Day Case Care Surgery Notes

Day Case Care Surgery Introduction

• Day care surgery is a term applied to performing a surgical procedure as a day case. This provides advantages to both patients and healthcare providers. It causes less disruption to the patient’s daily situation and contributes to financial savings to the hospital.
• It is an integral component of healthcare delivery in resource-rich countries, whereas in resource-poor countries, it is on the rising trend due to increasing popularity. There should be a team comprising of surgeon, anaesthetists, floor managers, operational managers and nursing staff.
• In India day case/care surgery is gaining popularity in cities. However, more than 70–80% population is in rural India. Most of these patients come late to the hospital and often they are illiterate. Hence the day case surgery is currently limited to urban patients in India.

Read And Learn More: Basic Principles Of Surgery Notes

Surgery Definitions:

• 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.

Indications for Day Care Surgery:

• Hernia surgeries
• Cataract surgeries
• Excision of lumps, excision of foreign body
• Parotidectomy
• Laparoscopic surgeries such as cholecystectomy

Types Of Care

• Office-based care: The investigations and ambulatory interventions are performed on an outpatient basis, providing ready access to patients. The disadvantage is that vey few procedures performed under local anaesthesia are included in this.
• Procedures that need general anaesthesia are not performed as this requires additional equipment and healthcare personnel.
• Stand-alone day care surgery: The surgeries in this care are performed in an isolated facility, either on a remote site or in the campus of a parent hospital.
• Procedures are limited to those performed under local anaesthesia, regional anaesthesia or minor procedures under general anaesthesia. This is to avoid overnight admissions which need to be transferred to the parent hospital, which may be some distance away.

Type Of Surgery Facilities

1. Self-contained integrated day: These are wellequipped hospitals having reception area, operation theatres and postoperative ward. Many surgeries can be performed here including laparoscopic cholecystectomies, laparoscopic hernia surgeries, etc.

• • There should be a good cooperation between all persons involved in the day case surgery. Patients should be able to understand the instructions given to him by the consultant. He should be able to come back to the hospital in case of any complications.

2. Integrated day and short-stay surgery facilities: Here daycare and short-stay surgery are feasible, where challenging procedures or day surgery on a less fit patient can be considered.

Selection Criteria

1. Medical Criteria:

• Age: Physiological health of the patients is more important than the chronological age. There is no upper age limit.
• Comorbidity: American Society of Anesthesiologists (ASA) classification is traditionally used to evaluate the patients.
  • ASA 1 and 2 patients are confined to the stand-alone units, whereas ASA 3 patients are suitable for hospital-integrated units.
  • Patients with hypertension are considered for day surgery when blood pressure is below 180/110 mmHg.
  • Patients with significant respiratory and cardiac disease have to be reviewed by anaesthetist before being accepted for day surgery.
• Obesity: Obesity is defined as body mass index of more than 30 kg/m2.
  • Traditionally, guidelines towards obese patients were conservative due to the fear of complications. The course of these patients is uneventful, although there is increased risk for nonserious intraoperative and postoperative respiratory complications.
  • Complications of morbid obesity such as sleep apnoea, hypertension and congestive cardiac failure should be managed preoperatively with an experienced team.
• Epilepsy: Patients with controlled epilepsy on medications should be managed as normal patients. It is important not to omit the medications in the preoperative medications. Patients with poorly controlled epilepsy on medications should be managed preoperatively with a medical team.
• Diabetes: The incidence of diabetes is on the increasing trend worldwide. An HbA1c of 8.5% indicates a good control. Patients with well-controlled type 1 and 2 diabetes mellitus can be considered for day surgery.

The American Society of Anesthesiologists (ASA) physical status classification:

• • The complications of diabetes such as renal disease, cardiovascular disease should be evaluated pre-operatively by an experienced team.
  • These patients should not be given oral hypoglycemic agents. Also, they should be operated first rather than late in the evening.
  • If the patient is on afternoon or evening lists or undergoing a complex surgery, he can be managed with the help of a diabetic team or the anaesthetist.
• Anticoagulants: Preoperative risk assessment with a cardiologist is important in managing patients on anticoagulation when it is felt that surgery will require its discontinuation.
  • Patients are often on anticoagulation due to atrial fibrillation, venous thromboembolism, or a prosthetic heart valve.
  • Patients may be receiving anticoagulants following stenting or coronary artery bypass graft. A few drugs may have to be stopped for 7 days before surgery. One such example is clopidogrel.
• Smoking: Patient should stop smoking at least 48 hours before surgery. Substance abuse patients are not the candidates for day case/care surgery.

