DAY CARE SURGERY

Introduction
• 50% elective surgery in UK
• 60% elective surgery in USA / Canada
• 23 – 50% % elective in India in selected centres

• NEED
• Long surgical waiting list
• Reduction in available beds
• High cost of in patients beds
• Improvement in anaesthesia and pain control
• Minimally invasive surgery
 Definition
• “Planned investigations and procedures done
on patients who are admitted and discharged
home the same day as surgery and who
require some facilities and time for recovery.”

• Criteria of inclusion
• Patient who spend few hours in hospital but, do not
stay overnight.
• Patient who spend upto 23 hrs in hospital.
• Minor procedures in outpatient or accident of
emergency department  not included
 Historical aspect
• 1909  James Nicholl reported 9000 children operated as
day cases

• 1912  Ralph Waters founded anaesthesia clinic in same way

as today’s day surgery unit

• 1951  Eric Farquharson carried out hernia repair under local

anaesthesia

• 1960  hospital based DSU appeared in USA

• 1969  Walter Heed set up 1st DSU named Phoenix

surgicentre…. ….
Benefits of day surgery
• Reduced cost
• Low post-operative morbidity
• Reduced thrombo-embolism and hospital
acquired infections
• Minimal disruption to patients life
• Early return to work and normal activities
• Children prefer it
Contd…

• More efficient high volume turnover of patients

• Reduced waiting lists for elective surgery
• In patients bed freed for major and emergency
surgery
• Fewer cancellation on day of surgery
 Problems of day surgery
• Initial cost of setting up DSU
• Good organization and management
needed
• Poor patient and procedure selection
• Trained and efficient staff needed
• Inadequate information given to patient
• Morbidity from anaesthesia and surgery
 Contd…
• Burden of care passed to patient’s family
• Increased community health care workload
• Quality of care in day surgery should be of same high
standard as that expected for inpatient surgery

• Lead to emergence of DSU

 Desirable features DSU
• Self contained: Reception , ward , theatres and
recovery area
• Adjacent parking
• Well planned patient flow
• Maintain as high standards as inpatient wards
and theatres
• Bed theatre ratios as prescribed
• Set protocols for selection , analgesia and
discharge to be followed
• Good record keeping
 Contd…
• Support services readily available
• Trained , experienced staff
• Consultant led anaesthesia and surgery
• Organized training with closed supervision of
trainees
• Clinical director in overall charge
• Team work between staff groups
• In tune with community services and GPs
 Organization of DSU

• Nurses  experienced with multi-skilling

specialized for children

• Ancillary staff  portering and domestic duties

• Technicians  record keeping, computer savvy

accurate and complete work-skills
high volume with fast turn over
Cont.…
• Medical staff ….
trainees are closely supervised …..
• Clinical director
• A consulant surgeon or anaesthetist
• Implement and audit good standards of
care
• Regular multidisciplinary meetings
required ….
 Essentials of good day care surgery
• Selection of appropriate procedure and patients
• Pre-admission assessment and information
• Anaesthesia and surgery with minimal morbidity
and complication
• Post-operative and post-discharge analgesia
• Discharge criteria and postoperative instructions
• Follow-up and audit
 Criteria for suitable procedures
• Minimal physiological alterations
• No excessive blood loss and fluid shifts
• Duration of 1-2 hrs maximum
• Oral analgesia after discharge
• Patient reasonably ambulant after discharge
• Avoid surgical drains
• Urinary catheters may be used
• Ensure minimal complications
Day care procedures
 Selection criteria for patients

• Social criteria

• Age

• Criteria for fitness of patients for general

anaesthesia
 Social criteria
• Responsible adult  escort patient home …
• Few stairs to climb
Good toilet facilities
Access to telephone
• Should live within 1 hr of hospital facilities
• Ready access to GPs on discharge …
• Concept of hospital hotels overnight
supervision at low cost in hotels …
• Concept of hospital at home ….
Developing countries  due to long
distance and difficult travelling, day
surgery introduction has been slow
to pick up.
Age

• Upper age limit  70 years

• Physiological age is more important than
actual age
• Lower age limit  facilities available
• Experienced staff
• Procedures undertaken
Criteria for selection of anaesthesia
• Patient
• Fit and ambulant
• Not grossly obese ( BMI <30 )
• Able to climb one flight of stairs

• Do not book patients with cardiovascular

disease
• Poorly controlled hypertension (BP > 170/100)
• Angina , CCF or PVD
• MI ,CVA or TIA in last 6 mnths
• Symptomatic valvular disease
• Cadio-myopathy
Contd …
• Respiratory disease
• Severe asthma or COPD

• Others
• IDDM or poorly controlled NIDDM
• Renal, hepatic disease
• Alcoholic , narcotic addiction
• Multiple sclerosis , myasthenia gravis
• Severe psychiatry disease
Contd …
• Do not book patient taking
• Anticoagulants
• Monoamine oxidase inhibitors
• Digoxin
• Systemic steroids
• Anti-dysarrhythmics
• Oral contraceptives
• Glycerly trinitrate
Essentials of good day care surgery

• Selection of appropriate procedure and patients

• Pre-admission assessment and information
• Anaesthesia and surgery with minimal morbidity
and complication
• Postoperative and post-discharge analgesia
• Discharge criteria and postoperative instructions
• Follow-up and audit
 Assessment before admission

• Surgeons are not good in assessing patients ….

