Anaesthetic Considerations of Day care surgery-

Dr Sheetal Jagtap Prof &Head Anaesthesiology

Dr D.Y. Patil Medical college &Hospital
Nerul, Navi Mu!ai
Introduction
"he "erinologies day care anesthesia, a!ulatory anesthesia #AA$, outpatient anesthesia, also %no&n as
day care surgery is all synonyous. "he a!ulatory anesthesia as the nae suggests eans patient &ill !e, 'street
fit(#a!ulant$ after anaesthesia. Day care surgery )anaesthesia signifies eaningfully to restrict to only, 'Day stay*.
+utpatient anaesthesia clinic &as started !y ,alph -aters in ./00, in Siou1 2ity of 3o&a. He ainly provided
anaesthesia for dental and inor surgeries. Su!se4uent interest in a!ulatory anesthesia and surgeries coupled &ith
recent advances in anesthetic and surgical techni4ues and safety have allo&ed rapid gro&th in a!ulatory surgery
throughout the &orld. 5sta!lishent of the Society for A!ulatory Anesthesia # SAM6A $ in 7SA in ./89 and
foral developent of AA as a su!specialty increased the nu!ers of surgeries perfored on day care !asis to a
large e1tent, so uch so that in ./8: a!out ;0< of all elective surgeries in 7SA &ere perfored on day care !asis
&hich has increased to nearly =0< of anesthesia services provided in >00=.3n 7SA the econoic pressure fro
insurance copanies gave !oost to this concept.
3n our country, 3ndian association for Day Surgery &as fored in >00; and is actively involved in
propagating this su!specialty #&&&.daysurgeryindia.org$
An A!ulatory Anaesthesia is one adinistered for a non eergency or elective surgical procedures, perfored on
carefully selected patients., &hich is underta%en &ith all its constituent eleents # adission , operation and
discharge hoe $ on the sae day. "he procedures ay!e conducted in free standing facility or in a hospital !ased
outpatient facility.
3n the recent ties availa!ility of rapid and short acting drugs &ith less potential to cause prolong side effects li%e
hangover, respiratory depression, or residual neurouscular !loc%ade, has facilitated the recovery and so nu!er of
pts. operated on a!ulatory !asis increased to large e1tent.
GUIDELINE FOR AMBULAOR! ANAE"#E"IA AND "URGER!
"he Aerican Society of Anaesthesiologists #ASA$ encourages the anesthesiologist to play a leadership role as the
Perioperative physician in all hospitals, a!ulatory surgical facilities and office !ased settings and to participate in
facility accreditation as a eans for standardi?ation and iproving the 4uality of patient care.
"hese guidelines apply to all care involving anesthesiology personnel adinistering a!ulatory anesthesia in
all settings and are su!@ect to periodic revision, as &arranted !y the evolution of technology and practice.
.. A licensed physician should !e in attendance in the facility or in the case of overnight care, iediately
availa!le !y telephone, at all ties during patient treatent and recovery and until the patients are
edically discharged.
>. "he facility ust !e esta!lished , constructed, e4uipped operated in accordance &ith applica!le local ,
state , federal la&s and regulations . at a iniu, all settings should have a relia!le source of o1ygen ,
suction, resuscitation e4uipent and eergency drugs. Specific reference is ade to the ASA 'Stateent
on Non operating ,oo Anestheti?ing Aocations.*
;. Staff should !e ade4uate to eet patient and facility needs for all procedures perfored in the setting and
should consist of B
a. Professional StaffB physicians and other practitioners &ho hold a valid license or
certificate are duly 4ualified. Nurses &ho are duly licensed and 4ualified.
!. Adinistrative Staff.
c. House%eeping and Maintenance Staff.
9. Physicians providing edical care in the facility should assue responsi!ility for credentials revie&,
delineation of privileges, 4uality assurance and peer revie&.
:. Cualified personalD and e4uipent should !e on hand to anage eergencies. "here should !e esta!lished
policies and procedures to respond to eergencies and unanticipated patient transfer to an acute care
facility.
