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Patient selection for day surgery
DAY SURGERY
Patient selection for day surgery
Learning objectives After reading this article you should be able to: C define and describe the day surgery pathway C explain the advantages of day surgery C outline surgical procedures and techniques suited to day surgery C judge patient suitability for day surgery C justify contraindications to day surgery C discuss patient options for day surgery anaesthesia
Leanne Darwin
Abstract Day surgery is a planned pathway delivered by a multidisciplinary team and is perhaps better described as ‘same day surgery’. In 2000 the NHS set a target of performing 75% of operations as same day surgery but practice varies widely; an assessment of 10 procedures easily performed as same day surgery showed rates varying from 19% to 90% by procedure and the potential day case rate was not being reached for any procedure. There is a move to ‘treat day surgery as the norm’ in an effort to increase rates of day surgery so this article describes patient selection and procedures for day surgery, and discusses techniques which can be employed by anaesthetists and surgeons to achieve the reduced surgical trauma, rapid recovery and minimal complications necessary for successful day surgery.
care and with a clinical lead who has a specific interest in day surgery. Effective preoperative preparation, encompassing selection and assessment, and protocol-driven, nurse-led discharge are fundamental to the pathway.
Benefits of day surgery Day surgery has benefits to the patient, clinician, and hospital which include: patients receive hospital treatment suited to their needs, but recover at home early mobilization lower risk of nosocomial infection lower risk of venous thromboembolism (VTE) lower risk of cancellation sparing overnight beds for major surgical cases faster throughput, easier booking and reduced waiting lists cost-effective commissioning.
Keywords Anaesthetic technique; day surgery; patient selection; regional anaesthesia; same day surgery; short stay surgery Royal College of Anaesthetists CPD Matrix: 3A06
Introduction/background The definition of day surgery in the UK and Ireland is admission to hospital for a planned surgical procedure and return home within the same day. ‘True day surgery’ patients are day case patients who require full theatre facilities and/or a general anaesthetic, so this does not include procedures performed in outpatient or endoscopy departments. Previously definitions have included ‘in hospital stay of less than 24 hours’. Although counted as inpatient treatment (except in the USA), 23-hour and short stay surgery apply the same principles of care as same day surgery and improve quality. The NHS Plan (2000) stated that ‘.around three quarters of operations will be carried out on a day case basis with no overnight stay required.’. Advances in surgical and anaesthetic technique allow increasingly complex surgery to be performed on a day case basis, but, whilst overall rates are difficult to measure, available data suggest they are highly variable. The NHS Institute worked with clinicians to identify 10 procedures which were deemed achievable as day cases and found day case rates from 19% to over 90% based on data from 2002/2003 (Table 1). No hospital is performing at uniformly high levels across all specialities and there remains scope to increase rates of day surgery. Day surgery is a planned pathway, ideally delivered in a specific self-contained unit by staff with training in day surgery
Surgical selection The Audit Commission listed a ‘basket’ of 25 procedures for day surgery in 1990 which was revised in 2001 (Table 2). Since 2001, advances in surgical and anaesthetic techniques have meant that more complex procedures, and a wider range of patients, can be considered for day surgery, so the British Association of Day Surgery widened the ‘basket’ by publishing a ‘trolley’ of procedures and have since increased scope by publishing a directory of over 200 procedures which should be considered for short stay elective surgery; these range from ‘procedure room’ to under 72-hour stay cases. Rather than asking ‘is this case suitable for day surgery’, we should now ask ‘is there any justification for admitting this patient?’ The principles of surgical selection include: abdominal and thoracic surgery should use minimally invasive techniques the degree of surgical trauma is more important than its duration postoperative pain should be manageable using local anaesthesia and oral analgesia there should be low risk of postoperative complications: no continuing blood loss or need for fluid therapy no specialist postoperative care or observation should be needed patients should be able to mobilize before discharge
Leanne Darwin MBChB MRCP FRCA is an Anaesthetic Specialty Trainee (ST7), Health Education North West. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
1
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
exercise tolerance is a more useful indicator than examination findings or preoperative testing. If the patient copes well at home preoperatively, and surgery should not affect functional status, then day surgery is appropriate. In all cases pre-existing comorbidities should be assessed and optimized, but their presence may support the use of day surgery rather than present a contraindication.
