Anesthesia Consideration for a day case surgery

1. Prep by Mukhtiar Ahmad
Lecturer anesthesia
IPMS-KMU Peshawar

2.  Ambulatory surgery
 Day-case surgery
 Same-day surgery
 Come and go surgery
 Day Case Anesthesia
 Pt. who is admitted for 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.

3.  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%
 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 hemorrhage or produce excessive
amounts of postoperative pain).

4.  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.

5.  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).

6.  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
 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

7.  Gynecology Dilatation & curettage, Laparoscopy, Vaginal termination of
pregnancy colposcopy & hysteroscopy.
 Plastic Surgery contracture release, removal of small skin lesion, nerve
decompression
 Ophthalmology Strabismus correction, Lacrimal duct probing, cataract
surgery & examination under G.A
 ENT Adenoidectomy, tonsillectomy, Myringotomy, insertion of grommets,
removal of foreign body, polyp removal
 Urology Cystoscopy, Circumcision, Vasectomy)
 Orthopaedics Arthroscopics, Carpal tunnel release. Reductions Ganglion
removal,
 General Surgery Breast lumps, Hernia, Varicose veins, Endoscopy, anal
fissure, Lap Cholecystectomy & Haemorroidectomy
 Pediatrics Circumcision, Orchidopexy, Squint, Dental extractions
polypectomy

8.  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
 Age: >50
 Weight: BMI < 30, (31-34 discuss with anaesthetic
deparment)
 Generally healthy i.e. can climb two flight of stairs

9. 1: Cardiovascular
 M.I/TIA/CVA within 6 months
 Hypertension (persistent diastolic > 110mmhg)
 Angina and low exercise tolerance
 Arrhythmias & heart failure & symptomatic valve
disease

10. 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

11. 5- Drugs
 Steriods
 Monoamine oxidase inhibitors
 Antocoagulants
 Antiarrhythmics
 Insulin

12.  An anesthetic room:- fully equipped, good lighting,
scavenging, piped gases and suction equipment,
anesthetic machine & monitoring equipment.
 An operating theater:- Should be of the same
specification as the in –patient equivalent
 A fully equipped recovery room

13.  Equipments:
 –Anaesthetic machine & monitors
 –Airway and intubation adjuncts
 –Suction apparatus
 –IV device
 –Drugs
 –Warming devices
 –Trolley – Spinal, CVP
 –Trained assistance

14. Equipments:
 –SPO2
 –BP & ECG
 –ETCO2
 –Temperature
 –Invasive IABP, CVP
 –Nerve stimulator
 –Gas analysis

16.  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

17.  Pre-operative Assessment.
 Pre-operative Preparation.
 Premedication.
 The purposes of pre-operative visit.
 History taking.
 Physical Examination
 Investigation
 Risk Assessment.
 Common causes for postponing Surgery.

20.  Not routinely prescribed for day cases, as it is usually
unnecessary. Drug that may be used include the
following
A- Benzodiazepines
B- Antiemetic
C- Antacids
D- H2-antagonist (If there is a risk of acid reflux)
E- Analgesics
 Routine use of narcotic (Opioids) analgesics for
premedication is not recommended unless the patient is
experiencing acute pain (Oral NSAIDs are used)

22.  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.

23. For many ambulatory procedures,
general anesthesia remains the most
popular technique with both patients
and surgeons.

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

25. 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
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

26.  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

27. Sevoflurane & 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 or TIVA of propofol with or
without the ultra-rapid-acting opioid remifentanil are
techniques which have minimal risk of PONV & short
recovery time.

28.  Opioids fentanyl, sufentanil, alfentanil, and
remifentanil) are used due to ultra short time effect
 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 DCA
18% with an LMA
45% with a tracheal tube and
3% with a face mask.
 RSI Patient at risk of aspiration still require a rapid-
sequence induction technique with tracheal intubation

29.  Many superficial outpatient surgical procedures do not
require the use of neuromuscular relaxants
 When Remifentanil is used in combination with
propofal for induction of anesthesia, tracheal intubation
can be performed without any muscle relaxants
 Succinylcholine is associated with muscle pains,
especially in ambulant patients and it is not ideal in the
day-case setting.

30. 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
 Atracurium are used during day case anesthesia

31.  Neostigmine
Antagonists may also produce unwanted side effects
(e.g., dizziness, headaches, PONV) that should be
considered before routinely using these drugs.
 NaloxoneNaloxone blocks or reverses the effects of opioid medication,
including extreme drowsiness, slowed breathing, or loss of consciousness.
An opioid is sometimes called a narcotic
 Flumazenil Flumazenil is a benzodiazepine antagonist. It works by
blocking receptors in the brain and central nervous system that
benzodiazepines need to reach to be active, which helps reduce
drowsiness and sedation.

32.  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.

33.  Epidural anesthesia 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

34. 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
Peripheral nerve blocks facilitate the recovery process
by minimizing the need for postoperative opioid
analgesics.
L.A blocks(infiltration) e.g. ilioinguinal Nerve Block
for inguinal hernia repair, Brachial plexus block for
hand & arm

35.  Female gender,
 Advanced age,
 Longer operations,
 Large fluid or blood loss
 Opioids use
 Nondepolarizing muscle relaxants
 Postoperative pain and PONV
 Spinal anesthesia

36.  Guidelines for safe discharge from an ambulatory
surgical facility include
 Stable vital signs
 Return to baseline orientation,
 Ambulation without dizziness,
 Minimal pain and PONV,
 Minimal bleeding at the surgical site.

38.  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.

39. THANK YOU