DAY CASE ANAESTHESIA

Dr. Omar Mohamed Danfour

Senior Lecturer –Specialist of Anesthesia & Intensive Care (MSU-IMS-Anesthesia Department)

Another Name • Ambulatory surgery

• Day-case surgery

• Same-day surgery

• Come and go surgery

Day Case Aneasthesia

Pt. who is admitted for investigation or operation on a planned non-resident basis. The pt occupies a bed in a ward or unit set aside for this purpose. Outpatient surgery allows a person to return home on the same day that a surgical procedure is performed.

Day Case Aneasthesia

During the last 30 years, there has been rapid expansion in the use of day-case surgery.

In the last 25 years, the percentage of pts going home the same day has increased from < 10% to approximately 65% in the united states

At the inception of day-case procedures, a case was considered suitable if it took less than 90 min to complete (do not cause sever haemorrhage or produce excessive amounts of postoperative pain).

• because investigators have found that the operating and anesthetic time is a strong predictor of postoperative complications (e.g., pain, emesis)and delayed discharge, as well as unanticipated admission to the hospital after ambulatory surgery .

With regard to the distance from the hospital to the pt’s home, and a responsible adult must be at home with the pt during first 24 h after surgery

The growth in ambulatory surgery would have not been possible without the development of improved anesthetic and surgical techniques.

Day Case Aneasthesia

The availability of rapid, shorter -acting anesthetic, analgesic, and muscle relaxant drugs has clearly facilitated the recovery process and allowed more extensive procedures to be performed on an ambulatory basis, irrespective of preexisting medical conditions.

Surgical procedures suitable for ambulatory surgery

should be accompanied by minimal postoperative physiologic disturbances and an uncomplicated recovery.

Prolonged stay or unanticipated admission after day -

case surgery are related to the surgical procedure (e.g., blood loss, pain, postoperative nausea and vomiting (PONV).

Day Case Aneasthesia

Advantages of DCA • Significant reduction in medical costs

• Increased availability of indoor beds

• Better comfort and greater control over the patient’s business and personal lives

• Some protection from hospital acquired infections and deep vein thrombosis

• Less social disruption to patients and their families and minimal need for inpatient hospital resources

• Particularly in children short separation from parents and family is very beneficial to the reduce separation-induced anxiety problems

• Faster recovery, more rapid discharge and better pain relief for outpatients.

• Less preoperative testing and postoperative medication

Surgical procedures commonly undertaken as day cases

1. Gynaecology:- (Dilatation & curettage, Laparoscopy, Vaginal termination of pregnancy colposcopy & hysteroscopy.

2. Plastic Surgery:- (Dupuytren’s contracture release, removal of small skin lesion, nerve decompression

3. Ophthalmology:-(Strabismus correction, lacrimal duct probing, cataract surgery & examination under G.A).

4. ENT:- (Adenoidectomy, tonsillectomy, Myringotomy, insertion of grommets, removal of foreign body, polyp removal & submucosal resection).

5. Urology:- (Cystoscopy, Circumcision, Vasectomy)

6. Orthopaedics:- (Arthroscopics, Carpal tunnel release, anal fissure, Ganglion removal, Lab Cholecystectomy & Haemorroidectomy )

7. General Surgery:- (Breast lumps, Herniae, Varicose veins, Endoscopy

8. Paediatrics:- (Circumcision, Orchidopexy, Squint, Dental extractions)

Guidelines for patient selection for day-case surgery under G.A

A- Patients should normally be ASA I , ASA II, or medically sable ASA III only, i.e. normally healthy people & those with minor systemic disease not interfering with normal activities a pt with moderate to severe systemic disease & some functional limitation

• Age: > 52 Weeks post-conception age • Weight: BMI < 30, (31-34 discuss with anaesthetic deparment)

• Generally healthy i.e. can climb two flight of stairs

B- Patients Exclusions:

1- Cardiovascular

• M.I/TIA/CVA within 6 months

• Hypertension (persistent diastolic > 110mmhg)

• Angina and low exercise tolerance

• Arrhythmias & heart failure & symptomatic valve disease

2- Respiratory:

• Acute respiratory tract infection

• Asthma requiring regular β2-agonists or steroids

3 Metabolic:

• Alcoholism/narcotic addiction

• Insulin-dependence diabetic

• Renal failure & or Liver failure

4- Neurological /Musculoskeletal

• Arthritis of jaw or neck, cervical spondylosis or Ankylosing Spondylosis

• Myopathies, muscular dystrophies or Myasthenia gravis

• Advanced multiple sclerosis

• Epilepsy >3 fits per year

5- Drugs

• Steriods

• Monoamine oxidase inhibitors

• Antocoagulants

• Antiarrhythmics

• Insulin

Facilities Available The hazards and risks of day-surgery general anesthesia are

no less than those for in-patient surgery; indeed, in some respects they may be greater and the facilities provided must be comparable

There is always the possibility of a minor operation developing into a major operation and this demands that the theatre is well equipped to deal with this eventuality.

