Day surgery list management

You have been asked to cover a morning day case general surgery list. Listed are two laparoscopic cholecystectomies and one inguinal hernia repair. During your preoperative assessments you discover that one of the patients has type 1 diabetes and the patient listed for the hernia repair has severe chronic obstructive pulmonary disease (COPD), with an FVC of 1 l and markedly reduced exercise tolerance. He has been optimized as much as possible by the respiratory team.

Communication with the operating surgeon is essential to ensure that the right patient is operated on at the right time. Although not an issue here, children should be prioritized first on the list. Patients with diabetes should also take priority, given that their glycaemic control may be impaired if fasted for prolonged periods.

There is an anaesthetic challenge on this list in the form of the patient with COPD. His pulmonary function tests and functional capacity suggest that he is unlikely to be suitable for a general anaesthetic, and a regional technique would be more appropriate. Given that this is a morning list, there is an opportunity to deliver a spinal anaesthetic whilst allowing adequate recovery time, should you feel the patient is suitable to be discharged. You have fewer grounds for cancellation as he is maximally treated.

Communication with the surgeon and theatre team at the team brief is vital – remember, other factors may influence list order, e.g. equipment availability, surgical concerns.

Organizing list order allows you to be proactive in managing starvation times and analgesia particularly. Anaesthetic techniques should ensure minimum stress and maximum comfort for the patients and should take into consideration the risks and benefits of the individual techniques.

Analgesia is paramount and must be long-acting but, as morbidity such as nausea and vomiting must be minimized, the indiscriminate use of opioids is discouraged (particularly morphine). Prophylactic oral analgesics, e.g. paracetamol, along with long-acting NSAIDs should be given to all patients unless contraindicated. These should be clearly prescribed and nursing staff informed to ensure drugs are given in a timely fashion. It should be noted that NSAIDs are to be avoided in ischaemic heart disease, cerebro- and reno-vascular disease, as per Medicines and Healthcare Products Regulatory Agency (MHRA) recommendations.

For certain procedures (e.g. laparoscopic cholecystectomy) there is evidence that standardized anaesthesia protocols or techniques improve outcome. Anaesthetists should adhere to such guidelines if they exist. Information regarding this can be found in the Association of Anaesthetists of Great Britain and Ireland (AAGBI) leaflets.

The use of local/regional anaesthetic techniques also needs consideration and may also serve to minimize IV opioid use. Prilotekal (hyperbaric 2% prilocaine) is now indicated for spinal anaesthesia in adults undergoing short surgical procedures – a standard dose to achieve a block up to T10 has a duration of action lasting, on average, 100–130 minutes.

Your aim is to ensure a quick turnaround of patients, who need minimal time in recovery. In addition to the analgesic strategies above, routine use of antiemetics, modest intraoperative IV fluid administration and minimizing starvation times all enhance throughput. Do not forget: patients are permitted clear fluids up to 2 hours prior. Where possible, allow them to drink water or a carbohydrate-loading drink. This will only work if you are certain of list order.