Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
PRESENTER AYENI,F.B
REGISTRAR,DEPARTMENT OF
ANAESTHESIA,ABUTH,ZARIA
MODERATOR DR NWASOR
CONSULTANT ANAESTHETIST,
ABUTH,ZARIA
OBJECTIVES
To define some terms necessary in the
understanding of Day Case Anaesthesia(DCA)
To highlight the Rational way of selecting
appropriate patients and procedures for DCA
To discuss the various Anaesthetic options
available for DCA
To describe the objective ways of selecting
patient fit for discharge from Day Case Unit
OUTLINE
Introduction
History/Epidemiology
Definition of Terms
Contraindications
OUTLINE
Conduct of DCA
Pre Anaesthetic Evaluation
Choice of Anaesthesia
Post Anaesthetic Care/Recovery
Discharge
Follow up and Audit
Peculiarities in our environment
Summary
References
DEFINITION OF TERMS
DAY CASE SURGERY
Admitted for investigation or operation
Planned non resident basis
Requires facility for recovery
23HOUR SURGERY
Admitted for investigation or operation
Discharged the next day
DEFINITION OF TERMS
OUT PATIENT CASES :
Minor procedures performed under LA
which do not generally require post op
recovery time
DAY CASE ANAESTHESIA :
Tailored to meet the need of Day Case
Surgery so the patient can go home soon
after the operation
HISTORY
James Nicoll (1864-1921) Day case surgeries
on 900 children in Sick Childrens Hospital ,
Glasgow , Scotland
N2O and Ether Dental Extraction
Society for Ambulatory Anaesthesia - 1984
INTRODUCTION
Evolved due to ;
Availability of rapid and short acting anaesthetic
agents
Improved monitoring devices
Advances in minimally invasive surgery
Escalating health care costs
HOSPITAL BASED
Separate day case facility within a hospital handling
only day cases
FREE STANDING
May be associated with a hospital but are housed in
separate building that share no space or patient care
function
Reception area
Anaesthetic Room
Play Room ( Children )
Operating Room
Recovery Room
Discharge Area
BENEFITS OF DCA/DCS
TO PATIENTS :
TO THE HOSPITAL
Free in-patients beds for major and emergency
surgeries
Reduction of nosocomial infections
Reduce waiting list for elective surgery
CONTRAINDICATIONS TO DCA/DCS
Social factors e.g patient refusal , unwilling to
comply with instructions
Infants of PCA < 40 60wks with history of
prematurity
Unstable ASA 2 , 3 , & 4
Morbidly obese patient with other systemic
diseases e.g Severe obstructive sleep apnoea
Acute substance abuse & acute concurrent illness
Susceptibility to malignant hyperthermia
suitability of a
patient for day case surgery is
attending
anaesthetist
that of the
IDEAL PROCESS
CHOICE OF ANAESTHESIA
The decision as to the type of Anaesthesia
must remain in the province of the Attending
Anaesthetist
Technique chosen will be based on :
Surgical requirement
Patient consideration
Experience of the Anaesthetist
Facilities and personnel of the DCU
ANAESTHETIC TECHNIQUE
There are 3 main anaesthetic options :
1) General Anaesthesia
2) Regional Anaesthesia
3) Monitored Anaesthesia Care
(MAC)
GENERAL ANAESTHESIA
Ideal Anaesthetic agent for day case surgery :
Smooth and rapid onset of action
Intra op amnesia and analgesia
Hemodynamic stability
Rapid recovery period without side effects
Cost effectiveness
GENERAL ANAESTHESIA
INDUCTION AGENT IV/INHALATIONAL
IV- PROPOFOL
THIOPENTAL
Rapid onset and relatively short duration of action
Impairs fine motor skills for several hrs after surgery
Can produce hangover sensation
