Anesthesia has made surgery feasible by providing a relaxed, sedated, pain-free patient. However, surgeries and anesthesia have their complications. Managing the postoperative period is as important as managing the surgery itself. But with the advent of daycare surgeries (DCS), the overall burden of postoperative management and prolonged hospitalization has reduced. This has been made possible due to the emergence of minimally invasive surgeries and newer advances in techniques of anesthesia and analgesia.
Commonly used terms and abbreviations have been described in Table 35.1.
DCS offer various advantages in terms of cost-effectiveness, reduced absenteeism from work, early ambulation, etc. (Table 35.2).
The success of daycare procedures is broadly based on careful selection not only of the patient but also the surgical procedure. Overall safety and postoperative care of the patient is also an important issue that should be kept in mind. Thus, broadly speaking, patient selection is divided into three major domains—surgical, social, and medical.
The advent of advanced minimally invasive surgical procedures has widened the boundaries of ambulatory anesthesia and DCS to a great extent. Surgeries not involving the breach of thoracic/abdominal cavities (except minimally invasive) or not followed by the risk of postoperative hemorrhage can be performed on a daycare basis. Also, the procedure should not require postoperative intravenous fluid therapy or analgesics. Examples of some surgical procedures that can be performed and not limited to have been mentioned in Table 35.3.
A patient should be scheduled for a daycare procedure only after ensuring a safe home environment, a responsible caregiver, convenient transportation, and communication access (e.g., telephone) in case the need arises. All instructions should be discussed verbally and in a written format by both the anesthesiologist as well as the surgeon.
Selection criteria should be done, keeping in mind the overall “medical fitness” of the patient. Thorough and well-documented history should be taken. Preanesthetic checkup is, therefore, of paramount importance in making the decision.
The idea behind preanesthetic evaluation is to screen the patient for any comorbidities and assess the impact of the patient’s fitness on the surgical outcome and perioperative management. Preoperative evaluation prevents needless delays and cancellations. This evaluation should be done based on structured format and can vary from one institution to another. But the following points must be specifically kept in mind while evaluating the patient for DCS:
Age: Despite having higher incidences of comorbidities, DCS in carefully selected geriatric patients offer all the advantages, as discussed above (Table 35.2). Also, there is reduced cognitive impairment and minimal separation from the home environment. Therefore, there is no upper limit of age, but age > 80 years is considered to be associated with higher perioperative risk.
Hypertension: Hypertension has a direct relation with increased perioperative adverse cardiac events, for example, myocardial ischemia. However, in the absence of associated end-organ damage, it is advised not to defer surgeries if blood pressure < 180/110 mm Hg.
Ischemic heart disease: History of myocardial infarction within 6 months, angina at rest, or with minimal physical activity, all pose as contraindications to elective surgical procedures. Detailed evaluation along with the assessment of high-risk factors like coexisting diabetes, peripheral vascular disease, poor exercise tolerance (<4 metabolic equivalents or METs) should be done before coming to the decision of whether or not to proceed with the procedure. β-blocker therapy should be continued throughout the procedure.
Asthma/chronic obstructive pulmonary disease (COPD): Asthmatic patients with good exercise tolerance, no recent history of asthma exacerbation/hospitalization, or systemic steroid intake can be posted for ambulatory anesthesia and DCS. Similarly, for COPD, asymptomatic patients without a recent history of smoking (>6–8 weeks) can be considered. However, avoidance of airway manipulation and preference to local/regional anesthesia are always warranted in these patients.
Acute upper respiratory tract infection: Afebrile patients with no features of lower respiratory tract involvement can be considered for regional anesthesia as day cases. It is best to avoid any tracheal manipulation, but if this cannot be avoided and the patient is febrile, then it is better to defer the case.
Obstructive sleep apnea (OSA): It is associated with a very high risk of perioperative adverse events like difficulty in airway handling, fall in oxygen saturation, airway obstruction, hypertension, and cardiac dysrhythmias. Opioids should better be avoided, or dose should be limited. These patients can be considered for DCS, provided the patient tolerates continuous positive airway pressure devices (CPAP) and is efficient in practicing this at home postdischarge.
Diabetes mellitus: Diabetic patients pose no contraindication to DCS unless they have associated comorbidities like autonomic dysfunction, cardiovascular or renal impairment (which can independently cause multiple complications). It is advised to schedule these patients as the first case. Patients should be clearly instructed to omit the morning dose of oral hypoglycemic agents or insulin. Their nil per oral time should be minimized postsurgery.
Renal and hepatic diseases: Patients with severe hepatic disease, a renal disease requiring dialysis, are not candidates for daycare procedures. However, minor procedures like dialysis fistula access can be performed under local/regional anesthesia on a daycare basis.
The standard guidelines of fasting, as proposed by ASA, are also followed for various daycare procedures (Table 35.4).