Day-Case Anaesthesia
The NHS plan predicts that 75% of all elective operations will be carried out as day cases. According to the British Association of Day Surgery (BADS), patients support day surgery because it provides timely treatment, less risk of cancellation, a lower incidence of hospital-acquired infection and an earlier return to normal activities. Procedures commonly selected for day-case care are those which take < 60 min to complete and which do not cause severe haemorrhage or produce excessive amounts of postoperative pain (Table 26.1). Increasingly complex cases are now performed as day-case procedures, including laparoscopic cholecystectomy and tonsillectomy. By extending day surgery opening hours and using staggered admission times, patients who would normally require hospital admission may be treated as day cases. The British Association of Day Surgery (BADS) publishes guidelines and protocols for the management of specific issues: for example, day surgery for patients with diabetes. BADS has also published a list of 25 procedures which should normally be undertaken as day cases. The NHS Modernisation Agency audited current day surgery rates for these procedures and set target rates for individual hospitals.
TABLE 26.1
A Selection of Surgical Procedures Commonly Undertaken as Day Cases
Gynaecology
Dilatation & curettage, laparoscopy, vaginal termination of pregnancy, colposcopy, hysteroscopy
Plastic Surgery
Dupuytren’s contracture release, removal of small skin lesions, nerve decompression
Ophthalmology
Strabismus correction, cataract surgery, lacrimal duct probing, examination under anaesthesia
ENT
Adenoidectomy, tonsillectomy, myringotomy, insertion of grommets, removal of foreign body, polyp removal, submucous resection
Urology
Cystoscopy, circumcision, vasectomy, transurethral bladder resection
Orthopaedics
Arthroscopies, carpal tunnel release, ganglion removal, bunion operation, removal of metalwork
General Surgery
Breast lumps, herniae, varicose veins, endoscopy, laparoscopic cholecystectomy, haemorrhoidectomy, anal fissure dilatation
Paediatrics
Circumcision, orchidopexy, squint, dental extractions
PATIENT SELECTION
Evidence has shown that many elderly patients cope better at home. Careful preoperative assessment should highlight patients who will require an extended time in hospital. Elderly patients are more likely to have comorbidities and these patients should be assessed according to their physiological rather than their chronological age. Careful medical and social preoperative assessment is required to help elderly patients to benefit from shorter hospital stays with less risk of postoperative confusion. The patient should stay a minimum of a 1-h drive from the hospital on the night following surgery and they should have an adult escort available for the first 24 h. An example of guidelines used for patient selection for day-case anaesthesia is shown in Table 26.2.
TABLE 26.2
Guidelines for Patient Selection for Day-Case Surgery Under General Anaesthesia
ASA 1 or 2 and medically stable ASA 3
Age: > 52 weeks post-conceptual age
Weight: body mass index = weight/height2 (kg m−2)
≤ 35: acceptable
> 35: discuss with anaesthetic department
Generally healthy, i.e. can climb two flights of stairs
Exclusions
Cardiovascular
MI/TIA/CVA within 6 months
Hypertension: persistent diastolic pressure > 110 mmHg
Unstable angina
Arrhythmias
Heart failure
Poor exercise tolerance
Symptomatic valve disease
Respiratory
Acute respiratory tract infection
Asthma requiring regular β2-agonists or steroids
Metabolic
Alcoholism /narcotic addiction
Insulin-dependent diabetes
Renal failure
Liver disease
Neurological/musculoskeletal
Severe arthritis of jaw or neck
Cervical spondylosis/ankylosing spondylitis
Myopathies/muscular dystrophies/ myasthenia gravis
Advanced multiple sclerosis
Epilepsy > 3 fits per year
Drugs
Steroids
Monoamine oxidase inhibitors
Anticoagulants
Antiarrhythmics
Insulin