Ten procedures that can easily be performed as day cases Procedure
National day case rate, %
Inguinal hernia Varicose veins Termination of pregnancy Cataract Sub-mucous resection (nasal cartilage) Extraction of wisdom teeth Cystoscopy/transurethral resection of bladder tumour Arthroscopy meniscectomy Excision of Dupuytren’s contracture Myringotomy/grommets
47.5 54.4 89.0 90.6 22.9 87.9 19.1
Cardiovascular disease Cardiovascular contraindications to day surgery are: severe angina (at rest or on minimal exertion) myocardial infarction or revascularization within the last 3 months heart failure with an exercise tolerance of less than 4 metabolic equivalents (METs) Exercise tolerance is a useful component of preoperative assessment. The ability to climb a flight of stairs (approximately 4 METs) is a predictor of good outcome. Hypertension should be well controlled before surgery and medication continued perioperatively. Although there is no evidence of increased risk when urgent surgery has been undertaken in uncontrolled hypertension, and measures to reduce hypertension rapidly before urgent surgery such as sublingual nifedipine or sedation have not been shown to reduce complications, the use of cardio-stable techniques are sensible.
73.1 41.7 85.0
NHS Institute (Hospital Episode Statistics, 2002/2003)
Table 1
the operating surgeon must have sufficient experience and a low complication rate in the procedure. Patients presenting for urgent surgery can be treated as day cases via a ‘planned acute’ pathway. After assessment, patients can be discharged and return for surgery at an appropriate time. This reduces repeated postponement of surgery on emergency lists due to prioritization of more serious cases, but a rigorous pathway with the following components is needed: identification of appropriate procedures: conditions which can be safely left untreated for a day or two, and manageable with oral analgesia identification of lists that can reliably accommodate cases clear pathways for day surgery clear preoperative patient information and post-discharge instruction in printed form.
Respiratory disease and obstructive sleep apnoea Adverse respiratory events are more common perioperatively in smokers, and those with asthma or chronic obstructive pulmonary disease. Although these rarely prolong recovery room stay, good preoperative control should be confirmed. Exercise tolerance is a more useful predictor than spirometry, and recent respiratory symptoms are predictive of complications so should delay surgery, but local or regional techniques can be always considered to permit day surgery in symptomatic patients.
Patient selection
‘Basket’ of day case procedures
There are very few absolute contraindications to day surgery. The majority of patients are appropriate unless there is a valid reason why overnight stay would be to their benefit. In making such a decision, both social and medical factors must be considered.
Orchidopexy Circumcision Inguinal hernia repair
Patient selection e social Patients (and/or their carers) must understand (and consent to) day surgery and postoperative care. Following procedures under general anaesthesia or sedation, a responsible person must escort the patient home and provide postoperative care of varying duration. The patient’s home circumstances must be suitable for postoperative care. This includes access to a telephone, and a location within reasonable journey time to emergency care in case of the need to attend. The siting of a lavatory and availability of central heating may need to be considered in some geographical locations.
Excision of breast lump Anal fissure dilatation or excision Haemorrhoidectomy Laparoscopic cholecystectomy Varicose vein stripping or ligation Transurethral resection of bladder tumour Excision of Dupuytren’s contracture Carpal tunnel decompression Excision of ganglion Arthroscopy
Patient selection e medical Selection is based on assessment of patient’s functional status rather than arbitrary limits such as age, American Society of Anesthesiologists (ASA) status or body mass index (BMI) and
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Bunion operations Removal of metal ware Extraction of cataract with/without implant Correction of squint Myringotomy Tonsillectomy Sub-mucous resection (nasal cartilage) Reduction of nasal fracture Operation for prominent ‘bat’ ears Dilatation and curettage/hysteroscopy Laparoscopy Termination of pregnancy
(Audit Commission, 2001)
Table 2 2
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
Obstructive sleep apnoea (OSA) is under-diagnosed, and signs and symptoms should be sought during assessment particularly in at-risk groups; the STOP-Bang score is useful in predicting OSA (Table 3). If existing symptoms are well controlled by continuous nasal positive airway pressure (NCPAP), day surgery can be considered and patients should bring their NCPAP equipment with them, and use it for any postoperative sleep periods, not just nocturnal. Anaesthetic technique should avoid opioids where possible, and local or regional techniques are well suited where site and nature of surgery allows.
