- Email: [email protected]
An overview of anaesthesia and patient selection for day surgery
Day case
An overview of anaesthesia and patient selection for day surgery
Day surgery is defined as ‘the admission of selected patients to hospital for a planned surgical procedure, who return home on the same day’. ‘True day surgery’ patients are defined as those who require full operating theatre facilities, with or without a general anaesthetic, and day cases not included as outpatient or endoscopy patients. ‘Extended’ day-case units (23-hour units) are increasingly used to support more major surgical procedures. These units may also assist the transfer of operations from inpatient to day case and allow the extension of operating times into the early evening. The capacity of extended day-case units needs to be planned, otherwise any excess may be taken over by emergency medical or surgical cases and existing day surgery will be compromised. However, when daycase patients stay in hospital overnight they are no longer classified as such. Some trusts arrange hotel facilities close to the day unit.
Matthew Molyneux Nia Griffith
Abstract Day surgery is increasingly recognized as the best form of treatment for a wide range of patients and procedures. As day surgery becomes more widely available, older patients with comorbidities and patients needing complex surgery are increasingly considered as suitable day cases. Standards for day surgery must be the same as for inpatient treatment and organization is the key to the successful running of a day unit. Day surgery needs to be meticulously planned, with appropriate patient selection, modern surgical and anaesthetic techniques, plus robust discharge criteria and follow-up. Attention to detail with good control of postoperative pain, nausea and vomiting are essential. Patient preference and choice may dictate where day surgery is performed in the future.
Benefits of day surgery The benefits of day surgery are listed below. • Patients receive treatment that is suited to their needs and allows them to recover in their own home. • Cancellation of surgery due to emergency pressures is unlikely in a dedicated day-case unit. • The risk of hospital-acquired infection is reduced. • Inpatient beds are released for major surgical cases. • Junior clinicians may be released if there is an effective, nurseled pre-assessment service overseen by a clinical lead (ideally, an anaesthetist). • Trusts improve their throughput of patients and reduce waiting lists. • Primary Care Trusts can commission cost-effective healthcare.
Keywords ambulatory surgery; analgesia; day surgery; investigations; pre-assessment; postoperative nausea and vomiting; selection criteria
Anaesthesia for day surgery is an expanding subspecialty. During the 1990s the proportion of operations performed in the UK as day cases increased from 34% to 65%. However, the 2001 Audit Commission Report showed that day-case units were not being used to their maximum capacity. The NHS Plan 2000 envisages that 75% of all elective surgery will be carried out as day cases ‘in the near future’, despite hospitals not performing at uniformly high levels across all specialties. Patient safety and departmental efficiency are paramount to a successful day-case unit. An interdisciplinary team approach to selecting and assessing patients, ordering appropriate investigations and preparing the patient for surgery is vital. Surgical and anaesthetic techniques must be tailored to day-case patients and discharge criteria must be robust. The incidence of major adverse events with day surgery is low.
Facilities and list planning in the day-surgery unit The most efficient day-case units are integrated and ring-fenced. Features of an ideal day-case unit are listed in Table 1. The facilities available at a day-case unit should include: • preoperative assessment area • admissions/waiting area • changing rooms • dedicated day-surgery theatres, with or without anaesthetic rooms • first-stage recovery area using day-surgery trolleys rather than beds • second-stage recovery/discharge area. Placing inpatients and day-case patients on the same list is inefficient, inappropriate and may increase the number of cancellations. However, if separate lists are not possible, day-case patients should be placed first on an inpatient list. The use of inpatient wards for day-case patients is not acceptable.
Matthew Molyneux, FRCA, is Specialist Registrar at Southmead Hospital, Bristol, UK. He qualified from St George’s Hospital Medical School, London, and is currently on the Bristol rotation. His interests include simulation medicine and regional anaesthesia.
Patient selection The appropriate selection of patients who are suitable for day surgery is the basis of good practice, together with the use of modern surgical and anaesthetic techniques. Since day surgery started, the definition of an ‘acceptable’ patient has changed and strictly held criteria have been relaxed. The question has now become, ‘is there any reason why this patient should not be treated as a day case?’ In the process of patient selection three areas should be considered: type of surgery, the patient’s social factors and medical conditions.
Nia Griffith, FRCA, is Consultant Anaesthetist at Southmead Hospital, part of North Bristol NHS Trust. She qualified from the University of Wales College of Medicine, Cardiff and trained in anaesthesia in Northampton, Oxford, Reading and Lyon, France. Her main interests are day surgery and regional anaesthesia.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
116
© 2007 Elsevier Ltd. All rights reserved.
Day case
Features of an ideal day-case unit
Social support for the day-case patient
• A senior manager directly responsible for day surgery only • Preoperative assessment procedure undertaken by dedicated day-surgery staff • Efficient scheduling and careful planning of case-mix • Clear policies and protocols for running the unit, focusing on patients • Appropriate levels of staff, who are multi-skilled • Effective follow-up and outreach with key audit measures • Involvement of patients, the public and community practitioners
• The carer should be a responsible adult and a relative, trusted friend or established carer • Both patient and carer must be able to understand instructions provided by healthcare staff • The carer must know the circumstances under which the unit should be contacted and also know who to contact • The patient should be cared for at home, which should ideally be less than 1 hour away from the unit • A telephone and toilet facilities should be available and easily accessible at the patient’s home
Table 1
Table 2
Type of surgery: the Audit Commission and the British Associa tion of Day Surgery (BADS) have produced a list or ‘basket’ of 25 surgical procedures that are suitable for day surgery. The procedures in each hospital will vary according to local agreed policy. Suitable procedures should: • be short (maximum 2 hours) • lead to minimal physiological insult • not cause excessive blood loss or fluid shifts • not be associated with serious postoperative complications • involve only pain that can be controlled with oral analgesics. As more complex procedures are added to the day-unit list, the postoperative assessment and discharge criteria become more important. In 2006, BADS produced a ‘Directory of procedures’ which recommends the proportion of procedures for different types of day-unit case: procedure-room surgery (e.g. banding haemorrhoids 100%, ‘manipulation under anaesthetic’ fractured nose 95%); traditional day surgery (e.g. primary repair inguinal hernia 95%, haemorrhoidectomy 65%); 23-hour stay (e.g. septorhinoplasty 90%, anterior cruciate ligament repair 65%); under 72-hour stay (e.g. subtotal thyroidectomy 80%). Procedures such as laser resection of the prostate, parathyroidectomies and vaginal hysterectomies are now being identified as day-surgery procedures. Surgeons are being encouraged to review the type of operation and postoperative management of some of the procedures they perform as ‘minimal access surgery’ becomes routine and hospital stay reduces. For rapid and seamless management of day-case patients, early access to other healthcare facilities such as physiotherapy, plastering services and occupational therapy is required.