E. Minial patient care should includeB Preoperative instructions and preparation, an appropriate
preanaesthesia evaluation and e1aination !y an anesthesiologist, prior to anaesthesia and surgery. 3n the
event that non physician personnel are utili?ed in the process, the anesthesiologist ust verify the
inforation and repeat and record essential %ey eleents of the evaluation and preoperative studies and
consultants as edically indicated.

A"A guide$ines for %&asic standards of 'erio(erati)e care and *onitoring+ and guidelines for
a!ulatory anaesthesia services should !e strictly follo&ed. Anesthesiologist should !e physically
present during the procedure and hiself discharge the patient &hen found fit for hoe Freadiness
&ith clear , &ritten instructions .
All personnel should !e trained in advance resuscitation techni4ues #6AS, A2AS$ and there !e &ritten
protocol for cardiopulonary eergencies for other internal or e1ternal disasters li%e fire, earth4ua%e,
accidents or transfer of high ris% patients to referral hospitals.
Miniu onitoring standards as per AA guidelines should !e follo&ed. All e4uipents should !e
aintained, periodically tested and inspected according to anufacturer(s specifications.
Assure ade4uate source of o1ygen, suction, resuscitative e4uipents and eergency drugs.
Patients safety should !e a priority and should not !e @eopardi?ed for patient(s convenience or cost
saving.
2ontrolled drug supply, storage and adinistration ust !e onitored.
Disposal of syringes, needles, and &aste aterial.
Provision of PA27 or recovery roo, staffs !y ade4uate trained nursing and paraedical staff.
Adission and discharge procedure fro PA27 or for fastGtrac%ing should !e clearly notified.
,elia!le escort ust accopany and !e given &ritten instructions for patient care or to contact in case
of an eergency.
2ontinuing edical educational prograe for the physician and other facility personnel.
Co**on$y cited &enefits of a*&u$atory surgery
Patient preference, especially children and the elderly, as it decreases separation fro their failiar hoe
environent.
Aac% of dependence on availa!ility of hospital !eds.
Hreater fle1i!ility in scheduling operations.
Ao& or!idity and ortality.
Ao&er incidence of infection.
Ao&er incidence of respiratory coplications li%e pulonary e!olis, pneuonia etc.
Higher volue of pts. # greater efficiency $
Shorter surgical &aiting lists.
Ao&er overall procedural costs.
Aess preoperative testing and postoperative edication.
A*&u$atory surgery unit can &e any one of the fo$$o,ing-
Hospital integrated
Hospital separated #!ut accessi!le to the hospital$
Satellite a!ulatory unit. #&hich &or%s under the sae adinistration$
Iree standing unit.#&hich is totally independent$
+ffice !ased.
D5S3HN B
51it
+ffice
)reception
-aiting area,
registration
2hanging roos Step do&n
recovery
5ntrance
"e$ection criteria
Ior a successful day care surgery progra, it is essential to have proper selection of patient, procedure and
anesthetic techni4ues and drugs. -e should also %eep in ind the rare occurrence of pro!les pertaining to
anesthesia and surgery and ust have ade4uate facilities for dealing &ith the sae.
./ "e$ection of (atient. Adission criteria need to !e ore stringent in free standing units.
Unani*ous agree*ent on se$ection inc$udes -
Healthy, young, ASA physical status 3 or 33 patients.
Short procedures perfored under MA2 or short HA.
Anticipated uncoplicated recovery.
Availa!ility of a responsi!le escort and careta%er at hoe including hygienic surroundings at hoe.
Access to the centre or other hospital in the area &ithin a reasona!le tie in case of an eergency.
"elephone or o!ile phone for counication.
Unani*ous disagree*ent on se$ection -
7nsta!le ASA physical status 333 and a!ove pts. &ith serious potentially lifeGthreatening diseases that are
not optially anaged.
Jery old patients.
Neonates and preature infants &ith gestational age K E0 &ee%s re4uiring general anesthesia for the fear of
post operative apnoea.
Mor!id o!esity coplicated !y syptoatic cardiovascular or respiratory pro!les.