Diabetes Diabetes is common, with a prevalence of 2e3% in Britain. In the past, concerns regarding perioperative hypoglycaemia from preoperative starvation and delayed resumption of oral intake owing to postoperative nausea and vomiting (PONV) denied diabetic patients day surgery. It is now accepted that stable diabetic patients are well suited to modern day surgery because of minimal interruption to daily routine and use of techniques to minimize PONV and resume oral intake as soon as possible after surgery. The Society for Ambulatory Anaesthesia (SAMBA) has issued a consensus statement on the perioperative management of diabetic patients undergoing day surgery. Diabetic patients require specific preoperative assessment because: type 1 diabetic patients are more liable to unplanned admission than type 2 diabetics diabetic stability in the months preceding surgery is key to successful day surgery, particularly in type 1 diabetes random blood glucose measurements are not useful in assessing preoperative diabetic stability useful indicators of diabetic stability are haemoglobin A1C (HbA1C) estimations, blood glucose profiles over preceding months, emergency admissions, hypoglycaemic attacks and medication changes there are insufficient data to recommend a fasting blood glucose or HbA1C above which day surgery should not proceed, but if there are complications of hyperglycaemia such as severe dehydration, ketoacidosis or hyperosmolar non-ketotic states, surgery should be postponed patients and carers should have a good understanding of diabetes and its management. Guidelines for perioperative management advise that: Hypoglycaemic medication other than long-acting insulins should be omitted on the morning of surgery; the return to usual medication and diet should occur as soon as possible after surgery. Metformin does not need to be withheld although it often is owing to concerns about the development of lactic acidosis should renal function deteriorate after surgery. Patients must bring their usual medication with them, and a sugary drink in case of preoperative hypoglycaemia. Patients should be scheduled as early as possible, preferably first on a list, but if they are likely to require perioperative insulin being second on the list reduces delays. The optimal blood glucose for day surgery is unknown. There is no evidence that any particular blood glucose is beneficial or harmful for patients undergoing day surgery so the target perioperative blood glucose level should depend upon the type and duration of surgery and anaesthetic technique. If the decision is made to proceed with surgery in patients with poorly controlled diabetes, target blood glucose levels should be around their preoperative baseline values. Dexamethasone 4 mg can be used for prevention of PONV in diabetics, but modification of hypoglycaemic therapy may be required. Vigilance for perioperative hypoglycaemia is essential. Patients should be warned of the possibility of delayed hyperglycaemia or hypoglycaemia before discharge.
Specific considerations ASA physical status Previous guidelines suggested that day surgery patients requiring general anaesthesia should normally be of ASA 1e2 status, but it is now accepted that ASA 3 patients are suitable following optimization, and even ASA 4 patients may undergo day surgery under local anaesthesia. Studies show that ASA 3 patients have a higher incidence of adverse incidents intraoperatively, but suffer fewer complications in the recovery period than ASA 1 and 2. Children The European Charter of Children’s Rights states that ‘.children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis.’ and day surgery in many specialities is well suited to children, including dental, ear, nose and throat, orthopaedic and some general procedures. Staff must have specific training, paediatric equipment is required, and children should be cared for in facilities designed for paediatric practice separate from adults. Some specific contra-indications exist: term babies under 1 month of age or ex-premature babies of less than 60 postconceptual weeks, in whom there is a risk of postoperative apnoeas. Elderly There is no arbitrary upper age limit for day surgery. Any comorbidities should be assessed and managed on an individual basis as for any other patient. Although haemodynamic disturbance is more common in the elderly during their perioperative course, outcomes are not adversely affected and there is no increase in postoperative complications. The incidence of postoperative cognitive dysfunction is reduced by day surgery but the social circumstances of elderly patients must be assessed very carefully, as they may require more formal support postoperatively. Obesity Obesity alone is not a contraindication to day surgery, and many day surgery units have increased and subsequently abolished upper limits of BMI. Whilst obese patients are more likely to suffer adverse events (particularly respiratory) perioperatively, these do not persist into the late recovery period and cannot be prevented by overnight hospital admission. Obese patients can be managed by experienced anaesthetists and bariatric surgery is increasingly being performed as day surgery. Techniques such as opioid-sparing analgesia regimes and early mobilization particularly benefit the obese.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
inflammatory drugs (NSAIDs) and paracetamol should be used if not contra-indicated, and in high-turnover day surgery lists, administration on the ward is a valuable time-saving measure; dose should be tailored to renal function.
STOP-Bang questionnaire 1. 2. 3. 4. 5. 6. 7. 8.