1- An admission area:- Reception, treatment & examination rooms, a nurses station, lavatories, a playroom and a discharge area.

2- An anesthetic room:- fully equipped, good lighting, scavenging, piped gases and suction equipment, anesthetic machine & monitoring equipment.

3- An operating theater:- Should be of the same specification as the in –patient equivalent. A good operating lighting light, air-conditioning, scrub-up and autoclave facilities

4- A fully equipped recovery room:- must always be equipped and staffed for the safe recovery of patient after G.A. Piped gas supplies and resuscitation equipment are mandatory and the full range of monitoring and ventilation equipment must be readily available

Other facilities that should be available include office space, equipment store, staff room, a panty to make drink and lavatories for patients, parents and staff.

Facilities Available

O.T Preparation

Outpatient surgery requires the same basic equipment as inpatient surgery

Equipments:

– Anaesthetic machine & monitors

– Airway and intubation adjuncts

– Suction apparatus

– IVD

– Drugs

– Warming devices

– Trolley – Spinal, CVP

– Trained assistance

Equipments: – SPO2

– BP & ECG

– ETCO2

– Temperature

– Invasive IABP, CVP, PA

– Nerve stimulator

– BIS (Bispectral Index monitor)

– Gas analysis

Monitor

Anc. Machine

Laryngoscope

O2

Defibrillator

Stethoscope

Suction

IV line

• The role of anesthetists for out pt surgery is enormous particularly regarding pt selection, preoperative evaluation & preparation, intra-operative anesthesia management, post operative care and safe discharge from out pt clinic. In Unexpected adverse situations, the pt may need hospitalization as per advice of the anesthetist concerned.

• There should be adequate number of house officers , nurses,& other personnel & at least one senior anesthetist.

Admission • Pts should be admitted to the ward in adequate time for

history-taking and examination

• Any investigation requested as an out pts should be available and noted.

• The surgeon should ensure the indication for surgery is still present

• The consent form should be signed if not already done.

• The operation site should be marked

• A pregnancy test in women of fertile age

• Staggering patient admission decreases waiting times and improve the efficiency of the unit.

Pre-operative Management • Pre-operative Assessment.

• Pre-operative Preparation.

• Premedication.

The purposes of pre-operative visit.

• History taking.

• Physical Examination.

• Risk Assessment.

• Common causes for postponing Surgery.

ANAESTHETIC EVALUATION

Ward

Clinic

Theater

1- History

2- Physical examinations

3- Review investigations

ASA classification

ANAESTHETIC EVALUATION

PREOPERATIVE ASSESSMENT

premedication Not routinely prescribed for day cases, as it is usually

unnecessary. Drug that may be used include the following:

A- Benzodiazepines:

• Temazepam 10-20 mg is effective anxiolytic for day cases, no delay in recovery times as measured by memory test cards and all pts were discharged from the day unit 3 h after administration of GA.

• Oral Midazolam has been used, but it associated with delay in immediate and late recovery compared with Temazepam

B- Antiemetic:

• Oral or & I.V, antiemetic may administered before operation or rectal antiemetic perioperatively if pts are at high risk of postoperative nausea and vomiting (PONV).

C- Antacids:

• If there is a risk of acid reflux, H2-antagonist are

commonly prescribed as a premedication in day surgery.

D- Analgesics: • Routine use of narcotic (opioid) analgesics for premedication is

not recommended unless the patient is experiencing acute pain

• Oral NSAIDs and paracetamol may be given preoperatively if declines rectal route perioperatively

• Oral COX II inhibitors have better GIT side effect profiles than NSAIDs and less antiplatelet effects

• Pt satisfaction with self- administration of rectal Diclofenac preoperatively has been reported

• Dermal application of tetracaine over a vein has a useful role for children & nervous adults or those with a neddle phobia.

C GA RA

TYPE OF ANAESTHESIA

Optimal Anesthetic Techniques

• The optimal anesthetic technique in the ambulatory setting would provide for excellent operating conditions, rapid "fast-track" recovery without postoperative side effects or complications, and a high degree of patient satisfaction.

• General, local, & regional anesthesia may be administered safely to day-case pt. The choice of technique should be determined by surgical requirements, anesthetic consideration, and patient’s physical status and preference.