Syndroic !a!iesG ay have eta!olic pro!les, difficult air&ay
Ma@or procedures involving fluid shifts and !lood transfusion and other physiological distur!ances, need
for i.v anti!iotics or parenteral opioids for pain control.
Hoo?ygous heoglo!inopathies and patient on anticoagulants. H)+ !leeding disorders
7sing ultiple chronic centrally active drug therapies and active cocaine
a!use !ecause of increased ris% of intraoperative coplications, including death.
Procedure re4uiring speciali?ed post operative care including e1tensive physiotherapy.
Poor patient acceptance, lac% of a responsi!le adult at hoe to care for the patient on the evening after
surgery and patient(s un&illingness to coply &ith instruction.

6et&een these e1trees there is a large group of patients for &ho soe ris% factor is present although any
a!ulatory centers around the &orld are perforing a@or surgical procedures in optii?ed patients routinely &ith
facilities for hospital adission if need !e, to reduce health care cost. Many a tie they are perfored as >;hr stay
cases.
3n the a!sence of definite recoendations in our country, each one of us has to e1ercise our sensi!ilities and
perfor the cases as in patient )out patients !asis for a1iu patient safety.
Patients falling in the a!ove group includeB
ASA333 patients !ut clinically sta!le.
Pree1isting cardiovascular conditions.#e.g. hypertension,2HI,angina$
Pree1isting respiratory conditions.#e.g. astha,2+PD$
Patients at e1trees of age i.e. KE onth and L=0 yrs.
+ld patients#L=0yrs there are reports to suggest that postoperative cognitive dysfunction is less fre4uent
&hen the procedure is done on outpatient !asis$
Mor!id o!esity !ut &ith no coGor!id conditions.#6M3L;:%g)>$
Patients suscepti!le to alignant hypertheria.
Preoperativ
e holding
+peration
theatre
Heneral
recovery
H)+ sudden death syndroe in faily.
Patients &ith 7,"3 &hich increases Perioperative respiratory coplications li%e cough, laryngospas and
!ronchospas.
Pediatric patients &ith h)o loud snoring. in soe centers they are evaluated &ith sleep studies
preoperatively to deterine the safety of outpatient anageent especially if they are for 5N" procedures.
"his group ay have postoperative respiratory coproise and re4uire prolonged recovery roo stay or
readission especially if they are sall.#K;yrs of age$
.0 "e$ection of 'rocedures
Duration of surgery-
+riginally liited to procedures lasting less than /0 inutes. Presently soe esta!lished centers do ta%e up longer
duration cases also.
"ype of surgery perfored at various centersB
Specialty "ypes of procedures
Dental "ooth e1traction, restoration, facial fractures.
Heneral surgery Ayph node !iopsy, endoscopy, e1cision of asses, heorrhoidectoy, herniorrhaphy,
circucision, Aaparoscopic procedures, varicose vein surgery, 3&D of a!scesses, tongue tie
release.
Hynecology 2one !iopsy, dilatation and curettage, M"P, hysteroscopy, laparoscopy, polypectoy, tu!al
ligation, vaginal hysterectoy.
+rthopedic Anterior cruciate repair, arthroscopy, !unionectoy, carpal tunnel
,elease, closed reduction, anipulation under anaesthesia, cast changes ,reoval of pins
and plates.
5N" astoidectoy,yringotoy,polypectoy,rhinoplasty,tonsillectoy,typanoplasty,closed
reduction of nasal fracture.Ascopy
Plastic surgery 6asal cell cancer e1cision, cleft lip repair, liposuction, aoplasty, otoplasty ,scar
revision, septorhinoplasty ,s%in graft, procedures for syndactyly and polydactyly.
7rology 6ladder surgery, circucision, cystoscopy, lithotripsy, orchidectoy, prostate !iopsy,
vasovasostoy.