Snoring: do you snore loudly (loud enough to be heard through closed doors)? Yes/No Tired: do you often feel tired, fatigued, or sleepy during daytime? Yes/No Observed: has anyone observed you stop breathing during your sleep? Yes/No Blood Pressure: do you have or are you being treated for high blood pressure? Yes/No Body mass index (BMI): BMI > 35 kg/m2? Yes/No Age: age over 50 years old? Yes/No Neck circumference: neck circumference greater than 40 cm? Yes/No Gender: male? Yes/No
Airway management The use of a laryngeal mask airway (LMA), rather than endotracheal intubation, reduces the risk of sore throat, and a face mask alone reduces the risk even further. Postoperative nausea and vomiting (PONV) The risk of PONV should be stratified by assessing for patient and surgical risk factors. In low risk cases, general measures include using preoperative non-opioid analgesia, minimizing fluid deficit and using short-acting anaesthetic agents titrated to effect. In intermediate-risk cases, single-agent prophylaxis with dexamethasone or a 5HT3 antagonist (on emergence) and the general measures described above is recommended. In high-risk cases combination prophylaxis with both agents and general measures as well as TIVA is advised. The use of regional blocks or NSAIDs reduces the need for postoperative opioids, so they may be valuable in preventing PONV as well as in providing analgesia.
A patient is at risk of obstructive sleep apnoea (OSA) if answering yes to three or more items, and at high risk of OSA if answering yes to five or more items.
Table 3
Usual medications In the majority of cases, the patient’s usual medication regime should be continued. This follows the principle of minimal interruption to usual routine for day surgery, but special consideration must be given to diabetic medication (see above) and anticoagulants, in which case the risks and benefits must be considered for each individual, depending on the indication for anticoagulation.
Regional anaesthesia Some patients and procedures may suit local anaesthesia alone, but wound infiltration should always be used to provide prolonged postoperative analgesia. Regional anaesthesia reduces or avoids some of the complications associated with general anaesthesia such as PONV, sore throat and myalgia; it can be a solo technique or as a supplement to general anaesthesia. Neuraxial blockade, specifically low-dose spinal anaesthesia, opens up the possibility of day surgery to patients who might otherwise have been considered unsuitable.
Principles of anaesthesia for day surgery Anaesthetic techniques employed in day surgery should be tailored to the patient and aim to minimize patient discomfort and achieve the most rapid recovery possible, so increasing the patient’s chance of early discharge. Careful attention to analgesia, minimizing PONV, using local and regional techniques when appropriate, and managing the airway safely with minimal trauma all reduce postoperative morbidity.
Conclusions True ‘day surgery’ is perhaps better described as ‘same day surgery’. There are many advantages of day surgery both for patients and health service and there are now very few absolute contraindications, so each case should be considered individually to enable more patients to experience its benefits. Successful day surgery depends upon a pathway delivered by trained and experienced multidisciplinary staff, with close attention to detail and the use of tailored surgical and anaesthetic techniques. A
Surgical technique Surgical techniques which minimize tissue trauma (including laparoscopic techniques) are well suited to day surgery and attention to detail by an experienced surgeon with gentle tissue handling and a deft approach pays dividends. Decompressing the abdomen thoroughly after laparoscopic sterilization using a pseudo-Valsalva manoeuvre has been shown to reduce pain, and abdominal wall lift techniques and those which avoid the use of gas reduce PONV.
FURTHER READING Association of Anaesthetists of Great Britain and Ireland (AAGBI). Day case and short stay surgery. May 2011. Also available at: www. aagbi.org/publications/publications-guidelines. British Association of Day Surgery handbook series, Also available at: www.daysurgeryuk.net. Bryson GL, Chung F, Cox RG, et al. Patient selection in ambulatory anesthesia: an evidence-based review, part 2. Can J Anesth 2004; 51: 782e94. Bryson GL, Chung F, Finegan BA, et al. Patient selection in ambulatory anesthesia: an evidence-based review, part 1. Can J Anesth 2004; 51: 768e81.