3

2 General Anesthesia For many ambulatory

procedures, general anesthesia remains the most popular technique with both patients and surgeons.

Any induction agents used in day-case anesthesia should ensure a smooth induction, good immediate recovery and a rapid return to street fitness.

• Propofol is now used widely as the primary induction agent which has advantage of rapid recovery & low incidence of PONV.

• Thiopental (3 to 6 mg/kg) is the prototypical intravenous induction drug with a rapid onset and a relatively short duration of action as a result of redistribution of the drug . However, thiopental impairs fine motor skills for several hours after surgery and can produce a "hangover“ sensation

General Anesthesia

• ketamine compares unfavorably with both the barbiturates and propofol for minor gynecologic procedures because of its prominent psychomimetic effects and higher incidence of PONV during the early postoperative period

• Although midazolam (0.2 to 0.4 mg/kg IV) has been used for induction of anesthesia in outpatients, its onset of action is slower and recovery is prolonged in comparison to the barbiturate compounds and propofol.

• Sevoflurane is the agent of choice for inhalational induction with advantage of Non irritant to the airways, rapid induction in both children & adults, minimal cardiovascular side effects. However, sevoflurane causes more PONV than propofol.

Maintenance of anesthesia: • Both sevofurane & desflurane are ideal agents for day-

case anesthesia

• Volatile anesthetics are associated with a higher incidence of vomiting in the early recovery period than propofol based anesthetic techniques

• Nitrous oxide increase the risk of PONV, but it reduce the requirements for volatile agents & risk of intraoperative awareness.

• Target-controlled infusion (TCI) of propofol with or without the ultra-rapid-acting opioid remifentanil are techniques which have minimal risk of PONV & short recovery time.

• Morphine, hydromorphone, oxymorphone, and meperidine have all been used in outpatient anesthesia

However, these opioid compounds are less popular than the more potent, rapid, and shorter-acting opioid analgesics (e.g., fentanyl, sufentanil, alfentanil, and remifentanil).

• The laryngeal mask airway (LMA) is used widely & avoids for intubation & extubation, which improves turnaround time between cases.

• The incidence of postoperative sore throat after ambulatory surgery was 18% with an LMA versus 45% with a tracheal tube and 3% with a face mask.

• Patient at risk of aspiration still require a rapid- sequence induction technique with tracheal intubation or in these situations to minimize the risk of gastric distention and ensure adequate ventilation in the Trendelenbmg posinduction .

• Many superficial outpatient surgical procedures do not require the use of neuromuscular relaxants.

• When remifentanil is used in combination with propofol for induction of anesthesia, tracheal intubation can be performed without any muscle relaxants .

• The choice of MR depends on the anticipated duration of surgery. Succinylcholine is associated with muscle pains, especially in ambulant patients and it is not ideal in the day-case setting.

• NDMRs: Use of the short- and intermediate-acting nondepolarizing muscle relaxants (e.g., cisatracurium, mivacurium) allows reversal of neuromuscular blockade even after brief surgical procedures

• Mivacurium may be advantageous for use during the maintenance period because reversal is seldom required if the drug is properly titrated

Antagonist (Reversal) Drugs

• Antagonists may also produce unwanted side effects (e.g., dizziness, headaches, PONV) that should be considered before routinely using these drugs.

• In addition, because their duration of action is often shorter than the agonist (e.g., naloxone, flumazenil), a "rebound“ of the agonist effect may occur.

Regional Anesthesia

Regional anesthesia can offer many advantages for the ambulatory patient population .

Spinal anesthesia has been used for day-case anesthesia, but the side effects of post-dural puncture headache & motor weakness, dizziness, urinary retention, and impaired balance may delay ambulation & discharge. Smaller-gauge pencil spinal needles have reduced the incidence of PDPH

• Shorter-acting local anesthetics may increase the use of day-cases. Prilocaine, Mepivacaine with or without opioid (pethidine, fentanyl), have also been used for out patient.

• Bupivacaine (3ml 0.17%) + 10μ Fentanyl has been used successfully for knee arthroscopy

Epidural anesthesia is technically more

difficult to perform, it has a slower onset of action, the potential for intravascular or intra-thecal injection exists, and it is associated with a greater chance of an incomplete sensory block than spinal anesthesia.

Caudal block is used to reduce pain in paediatric pts for circumcision, herinorraphy, hypospadias or orchidopexy using 0.25% plain bupivacaine; this provides excellent post operative analgesia.

Local anesthetic block are an excellent choice

for day-case pts because of the low incidence of PONV & good post operative analgesia

Peripheral nerve blocks facilitate the recovery process by minimizing the need for postoperative opioid analgesics.