and specific anaesthetic issues, such as difficult airway, reflux, previous anaesthetic complications, noted (see below). Patient assessment An integrated care pathway (ICP) is ideal for day surgery. An ICP contains all the patient information in one standardized booklet, including assessment, relevant investigations, consent, the anaesthetic and surgical record, recovery, discharge and follow-up. The ICP ensures that the patient is screened for surgical, social and anaesthetic factors and that the information is immediately available to the anaesthetist on the day of surgery. This avoids repetition of the history, examination and investigations and allows the anaesthetist to focus on specific issues of concern. An ICP is also beneficial for audit purposes. Nursing staff who are trained in day-surgery assessment screen patients for any medical pathology and potential anaesthetic problems according to locally developed guidelines. If concerned, the nurses can discuss any issues with a designated consultant anaesthetist and seek advice on the suitability of a patient for day surgery or referral to appropriate specialties. Generally, treatment of underlying medical conditions needs to be optimized before surgery by the patient’s general practitioner. This interdisciplinary team approach is key to an efficient, safe unit and reduces the number of cancellations on the day of surgery. Telephone assessments of patients may be used, but faceto-face interviews give better patient satisfaction, reduce anxiety and improve the patient’s understanding of the procedure. Written information about the procedure and admission process may also be given to the patient at an interview to reinforce verbal information. Preoperative assessment also provides an opportunity for the patients to familiarize themselves with the day unit and be given information about preparation for admission.
Social factors: without a social support structure in place even the healthiest patient undergoing minor surgery is not suitable as a day case. A responsible adult needs to bring the patient to the day-surgery unit and care for them for at least 24 hours after discharge, or longer for more invasive procedures. Important factors for the social support for the day-case patient are shown in Table 2.
Medical background and history Generally, patients of American Society of Anesthesiologists (ASA) grades 1 and 2 are suitable for day surgery. ASA grade 3 patients should also be considered and may well benefit from day surgery. However, there are no strict rules. Experience and common sense applied to the surgical and anaesthetic requirements are very important. Careful pre-admission screening, op timization of fitness before admission, consideration of local or regional anaesthesia and skilled anaesthesia with identification of
Medical conditions: the general medical status of the day-case patient (e.g. asthma, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), epilepsy) should be reviewed
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
117
© 2007 Elsevier Ltd. All rights reserved.
Day case
Diabetes: patients with well-controlled diabetes are suitable for day surgery. The assessment should ensure: • no history of repeated hypoglycaemic attacks or recurrent admissions to hospital with complications of diabetes • HbA1c lower than 8% • patient and carer are able to measure blood glucose at home • patient and carer understand hypoglycaemia and its treatment. Special consideration must be given to patients with diabetes who have a history of postoperative nausea and vomiting (PONV) or those having surgery likely to result in reduced oral intake postoperatively. These patients should be treated as inpatients. Patients with non-insulin-dependent diabetes that is well controlled should omit their oral hypoglycaemic agents on the morning of surgery and restart with the first meal after surgery. Blood glucose should be recorded 1 hour before, during and at 2-hourly intervals after the procedure until the patient’s first meal. Patients with insulin-controlled diabetes are more susceptible to hypo- or hyperglycaemia. These patients should be scheduled first on a morning list. Local guidelines on perioperative insulin dosing regimens should be followed. Typically, the dose of longacting insulin the night before is reduced by one-third and the morning dose of insulin is omitted. Subcutaneous, short-acting insulin is resumed with the first meal. Blood glucose needs to be checked hourly perioperatively.
those who need overnight admission postoperatively is important in those less fit patients. Age is not a contraindication to day surgery; however, it increases the likelihood of other diseases, especially hypertension and cardiac disease. Children benefit from being treated as day cases. Airway: patients with known or likely difficulties in tracheal intubation should be excluded because of the lack of specialist equipment and expertise readily available, especially in a standalone unit. Planning and turnover of the list is also disrupted. Reflux is not a contraindication to day surgery. It should be screened for in the assessment, treated preoperatively if possible, and a safe anaesthetic technique applied (i.e. a rapid-sequence intubation if required). Respiratory disease: asthma, chronic obstructive pulmonary disease and smoking are common. Provided these conditions are well controlled, patients are suitable for day surgery. Poor control, recent exacerbation of symptoms or severe exercise limitation in these patients requiring general anaesthesia is an indication for postponement of day surgery (pending investigations and therapy) or exclusion from day surgery in favour of inpatient treatment. Obstructive sleep apnoea is contra indicated for general anaesthesia as a day case, although local and regional anaesthetic techniques may be considered for this group.
Obesity: comorbidities, anaesthetic problems and postoperative complications are all more common in obese patients. Compli cations associated with obesity are summarized in Table 3. In addition, healthcare staff are also at risk when moving obese patients and the weight limit of trolleys, theatre tables and beds may be exceeded. Patients with a body mass index (BMI) of less than 35, with limited comorbidities are usually suitable for day surgery and those with a BMI between 35 and 40 may be suitable for minor procedures provided an experienced anaesthetist is present. In practice, obese patients may provide intraoperative challenges but rarely fail to reach the criteria required for discharge.
Cardiovascular disease: absolute contraindications to day surgery comprise: • myocardial infarction within the past 6 months • angina causing marked limitation in daily activity • congestive cardiac failure • symptomatic valvular disease • cardiomyopathy • tachyarrhythmias • second- or third-degree heart block. Relative contraindications for cardiovascular disease comprise: • myocardial infarction more than 6 months previously • untreated mild angina • high blood pressure (systolic >175 mm Hg or diastolic >100 mm Hg) • cerebrovascular accident in the past 6 months • controlled atrial fibrillation • previous deep vein thrombosis or pulmonary embolism. Patients with relative contraindications should have their treatment optimized before surgery. If the patient is able to climb at least one flight of stairs (equivalent to 4 metabolic equivalents (METs); 1 MET is the oxygen consumption of healthy man at rest −3.5 ml/kg/min) the perioperative cardiac risk is low and day surgery is suitable. Patients at risk of thrombosis risk will need compression stockings, clexane and early mobilization.
