Transcript Anesthesia for day case surgery

By
Hala S. El-Ozairy,MD.
Lecturer of anesthesia and
ICU,
 Definition.
 Day case unit.
 Advantages.
 Disadvantages.
 Suitability for day case surgery.
 Contraindications.
 Patient preparation.
 Choice of anesthesia.
 Postoperative management.
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 generally require
postoperative recovery time.
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.
 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.
 Reception area.
 Play room (pediatric).
 Discharge area.
 Anesthetic room.
 Operating room (fully equipped).
 Recovery room.
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.
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 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.
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.
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 agerelated 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.
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.
Gynae: D&C, laparoscopy, VTOP, colposcopy.
Plastics: removal of skin lesions, Dupuytren‘s
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.
Medical
Psychological
Conditions
Social
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.
Liver disease.
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.
Insulin.
psychologically unstable,
e.g. psychosis.
concept of day surgery
unacceptable to patient.
 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.
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.
Pt‘s 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 Men
Women
<40
None
Pregnancy test
40–49
ECG
Hematocrit level,
pregnancy test
50–64
ECG
Hemoglobin or hematocrit
level, ECG
65–74
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
• 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.
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 (H2-antagonists).
Analgesics: Paracetamol and NSAIDs.
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.
 General anesthesia
 Regional anesthesia.
 Monitored anesthesia care
(MAC).
 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 +/- Remifentanil…high cost.
• VIMA: Sevoflurane (more PONV).
 Airway: GA mask, LMA, COPA or even ETT.
 Muscle-relaxants:
• Succinylcholinemuscle pains.
• NDMRshort-acting, Atracurium, Mivacurium,
Vecuronium, Cisatracurium.
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.
• 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).
Advantages • ability to communicate with staff during surgery.
to patient
• ability to observe the procedure (arthroscopy).
• earlier mobilization including immediate physiotherapy.
Advantages
to surgeon
• enables accurate assessment of function before end of surgery.
• allows discussion of operative findings and treatment options at surgery.
• options of direct transfer to second-stage recovery.
• shortens patient’s time in recovery room.
• reduces post-operative nursing requirements.
Advantages • fewer hospital admissions
for institution • overall reduction in facility costs.
 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
(central blocks).
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.
 IVRA is most suitable for short duration (<45–60 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 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,
e.g: supraclavicular approach
(pneumothrax).
• 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 complications.
Discharge criteria.
Anesthetic
complications
• PONV
• Pain
• Others:
prolonged
somnolence,
headache,
urinary
retention,
muscle pain,
sore throat,
hoarseness,
croup, IV site
problems.
Medical
complications
• CVS: hyper or
hypotension,
arrhythmias,
CHF,…..
• Pulmonary:
bronchospasm,
atelectasis,
aspiration,….
Surgical
complications
• Bleeding
• Unsuccessful
procedures
Patient
related
factors
Anesthesia
related
factors
Surgery
related
factors
• 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.
• Operative procedure: Strabismus, orchiopexy,..
• Length of surgery.
• Blood in the GIT: tonsillectomy,…
• Forcing oral intake.
• Premature ambulation (postural hypotension).
• 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.
 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