Choice of drugs Drugs with a reliable safety profile, rapid recovery and minimal side effects are best for day surgery anaesthesia. These include propofol (especially as part of total intravenous anaesthesia (TIVA)), alfentanil, remifentanil, mivacurium, desflurane and sevoflurane. The use of remifentanil may be limited by the necessity for a longer acting opioid once the infusion has stopped. The incidence of suxamethonium-induced myalgia is reportedly 20e70%, even after pre-treatment with a low dose of a nondepolarizing muscle relaxant, so this drug should be avoided. Prophylactic oral analgesia using long-acting non-steroidal anti-
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
4
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
Patient selection for day surgery
Learning objectives After reading this article you should be able to: C define and describe the day surgery pathway C explain the advantages of day surgery C outline surgical procedures and techniques suited to day surgery C judge patient suitability for day surgery C justify contraindications to day surgery C discuss patient options for day surgery anaesthesia
Leanne Darwin
Abstract Day surgery is a planned pathway delivered by a multidisciplinary team and is perhaps better described as ‘same day surgery’. In 2000 the NHS set a target of performing 75% of operations as same day surgery but practice varies widely; an assessment of 10 procedures easily performed as same day surgery showed rates varying from 19% to 90% by procedure and the potential day case rate was not being reached for any procedure. There is a move to ‘treat day surgery as the norm’ in an effort to increase rates of day surgery so this article describes patient selection and procedures for day surgery, and discusses techniques which can be employed by anaesthetists and surgeons to achieve the reduced surgical trauma, rapid recovery and minimal complications necessary for successful day surgery.
care and with a clinical lead who has a specific interest in day surgery. Effective preoperative preparation, encompassing selection and assessment, and protocol-driven, nurse-led discharge are fundamental to the pathway.
Benefits of day surgery Day surgery has benefits to the patient, clinician, and hospital which include: patients receive hospital treatment suited to their needs, but recover at home early mobilization lower risk of nosocomial infection lower risk of venous thromboembolism (VTE) lower risk of cancellation sparing overnight beds for major surgical cases faster throughput, easier booking and reduced waiting lists cost-effective commissioning.
Keywords Anaesthetic technique; day surgery; patient selection; regional anaesthesia; same day surgery; short stay surgery Royal College of Anaesthetists CPD Matrix: 3A06
Introduction/background The definition of day surgery in the UK and Ireland is admission to hospital for a planned surgical procedure and return home within the same day. ‘True day surgery’ patients are day case patients who require full theatre facilities and/or a general anaesthetic, so this does not include procedures performed in outpatient or endoscopy departments. Previously definitions have included ‘in hospital stay of less than 24 hours’. Although counted as inpatient treatment (except in the USA), 23-hour and short stay surgery apply the same principles of care as same day surgery and improve quality. The NHS Plan (2000) stated that ‘.around three quarters of operations will be carried out on a day case basis with no overnight stay required.’. Advances in surgical and anaesthetic technique allow increasingly complex surgery to be performed on a day case basis, but, whilst overall rates are difficult to measure, available data suggest they are highly variable. The NHS Institute worked with clinicians to identify 10 procedures which were deemed achievable as day cases and found day case rates from 19% to over 90% based on data from 2002/2003 (Table 1). No hospital is performing at uniformly high levels across all specialities and there remains scope to increase rates of day surgery. Day surgery is a planned pathway, ideally delivered in a specific self-contained unit by staff with training in day surgery
Surgical selection The Audit Commission listed a ‘basket’ of 25 procedures for day surgery in 1990 which was revised in 2001 (Table 2). Since 2001, advances in surgical and anaesthetic techniques have meant that more complex procedures, and a wider range of patients, can be considered for day surgery, so the British Association of Day Surgery widened the ‘basket’ by publishing a ‘trolley’ of procedures and have since increased scope by publishing a directory of over 200 procedures which should be considered for short stay elective surgery; these range from ‘procedure room’ to under 72-hour stay cases. Rather than asking ‘is this case suitable for day surgery’, we should now ask ‘is there any justification for admitting this patient?’ The principles of surgical selection include: abdominal and thoracic surgery should use minimally invasive techniques the degree of surgical trauma is more important than its duration postoperative pain should be manageable using local anaesthesia and oral analgesia there should be low risk of postoperative complications: no continuing blood loss or need for fluid therapy no specialist postoperative care or observation should be needed patients should be able to mobilize before discharge
Leanne Darwin MBChB MRCP FRCA is an Anaesthetic Specialty Trainee (ST7), Health Education North West. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
1
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
exercise tolerance is a more useful indicator than examination findings or preoperative testing. If the patient copes well at home preoperatively, and surgery should not affect functional status, then day surgery is appropriate. In all cases pre-existing comorbidities should be assessed and optimized, but their presence may support the use of day surgery rather than present a contraindication.