Complications associated with obesity in day surgery • Sleep apnoea • Ischaemic heart disease • Hypertension • Diabetes • Gastrointestinal reflux • Difficult intravenous access • Difficult intubation • Problems with monitoring (blood pressure cuffs) • Difficult placing of regional blocks • Perioperative hypoxia • Prolonged surgery • Postoperative wound complications (delayed healing and infections) • Postoperative chest infections • Increased risk of deep vein thrombosis or pulmonary embolism
Hypertension: hypertensive patients should have their blood ressure controlled before selection for day surgery. Once p identified at pre-assessment the patient should return to their GP’s care for blood pressure control with a delay of surgery for at least 2–4 weeks for adjustment. An ECG is essential as cardiac disease is an association.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Table 3
118
© 2007 Elsevier Ltd. All rights reserved.
Day case
Renal system: day surgery is generally not suitable for patients undergoing haemodialysis or chronic ambulatory peritoneal dia lysis because of practical difficulties and comorbidity. However, some simple procedures can be undertaken (e.g. fistula formation, carpal tunnel decompression and other local anaesthetic procedures).
Investigations Preoperative tests: ‘Preoperative tests, The use of routine preoperative tests for elective surgery’, developed by consensus of expert opinion and issued by the National Institute of Clinical Excellence (NICE) in June 2003, is a useful guide for investigations in all elective surgery (see Further Reading). The following tests should be performed where appropriate: • full blood count in patients who are likely to have anaemia • clotting screen in patients with liver disease, those who consume excessive alcohol or those who are taking anticoagulants • sickle cell test in patients of Afro-Caribbean origin • electrolytes and creatinine in patients aged more than 70 years, those with renal or cardiac disease or diabetes, or those taking diuretics, digoxin or steroids • ECG in all patients aged more than 60 years and those younger patients with a cardiac history or risk factors (hypertension, dysrhythmias, diabetes, hyperlipidaemia) • thyroid-function test to ensure euthyroid if the patient is taking thyroxine • Chest radiograph, lung function tests and arterial blood gases are rarely indicated.
Liver disease: patients with advanced liver disease are unsuitable for day surgery. Neurological disease: epilepsy is not a contraindication to day surgery. Patients who have well-controlled epilepsy and infrequent fits are suitable. Patients with neuromuscular disorders, myasthenia gravis, or myotonias are not suitable. Those with multiple sclerosis or myalgic encephalopathy may be suitable for minor procedures. Psychiatric patients and patients with learning difficulties: many of these patients benefit from a short stay in hospital and rapid return to their normal environment. The patient’s usual medication should be given. A carer familiar to the patient should be present while the patient is on the ward and also at induction and recovery.
Patient information Patients should be informed at their first outpatient meeting with their doctor that their procedure will be done in the day-case unit. Ideally, a day-case pre-assessment nurse will also be present at this first meeting. This affirms that their procedure is normally done as day surgery and allows treatable conditions to be identified at an early stage. Information leaflets specific to each procedure should be given to the patient and carer. These leaflets contain instructions on preoperative fasting time, which drugs to take on the morning of surgery and advice on the time that they will be absent from work, as well as what to expect in the perioperative period and the level of pain and discomfort to expect postoperatively. Wellinformed patients will be less anxious and more motivated. To reduce the incidence of non-attendance, patients should be contacted in the week before admission to the unit to confirm that there are no changes in their medical condition. Cancellations for any reason impact significantly on the efficiency of a day-surgery service. Nationally, more than two-thirds of cancellations are initiated by the patient, with less than 10% due to clinical reasons. This highlights the importance of patient information and motivation in the selection process.
Pregnancy: all women of childbearing age should be asked about the possibility of pregnancy. Anaesthesia at any stage carries some risk for the mother and fetus. Recreational drug use: the risk of using recreational drugs within 24 hours of general anaesthesia should be discussed with the patient and recorded. Particular caution should be taken with patients using Ecstasy or cocaine because cardiovascular instability is more common. Cannabis use is not a contraindication but it should be stopped 2 weeks before surgery. Patients using narcotics (e.g. diamorphine) may experience difficulties with pain control postoperatively. It may be necessary to admit these patients for pain management under the guidance of a pain team. Prescribed drugs: patients should be asked to bring all their regular drugs in to hospital with them. Most drugs should be taken as normal on the day of surgery, including cardiac, antihypertensive, anticonvulsant and antireflux medication. Specific advice should be given to patients taking warfarin and clopidigrel. The contraceptive pill and aspirin (the latter for prevention of myocardial infarct or cerebrovascular accident) should be continued unless instructed otherwise by the surgeon. Very few patients are still taking monoamine oxidase inhibitors; however, for patients taking this type of drug, ephedrine, metaraminol and pethidine should be considered unsafe. Noradrenaline, phenylephrine, fentanyl, morphine and alfentanil are safe alternatives.
Anaesthetic technique Good day-case anaesthetic management includes the following criteria: • patient safety as the main priority (as for inpatient anaesthesia) • optimal conditions for the surgeon • a rapid patient recovery • good postoperative analgesia • minimal nausea and vomiting. Preoperative factors: after reviewing the nurse assessment in the ICP and the current routine observations, the anaesthetist should visit the patient before the list begins. At this visit the following should be considered or confirmed. • Fasting guidelines should be adhered to, with 6 hours fasting for solid food and 2 hours for clear fluids. Patients for routine
Anaesthetic history: patients with a history of malignant hyperpyrexia, previous anaphylaxis, suxamethonium apnoea or significant morbidity after anaesthesia should have their notes reviewed by an anaesthetist. These patients may be suitable as day cases, depending on the nature of the surgery.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
119
© 2007 Elsevier Ltd. All rights reserved.
Day case
inor local anaesthetic procedures should not be expected to m fast. • All routine medications should have been taken if appropriate, with H2-blockers or proton-pump inhibitors given if needed. • An anaesthetic plan should be made, with appropriate patient discussion and consent. • Sedative premedication should be avoided. If necessary, oral midazolam (0.5 mg/kg; maximum 15 mg) in cordial may be given to children or temazepam (10–20 mg) to adults for severe anxiety. Distraction techniques such as music, TV or magazines are preferable. • Paracetamol, 1 g for adults or 40 mg/kg load for children, with or without non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. diclofenac or ibuprofen) given orally at least 1 hour pre-induction is a useful adjunct to anaesthesia, has few side effects and provides intra- and postoperative analgesia. Nurses on some units may prescribe and give simple analgesics such as paracetamol pre- and postoperatively, following local guidelines. In practice, slow-release ibuprofen 1600 mg provides effective, long-lasting analgesia.