Therefore, an increasing number of ambulatory cases are being performed with a combination of local anesthetic nerve blocks and intravenous sedation (so-called monitored anesthesia care [MAC])

• Femoral & sciatic N B give superior analgesia after complex knee surgery

• L.A blocks e.g. ilioinguinal Nerve Block for inguinal hernia repair, Brachial plexus block for hand & arm

Intra-articular local anesthetics are useful following arthroscopy of the knee or shoulder.

intravenous regional anesthesia (Bier’s block) For short superficial surgical hand & forearm procedures «60 minutes) limited to a single extremity, technique with 0.5% Lidocaine is a simple and reliable technique

Cerebral Monitoring • Monitoring patient vital signs remains the most

common method for determining the "depth of anesthesia" during surgery.

• Recent studies have suggested that the use of cerebral monitoring improves early recovery after general anesthesia in the ambulatory setting because of its ability to minimize both "overdosing" and "underdosing “ with both intravenous (e.g., propofol) and inhaled anesthetic (e.g., sevoflurane and desflurane) drugs during the maintenance period.

Monitored Anesthesia Care

Recovery and Post operative care • The recovery area should be provided with the same range

of monitoring equipment and resuscitation facilities as available in an inpatient facilities.

• Post operative pain control should be started pre-or intra-operatively by IV or inhalational anesthesia with combination of NSAIDs, Paracetamol, shorter acting opioid and local/regional block

• For routine antiemetic prophylaxis, the most cost-effective combination consists of low dose droperidol (0.5 to 1 mg) and dexamethasone (4 to 8 mg).

• PONV may be treated with IV 5HT3 antagonist, dexamethasone, or cyclizine & IM prochloroperazine as well as adequate analgesia & hydration.

• The three stages of recovery after ambulatory surgery are the early, intermediate, and late recovery periods .

• The early and intermediate recovery stages occur in the ambulatory surgical facility, whereas

• The late recovery refers to the resumption of normal daily activities and occurs after discharge home

Recovery

Early recovery • The time interval during which patients emerge

from anesthesia, recover control of their protective reflexes, and resume early motor activity.

• During this phase of recovery, patients are cared for in the post anesthetic care unit PACU, where their vital signs and oxygen saturation are carefully monitored and supplemental oxygen, analgesics, or anti emetics can be readily administered.

Intermediate recovery

• During the intermediate recovery period, patients are usually cared in a reclining chair and progressively begin to ambulate, drink fluids, void, and prepare for discharge.

• Most ambulatory surgical facilities have a separate area for the intermediate recovery of outpatients to a home-ready state

• The late recovery period starts when the patient is discharged home and continues until functional recovery is achieved and the patient is able to resume normal activities of daily living.

• The anesthetics, analgesics, and anti emetics can also have an effect on the patient's recovery during the post-discharge period.

• However, the surgical procedure itself has the highest impact on the patient's full functional recovery.

late recovery

Factors that predict a more prolonged stay in the day-surgery unit include female gender, advanced age, longer operations, large fluid or blood loss and opioid use, nondepolarizing muscle relaxants, postoperative pain and PONV, and spinal anesthesia.

DISCHARGE CRITERIA

Discharge after General Anesthesia

and Monitored Anesthesia Care

Guidelines for safe discharge from an ambulatory

surgical facility include stable vital signs, return to baseline orientation, ambulation without dizziness, minimal pain and PONV, and minimal bleeding at the surgical site.

Patients who achieve a score of 9 or greater and have an adult escort are considered fit for discharge (or home ready).

Discharge After Regional Anesthesia With spinal or epidural anesthesia,

• It is generally accepted that motor and sensory function returns before sympathetic nerve function.

• Residual blockade of the sympathetic nerve supply to the bladder and urethra may cause urinary retention.

• Before ambulation, these patients should have normal perianal (S4-5) sensation, the ability to plantar-reflex the foot, and proprioception of the big toe.

• Thus, discharge criteria after spinal and epidural anesthesia should include the return of normal sensation, muscle strength, and proprioception, as well as the return of sympathetic nervous function.

General Advises • Pts should be advised against driving, Operating power

tools, making important decisions, and ingesting alcohol for at least 24 hrs after the procedure.

• Pts should be advised that they may experience pain, headache, nausea, vomiting, dizziness, and skeletal muscle aches and pains that can’t be attributed to the surgical incision

• It must be confirmed that a responsible adult will accompany (drive) the pt home and if appropriate remain with the pt for some period of time

• At some facilities, staff members telephone the pt the next day to determine the progress of recovery.