• Anesthesiologists  impractical ….time , cost ,
manpower-wise
• Alternative  Filtering process
• Special nurses using planned questionnaire for
assessment
• Investigations done according to answers
• Anaesthesiologists review the case
 Pre-admission information…
• On front page
• Time and date of operation with contact nos.
• Need for an escort or taxi to go home
• Females to notify DSU if pregnant or in menses
• Instructions not to drive for 48 hrs
• Fasting instructions
• Do not omit medication unless specified
• Instructions for clothing , valuables
 Contd…
• Other information on day surgery
• Map , parking and how to find DSU
• Brief description of what will happen, PEMs
• Duration for stay and time for escort to come
• Post-anaesthetic restrictions on driving etc.
• Who to contact on discharge
Contd…

• Procedure specific information

• Procedure of operation
• Preoperative preparation
• Expected postoperative morbidity
• Rest duration
• Wound management , stitch removal
and follow up
Benefits of pre-admission clinic
• Problems sorted out before admission
• Unnecessary investigations reduced
• Cancellation on day of surgery reduced
• Patients better prepared and informed
• Non-attendance reduced
• Peri operative complications reduced
• Unplanned overnight admission reduced
Morbidity after day surgery

• Major
• Myocardial infarction
• Pulmonary embolus
• Respiratory failure
• Cerebrovascular accidents
• Major postoperative haemorrhage
• Unrecognised damage to viscus …..
Contd…
• Minor
• Pain
• Nausea and vomiting
• Dizziness and drowsiness
• Minor bleeding
• Infection
• Sore throat and headache ….
 Essentials of good day care surgery

• Selection of appropriate procedure and patients

• Pre-admission assessment and information
• Anaesthesia and surgery with minimal morbidity
and complication
• Postoperative and post-discharge analgesia
• Discharge criteria and postoperative instructions
• Follow-up and audit
Anaesthesia

• Anaesthetic morbidity  major reason for

unplanned readmission

• Two types
• Local /regional anaesthesia
• General anaesthesia
Local anaesthesia
• Ideal
• Excellent for elderly
• Economical
• BUT
• More time consuming
• Requires gentle hand
• Not preferred by patients
 Contd…
• Types
• Spinal
• Caudal
• Epidural

• Disadvantage
• Time required to give and start action are more
• Delay in mobilization
• High incidence  urinary retention
Contd …

• Drug used
• Long acting bupivacaine
• If speed of onset  lignocaine
added
• Prilocaine , chloroprocaine 
Beir block….
 General anaesthesia
• Good for children

• Propofol  drug of choice for IV induction

• Drug of choice for maintenance
• Good anaesthetic condition
• Rapid Problem free recovery
• Incidence of post op nausea and vomiting is less
 Contd…
• Inhalation induction
• Sevoflurane drug of choice for induction
• Has replaced halothane
• Maintenence  volatile agent
• Isoflurane
• Enflurane
• Nitrous oxide in oxygen
Contd …

• Short acting opoid

• Alfentanyl or fentanyl
• Reduces dose
• Provide analgesia  early post op

• Remifentanyl  ultrashort acting opoid .

Analgesia
• Good pain control is essential to prevent
• Delay in discharge
• Unplanned overnight admission
• GP consultation after discharge
• Distress and dis-satisfaction
• Limitation to early mobilisation
• Prolongation of return to normal function

• Morphine
• Less used as sedative PONV
Contd…

• Multimodal analgesia
• NSAIDS
• Local anaesthetics
• Short acting opoid

• Oral analgesics  3-5 days post

discharge
 Discharge guidelines

• Oriented to time, place, person

• Tolerate oral fluids
• Can void
• Dress
• Walk without assistance

• Patient must not have

• Nausea and vomiting
• Excessive pain
• Bleeding or
• Fever
Follow-up audit and quality control
• Good day care surgery means
• Nonattendance
• Cancellation
• Complication before and after discharge
• Overnight admission
• Readmission
• Are audited and improvement made
• Telephone call next day reassures patient 
immediate feedback of analgesia and
problems
 Future
• It is not the Fastest surgery on the Fittest patient

• But has included older less fit patients with more major
procedures

• And with advancement in medical science  has good

prospects
THANK YOU