MRCS part 1 : notes: day care surgery

Discussion in 'MRCS Forum' started by akash, Nov 6, 2005.

  1. akash

    akash Guest

    Day case surgery implies that the patient’s admission to the hospital is scheduled and the patient is supposed to be discharged the same day of admission.

    Advantages for the patient and hospital:

    -Reduced disruption of patients’ normal social lives
    -Psychological benefit of avoiding prolonged hospital stay
    -Reduced morbidity including nosocomial infections

    -Reduced in-patient waiting lists
    -Increased availability of in-patient beds
    -Reduced costs

    Safe day case surgery requires appropriate

    -Patient selection
    -Operative procedures
    -Anaesthetic techniques

    Patient Selection:

    Patients should fulfill the following criteria

    -Age less than 70 years [safe range is 16-65 years; healthy patients more than 65 years can be considered depending upon the procedure].
    -ASA Grade 1 or 2
    -BMI less than 30
    -Drug controlled diabetics are never suitable for day case
    -Essential hypertension is not a contraindication, provided control is good.
    -CVS diseases such as angina, cardiac failure and arrythmias are unacceptable for day case. However, controlled atrial fibrillation is an exception to the above.
    -Availability of a responsible adult

    General requirements:

    -Patient should have an access to a telephone
    -Live within an hours traveling time from the hospital
    -Requires close co-operation between surgeon, anaesthetist and day unit
    -Preoperative screening should be performed
    -Can be carried by a questionnaire and/or a nurse-lead assessment clinic
    -Patients requiring extensive investigation are not suitable for day case surgery
    -Patient must not go home by public transport and preferably not by taxi.
    -Patient should be advised to avoid alcohol for 24 hrs post operatively because alcohol acts synergistically with the residual affects of the anaesthetics used.

    Category of Surgery

    -Operations for day case surgery vary between specialties
    -Appropriateness may be expanded by the facility for an overnight stay
    -Short duration [usually less than 45 minutes]
    -Should not require post-op opioid analgesia.
    -Low incidence of postoperative complications
    -Not require blood transfusion
    -Laparoscopic surgery can now be performed, usually with an overnight stay
    -Surgery should be performed by an experienced surgeon
    -Access to in-patient beds should be available if required
    -Surgery where there will be major limitation of mobility is no preferred.
    -While unilateral inguinal hernia repair under local anaesthesia is a suitable day case, bilateral repair is not.

    Type of anaesthesia:

    -Principles of anaesthesia are the same as for in-patient care
    -Requires high quality induction, maintenance and recovery
    -Recovery should be free from side effects
    -Anaesthesia should be performed by an experienced anaesthetist
    -Local and regional anaesthetic techniques should be encouraged
    -Spinal anaesthesia and femoral nerve block are considered unsuitable because of major limitation in mobility which results.
    -Caudal anaesthesia is acceptable in small children.
    -Spinal anaesthesia in ambulatory patients should be avoided for the risk of post dural puncture headache and postural hypotension; can be considered with improved techniques and needles.
    -Elective tracheal intubation should be avoided.
    -Elective controlled ventilation was considered as a contraindication till the advent of mivacurium (doesn’t need reversal).
    -Thiopentone is not a suitable inducing agent, while propofol is the preferred one.
    -Post op pain should be controlled by regional anaesthetic techniques and NSAIDs. Rectal diclofenac is widely used.

    Discharge criteria

    Prior to discharge from the day case unit patients should

    -Have stable vital signs
    -Be alert and orientated
    -Be comfortable / pain free
    -Be able to walk
    -Be able to tolerate oral fluids
    -Have minimal nausea and vomiting
    -Adequate follow-up arrangements should be made
    -Patients should be provided with information sheets
    -Should be provided with contact telephone numbers

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