstrual
age.
• Obstructive sleep apnea (OSA)not suitable
for day surgery

71. Day surgery for children
• The home environment
• distance from the hospital
• Parents’ access to transport and a telephone
• Parents must be able to understand
instructions, recognise complications that
would require a return to hospital.

72. Day surgery for Older patients

73. Day surgery for Older patients
• Is ideal for older patients
• Older patients are less likely to admit to
feeling unwell, uncomfortable or distressed.
• They are often already partially dehydrated
• Prone to hypoglycaemia.
• Prone to hyponatremiain

74. Take home messages
• The International Association for
Ambulatory Surgery (IAAS)

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