+phthalology 2ataract e1traction ,chala?ion e1cision, nasolacrial duct pro!ing, stra!isus repair,
tonoetry
Deratology 51cision of s%in repair
Pain clinic 2heical sypathectoy, epidural in@ection, nerve !loc%s
Diagnostics and
therapeutic procedures
Aaryngoscopy , tracheoG!ronchoscopy, oesophagoscopy, dilatation, gastroscopy,
colonoscopy, cystoscopy, 2" Scan, M,3, transoesophageal echocardiography, cardiac
catheteri?ation.
As entioned earlier the procedure selected should !e coforta!le to handle for the patient, relatives,
anesthesiologist, surgeon and other health care &or%ers involved in the progra.
Preoperative assessent including a detailed history , physical e1aination and chec%ing investigation reports#as
dictated !y the patients health status and planned surgery$ is very iportant for a successful outcoe. 3t can !e
perfored in a preoperative clinic or !y telephonic intervie& !y trained and dedicated nursing staff 3t has to !e
follo&ed up !y edical staff !efore su!@ecting the patient to anaesthesia and surgery. Iurther diagnostic evaluation,
treatent and optii?ation are re4uired for success. Preedication is usually not re4uired !ut ay !e iportant in
soe selected patients for an1iolysis. 3t is necessary to identify patients &ith difficult air&ay to deterine their
inclusivity and plan anageent.
Pre operative education of the patient)care ta%er)parents !y !rochures, paphlets and video tapes reduces
preoperative an1iety and iproves outcoe and so attepts ust !e ade to achieve this end. Cualified
anesthesiologist trained in adinistration of general and)or regional anaesthesia is essential. "he efficient and
ade4uate anaesthesia service re4uired BG
All necessary e4uipents for elective)eergency operation and training in cardioGpulonary resuscitation
and anageent of difficult air&ay.
Post anaesthesia care notes &ith discharge suary fulfilling criteria for eergence, hoe readiness.
-ritten plan to shift eergency case to the satellite day care units or !ac% to the hospital should !e clearly
docuented.
All the surgical and anaesthesia e4uipents should eet the sae standards as those of the
hospital to &hich it is attached. Monitoring e4uipents as laid do&n according to the iniu essential ust !e
ade availa!le.
P+S5 MD is the pneuonic e1plaining the iniu re4uireent of any such unit as regards the essential
facilities for pt. care.
P positive pressure capa!ility for ventilation # a!u to ventilator $
+ o1ygen supply source
S suction unit
5 eergency e4uipentsGair&ays, laryngoscope, 5"", defi!rillator, AMA )
Proseal AMA
M onitoring e4uipents F autoated 6P, SP+>, 52H, 5t2+>, 63S,
"eperature onitor
D drugs F anesthetic, life saving and others
ANAE"#E"IA ADMINI"RAION
Successful day surgery anesthesia rounds around 9 'As*B
1/ A*&u$ation
./ A$ertness
2/ Ana$gesia
9. A$i*entationG prevention of nausea and voiting.
3t is the 4uality of recovery fro anesthesia &hich is particularly iportant in day surgical &or%.
Anesthesia for day surgery should ensure a rapid recovery &ith s&ift return to street fitness
Aocal, general and spinal anesthesia are all coonly used anesthetic techni4ue for a!ulatory surgery.
Ho&ever opinion differs as to the !est anesthetic techni4ue for these surgical procedures. ,ather than siply
generali?ing as to the !est anesthetic techni4ue for a!ulatory surgery, it is necessary to individually analy?e each
surgical procedure.
"he optial anesthetic techni4ue in the a!ulatory setting &ould provideB
.. 51cellent operating conditions
>. ,apid recovery
;. No postGoperative side effects
9 .High degree of patient satisfaction 3n the current cost conscious environent it is iportant to also e1aine
the ipact of anesthetic techni4ue on +.,. turnover as &ell as recovery process !ecause prolonged recovery tie
and reduced efficiency and productivity contri!ute to increased cost of surgical care. 3n addition patient satisfaction
&ith their periGoperative e1perience and 4uality of recovery is iproved. -hen the anesthetic techni4ue chosen for
the procedure is associated &ith lo& incidence of post operative side effects e.g Pain Di??iness, Headache, Post
operative nausea and voiting
,outine use of prophylactic antieetic drug during general anesthesia has !een found to increase patient
satisfaction, furtherore, use local infiltration and peripheral nerve !loc%, decrease post operative pain irrespective
of the anesthetic techni4ue used. Another fact is that the success of anesthetic techni4ue depends not only on the
anesthesiologist !ut also on the s%ill of the surgeon in providing effective infiltration anesthesia and gentle handling
of the tissues during operative procedures.