Ten procedures that can easily be performed as day cases Procedure
National day case rate, %
Inguinal hernia Varicose veins Termination of pregnancy Cataract Sub-mucous resection (nasal cartilage) Extraction of wisdom teeth Cystoscopy/transurethral resection of bladder tumour Arthroscopy meniscectomy Excision of Dupuytren’s contracture Myringotomy/grommets
47.5 54.4 89.0 90.6 22.9 87.9 19.1
Cardiovascular disease Cardiovascular contraindications to day surgery are: severe angina (at rest or on minimal exertion) myocardial infarction or revascularization within the last 3 months heart failure with an exercise tolerance of less than 4 metabolic equivalents (METs) Exercise tolerance is a useful component of preoperative assessment. The ability to climb a flight of stairs (approximately 4 METs) is a predictor of good outcome. Hypertension should be well controlled before surgery and medication continued perioperatively. Although there is no evidence of increased risk when urgent surgery has been undertaken in uncontrolled hypertension, and measures to reduce hypertension rapidly before urgent surgery such as sublingual nifedipine or sedation have not been shown to reduce complications, the use of cardio-stable techniques are sensible.
73.1 41.7 85.0
NHS Institute (Hospital Episode Statistics, 2002/2003)
Table 1
the operating surgeon must have sufficient experience and a low complication rate in the procedure. Patients presenting for urgent surgery can be treated as day cases via a ‘planned acute’ pathway. After assessment, patients can be discharged and return for surgery at an appropriate time. This reduces repeated postponement of surgery on emergency lists due to prioritization of more serious cases, but a rigorous pathway with the following components is needed: identification of appropriate procedures: conditions which can be safely left untreated for a day or two, and manageable with oral analgesia identification of lists that can reliably accommodate cases clear pathways for day surgery clear preoperative patient information and post-discharge instruction in printed form.
Respiratory disease and obstructive sleep apnoea Adverse respiratory events are more common perioperatively in smokers, and those with asthma or chronic obstructive pulmonary disease. Although these rarely prolong recovery room stay, good preoperative control should be confirmed. Exercise tolerance is a more useful predictor than spirometry, and recent respiratory symptoms are predictive of complications so should delay surgery, but local or regional techniques can be always considered to permit day surgery in symptomatic patients.
Patient selection
‘Basket’ of day case procedures
There are very few absolute contraindications to day surgery. The majority of patients are appropriate unless there is a valid reason why overnight stay would be to their benefit. In making such a decision, both social and medical factors must be considered.
Orchidopexy Circumcision Inguinal hernia repair
Patient selection e social Patients (and/or their carers) must understand (and consent to) day surgery and postoperative care. Following procedures under general anaesthesia or sedation, a responsible person must escort the patient home and provide postoperative care of varying duration. The patient’s home circumstances must be suitable for postoperative care. This includes access to a telephone, and a location within reasonable journey time to emergency care in case of the need to attend. The siting of a lavatory and availability of central heating may need to be considered in some geographical locations.
Excision of breast lump Anal fissure dilatation or excision Haemorrhoidectomy Laparoscopic cholecystectomy Varicose vein stripping or ligation Transurethral resection of bladder tumour Excision of Dupuytren’s contracture Carpal tunnel decompression Excision of ganglion Arthroscopy
Patient selection e medical Selection is based on assessment of patient’s functional status rather than arbitrary limits such as age, American Society of Anesthesiologists (ASA) status or body mass index (BMI) and
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Bunion operations Removal of metal ware Extraction of cataract with/without implant Correction of squint Myringotomy Tonsillectomy Sub-mucous resection (nasal cartilage) Reduction of nasal fracture Operation for prominent ‘bat’ ears Dilatation and curettage/hysteroscopy Laparoscopy Termination of pregnancy
(Audit Commission, 2001)
Table 2 2
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
Obstructive sleep apnoea (OSA) is under-diagnosed, and signs and symptoms should be sought during assessment particularly in at-risk groups; the STOP-Bang score is useful in predicting OSA (Table 3). If existing symptoms are well controlled by continuous nasal positive airway pressure (NCPAP), day surgery can be considered and patients should bring their NCPAP equipment with them, and use it for any postoperative sleep periods, not just nocturnal. Anaesthetic technique should avoid opioids where possible, and local or regional techniques are well suited where site and nature of surgery allows.
