General surgery ابرار نزار.
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Day Case Surgery
Definition
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.
Definition 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 Referring doctor
Selection criteria
● Medical criteria: use physiological rather than chronological age since there is no upper
limit for age.
Comorbidity
1)Hypertension:
Many patients who are fit but hypertensive are incorrectly excluded from day surgery.
There is no evidence to support cancellation when blood pressure is below 180/110 mmHg.
2)Diabetes
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. Diabetes is associated with potentially severe
comorbidities, such as renal disease, autonomic neuropathy and cardiovascular disease,
and so these patients must be assessed carefully preoperatively and managed by an
experienced team.
Success depends on ensuring these patients return to normal eating and drinking and
managing their own diabetes as quickly as possible in the postoperative period.
3)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. Patients who are on
medication but remain poorly controlled need careful review and discussion with their
medical and anesthetic teams.
4)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 (figure 1). Traditional
guidelines are conservative about obesity due to fears of intra- and postoperative
complications. They should however, be managed by experienced medical and nursing
staff. Hypertension, congestive cardiac failure and sleep apnea are all more common in
patients with morbid obesity, but in selected and optimized patients, a BMI up to 40 for
surface procedures and 38 for laparoscopic procedures are acceptable and achievable in
advanced units.
Figure 1: BMI calculator
5) 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. When it is felt that surgery will require its discontinuation, this should
be discussed with their cardiologist and the risks involved explained to the patient.
● Social criteria:
- 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 criteria:
-Operations up to 2 hours recognized day surgery procedures
-Suitable control of pain
-Ability to eat and drink within a reasonable timescale
Preoperative assessment surgery
The evaluation and optimization 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 anesthetist with an interest in day surgery. The
consultation consists of:
1-a basic health screen to include the measurement of BMI,
2-blood pressure and an assessment of past medical history with
current medication recorded.
3-Appropriate investigations are performed to ensure the patient is fit for
surgery.
4-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.
•When mixed lists of day and inpatient cases are planned, then day cases are scheduled
first. The mixing of day and complex inpatient cases is not advisable. The complex case
may be inappropriately delayed if the day case is scheduled first and, conversely, if the day
case patient is scheduled later, there is a risk of cancellation or unplanned overnight
admission for the day case.
Anesthesia and analgesia
Successful day surgery anesthesia requires a multimodal approach to analgesia, while
ensuring patients are given optimal dosages of anesthetic agent. The agents used matter
less than the skill of the person providing anesthesia.
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 anesthesia can be maintained by any of the traditional
inhalational agents. Total intravenous anesthesia (TIVA) techniques using propofol are
also popular and offer the advantage of reduced postoperative nausea and vomiting
(PONV). The use of intraoperative analgesia will depend on the procedure being
performed.
When available, the anesthetist should use short-acting opioids (fentanyl, alfentanil).
Careful use of these agents can minimize the incidence of PONV. Where the choice
is limited to morphine, this should be used in small doses (<0.1 mg/kg) to minimize
sedation and PONV. Wherever possible, a long-acting local anesthetic agent such as
bupivacaine should be injected into wounds by the surgeon.
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.
Discharge
The assessment of when a patient is fit for discharge is best performed by trained day
surgery nurses using strict discharge criteria (Table 1). 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.
Paracetamol, NSAIDs and codeine form the basis of the drugs available in many countries.
TABLE 1
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
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