.
Drugs and MonitoringB
"he availa!ility of rapid short acting i.v #Propofol$ and inhalation anesthetics #SevoG Desflurane$ analgesics
#Ientanyl, ,eifentanil$ and ad@uvant drugs as &ell as iproved cere!ral onitoring capa!ilities has facilitated the
recovery process after general anesthesia techni4ue. Aight general anesthesia techni4ue &ith laryngeal as% air&ay
device and local anesthetic infiltration has deonstrated that out patients undergoing superficial surgical procedures
#e.g. Hernia repair, !reast surgery, superficial cosetic surgery$ are a!le to a!ulate &ithin ;0 in and can !e
discharged hoe &ithin E0 in. after fast trac%ing.
-hen tracheal intu!ation is re4uired e.g. laparoscopic procedure, ris% factors for aspiration tonsillectoyG dia!etic
patient, esophageal dysfunctionG Analgesia &ith use of inial effective dose of short acting +piod. e.g.
,eifentanilG 0..>:Mg) Ng, SufentanilG 0..Mg)Ng to 0.:Mg)Ng &ith titration can facilitate early recovery process.
on
M7A"3M+DAA APP,+A2H "+ P,5J5N"3NH P+S" +P5,A"3J5 2+MPA32A"3+NS
NA7S5A AND J+M3"3NHB ,outine antieetic prophyla1isB 5N" cases, feale pt. , previous history of P+NJ
are considered high ris% and need prophylactic easures for P+NJ. Propofol is the drug of choice for anesthesia.
3n case one drug fails use another drug fro different group the ost cost effective co!ination consists of
Droperidol #0.: to .g$ and de1aethasone 9G 8g appears to facilitate an earlier discharge. +ut patients at high
ris% of P+NJ &ill !enefit fro addition of a :H"; antagonist e.g +ndansetron, Dolesatron, Hranisatron.
Ade4uate hydration in addition to co!ination of antieetic therapy. Siply ensuing ade4uate hydration &ill
inii?e nausea and other side effects #di??iness, dro&siness, thirst$ during post operative period. M7A"3M+DAA
APP,+A2H "+ P,+J3D3NH P+S" +P5,A"3J5 ANAAH5S3AG P,55MP"3J5
Preeptive addition of %etaine =:G .00 Mg)Ng, de1aethasone along &ith potent NSA3D can
effectively control pain.
Discharge criteria
3deally &ith correct choice of anesthetic techni4ue and drugs, patient should !e Ohoe ready( &ithin a fe&
hours. Procedures perfored correctly under AA &ith or &ithout sedation under MA2, short HA &ithout intu!ation
and use of currently availa!le rapid shorter acting anesthetic and analgesic agents and NM6Ds coupled &ith
iproved anesthetic and surgical techni4ues #M3S$ has facilitated the recovery process to a great e1tent. 7se of
anesthetic depth onitors li%e 63S &ill reduce the chances of a&areness as &ell as e1cessive use of anesthetic
agents and is li%ely to !e used for ore and ore cases.
A ulticenter study on fast trac% anaesthesia found that PA27 !ypass rate after ipleentation of a fast trac%
progra after general anaesthesia increased fro 0.9< #9 of ..:.$ to ;..8<#;E. of ..;E$ &ithout increasing the
incidence of adverse events. Siilar study conducted !y Patel et al in pediatric surgical patients undergoing less
than /0in duration of procedure, confired that fastGtrac%ing is safer feasi!le and !eneficial &hen specific
selection criteria are utili?ed.
Modified Aldrete scoring syste should !e used to transfer the surgical patients to !ypass PA27.
