Day Care Surgery.pptx

for medical education

1. Day Care Surgery

2. DAY SURGERY The delivery of a surgical procedure on a day case basis offers advantages in providing significant benefits for both patient and healthcare providers. The removal of an overnight stay causes less disruption to the patient’s domestic and social situation, and provides significant financial savings to the hospital. In resource-rich countries, day surgery is now an integral component of healthcare delivery, while in resourcepoor countries, day surgery is increasing in popularity due to patient preference and healthcare reorganisation .

3. Day surgery is defined as the admission and discharge of a patient for a specific procedure within the 12-hour working day. Where a patient requires an overnight admission, then the term ‘23 hour stay’ should be used. Success in day surgery requires each component of the pathway to be safe and efficient and to be performed in sequence. Unplanned overnight admissions are minimized by ensuring that: the patient is informed and fit for the procedure; the procedure itself is achievable as a day case; the procedure is scheduled early on the operating list to allow safe recovery and discharge; and

4. the home environment can support a postoperative ambulatory patient. Definition of terms used in ambulatory surgery Outpatient surgery: not admitted to a ward facility Procedure room surgery: surgery not requiring full sterile theatre facilities Day or same-day surgery: admitted and discharged within the 12-hour day Overnight stay: 23-hour admission with early morning discharge Short-stay surgery: admission of up to 72 hours

5. SELECTION CRITERIA Medical criteria Age There is no upper age limit. The physiological health of the patient is a superior determinant of day surgery success. Medical : use physiological rather than chronological age ASA status over 2 requires careful review Provided that the BMI is under 40, this alone is not a contraindication

6. Social : a responsible adult carer must be available for the first 24 hours, for the elderly and patients at risk of covert bleeding home conditions need to be suitable ability to contact hospital in an emergency Surgical: operations up to 2 hours recognised day surgery procedures ability to eat and drink within a reasonable timescale

7. Comorbidity Day surgery units traditionally use the American Society of Anaesthesiologists (ASA) Classification, which is a crude evaluation of chronic health Stand-alone units often confine their criteria to ASA 1 and 2 patients, while ASA 3 patients are more suitable for hospital-integrated units. Patients with significant respiratory or cardiovascular disease should be reviewed by an anaesthetist before being accepted for day surgery.

8. Diabetes The incidence of diabetes is increasing worldwide. Patients with well-controlled Type 1 and Type 2 diabetes are good candidates for the well-managed day surgery pathway. Control can be assessed by measuring their HBA1c, with a level of below 8.5% indicating good control. Epilepsy A diagnosis of epilepsy does not contraindicate day surgery. Patients who have well-controlled epilepsy should be managed as normal patients, though it is important to ensure that their regular medication is not omitted in the preoperative period.

9. Obesity The body mass index (BMI) is calculated as weight in kilograms divided by the square of height in metres (kg/m2) and obesity is defined as a BMI >30. Traditional guidelines are conservative about obesity due to fears of intra- and postoperative complications. Although there is an increased incidence of non-serious respiratory complications intraoperatively and in the immediate postoperative recovery period, the course of these patients is otherwise uneventful.

10. Anticoagulants Patients are generally on oral anticoagulants due to atrial fibrillation, previous thromboembolism or because they have a metal heart valve. It is therefore important to review these patients carefully before deciding to discontinue their anticoagulant for their operation. Social criteria Safe and comfortable discharge home requires the patient to be accompanied by a responsible and physically able adult. A journey time to home of 1 hour or less is advocated, but the comfort of the journey rather than the time involved is more relevant.

11. Surgical criteria Patients undergoing procedures up to 2 hours in duration can safely undergo day surgery with modern anaesthetic techniques. The degree of surgical trauma is an important determinant of success, with entry to abdominal and thoracic cavities confined to minimal access techniques Whatever the procedure, the main requirement is that there is suitable control of pain and the ability to drink and eat in a reasonable timescale.

12. PREOPERATIVE ASSESSMENT The evaluation and optimisation of a patient’s fitness for surgery is known as preoperative assessment and is best performed by a specialist nursing team with support from an anaesthetist with an interest in day surgery. All elective surgical patients should be initially regarded as suitable for day surgery until proved otherwise. The assessment should be performed early in the pathway to allow time to optimize health problems before surgery. The consultation consists of a basic health screen to include the measurement of BMI, blood pressure and an assessment of past medical history with current medication recorded.

13. Appropriate investigations are performed to ensure the patient is fit for surgery. The patient and/or their carer should be given verbal and written information regarding admission, operation and discharge. PERIOPERATIVE MANAGEMENT Scheduling With dedicated day surgery lists, major procedures should be scheduled early on morning lists to allow maximum recovery time. When the list is in the afternoon, the allocation of local or regional anaesthetic cases later in the day helps reduce unplanned overnight admissions.

