Anaesthetic Considerations of Day care surgery-Dr Sheetal Jagtap Prof &Head Anaesthesiology Dr D.Y. Patil Medical college &Hospital

Nerul, Navi Mumbai

Introduction

The Terminologies day care anesthesia, ambulatory anesthesia (AA), outpatient anesthesia, also known as day care surgery is all synonymous. The ambulatory anesthesia as the name suggests means patient will be, street fit(ambulant) after anaesthesia. Day care surgery /anaesthesia signifies meaningfully to restrict to only, Day stay. Outpatient anaesthesia clinic was started by Ralph Waters in 1900, in Sioux City of Iowa. He mainly provided anaesthesia for dental and minor surgeries. Subsequent interest in ambulatory anesthesia and surgeries coupled with recent advances in anesthetic and surgical techniques and safety have allowed rapid growth in ambulatory surgery throughout the world. Establishment of the Society for Ambulatory Anesthesia ( SAMBA ) in USA in 1984 and formal development of AA as a subspecialty increased the numbers of surgeries performed on day care basis to a large extent, so much so that in 1985 about 30% of all elective surgeries in USA were performed on day care basis which has increased to nearly 70% of anesthesia services provided in 2007.In USA the economic pressure from insurance companies gave boost to this concept.

In our country, Indian association for Day Surgery was formed in 2003 and is actively involved in propagating this subspecialty (www.daysurgeryindia.org)An Ambulatory Anaesthesia is one administered for a non emergency or elective surgical procedures, performed on carefully selected patients., which is undertaken with all its constituent elements ( admission , operation and discharge home ) on the same day. The procedures maybe conducted in free standing facility or in a hospital based outpatient facility.

In the recent times availability of rapid and short acting drugs with less potential to cause prolong side effects like hangover, respiratory depression, or residual neuromuscular blockade, has facilitated the recovery and so number of pts. operated on ambulatory basis increased to large extent.

GUIDELINE FOR AMBULATORY ANAESTHESIA AND SURGERYThe American Society of Anaesthesiologists (ASA) encourages the anesthesiologist to play a leadership role as the Perioperative physician in all hospitals, ambulatory surgical facilities and office based settings and to participate in facility accreditation as a means for standardization and improving the quality of patient care. These guidelines apply to all care involving anesthesiology personnel administering ambulatory anesthesia in all settings and are subject to periodic revision, as warranted by the evolution of technology and practice.

1. A licensed physician should be in attendance in the facility or in the case of overnight care, immediately available by telephone, at all times during patient treatment and recovery and until the patients are medically discharged.

2. The facility must be established , constructed, equipped operated in accordance with applicable local , state , federal laws and regulations . at a minimum, all settings should have a reliable source of oxygen , suction, resuscitation equipment and emergency drugs. Specific reference is made to the ASA Statement on Non operating Room Anesthetizing Locations. 3. Staff should be adequate to meet patient and facility needs for all procedures performed in the setting and should consist of :

a. Professional Staff: physicians and other practitioners who hold a valid license or certificate are duly qualified. Nurses who are duly licensed and qualified.

b. Administrative Staff.

c. Housekeeping and Maintenance Staff.

4. Physicians providing medical care in the facility should assume responsibility for credentials review, delineation of privileges, quality assurance and peer review.

5. Qualified personal; and equipment should be on hand to manage emergencies. There should be established policies and procedures to respond to emergencies and unanticipated patient transfer to an acute care facility.

6. Minimal patient care should include: Preoperative instructions and preparation, an appropriate preanaesthesia evaluation and examination by an anesthesiologist, prior to anaesthesia and surgery. In the event that non physician personnel are utilized in the process, the anesthesiologist must verify the information and repeat and record essential key elements of the evaluation and preoperative studies and consultants as medically indicated.

ASA guidelines for basic standards of Perioperative care and monitoring and guidelines for ambulatory anaesthesia services should be strictly followed. Anesthesiologist should be physically present during the procedure and himself discharge the patient when found fit for home readiness with clear , written instructions . All personnel should be trained in advance resuscitation techniques (BLS, ACLS) and there be written protocol for cardiopulmonary emergencies for other internal or external disasters like fire, earthquake, accidents or transfer of high risk patients to referral hospitals.

Minimum monitoring standards as per AA guidelines should be followed. All equipments should be maintained, periodically tested and inspected according to manufacturers specifications.

Assure adequate source of oxygen, suction, resuscitative equipments and emergency drugs.

Patients safety should be a priority and should not be jeopardized for patients convenience or cost saving.

Controlled drug supply, storage and administration must be monitored.

Disposal of syringes, needles, and waste material.

Provision of PACU or recovery room, staffs by adequate trained nursing and paramedical staff.

Admission and discharge procedure from PACU or for fast-tracking should be clearly notified.

Reliable escort must accompany and be given written instructions for patient care or to contact in case of an emergency. Continuing medical educational programme for the physician and other facility personnel.

Commonly cited benefits of ambulatory surgery

Patient preference, especially children and the elderly, as it decreases separation from their familiar home environment.

Lack of dependence on availability of hospital beds.

Greater flexibility in scheduling operations.

Low morbidity and mortality.

Lower incidence of infection.

Lower incidence of respiratory complications like pulmonary embolism, pneumonia etc.

Higher volume of pts. ( greater efficiency )

Shorter surgical waiting lists.

Lower overall procedural costs.

Less preoperative testing and postoperative medication.

Ambulatory surgery unit can be any one of the following: Hospital integrated Hospital separated (but accessible to the hospital)

Satellite ambulatory unit. (which works under the same administration)

Free standing unit.(which is totally independent)

Office based.