'ACU By 'ass Criteria- 3'A""$
2o!ined odified Aldrete scale &ith evaluation of P+NJ and post +P pain, to !ypass PA27 patient ust have
post op score of .> points of .9 points.
Criteria for o&ser)ation O&ser)ation "core (oints
.$Aevel of consciousness A&a%e and oriented >
Arousal &ith inial stiulation .
,esponds only to tactile
stiulation
0
Physical activity Moves all li!s on coand >
Soe &ea%ness in li!s .
7na!le to a%e voluntary
oveents
0
Haeodynaic status 6P K .: < of !aseline >
6P !et&een .: to ;0 < of
!aseline
.
6P K ;0 < of !aseline 0
,espiration A!le to ta%e deep !reaths >
"achpnoea and good cough .
Dyspnoea and &ea% cough 0
+> saturation L /0< on roo air >
L /0< &ith Nasal Prong +>
supply
.
K /0< &ith +> 0
Pain No pain or ild discofort >
Moderate to severe pain
controlled &ith analgesics
.
Pain in spite of edications 0
P+NJ Mild Nausea)cofort
"ransient reching)voiting
Persistant od to sever
Nausea )voiting
>
.
0
.9Point score total L .> for discharge.
3n case of spinal or epidural or regional anesthesia,
Ai! oveents Purposeful oveent of at least
one upper and one lo&er li!
>
+nly one upper li! oveent .
No li! oveent 0
6P K >0 < of !aseline and N+
orthostatic hypotension
>
>0 to 90 < of !aseline !ut N+
orthostatic hypotension
.
K 90 < of !aseline or orthostatic
hypotension
0
'ro(er guide$ines for a safe discharge inc$udeB
Sta!le vital signs for at least one hour.
A!sent or inial surgical !leeding fro operation site.
A!ility to &al% unsupported or &ith inial support.
Minial or nil nausea and voiting after treatent.
Minial pain that is tolera!le and accepta!le to the patient.
A!ility to retain oral fluid and to void. "here are certain controversies regarding this, there are studies to
sho& that patient are forced to drin% fluids prior to discharge have an increased incidence of P+NJ and
hence there is no need to fulfill this condition. Also patients should !e given fluids &hen they feel hungry
and not &hen they feel thirsty. Studies have sho&n this approach to reduce P+NJ. "he outcoe of patients
can also !e iproved !y giving 3J fluids for the starvation period and liiting NP+ orders to @ust >hrs
!efore surgery. "his has decreased incidence of preoperative hypoglyceia.
3n certain high ris% group for urinary retention, ultrasound onitoring of !ladder volue is used to
deterine the need for catheteri?ation.
Patients operated under 2N6 ust have return of perianal sensation and proprioception of great toe.
Patients operated under ple1us !loc% should !e advised to ta%e care of insensate li! and ust have a sling
for protection. 3n soe centre continuous peripheral nerve !loc% using a disposa!le infusion device is
soeties used to e1tend the period of analgesia at hoe after discharge. "hough the coplete safety of
this is not yet fully esta!lished.
Jer!al and &ritten instructions regarding edications, do(s and don(t(s ,follo& up visits ,contact nu!ers
of the hospital and doctors and sufficient stoc% of edications should !e supplied.
3n soe centers discharge is follo&ed !y telephonic intervie& to ensure patient &ell!eing.
Despite all precautions and even &ith proper patient selection ,a sall percentage of patients ay re4uire
overnight hospital stay or readission after discharge and the tea e!ers ust !e ready for this.
2oon causes for a!ove are surgical factors li%e pain and !leeding ,anesthetic factors li%e P+NJ and
other anaesthesia related coplications and edical factors.
,arely patients ay present &ith an acute illness and ay have to !e rescheduled.
Conc$usion-
An attept is there, all over the &orld to a%e day care surgery universal. Patient education and preparation ,use
of ne&er short acting anesthetic agents and iproved surgical techni4ues is sure to a%e this ore accepta!le to
patients. -e as anesthesiologists have a great role to play in this change.