2. Social Criteria:

• A patient accompanied by a responsible adult is the key to a safe and comfortable discharge. A travel time of less than one hour is considered ideal although the comfort of the journey is more important.
• The means of contacting the hospital, if a complication occurs, is an important aspect of a safe discharge. As mentioned earlier, due to these reasons, many of our patients will not get the benefit of day case/surgery.

3. Surgical Criteria:

• An operating time of 2 hours in duration is considered safe as a day surgery. Suitable control of pain and the ability to eat and drink a reasonable amount is the main requirement.
• Venous thromboembolism risk assessment is important in patients undergoing complex surgery.

Preoperative Assessment

• The preoperative assessment of the patient is best done by an anaesthetist who specializes in day surgery. It should be done early in the pathway to allow time to optimise health problems before surgery. All patients should be considered for day surgery unless proven otherwise.
• Relevant investigations are conducted to assess the fitness of the patient for surgery. Informed and written consent is taken after informing the patient about admission, operation, and discharge.

Perioperative Management

Scheduling: Day surgeries are preferably planned in the morning to make monitoring and early discharge of the patient feasible. If there is a list in the afternoon, local and regional anaesthesia cases are planned for later in the day. Mixing of day case and complex inpatient cases is not recommended.

Anaesthesia and analgesia: Multimodal analgesia is required to make a day case surgery successful. It is started in the preoperative period with paracetamol and non-steroidal anti-inflammatory drugs.

• Intraoperative anaesthesia is maintained by any of the inhalational agents. The anaesthetist rather than the drugs used matter more. Total intravenous anaesthesia (TIVA) offers the advantage of reduced postoperative nausea and vomiting.
• Short-acting agents are preferred whenever feasible. When morphine is used, it is given in minimal doses to reduce postoperative nausea and vomiting.
• Local anaesthetic such as bupivacaine when injected into the wounds helps prolong the effect of analgesia.
• Postoperative monitoring of pain is important and further doses of analgesia should be given accordingly to make the patient comfortable and fit for discharge on the same day.

Postoperative complications: The complications of day surgery are like that of inpatient surgery. However, since day surgery patients are discharged on the same day, monitoring in the immediate postoperative period is important.

• Reactionary haemorrhage is uncommon but important in cases such as tonsillectomy and laparoscopic procedures.
• Slow bleeding and hypovolaemia can be dangerous. In India, such surgeries can be done only if patient understands the complications and also has the facility to call for ambulance and reach the hospital quickly.
• Covert haemorrhage is a danger in laparoscopic procedures and it might manifest as delayed recovery or uncontrollable abdominal pain.
• High index of suspicion is required in such patients and timely intervention is vital. Postoperative nausea and vomiting is not uncommon and need to be managed to facilitate same day discharge.

Discharge

• Discharge criteria are important in assessing a patients fitness for discharge which is done by a trained day surgery nurse.
• Postoperative review by a surgeon is important but the discharge should not be delayed by failure of their timely attendance.
• There must be a caretaker person to look after the patient once he or she gets discharged after the surgery. He should be able to provide some simple basic care such as pain relief tablets or even to dress a small ooze from the suture line.
• He should available for the next 24 hours to the patient soon after the surgery.

Discharge Criteria:

1. Just before discharge, look at the operated sites. Example: Hernial site at groin, oral cavity as in tonsillectomy. If any degree of suspicion arises, observe them more carefully for another few hours. If any oozing or bleeders are identified within 6–8 hours means better to stop the bleeding and delay discharge.
2. Look at the vitals: Pulse rate, breathing, blood pressure. Only when they are stable, discharge can be considered.
3. Talk to the patient and ask him to obey a few commands such as showing the tongue, identifying relatives or hospital. Simple leading question is— where are you now? Do you have any pain? Can you tolerate this pain?
4. A few common side effects of anaesthetics such as nausea or vomiting are present or not, if present should be minimal. Such patient tolerates liquid and semi-solid food.
5. A contact number should be given to the patient in case of any emergency.