Anesthesia for day

case surgery
By
Hala S. El-Ozairy,MD.
Lecturer of anesthesia and
ICU,

Objectives
Definition.
Day case unit.
Advantages.
Disadvantages.
Suitability for day case surgery.
Contraindications.
Patient preparation.
Choice of anesthesia.
Postoperative management.

Definition
A surgical day case is defined by the

Royal College of Surgeons of England

as "a patient who is admitted for
investigation or operation on a planned
non-resident basis and who
nonetheless requires facilities for
recovery".
Day case surgery must be
distinguished from 'out-patient cases'.
These are minor procedures performed
under a local anesthetic which do not

Some definitions
An outpatient is a patient who is not
hospitalized overnight but who visits a
hospital, clinic, or associated facility for
diagnosis or treatment. Treatment
provided in this fashion is called
ambulatory care.
Ambulatory anesthesia is tailored to
meet the needs of ambulatory surgery
so the patient can go home soon after
the operation.

Day case unit

Hospital integrated:
The patients are managed in the same facility as
inpatients but they may have separate preoperative
preparation and second stage recovery area.
Hospital based:

Separate day case facility within a hospital

handling only day cases.
Free standing:
These surgical and diagnostic facilities may be
associated with hospitals but are housed in separate
buildings that share no space or patient care functions.

Facilities Available
Reception area.
Play room (pediatric).
Discharge area.
Anesthetic room.
Operating room (fully equipped).
Recovery room.

Advantages
Day case surgery is advantageous to several
groups:
patients:
know when operation will be, little risk of cancellation.
minimal time away from home which is particularly beneficial for

pediatric patients.
Earlier ambulation.
It decreases the risk of nosocomial infection especially in
children.

surgeons:
less risk of cancellation permits better scheduling of operating

lists .
greater turnover of cases.
less delay between cases, usually because less preparation is
required.
release of in-patient beds that would have been occupied by day
case patients.

Advantages
Day case surgery is advantageous to
several groups:
Hospital management:
financial saving ranging from 19% to
70% compared to in-patient
treatment.
cost-effective treatment, still attaining
clinical goals.
facilitates less demand for in-patient
beds.

Disadvantages
Disadvantages of day case surgery
include:
the need for a responsible person to
oversee the day case patient at home
for the first 24-48 hours.
the restriction of day case surgery to
experienced senior staff; little
opportunity for junior staff to practice.
extra work for the general practitioner
in the postoperative period; patients
often ring them for advice or treatment.

Suitability for day case surgery

It is done by:
Preoperative visit.
Telephone interview.
Review of healthcare
questionnaire which can be done
using the internet.
All are usually done by the
anesthetist.

Issues when assessing a patient's

appropriateness for day surgery
include:
physical status - ASA I or II are
permitted.
Age.
type of surgery.
length of anesthesia.
type of anesthesia.
recovery criteria.
Transport.
postoperative pain relief.

Age:
Although the acceptability of patients at
the extremes of age (i.e., <6 months and
>70 years) has been questioned, age
alone should not be considered a deterrent
in the selection of patients for ambulatory
surgery. Many studies have failed to
demonstrate an age-related increase in
recovery time or incidence of
complications after ambulatory anesthesia.
Even the so called elderly patient (>100
years) should not be denied ambulatory
surgery solely on the basis of age.

Type of surgery
Operations

for day case surgery vary between

specialties.
Appropriateness may be expanded by the
facility for an overnight stay.
Generally operations should be:
Short duration (<90 min).
Low incidence of postoperative complications.
Not requiring blood transfusion.
Not requiring major postoperative analgesia.
Surgery should be performed by an
experienced surgeon.

Procedures commonly done as

day cases:

Gynae: D&C, laparoscopy, VTOP, colposcopy.

Plastics: removal of skin lesions, Dupuytrens

contracture release, nerve compressions.

Ophtalmics: Strabismus correction, lacrimal duct
probing, EUA.
ENT: Adenoidectomy, Tonsillectomy, myringotomy,
Grommets, Removal of FB, polyp removal.
Urology: Cystoscopy, circumcision, vasectomy.
Orthopedics: arthroscopies, carpal tunnel release,
ganglion removal.
General Surgery: Breast lumps, varicose veins,
herniae, endoscopy.
Peds: Circumcision, orchiopexy, Squint, dental
extractions.