GENERAL ANAESTHESIA
KETAMINE
Prominent psychomimetic effect
Higher incidence of PONV
MIDAZOLAM
Slow onset of action
Prolonged recovery when compared to propofol
N2O
Reduce requirements for volatile agents & risk of
intra op awareness
Increase risk of PONV
LMA
Face mask
ETT
GA MUSCLE RELAXANT
Choice of muscle relaxant depends on
anticipated duration of surgery
SUCCINYLCHOLINE
Not ideal in Day case setting
GA - MONITORING
Standard
Monitoring awareness
Stability of BP & PR
Lack of movement in response to surgical
stimulation
Bispectral index ( BIS )
FOR INSTITUTION :
CAUDAL :
Easier to perform
Produces excellent relieve of pain post op especially in
children
Use dilute solution 0.125% Bupivacaine
ANALGESICS
NSAIDS
?OPIODS
DISCHARGE
Responsibility of :
Attending Anaesthetist
Surgeon
Nursing officer in charge of the DCU
DISCHARGE
Patient must be escorted home by a responsible
adult and ideally , by private transport
Patient must be advised verbally and in written
,that, in the 1st 24hrs post op, he/she must not ;
DISCHARGE CRITERIA
DISCHARGE CRITERIA
Patients at significant risk of urinary retention
must have passed urine
A responsible adult to take the patient home
Resumption of oral intake is encouraged
though no longer required to be
demonstrated prior to discharge
DISCHARGE CRITERIA
Short stay surgical patient should have a
protocol based discharge from 1st stage to the
ward ( 2nd stage ) and from the ward to home
Two commonly used discharge criteria after
GA and MAC are :
1) Aldrete Discharge Criteria
2) Post Anaesthetic Discharge Scoring System
(PADSS)
BREATHING
Able to deep breath and cough freely (2), Dyspnoea,
shallow or limited breathing (1), Apnoea (0)
OXYGEN SATURATION
Maintains oxygen saturation of >92%on room air (2)
Needs oxygen supplement to maintain SPO2 >90% (1)
Oxygen saturation < 90% (0)
2
1
0
CONSCIOUSNESS
Fully awake
Rousable to speech Not responding
-
2
1
0
VITAL SIGNS
BP & PR within 20% of pre op baseline - 2
BP & PR within 20-40% of pre op baseline 1
BP & PR > 40% of pre op baseline
-0
PAIN
Acceptable to patient
Not acceptable to patient
Not acceptable to patient or nurse -
2
1
0
UNPLANNED ADMISSION
ANAESTHETICS :
PONV ,Complications , Delayed Recovery
SURGICAL :
Pain , Complications , Extensive Surgery
MEDICAL :
Undiagnosed medical conditions
SOCIAL :
Late surgery ,
PECULIARITIES IN OUR
ENVIRONMENT
PATIENT
PROCEDURE
ANAESTHETIST
FACILITY
SUMMARY
Only broad guidelines for patient and
procedure selection
Multidisciplinary team work and effective
communication form the cornerstone of DCA
Post op Analgesia and prevention of PONV is
vitalIF THERE IS A NERVE TO BLOCK , LET US
BLOCK IT
Continuous process evaluation is mandatory
REFERENCES
Day Case and Short Stay Surgery : Published by
The Association of Anaesthetists of Great Britain
& Ireland , May 2011
Australian and New Zealand College of
Anaesthetist Recommendation for the peri op
care of patient selected for Day Case Surgery
Reviewed 2010
The Hong Kong College of Anaesthesiologist
Guidelines for Day Case Surgery Reviewed Feb.
2002
REFERENCES
Anaesthesiology by Atuso Ambulatory
Surgery ; Chapter 60
British Journal of Anaesthesia 87(1):Pg 7387(2001) Analgesia for Day Case Surgery
Day Surgery and 23Hr Surgery at UCH, London
Guidelines and Protocol; May 2008
Questions and Answers in Anaesthesia &
Intensive Care : Page 140-142
Thank
you for
your
Attention