journey home, which delays their return to normal activity and work. The choice of anaesthetic technique affects the prevalence of PONV, with total intravenous anaesthesia achieving the best results. Anti-emetics are not routinely indicated and should be reserved for treatment of PONV or as prophylaxis in high-risk patients. The surgical risk factors for PONV include: • oral or ENT surgery • squint surgery • laparoscopic surgery. Patient risk factors include: • female gender • not smoking • history of PONV or motion sickness. When the preoperative risk factors have been identified, a multimodal approach to prevent PONV should be used, with the reduction of avoidable triggers. Prophylaxis can be aimed at low (0 or 1 risk factors), medium (2–3) or high (>3) risk factors and treated accordingly. The following should be considered when attempting to reduce the risk of PONV: • general anaesthesia can be avoided by using regional or local anaesthesia • total intravenous anaesthesia is preferable to inhaled anaesthetic agents • good perioperative hydration reduces PONV • nitrous oxide should be avoided • morphine analgesia triples the incidence of PONV • medium-risk patients (2–3 risk factors) should be given ondansetron or dexamethasone • high-risk patients (>3 risk factors) should be given two antiemetic drugs after induction of anaesthesia (e.g. ondansetron 4 mg and dexamethasone 4–8 mg) • metoclopramide in its usual dose is probably an ineffective anti-emetic in the immediate postoperative period.
Induction and maintenance • Total intravenous anaesthesia is widely used because of its anti-emetic properties and the rapid emergence profile of propofol. Target-controlled infusion allows smaller doses of propofol to be given. Propofol induction and isoflurane/sevoflurane/ desflurane maintenance are suitable alternatives; however, the incidence of PONV may be higher than with intravenous anaesthesia. • The use of short-acting opioids (fentanyl, alfentanil, remifentanil) reduces the incidence of PONV compared with morphine and improves recovery times. • NSAIDs, paracetamol and local anaesthetic blocks or infiltration should be used whenever possible. • A laryngeal mask airway is quicker and smoother than tracheal intubation, but patient safety must not be compromised. When intubating, short-acting neuromuscular blocking agents (atracurium, mivacurium) are useful. • Suxamethonium should be avoided (unless specifically indicated) because it causes significant postoperative muscular pain in those who mobilize early. • Anti-emetics can be used (see below). • Forced air warming prevents hypothermia during long pro cedures or when the patient undergoes greater exposure.
Local anaesthesia Regional anaesthesia is widely used in Europe and America and is increasingly popular in the UK. The advantages of regional anaesthesia include less risk of PONV, less CNS dysfunction, postoperative pain relief and low cost. The main disadvantage of regional anaesthesia is the time taken to establish suitable anaesthesia for the surgical requirements, resulting in a reduced patient throughput. Units that regularly use regional techniques have separate ‘block rooms’ and extra staff so that a high turnover is maintained. Spinal anaesthesia should be performed with short-acting local anaesthetics and minimal opioid to avoid urinary retention. The patient must pass urine and show full recovery of motor power and proprioception before discharge. Post-dural puncture headache is more common in the day-case than in the hospital setting. Epidurals are rarely indicated in day surgery because of the time required to establish the block. Peripheral nerve blocks in cooperative patients, with or without sedation, are useful techniques in skilled hands. Discharge of these patients requires their compliance with instructions specific to the block (e.g. after brachial plexus block, keeping the arm elevated in a protective sling). Written information should be given to the patient. Femoral nerve blocks limit mobilization after surgery, but ankle blocks are very useful after forefoot surgery.
Postoperative anaesthesia • Pre- and intraoperative inclusion of paracetamol, NSAIDs, opioids and local anaesthetics should provide early analgesia. • Fentanyl bolus (20 μg) every 5 minutes provides fast-onset analgesia in recovery whilst awaiting the onset of local anaesthesia and simple analgesics. • Morphine may be required but increases PONV and delays discharge. • Simple oral analgesics may be given in recovery to patients once awake with mild-to-moderate pain. Postoperative nausea and vomiting PONV continues to be a challenge for day surgery. Up to 30% of patients experience PONV at some point after surgery. It can delay discharge, cause a hospital stay or distress a patient on the
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
120
© 2007 Elsevier Ltd. All rights reserved.
Day case
risk of PONV or to those with nausea at discharge. These should be pre-packed, available for dispensing from the day-case unit and be accompanied by an information leaflet on how to take the medication. Sick notes should be issued to all day-case patients by the surgeon to reduce the need for attending primary care. Post-discharge telephone calls made the morning following surgery to specific patient groups by nursing staff are appreciated by patients and are effective at enhancing patient’s overall treatment experience and satisfaction levels. Outcome measures such as cancellations, admissions, morbidity, mortality, re-admissions and patient satisfaction are important and should be reviewed regularly. ◆
Recovery After day surgery, recovery can be divided into two Phases. Phase 1 involves the emergence from anaesthesia and the recovery of protective reflexes and motor function. Phase 2 involves the recovery of coordination and return of normal physiology. With modern anaesthesia, Phase 1 recovery is becoming more rapid and patients can be transferred straight from the operating theatre to Phase 2 recovery (fast tracking). This transfer can result in an early discharge home. Consequently, there is no minimum stay requirement for day surgery for most simple procedures. Discharge Discharge from the day-case unit should be nurse-led when certain criteria are met. Reliable discharge tools such as the Postanaesthesia Discharge Scoring System can be used (see page 124). Overnight admissions occur in approximately 1–5% of day cases depending on the unit and the rigidity of the selection criteria. These admissions are most frequently caused by surgical factors (bleeding, perforated viscus, extensive surgery). Anaesthesia-related causes are more common with general anaesthesia than with regional anaesthesia and frequently include PONV and uncontrolled pain. Social factors may change, making an overnight stay necessary. Patients should be given an adequate supply of suitable oral analgesics to take home. These usually include regular paracetamol and ibuprofen, plus codeine phosphate or tramadol for breakthrough pain. An anti-emetic can be given to those at
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Further reading British Association of Day Surgery (BADS). www.bads.co.uk (accessed 23 November 2006). Day surgery – a good practice guide 2004. www.wise.nhs.uk/cmsWISE/ HIC/HIC1/HIC1.htm (accessed 23 November 2006). Day surgery: operational guide, waiting, booking and choice, 2002. www.publications.doh.gov.uk (accessed 23 November 2006). National Institute of Clinical Excellence: investigations in elective surgery 2003. www.nice.org.uk/page.aspx?o=56818 (accessed 12 December 2006). Smith I, ed. Day case anaesthesia. London: BMJ Books, 2000.