DESIGN :

Exit

Entrance

Selection criteriaFor a successful day care surgery program, it is essential to have proper selection of patient, procedure and anesthetic techniques and drugs. We should also keep in mind the rare occurrence of problems pertaining to anesthesia and surgery and must have adequate facilities for dealing with the same.

2. Selection of patient. Admission criteria need to be more stringent in free standing units. Unanimous agreement on selection includes : Healthy, young, ASA physical status I or II patients.

Short procedures performed under MAC or short GA.

Anticipated uncomplicated recovery.

Availability of a responsible escort and caretaker at home including hygienic surroundings at home.

Access to the centre or other hospital in the area within a reasonable time in case of an emergency.

Telephone or mobile phone for communication.

Unanimous disagreement on selection :

Unstable ASA physical status III and above pts. with serious potentially life-threatening diseases that are not optimally managed.

Very old patients.

Neonates and premature infants with gestational age < 60 weeks requiring general anesthesia for the fear of post operative apnoea.

Morbid obesity complicated by symptomatic cardiovascular or respiratory problems.

Syndromic babies- may have metabolic problems, difficult airway

Major procedures involving fluid shifts and blood transfusion and other physiological disturbances, need for i.v antibiotics or parenteral opioids for pain control.

Homozygous hemoglobinopathies and patient on anticoagulants. H/O bleeding disorders Using multiple chronic centrally active drug therapies and active cocaine abuse because of increased risk of intraoperative complications, including death.

Procedure requiring specialized post operative care including extensive physiotherapy.

Poor patient acceptance, lack of a responsible adult at home to care for the patient on the evening after surgery and patients unwillingness to comply with instruction.

Between these extremes there is a large group of patients for whom some risk factor is present although many ambulatory centers around the world are performing major surgical procedures in optimized patients routinely with facilities for hospital admission if need be, to reduce health care cost. Many a time they are performed as 23hr stay cases.

In the absence of definite recommendations in our country, each one of us has to exercise our sensibilities and perform the cases as in patient /out patients basis for maximum patient safety.

Patients falling in the above group include:

ASAIII patients but clinically stable.

Preexisting cardiovascular conditions.(e.g. hypertension,CHF,angina)

Preexisting respiratory conditions.(e.g. asthma,COPD)

Patients at extremes of age i.e. 70 yrs.

Old patients(>70yrs there are reports to suggest that postoperative cognitive dysfunction is less frequent when the procedure is done on outpatient basis)

Morbid obesity but with no co-morbid conditions.(BMI>35kg/m2)

Patients susceptible to malignant hyperthermia.

H/O sudden death syndrome in family.

Patients with URTI which increases Perioperative respiratory complications like cough, laryngospasm and bronchospasm.

Pediatric patients with h/o loud snoring. in some centers they are evaluated with sleep studies preoperatively to determine the safety of outpatient management especially if they are for ENT procedures. This group may have postoperative respiratory compromise and require prolonged recovery room stay or readmission especially if they are small.( 90% on room air2

> 90% with Nasal Prong O2 supply1

< 90% with O20

PainNo pain or mild discomfort2

Moderate to severe pain controlled with analgesics1

Pain in spite of medications 0

PONVMild Nausea/comfortTransient reching/vomiting

Persistant mod to sever Nausea /vomiting2

1

0

14Point score total > 12 for discharge.

In case of spinal or epidural or regional anesthesia,

Limb movements Purposeful movement of at least one upper and one lower limb2

Only one upper limb movement1

No limb movement0

BP< 20 % of baseline and NO orthostatic hypotension2

20 to 40 % of baseline but NO orthostatic hypotension1

< 40 % of baseline or orthostatic hypotension0

Proper guidelines for a safe discharge include:

Stable vital signs for at least one hour.

Absent or minimal surgical bleeding from operation site.

Ability to walk unsupported or with minimal support.

Minimal or nil nausea and vomiting after treatment.

Minimal pain that is tolerable and acceptable to the patient.

Ability to retain oral fluid and to void. There are certain controversies regarding this, there are studies to show that patient are forced to drink fluids prior to discharge have an increased incidence of PONV and hence there is no need to fulfill this condition. Also patients should be given fluids when they feel hungry and not when they feel thirsty. Studies have shown this approach to reduce PONV. The outcome of patients can also be improved by giving IV fluids for the starvation period and limiting NPO orders to just 2hrs before surgery. This has decreased incidence of preoperative hypoglycemia.

In certain high risk group for urinary retention, ultrasound monitoring of bladder volume is used to determine the need for catheterization.

Patients operated under CNB must have return of perianal sensation and proprioception of great toe.

Patients operated under plexus block should be advised to take care of insensate limb and must have a sling for protection. In some centre continuous peripheral nerve block using a disposable infusion device is sometimes used to extend the period of analgesia at home after discharge. Though the complete safety of this is not yet fully established.

Verbal and written instructions regarding medications, dos and donts ,follow up visits ,contact numbers of the hospital and doctors and sufficient stock of medications should be supplied.

In some centers discharge is followed by telephonic interview to ensure patient wellbeing.

Despite all precautions and even with proper patient selection ,a small percentage of patients may require overnight hospital stay or readmission after discharge and the team members must be ready for this. Common causes for above are surgical factors like pain and bleeding ,anesthetic factors like PONV and other anaesthesia related complications and medical factors.

Rarely patients may present with an acute illness and may have to be rescheduled.

Conclusion:

An attempt is there, all over the world to make day care surgery universal. Patient education and preparation ,use of newer short acting anesthetic agents and improved surgical techniques is sure to make this more acceptable to patients. We as anesthesiologists have a great role to play in this change.

Waiting area, registration

Changing rooms

Step down recovery

Office /reception

Operation theatre

General recovery

Preoperative holding