Diabetes Diabetes is common, with a prevalence of 2e3% in Britain. In the past, concerns regarding perioperative hypoglycaemia from preoperative starvation and delayed resumption of oral intake owing to postoperative nausea and vomiting (PONV) denied diabetic patients day surgery. It is now accepted that stable diabetic patients are well suited to modern day surgery because of minimal interruption to daily routine and use of techniques to minimize PONV and resume oral intake as soon as possible after surgery. The Society for Ambulatory Anaesthesia (SAMBA) has issued a consensus statement on the perioperative management of diabetic patients undergoing day surgery. Diabetic patients require specific preoperative assessment because: type 1 diabetic patients are more liable to unplanned admission than type 2 diabetics diabetic stability in the months preceding surgery is key to successful day surgery, particularly in type 1 diabetes random blood glucose measurements are not useful in assessing preoperative diabetic stability useful indicators of diabetic stability are haemoglobin A1C (HbA1C) estimations, blood glucose profiles over preceding months, emergency admissions, hypoglycaemic attacks and medication changes there are insufficient data to recommend a fasting blood glucose or HbA1C above which day surgery should not proceed, but if there are complications of hyperglycaemia such as severe dehydration, ketoacidosis or hyperosmolar non-ketotic states, surgery should be postponed patients and carers should have a good understanding of diabetes and its management. Guidelines for perioperative management advise that: Hypoglycaemic medication other than long-acting insulins should be omitted on the morning of surgery; the return to usual medication and diet should occur as soon as possible after surgery. Metformin does not need to be withheld although it often is owing to concerns about the development of lactic acidosis should renal function deteriorate after surgery. Patients must bring their usual medication with them, and a sugary drink in case of preoperative hypoglycaemia. Patients should be scheduled as early as possible, preferably first on a list, but if they are likely to require perioperative insulin being second on the list reduces delays. The optimal blood glucose for day surgery is unknown. There is no evidence that any particular blood glucose is beneficial or harmful for patients undergoing day surgery so the target perioperative blood glucose level should depend upon the type and duration of surgery and anaesthetic technique. If the decision is made to proceed with surgery in patients with poorly controlled diabetes, target blood glucose levels should be around their preoperative baseline values. Dexamethasone 4 mg can be used for prevention of PONV in diabetics, but modification of hypoglycaemic therapy may be required. Vigilance for perioperative hypoglycaemia is essential. Patients should be warned of the possibility of delayed hyperglycaemia or hypoglycaemia before discharge.
Specific considerations ASA physical status Previous guidelines suggested that day surgery patients requiring general anaesthesia should normally be of ASA 1e2 status, but it is now accepted that ASA 3 patients are suitable following optimization, and even ASA 4 patients may undergo day surgery under local anaesthesia. Studies show that ASA 3 patients have a higher incidence of adverse incidents intraoperatively, but suffer fewer complications in the recovery period than ASA 1 and 2. Children The European Charter of Children’s Rights states that ‘.children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis.’ and day surgery in many specialities is well suited to children, including dental, ear, nose and throat, orthopaedic and some general procedures. Staff must have specific training, paediatric equipment is required, and children should be cared for in facilities designed for paediatric practice separate from adults. Some specific contra-indications exist: term babies under 1 month of age or ex-premature babies of less than 60 postconceptual weeks, in whom there is a risk of postoperative apnoeas. Elderly There is no arbitrary upper age limit for day surgery. Any comorbidities should be assessed and managed on an individual basis as for any other patient. Although haemodynamic disturbance is more common in the elderly during their perioperative course, outcomes are not adversely affected and there is no increase in postoperative complications. The incidence of postoperative cognitive dysfunction is reduced by day surgery but the social circumstances of elderly patients must be assessed very carefully, as they may require more formal support postoperatively. Obesity Obesity alone is not a contraindication to day surgery, and many day surgery units have increased and subsequently abolished upper limits of BMI. Whilst obese patients are more likely to suffer adverse events (particularly respiratory) perioperatively, these do not persist into the late recovery period and cannot be prevented by overnight hospital admission. Obese patients can be managed by experienced anaesthetists and bariatric surgery is increasingly being performed as day surgery. Techniques such as opioid-sparing analgesia regimes and early mobilization particularly benefit the obese.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002
DAY SURGERY
inflammatory drugs (NSAIDs) and paracetamol should be used if not contra-indicated, and in high-turnover day surgery lists, administration on the ward is a valuable time-saving measure; dose should be tailored to renal function.
STOP-Bang questionnaire 1. 2. 3. 4. 5. 6. 7. 8.