121
© 2007 Elsevier Ltd. All rights reserved.
An overview of anaesthesia and patient selection for day surgery
Day surgery is defined as ‘the admission of selected patients to hospital for a planned surgical procedure, who return home on the same day’. ‘True day surgery’ patients are defined as those who require full operating theatre facilities, with or without a general anaesthetic, and day cases not included as outpatient or endoscopy patients. ‘Extended’ day-case units (23-hour units) are increasingly used to support more major surgical procedures. These units may also assist the transfer of operations from inpatient to day case and allow the extension of operating times into the early evening. The capacity of extended day-case units needs to be planned, otherwise any excess may be taken over by emergency medical or surgical cases and existing day surgery will be compromised. However, when daycase patients stay in hospital overnight they are no longer classified as such. Some trusts arrange hotel facilities close to the day unit.
Matthew Molyneux Nia Griffith
Abstract Day surgery is increasingly recognized as the best form of treatment for a wide range of patients and procedures. As day surgery becomes more widely available, older patients with comorbidities and patients needing complex surgery are increasingly considered as suitable day cases. Standards for day surgery must be the same as for inpatient treatment and organization is the key to the successful running of a day unit. Day surgery needs to be meticulously planned, with appropriate patient selection, modern surgical and anaesthetic techniques, plus robust discharge criteria and follow-up. Attention to detail with good control of postoperative pain, nausea and vomiting are essential. Patient preference and choice may dictate where day surgery is performed in the future.
Benefits of day surgery The benefits of day surgery are listed below. • Patients receive treatment that is suited to their needs and allows them to recover in their own home. • Cancellation of surgery due to emergency pressures is unlikely in a dedicated day-case unit. • The risk of hospital-acquired infection is reduced. • Inpatient beds are released for major surgical cases. • Junior clinicians may be released if there is an effective, nurseled pre-assessment service overseen by a clinical lead (ideally, an anaesthetist). • Trusts improve their throughput of patients and reduce waiting lists. • Primary Care Trusts can commission cost-effective healthcare.
Keywords ambulatory surgery; analgesia; day surgery; investigations; pre-assessment; postoperative nausea and vomiting; selection criteria
Anaesthesia for day surgery is an expanding subspecialty. During the 1990s the proportion of operations performed in the UK as day cases increased from 34% to 65%. However, the 2001 Audit Commission Report showed that day-case units were not being used to their maximum capacity. The NHS Plan 2000 envisages that 75% of all elective surgery will be carried out as day cases ‘in the near future’, despite hospitals not performing at uniformly high levels across all specialties. Patient safety and departmental efficiency are paramount to a successful day-case unit. An interdisciplinary team approach to selecting and assessing patients, ordering appropriate investigations and preparing the patient for surgery is vital. Surgical and anaesthetic techniques must be tailored to day-case patients and discharge criteria must be robust. The incidence of major adverse events with day surgery is low.
Facilities and list planning in the day-surgery unit The most efficient day-case units are integrated and ring-fenced. Features of an ideal day-case unit are listed in Table 1. The facilities available at a day-case unit should include: • preoperative assessment area • admissions/waiting area • changing rooms • dedicated day-surgery theatres, with or without anaesthetic rooms • first-stage recovery area using day-surgery trolleys rather than beds • second-stage recovery/discharge area. Placing inpatients and day-case patients on the same list is inefficient, inappropriate and may increase the number of cancellations. However, if separate lists are not possible, day-case patients should be placed first on an inpatient list. The use of inpatient wards for day-case patients is not acceptable.
Matthew Molyneux, FRCA, is Specialist Registrar at Southmead Hospital, Bristol, UK. He qualified from St George’s Hospital Medical School, London, and is currently on the Bristol rotation. His interests include simulation medicine and regional anaesthesia.
Patient selection The appropriate selection of patients who are suitable for day surgery is the basis of good practice, together with the use of modern surgical and anaesthetic techniques. Since day surgery started, the definition of an ‘acceptable’ patient has changed and strictly held criteria have been relaxed. The question has now become, ‘is there any reason why this patient should not be treated as a day case?’ In the process of patient selection three areas should be considered: type of surgery, the patient’s social factors and medical conditions.
Nia Griffith, FRCA, is Consultant Anaesthetist at Southmead Hospital, part of North Bristol NHS Trust. She qualified from the University of Wales College of Medicine, Cardiff and trained in anaesthesia in Northampton, Oxford, Reading and Lyon, France. Her main interests are day surgery and regional anaesthesia.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
116
© 2007 Elsevier Ltd. All rights reserved.
Day case
Features of an ideal day-case unit
Social support for the day-case patient
• A senior manager directly responsible for day surgery only • Preoperative assessment procedure undertaken by dedicated day-surgery staff • Efficient scheduling and careful planning of case-mix • Clear policies and protocols for running the unit, focusing on patients • Appropriate levels of staff, who are multi-skilled • Effective follow-up and outreach with key audit measures • Involvement of patients, the public and community practitioners
• The carer should be a responsible adult and a relative, trusted friend or established carer • Both patient and carer must be able to understand instructions provided by healthcare staff • The carer must know the circumstances under which the unit should be contacted and also know who to contact • The patient should be cared for at home, which should ideally be less than 1 hour away from the unit • A telephone and toilet facilities should be available and easily accessible at the patient’s home
Table 1
Table 2
Type of surgery: the Audit Commission and the British Associa tion of Day Surgery (BADS) have produced a list or ‘basket’ of 25 surgical procedures that are suitable for day surgery. The procedures in each hospital will vary according to local agreed policy. Suitable procedures should: • be short (maximum 2 hours) • lead to minimal physiological insult • not cause excessive blood loss or fluid shifts • not be associated with serious postoperative complications • involve only pain that can be controlled with oral analgesics. As more complex procedures are added to the day-unit list, the postoperative assessment and discharge criteria become more important. In 2006, BADS produced a ‘Directory of procedures’ which recommends the proportion of procedures for different types of day-unit case: procedure-room surgery (e.g. banding haemorrhoids 100%, ‘manipulation under anaesthetic’ fractured nose 95%); traditional day surgery (e.g. primary repair inguinal hernia 95%, haemorrhoidectomy 65%); 23-hour stay (e.g. septorhinoplasty 90%, anterior cruciate ligament repair 65%); under 72-hour stay (e.g. subtotal thyroidectomy 80%). Procedures such as laser resection of the prostate, parathyroidectomies and vaginal hysterectomies are now being identified as day-surgery procedures. Surgeons are being encouraged to review the type of operation and postoperative management of some of the procedures they perform as ‘minimal access surgery’ becomes routine and hospital stay reduces. For rapid and seamless management of day-case patients, early access to other healthcare facilities such as physiotherapy, plastering services and occupational therapy is required.