Contraindications
Medical
Psychologica
Condition l
s

Social

Medical conditions
Cardiovascular:
Prev MI.
Hypertension, diast.>100 mmHg.
Angina, at rest, low exercise tolerance.
Arrhythmias.
Cardiac failure.
Respiratory:
Acute RTIs.
Asthma requiring reg beta-2 agonists or steroids.
COPD.
Metabolic:
Alcoholism.
IDDM.
Renal failure.

Neurological, Musculoskeletal:
Arthritis jaw, neck, cervical spondylosis,
ankylosing spondylitis.
Myopathies, muscular dystrophies or
Myasthenia gravis.
MS.
CVA or TIA.
Epilepsy > 3 fits/year.
Drugs:
Steroids.
MAO inhibitors.
Anticoagulants.
Antiarrhythmics.

psychological:
psychologically unstable,

e.g. psychosis.
concept of day surgery

unacceptable to patient.

Social:
lives over one hour away from

unit.
no reliable person to drive patient
home after surgery and look after
them for the first 24-48 hours
postoperatively.
at home, no access to a lift,
telephone or indoor toilet and
bathroom.

Patient preparation:

Full explanation.
Pt should be given written instructions

incuding:
Pre-op fasting:
Nil by mouth from midnight (solids).
Clear fluids until 3 hours pre-op.
Pts usual medication (i.e antihypertensives
should be taken, oral hypoglycaemics should
be omitted). Pts should bring in their own
medications.
Pt should stop smoking.
The date and time of attendance.
Complete registration is done.
Informed consent is signed.
List of the investigations required.

Age
range
<40
4049

Men

Women

None
ECG

Pregnancy test
Hematocrit level,
pregnancy test

5064

ECG

Hemoglobin
hematocrit level, ECG

6574

Hemoglobin or
hematocrit level, ECG,
serum urea nitrogen,
glucose

Hemoglobin or
hematocrit level, ECG,
serum urea nitrogen,
glucose

>75

Hemoglobin or
hematocrit level, ECG,
serum urea nitrogen,
chest radiograph

Hemoglobin or
hematocrit level, ECG,
serum urea nitrogen,
chest radiograph

or

DAY OF SURGERY
The patient meets the anesthesiologist who
will review his medical and anesthesia history
and the results of any laboratory tests and will
answer any further questions.
Nurses give the patient the identifying
bracelet and record the vital signs, and the
anesthesiologist and surgeon then visit to
complete any evaluations and mark the site of
surgery.
Intravenous fluids will be started and
preoperative medications given.

Premedication
Benzodiazepines: if indicated. Temazepam
provides effective anxiolysis without
delays in recovery and discharge times.
Antiemetics: p.o preop or i.v. periop for high
risk pts (i.e. 5 HT-antagonists,
dexamethasone in ped).
Antacids: if risk of acid reflux (H2antagonists).
Analgesics: Paracetamol and NSAIDs.

What types of anesthesia are

available?
There are several types of anesthetic
techniques available for day case
surgery ranging from local anesthesia
to general anesthesia.
The anesthetic technique
recommended depends on several
factors. In some cases, the surgical
procedure dictates what kind of
anesthesia will be needed.

There are three anesthetic options:

General anesthesia
Regional anesthesia.
Monitored anesthesia care

(MAC).

General Anesthesia
Choice of agents depends on requirements of pt and

preference of anesthetist.
Induction agent:
i.v. Propofol is used widely (easy &quick recovery,
clear head, little PONV).
gas: Sevoflurane is non-irritant to airway, rapid
induction, minimal side-effects, but more PONV.
Maintainance:
N2O: higher incidence PONV, but lower
requirements for volatiles.
TIVA: Propofol +/- Remifentanilhigh cost.
VIMA: Sevoflurane (more PONV).
Airway: GA mask, LMA, COPA or even ETT.
Muscle-relaxants:
Succinylcholinemuscle pains.
NDMRshort-acting, Atracurium, Mivacurium,
Vecuronium, Cisatracurium.

Monitors
Standard.
Monitoring Awareness:

Stability of blood pressure and

heart rate.
Lack of patient movement in
response to surgical stimulation.
The bispectral index : BIS has been
shown to be a reliable indicator to
prevent awareness and facilitate
rapid emergence from anesthesia.

options of direct transfer to second-stage recovery.

shortens patients time in recovery room.
reduces post-operative nursing requirements.
fewer hospital admissions
overall reduction in facility costs.

enables accurate assessment of function before end of surgery.

allows discussion of operative findings and treatment options at
surgery.

avoidance of general anesthetic with its related complications.

minimal incidence of nausea and vomiting.
improved post-operative pain relief.
shortened recovery room time (can by-pass first-stage recovery).
ability to communicate with staff during surgery.
ability to observe the procedure (arthroscopy).
earlier mobilization including immediate physiotherapy.