14. Anaesthesia and analgesia Successful day surgery anaesthesia requires a multimodal approach to analgesia, while ensuring patients are given optimal dosages of anaesthetic agent . The agents used matter less than the skill of the person providing anaesthesia . Multimodal analgesia starts in the preoperative period and unless contraindicated, patients should receive full oral doses of paracetamol and a non-steroidal anti-inflammatory drug, such as ibuprofen. Intraoperative anaesthesia can be maintained by any of the traditional inhalational agents. Total intravenous anaesthesia (TIVA) techniques using propofol are also popular and offer the advantage of reduced postoperative nausea and vomiting (PONV).

15. Pain levels should be routinely assessed in the postoperative recovery area. Further doses of paracetamol, fentanyl or low doses of morphine can be used to ensure that patients are comfortable prior to return to the ward. Postoperative complications The range of postoperative complications is no different from inpatient surgery. However, the fact that the patient is discharged home within a few hours of surgery requires proactive monitoring in the immediate postoperative period. Reactionary haemorrhage is uncommon but requires careful consideration following tonsillectomy and laparoscopic procedures.

16. Reactionary haemorrhage following tonsillectomy occurs within the first 6 hours and these patients should be monitored for this period. The danger in laparoscopic surgery is covert haemorrhage , especially in young fit patients who can lose over 15% of their blood volume before showing any cardiovascular signs of hypovolaemia (tachycardia and hypotension).

17. ELECTIVE DAY SURGERY For some surgical specialties, over 90% of their elective workload can be achieved in day surgery. As a result, teaching and training now routinely occurs on day surgery lists but requires structure and close supervision. As the spectrum of procedures has increased and become more challenging, many surgeons have increased their involvement in day surgery. This is important because safe and efficient day surgery demands the competence and skill of an experienced surgeon.

18. The risk of postoperative haemorrhage occurring once the patient has returned home is often stated as a major reason to keep the patient in hospital overnight, especially where the abdominal or thoracic cavities have been entered. Reactionary haemorrhage commonly occurs in the first 4–6 hours after surgery, but the patient is unlikely to have been discharged home within this time period. It may be caused by slippage of a ligature or displacement of blood clot, precipitated by a rise in blood pressure, coughing or increased mobility. Postoperative monitoring of vital signs should alert the recovery team to any underlying bleed.

19. Good surgical technique requires minimal tissue traction or tension and good haemostasis . In day surgery these attributes are even more important. Volume procedures where 40% or more should be performed on a day case basis. Abdominal - Excisional/treatment of anal lesions, haemorrhoidectomy , primary and recurrent inguinal/femoral herniae , laparoscopic cholecystectomy, laparoscopic fundoplication, pilonidal sinus surgery Breast - Excision/biopsy breast lesion, sentinel node excision Genitourinary - Laser prostatectomy, orchidectomy, circumcision, excision of hydrocoele/varicocele/epididymis

20. Orthopedic - Dupuytren’s fasciectomy, carpal tunnel release, therapeutic arthroscopy of knee or shoulder, bunion operations, removal of metalwork Vascular - Varicose vein procedures, thoracoscopic sympathectomy

21. EMERGENCY DAY SURGERY Many emergency surgical procedures are minor and non-life threatening, and traditionally have been considered low priority for surgical intervention. Many of these cases, such as incision and drainage of abscesses, can be safely discharged home after their initial evaluation in the emergency department. They are provided with adequate analgesia and scheduled to return to the hospital at an appointed time the following day, suitably starved for their operation. This allows same-day discharge for minor emergency procedures.

22. If performed early in the day, the surgery rather than the pathway, may be defined as ‘day case’. Some patients may, by chance, achieve a true day case pathway with admission, operation and discharge in the same day, provided they are admitted early in the day, there is no diagnostic delay and a theatre slot is available.

23. DISCHARGE The assessment of when a patient is fit for discharge is best performed by trained day surgery nurses using strict discharge criteria While postoperative review by the surgical team is encouraged, the discharge should not be delayed by failure of their timely attendance. A suitable supply of analgesics for the management of pain should be provided. Discharge criteria Vital signs stable for at least 1 hour Correct orientation as to time, place and person Adequate pain control with supply of oral analgesia Understands how to use oral analgesia supplied

24. Ability to dress and walk where appropriate Minimal nausea, vomiting or dizziness Has taken oral fluids Minimal bleeding or wound drainage Has passed urine (if appropriate) Has a responsible adult to take them home Written and verbal instructions given about postoperative care Knows when to come back for follow-up (if appropriate) Emergency contact number supplied

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