and specific anaesthetic issues, such as difficult airway, reflux, previous anaesthetic complications, noted (see below). Patient assessment An integrated care pathway (ICP) is ideal for day surgery. An ICP contains all the patient information in one standardized booklet, including assessment, relevant investigations, consent, the anaesthetic and surgical record, recovery, discharge and follow-up. The ICP ensures that the patient is screened for surgical, social and anaesthetic factors and that the information is immediately available to the anaesthetist on the day of surgery. This avoids repetition of the history, examination and investigations and allows the anaesthetist to focus on specific issues of concern. An ICP is also beneficial for audit purposes. Nursing staff who are trained in day-surgery assessment screen patients for any medical pathology and potential anaesthetic problems according to locally developed guidelines. If concerned, the nurses can discuss any issues with a designated consultant anaesthetist and seek advice on the suitability of a patient for day surgery or referral to appropriate specialties. Generally, treatment of underlying medical conditions needs to be optimized before surgery by the patient’s general practitioner. This interdisciplinary team approach is key to an efficient, safe unit and reduces the number of cancellations on the day of surgery. Telephone assessments of patients may be used, but faceto-face interviews give better patient satisfaction, reduce anxiety and improve the patient’s understanding of the procedure. Written information about the procedure and admission process may also be given to the patient at an interview to reinforce verbal information. Preoperative assessment also provides an opportunity for the patients to familiarize themselves with the day unit and be given information about preparation for admission.
Social factors: without a social support structure in place even the healthiest patient undergoing minor surgery is not suitable as a day case. A responsible adult needs to bring the patient to the day-surgery unit and care for them for at least 24 hours after discharge, or longer for more invasive procedures. Important factors for the social support for the day-case patient are shown in Table 2.
Medical background and history Generally, patients of American Society of Anesthesiologists (ASA) grades 1 and 2 are suitable for day surgery. ASA grade 3 patients should also be considered and may well benefit from day surgery. However, there are no strict rules. Experience and common sense applied to the surgical and anaesthetic requirements are very important. Careful pre-admission screening, op timization of fitness before admission, consideration of local or regional anaesthesia and skilled anaesthesia with identification of
Medical conditions: the general medical status of the day-case patient (e.g. asthma, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), epilepsy) should be reviewed
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
117
© 2007 Elsevier Ltd. All rights reserved.
Day case
Diabetes: patients with well-controlled diabetes are suitable for day surgery. The assessment should ensure: • no history of repeated hypoglycaemic attacks or recurrent admissions to hospital with complications of diabetes • HbA1c lower than 8% • patient and carer are able to measure blood glucose at home • patient and carer understand hypoglycaemia and its treatment. Special consideration must be given to patients with diabetes who have a history of postoperative nausea and vomiting (PONV) or those having surgery likely to result in reduced oral intake postoperatively. These patients should be treated as inpatients. Patients with non-insulin-dependent diabetes that is well controlled should omit their oral hypoglycaemic agents on the morning of surgery and restart with the first meal after surgery. Blood glucose should be recorded 1 hour before, during and at 2-hourly intervals after the procedure until the patient’s first meal. Patients with insulin-controlled diabetes are more susceptible to hypo- or hyperglycaemia. These patients should be scheduled first on a morning list. Local guidelines on perioperative insulin dosing regimens should be followed. Typically, the dose of longacting insulin the night before is reduced by one-third and the morning dose of insulin is omitted. Subcutaneous, short-acting insulin is resumed with the first meal. Blood glucose needs to be checked hourly perioperatively.
those who need overnight admission postoperatively is important in those less fit patients. Age is not a contraindication to day surgery; however, it increases the likelihood of other diseases, especially hypertension and cardiac disease. Children benefit from being treated as day cases. Airway: patients with known or likely difficulties in tracheal intubation should be excluded because of the lack of specialist equipment and expertise readily available, especially in a standalone unit. Planning and turnover of the list is also disrupted. Reflux is not a contraindication to day surgery. It should be screened for in the assessment, treated preoperatively if possible, and a safe anaesthetic technique applied (i.e. a rapid-sequence intubation if required). Respiratory disease: asthma, chronic obstructive pulmonary disease and smoking are common. Provided these conditions are well controlled, patients are suitable for day surgery. Poor control, recent exacerbation of symptoms or severe exercise limitation in these patients requiring general anaesthesia is an indication for postponement of day surgery (pending investigations and therapy) or exclusion from day surgery in favour of inpatient treatment. Obstructive sleep apnoea is contra indicated for general anaesthesia as a day case, although local and regional anaesthetic techniques may be considered for this group.
Obesity: comorbidities, anaesthetic problems and postoperative complications are all more common in obese patients. Compli cations associated with obesity are summarized in Table 3. In addition, healthcare staff are also at risk when moving obese patients and the weight limit of trolleys, theatre tables and beds may be exceeded. Patients with a body mass index (BMI) of less than 35, with limited comorbidities are usually suitable for day surgery and those with a BMI between 35 and 40 may be suitable for minor procedures provided an experienced anaesthetist is present. In practice, obese patients may provide intraoperative challenges but rarely fail to reach the criteria required for discharge.
Cardiovascular disease: absolute contraindications to day surgery comprise: • myocardial infarction within the past 6 months • angina causing marked limitation in daily activity • congestive cardiac failure • symptomatic valvular disease • cardiomyopathy • tachyarrhythmias • second- or third-degree heart block. Relative contraindications for cardiovascular disease comprise: • myocardial infarction more than 6 months previously • untreated mild angina • high blood pressure (systolic >175 mm Hg or diastolic >100 mm Hg) • cerebrovascular accident in the past 6 months • controlled atrial fibrillation • previous deep vein thrombosis or pulmonary embolism. Patients with relative contraindications should have their treatment optimized before surgery. If the patient is able to climb at least one flight of stairs (equivalent to 4 metabolic equivalents (METs); 1 MET is the oxygen consumption of healthy man at rest −3.5 ml/kg/min) the perioperative cardiac risk is low and day surgery is suitable. Patients at risk of thrombosis risk will need compression stockings, clexane and early mobilization.