Advantages
for
institution

Advantages
to surgeon

Advantages
to patient

Regional anesthesia
Advantages:

Regional anesthesia
Disadvantages:
Takes longer because of:
discussion with patient.
block procedure.
onset time.
gentle tissue handling.
incomplete block necessitating
supplementation or conversion to general
anesthetic.
Requires surgeon and patient co-

operation.
Risk of post-spinal headache.
Prolonged regional block may result in
urinary retention and delayed discharge

Regional anesthetic techniques:

A number of regional anesthetic techniques can be used for
day-case surgery:
At completion of surgery, infiltration of the wound using a
long-acting local anesthetic (e.g. 0.25% bupivacaine)
provides prolonged postoperative analgesia.
For ocular surgery, peribulbar, retrobulbar or topical
blocks can be performed safely, effectively and with few
complications.
Caudal block is easy to perform and provides excellent
analgesia for perineal or inguinal surgery.
Blocks may be performed on the ilioinguinal nerve,
iliohypogastric nerve, the brachial plexus, femoral nerve
or digital nerves.
Ring blocks of the wrist or ankle and local infiltration are
simple and effective.

Intravenous regional anesthesia

(IVRA)
IVRA is most suitable for short duration (<4560

min) surgical procedures in distal extremities

(forearm, hand, ankle and foot).
Good surgical anesthesia can be achieved rapidly
after the injection of local anesthetic and recovery
is fast after the release of the tourniquet.
The published success rates range from 94% to
100%.
The main problems of the technique are related to
the requirement for a tourniquet, and include
restricted area of anesthesia, pain associated with
the tourniquet, and risk of local anesthetic toxicity
due to accidental release of the tourniquet.

Peripheral nerve blocks

Peripheral nerve blocks provide

excellent analgesia over a limited

field and with minimal systemic
effects.
Peripheral nerve blocks have
extended the indications for day-case
surgical procedures such as major
shoulder surgery and knee
reconstruction.
Avoid techniques that may be
associated with occult complications,

Monitored anesthesia care (MAC):

It was previously called conscious

sedation.
It is a combination of local anesthesia
with intravenous sedation and
analgesic drugs under monitor by the
anesthetist.
Up to 50% of all day case procedures
can be performed with a MAC
technique.

Postoperative management
Postoperative complications.

Discharge criteria.

Postoperative complications
Anesthetic
complications

Medical
complications

Surgical
complications

PONV
Pain
Others:
prolonged
somnolence,
headache,
urinary
retention,
muscle pain,
sore throat,
hoarseness,
croup, IV site
problems.

CVS: hyper or
hypotension,
arrhythmias,
CHF,..
Pulmonary:
bronchospas
m,
atelectasis,
aspiration,.

Bleeding
Unsuccessful
procedures

 Operative procedure: Strabismus,

orchiopexy,..
Length of surgery.
Blood in the GIT: tonsillectomy,
Forcing oral intake.
Premature ambulation (postural hypotension).
Pain.

Age.
Gender.
Pre-existing disease (e.g.: Diabetes)
History of motion sickness.
History of PONV.
Smoking
Level of anxiety

Premedication.
Opioid analgesia.
Induction and maintenance drugs.
Reversal drugs.
Gastric distention.
Inadequate hydration.

Surgery
related
factors
Anesthesi
a related
factors
Patient
related
factors

PONV

Postoperative pain
Should start pre- or intraoperative by:
Opioids:Short-acting opioids (Fentanyl,
Alfentanil), avoid Morphine if possible if
high risk of PONV.
LA/regional blocks (i.e. Caudal block in kids;
Ropivacaine more selective sensory block
than Bupiv.).
Ketorolac: 0.5-1 mg/kg Iv or IM. It does not
cause nausea or vomiting or respiratory
depression.
Acetaminophen: 25-40 mg/Kg orally or
rectally.
Cox-2 inhibitors: Parecoxib 20-100 mg Iv or
IM. No GIT side effects of other NSAIDs.

Discharge criteria
Prior to discharge from the day case unit patients

should:
Have stable vital signs.
Be alert and orientated.
Be comfortable / pain free.
Be able to walk.
Be able to tolerate oral fluids.
Have minimal nausea and vomiting.

Adequate follow-up arrangements should be made.

Patients should be provided with information

sheets.
Should be provided with contact telephone
numbers.

Thanks