Snoring: do you snore loudly (loud enough to be heard through closed doors)? Yes/No Tired: do you often feel tired, fatigued, or sleepy during daytime? Yes/No Observed: has anyone observed you stop breathing during your sleep? Yes/No Blood Pressure: do you have or are you being treated for high blood pressure? Yes/No Body mass index (BMI): BMI > 35 kg/m2? Yes/No Age: age over 50 years old? Yes/No Neck circumference: neck circumference greater than 40 cm? Yes/No Gender: male? Yes/No
Airway management The use of a laryngeal mask airway (LMA), rather than endotracheal intubation, reduces the risk of sore throat, and a face mask alone reduces the risk even further. Postoperative nausea and vomiting (PONV) The risk of PONV should be stratified by assessing for patient and surgical risk factors. In low risk cases, general measures include using preoperative non-opioid analgesia, minimizing fluid deficit and using short-acting anaesthetic agents titrated to effect. In intermediate-risk cases, single-agent prophylaxis with dexamethasone or a 5HT3 antagonist (on emergence) and the general measures described above is recommended. In high-risk cases combination prophylaxis with both agents and general measures as well as TIVA is advised. The use of regional blocks or NSAIDs reduces the need for postoperative opioids, so they may be valuable in preventing PONV as well as in providing analgesia.
A patient is at risk of obstructive sleep apnoea (OSA) if answering yes to three or more items, and at high risk of OSA if answering yes to five or more items.
Table 3
Usual medications In the majority of cases, the patient’s usual medication regime should be continued. This follows the principle of minimal interruption to usual routine for day surgery, but special consideration must be given to diabetic medication (see above) and anticoagulants, in which case the risks and benefits must be considered for each individual, depending on the indication for anticoagulation.
Regional anaesthesia Some patients and procedures may suit local anaesthesia alone, but wound infiltration should always be used to provide prolonged postoperative analgesia. Regional anaesthesia reduces or avoids some of the complications associated with general anaesthesia such as PONV, sore throat and myalgia; it can be a solo technique or as a supplement to general anaesthesia. Neuraxial blockade, specifically low-dose spinal anaesthesia, opens up the possibility of day surgery to patients who might otherwise have been considered unsuitable.
Principles of anaesthesia for day surgery Anaesthetic techniques employed in day surgery should be tailored to the patient and aim to minimize patient discomfort and achieve the most rapid recovery possible, so increasing the patient’s chance of early discharge. Careful attention to analgesia, minimizing PONV, using local and regional techniques when appropriate, and managing the airway safely with minimal trauma all reduce postoperative morbidity.
Conclusions True ‘day surgery’ is perhaps better described as ‘same day surgery’. There are many advantages of day surgery both for patients and health service and there are now very few absolute contraindications, so each case should be considered individually to enable more patients to experience its benefits. Successful day surgery depends upon a pathway delivered by trained and experienced multidisciplinary staff, with close attention to detail and the use of tailored surgical and anaesthetic techniques. A
Surgical technique Surgical techniques which minimize tissue trauma (including laparoscopic techniques) are well suited to day surgery and attention to detail by an experienced surgeon with gentle tissue handling and a deft approach pays dividends. Decompressing the abdomen thoroughly after laparoscopic sterilization using a pseudo-Valsalva manoeuvre has been shown to reduce pain, and abdominal wall lift techniques and those which avoid the use of gas reduce PONV.
FURTHER READING Association of Anaesthetists of Great Britain and Ireland (AAGBI). Day case and short stay surgery. May 2011. Also available at: www. aagbi.org/publications/publications-guidelines. British Association of Day Surgery handbook series, Also available at: www.daysurgeryuk.net. Bryson GL, Chung F, Cox RG, et al. Patient selection in ambulatory anesthesia: an evidence-based review, part 2. Can J Anesth 2004; 51: 782e94. Bryson GL, Chung F, Finegan BA, et al. Patient selection in ambulatory anesthesia: an evidence-based review, part 1. Can J Anesth 2004; 51: 768e81.
Choice of drugs Drugs with a reliable safety profile, rapid recovery and minimal side effects are best for day surgery anaesthesia. These include propofol (especially as part of total intravenous anaesthesia (TIVA)), alfentanil, remifentanil, mivacurium, desflurane and sevoflurane. The use of remifentanil may be limited by the necessity for a longer acting opioid once the infusion has stopped. The incidence of suxamethonium-induced myalgia is reportedly 20e70%, even after pre-treatment with a low dose of a nondepolarizing muscle relaxant, so this drug should be avoided. Prophylactic oral analgesia using long-acting non-steroidal anti-
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Please cite this article in press as: Darwin L, Patient selection for day surgery, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/ 10.1016/j.mpaic.2015.12.002