Complications associated with obesity in day surgery • Sleep apnoea • Ischaemic heart disease • Hypertension • Diabetes • Gastrointestinal reflux • Difficult intravenous access • Difficult intubation • Problems with monitoring (blood pressure cuffs) • Difficult placing of regional blocks • Perioperative hypoxia • Prolonged surgery • Postoperative wound complications (delayed healing and infections) • Postoperative chest infections • Increased risk of deep vein thrombosis or pulmonary embolism
Hypertension: hypertensive patients should have their blood ressure controlled before selection for day surgery. Once p identified at pre-assessment the patient should return to their GP’s care for blood pressure control with a delay of surgery for at least 2–4 weeks for adjustment. An ECG is essential as cardiac disease is an association.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Table 3
118
© 2007 Elsevier Ltd. All rights reserved.
Day case
Renal system: day surgery is generally not suitable for patients undergoing haemodialysis or chronic ambulatory peritoneal dia lysis because of practical difficulties and comorbidity. However, some simple procedures can be undertaken (e.g. fistula formation, carpal tunnel decompression and other local anaesthetic procedures).
Investigations Preoperative tests: ‘Preoperative tests, The use of routine preoperative tests for elective surgery’, developed by consensus of expert opinion and issued by the National Institute of Clinical Excellence (NICE) in June 2003, is a useful guide for investigations in all elective surgery (see Further Reading). The following tests should be performed where appropriate: • full blood count in patients who are likely to have anaemia • clotting screen in patients with liver disease, those who consume excessive alcohol or those who are taking anticoagulants • sickle cell test in patients of Afro-Caribbean origin • electrolytes and creatinine in patients aged more than 70 years, those with renal or cardiac disease or diabetes, or those taking diuretics, digoxin or steroids • ECG in all patients aged more than 60 years and those younger patients with a cardiac history or risk factors (hypertension, dysrhythmias, diabetes, hyperlipidaemia) • thyroid-function test to ensure euthyroid if the patient is taking thyroxine • Chest radiograph, lung function tests and arterial blood gases are rarely indicated.
Liver disease: patients with advanced liver disease are unsuitable for day surgery. Neurological disease: epilepsy is not a contraindication to day surgery. Patients who have well-controlled epilepsy and infrequent fits are suitable. Patients with neuromuscular disorders, myasthenia gravis, or myotonias are not suitable. Those with multiple sclerosis or myalgic encephalopathy may be suitable for minor procedures. Psychiatric patients and patients with learning difficulties: many of these patients benefit from a short stay in hospital and rapid return to their normal environment. The patient’s usual medication should be given. A carer familiar to the patient should be present while the patient is on the ward and also at induction and recovery.
Patient information Patients should be informed at their first outpatient meeting with their doctor that their procedure will be done in the day-case unit. Ideally, a day-case pre-assessment nurse will also be present at this first meeting. This affirms that their procedure is normally done as day surgery and allows treatable conditions to be identified at an early stage. Information leaflets specific to each procedure should be given to the patient and carer. These leaflets contain instructions on preoperative fasting time, which drugs to take on the morning of surgery and advice on the time that they will be absent from work, as well as what to expect in the perioperative period and the level of pain and discomfort to expect postoperatively. Wellinformed patients will be less anxious and more motivated. To reduce the incidence of non-attendance, patients should be contacted in the week before admission to the unit to confirm that there are no changes in their medical condition. Cancellations for any reason impact significantly on the efficiency of a day-surgery service. Nationally, more than two-thirds of cancellations are initiated by the patient, with less than 10% due to clinical reasons. This highlights the importance of patient information and motivation in the selection process.
Pregnancy: all women of childbearing age should be asked about the possibility of pregnancy. Anaesthesia at any stage carries some risk for the mother and fetus. Recreational drug use: the risk of using recreational drugs within 24 hours of general anaesthesia should be discussed with the patient and recorded. Particular caution should be taken with patients using Ecstasy or cocaine because cardiovascular instability is more common. Cannabis use is not a contraindication but it should be stopped 2 weeks before surgery. Patients using narcotics (e.g. diamorphine) may experience difficulties with pain control postoperatively. It may be necessary to admit these patients for pain management under the guidance of a pain team. Prescribed drugs: patients should be asked to bring all their regular drugs in to hospital with them. Most drugs should be taken as normal on the day of surgery, including cardiac, antihypertensive, anticonvulsant and antireflux medication. Specific advice should be given to patients taking warfarin and clopidigrel. The contraceptive pill and aspirin (the latter for prevention of myocardial infarct or cerebrovascular accident) should be continued unless instructed otherwise by the surgeon. Very few patients are still taking monoamine oxidase inhibitors; however, for patients taking this type of drug, ephedrine, metaraminol and pethidine should be considered unsafe. Noradrenaline, phenylephrine, fentanyl, morphine and alfentanil are safe alternatives.
Anaesthetic technique Good day-case anaesthetic management includes the following criteria: • patient safety as the main priority (as for inpatient anaesthesia) • optimal conditions for the surgeon • a rapid patient recovery • good postoperative analgesia • minimal nausea and vomiting. Preoperative factors: after reviewing the nurse assessment in the ICP and the current routine observations, the anaesthetist should visit the patient before the list begins. At this visit the following should be considered or confirmed. • Fasting guidelines should be adhered to, with 6 hours fasting for solid food and 2 hours for clear fluids. Patients for routine
Anaesthetic history: patients with a history of malignant hyperpyrexia, previous anaphylaxis, suxamethonium apnoea or significant morbidity after anaesthesia should have their notes reviewed by an anaesthetist. These patients may be suitable as day cases, depending on the nature of the surgery.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
119
© 2007 Elsevier Ltd. All rights reserved.
Day case
inor local anaesthetic procedures should not be expected to m fast. • All routine medications should have been taken if appropriate, with H2-blockers or proton-pump inhibitors given if needed. • An anaesthetic plan should be made, with appropriate patient discussion and consent. • Sedative premedication should be avoided. If necessary, oral midazolam (0.5 mg/kg; maximum 15 mg) in cordial may be given to children or temazepam (10–20 mg) to adults for severe anxiety. Distraction techniques such as music, TV or magazines are preferable. • Paracetamol, 1 g for adults or 40 mg/kg load for children, with or without non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. diclofenac or ibuprofen) given orally at least 1 hour pre-induction is a useful adjunct to anaesthesia, has few side effects and provides intra- and postoperative analgesia. Nurses on some units may prescribe and give simple analgesics such as paracetamol pre- and postoperatively, following local guidelines. In practice, slow-release ibuprofen 1600 mg provides effective, long-lasting analgesia.
journey home, which delays their return to normal activity and work. The choice of anaesthetic technique affects the prevalence of PONV, with total intravenous anaesthesia achieving the best results. Anti-emetics are not routinely indicated and should be reserved for treatment of PONV or as prophylaxis in high-risk patients. The surgical risk factors for PONV include: • oral or ENT surgery • squint surgery • laparoscopic surgery. Patient risk factors include: • female gender • not smoking • history of PONV or motion sickness. When the preoperative risk factors have been identified, a multimodal approach to prevent PONV should be used, with the reduction of avoidable triggers. Prophylaxis can be aimed at low (0 or 1 risk factors), medium (2–3) or high (>3) risk factors and treated accordingly. The following should be considered when attempting to reduce the risk of PONV: • general anaesthesia can be avoided by using regional or local anaesthesia • total intravenous anaesthesia is preferable to inhaled anaesthetic agents • good perioperative hydration reduces PONV • nitrous oxide should be avoided • morphine analgesia triples the incidence of PONV • medium-risk patients (2–3 risk factors) should be given ondansetron or dexamethasone • high-risk patients (>3 risk factors) should be given two antiemetic drugs after induction of anaesthesia (e.g. ondansetron 4 mg and dexamethasone 4–8 mg) • metoclopramide in its usual dose is probably an ineffective anti-emetic in the immediate postoperative period.
Induction and maintenance • Total intravenous anaesthesia is widely used because of its anti-emetic properties and the rapid emergence profile of propofol. Target-controlled infusion allows smaller doses of propofol to be given. Propofol induction and isoflurane/sevoflurane/ desflurane maintenance are suitable alternatives; however, the incidence of PONV may be higher than with intravenous anaesthesia. • The use of short-acting opioids (fentanyl, alfentanil, remifentanil) reduces the incidence of PONV compared with morphine and improves recovery times. • NSAIDs, paracetamol and local anaesthetic blocks or infiltration should be used whenever possible. • A laryngeal mask airway is quicker and smoother than tracheal intubation, but patient safety must not be compromised. When intubating, short-acting neuromuscular blocking agents (atracurium, mivacurium) are useful. • Suxamethonium should be avoided (unless specifically indicated) because it causes significant postoperative muscular pain in those who mobilize early. • Anti-emetics can be used (see below). • Forced air warming prevents hypothermia during long pro cedures or when the patient undergoes greater exposure.
Local anaesthesia Regional anaesthesia is widely used in Europe and America and is increasingly popular in the UK. The advantages of regional anaesthesia include less risk of PONV, less CNS dysfunction, postoperative pain relief and low cost. The main disadvantage of regional anaesthesia is the time taken to establish suitable anaesthesia for the surgical requirements, resulting in a reduced patient throughput. Units that regularly use regional techniques have separate ‘block rooms’ and extra staff so that a high turnover is maintained. Spinal anaesthesia should be performed with short-acting local anaesthetics and minimal opioid to avoid urinary retention. The patient must pass urine and show full recovery of motor power and proprioception before discharge. Post-dural puncture headache is more common in the day-case than in the hospital setting. Epidurals are rarely indicated in day surgery because of the time required to establish the block. Peripheral nerve blocks in cooperative patients, with or without sedation, are useful techniques in skilled hands. Discharge of these patients requires their compliance with instructions specific to the block (e.g. after brachial plexus block, keeping the arm elevated in a protective sling). Written information should be given to the patient. Femoral nerve blocks limit mobilization after surgery, but ankle blocks are very useful after forefoot surgery.
Postoperative anaesthesia • Pre- and intraoperative inclusion of paracetamol, NSAIDs, opioids and local anaesthetics should provide early analgesia. • Fentanyl bolus (20 μg) every 5 minutes provides fast-onset analgesia in recovery whilst awaiting the onset of local anaesthesia and simple analgesics. • Morphine may be required but increases PONV and delays discharge. • Simple oral analgesics may be given in recovery to patients once awake with mild-to-moderate pain. Postoperative nausea and vomiting PONV continues to be a challenge for day surgery. Up to 30% of patients experience PONV at some point after surgery. It can delay discharge, cause a hospital stay or distress a patient on the
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
120
© 2007 Elsevier Ltd. All rights reserved.
Day case
risk of PONV or to those with nausea at discharge. These should be pre-packed, available for dispensing from the day-case unit and be accompanied by an information leaflet on how to take the medication. Sick notes should be issued to all day-case patients by the surgeon to reduce the need for attending primary care. Post-discharge telephone calls made the morning following surgery to specific patient groups by nursing staff are appreciated by patients and are effective at enhancing patient’s overall treatment experience and satisfaction levels. Outcome measures such as cancellations, admissions, morbidity, mortality, re-admissions and patient satisfaction are important and should be reviewed regularly. ◆
Recovery After day surgery, recovery can be divided into two Phases. Phase 1 involves the emergence from anaesthesia and the recovery of protective reflexes and motor function. Phase 2 involves the recovery of coordination and return of normal physiology. With modern anaesthesia, Phase 1 recovery is becoming more rapid and patients can be transferred straight from the operating theatre to Phase 2 recovery (fast tracking). This transfer can result in an early discharge home. Consequently, there is no minimum stay requirement for day surgery for most simple procedures. Discharge Discharge from the day-case unit should be nurse-led when certain criteria are met. Reliable discharge tools such as the Postanaesthesia Discharge Scoring System can be used (see page 124). Overnight admissions occur in approximately 1–5% of day cases depending on the unit and the rigidity of the selection criteria. These admissions are most frequently caused by surgical factors (bleeding, perforated viscus, extensive surgery). Anaesthesia-related causes are more common with general anaesthesia than with regional anaesthesia and frequently include PONV and uncontrolled pain. Social factors may change, making an overnight stay necessary. Patients should be given an adequate supply of suitable oral analgesics to take home. These usually include regular paracetamol and ibuprofen, plus codeine phosphate or tramadol for breakthrough pain. An anti-emetic can be given to those at
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Further reading British Association of Day Surgery (BADS). www.bads.co.uk (accessed 23 November 2006). Day surgery – a good practice guide 2004. www.wise.nhs.uk/cmsWISE/ HIC/HIC1/HIC1.htm (accessed 23 November 2006). Day surgery: operational guide, waiting, booking and choice, 2002. www.publications.doh.gov.uk (accessed 23 November 2006). National Institute of Clinical Excellence: investigations in elective surgery 2003. www.nice.org.uk/page.aspx?o=56818 (accessed 12 December 2006). Smith I, ed. Day case anaesthesia. London: BMJ Books, 2000.
121
© 2007 Elsevier Ltd. All rights reserved.