|Year : 2017 | Volume
| Issue : 4 | Page : 327-333
Anesthesia for day-care surgeries: Current perspectives
Sukhminder Jit Singh Bajwa1, Veenita Sharma1, Ridhima Sharma2, Arvinder Pal Singh3
1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
2 Department of Anaesthesiology and Intensive Care, St. Stephan College, New Delhi, India
3 Department of Anaesthesiology and Intensive Care India, SGRD Medical College, Amritsar, Punjab, India
|Date of Submission||03-Feb-2017|
|Date of Acceptance||09-Apr-2017|
|Date of Web Publication||4-Sep-2017|
Sukhminder Jit Singh Bajwa
House No. 27-A, Ratan Nagar, Tripuri, Patiala - 147 001, Punjab
Source of Support: None, Conflict of Interest: None
Day-care surgery has become a popular modality of surgical intervention throughout the globe. Numerous factors including the economic and financial issues are driving this therapeutic modality to a widespread acceptance among surgeons and anesthesiologists. Advancements in anesthesia and surgical techniques as well as availability of newer drugs are largely responsible for the progress of day-care surgeries. Numerous challenges are still faced by anesthesiologists and surgeons in carrying out day-care surgeries, especially in spite of these advancements, at resource-limited setups. The first right step in successfully delivering the day-care surgical services includes proper selection of the patients. The preanesthetic evaluation is highly essential in determining the suitability of the patient for day-care anesthesia and surgery as well as the formulation of various anesthetic plans and strategies. The current review is intended to highlight inherent challenges and probable solutions to them for this rapidly progressing anesthesia.
Keywords: Ambulatory anesthesia, day-care anesthesia, day-care surgery
|How to cite this article:|
Bajwa SJ, Sharma V, Sharma R, Singh AP. Anesthesia for day-care surgeries: Current perspectives. Med J DY Patil Univ 2017;10:327-33
| Introduction|| |
Day-care surgery, that is, the patient being discharged from the hospital on the same day of surgical procedure, has become immensely popular modality of treatment throughout the globe. The forthcoming era will definitely see a much larger number of patients and physicians opting for this surgical trend. The fast pace of life, adoption of nuclear family structure, need of early return to work, and resumption of daily routine chores to maintain social and professional competitiveness, are few of the important factors which have propelled this treatment modality to newer heights., Moreover, the relative shortage of beds in the hospital and scarce economic resources due to ever increasing patient population has boosted the concept of small incisions and minimal invasive surgeries, thus allowing for more surgical procedures to be performed on day-care basis.,,
Anesthesia for day-care (ambulatory anesthesia) surgeries may require administration of general, regional, and local anesthesia or monitored anesthesia care supplemented with sedation. The advancements in anesthesia techniques and availability of newer drugs have contributed largely to the progress of day-care surgery. However, provision of day-care anesthesia services is a challenging task. The main challenges include the logistics and organization of the day-care setup to make it function efficiently, effectively, and safely.,, These difficulties are accentuated in resource-challenged settings.
| Historical Aspects|| |
The first novel attempt to describe ambulatory surgery is largely attributed to a Glasgow Hospital surgeon, Dr. Nicoll who reported a series of more than 9000 patients undergoing day-care procedures. The day-care procedure-based hospital teaching was first introduced in 1962, whereas an exclusive ambulatory surgery hospital was first created in 1969. The formal development of ambulatory anesthesia came into an existence with the establishment of the Society for Ambulatory Anesthesia, “SAMBA,” in 1984 along with the starting of postgraduate subspecialty training program.
| Current Scenario|| |
Among developed nations, 66% of surgical procedures are performed on outpatient basis in the United States, whereas 50% of the surgeries in the United Kingdom are performed on day-care basis with an ambitious target of 75% over the next decade. Nonuniform reporting of data from developing nations like India makes it extremely difficult to gauge the progress of this subspecialty of anesthesia in these nations. However, from the available data from an unpublished source, it can be stated that 11%–23% of the surgeries in India performed in hospital settings are on outpatient basis. The majority of surgeries are performed by ophthalmology, otorhinolaryngology, gynecology, and general surgery specialties [Table 1].
| Day-Care Anesthesia and Surgery: the Pros and Cons|| |
The popularity of day-care anesthesia and surgery is attributable to numerous factors which may include but are not limited to the following:,,,
- Lack of dependency on availability of hospital beds
- Greater flexibility in scheduling surgeries
- Reduced incidence of nosocomial infections
- Shorter surgical waiting lists
- Lower overall procedural costs
- Higher volume of patients leading to higher efficiency
- Recovery in a familiar environment
- Contribution to the economic growth of the nation.
However, day-care anesthesia and surgery are associated with certain limitations and disadvantages which include but are not limited to the following:,,,
- Surgical and anesthetic complications resulting in unplanned readmissions to the hospital
- Need for higher expertise level
- Possible chances of negligence in preoperative anesthetic assessment
- Lesser compliance to preoperative fasting instructions and preoperative medications
- Higher anxiety levels among patients.
| Day-Care Setup and Facility Design|| |
Day-care surgery should ideally be provided in a self-contained unit that is functionally and structurally separate from inpatient wards and theaters. The possible suggestion for such functioning may involve.,,
Ambulatory surgical patients are managed in the same surgery facility as inpatients. Outpatients may have separate preoperative preparation and recovery areas.
A separate ambulatory surgical facility within a hospital handles only outpatients.
These surgical and diagnostic facilities may be associated with a hospital or medical center but are housed in separate buildings that share no space or patient care functions. Preoperative evaluation, surgical care, and recovery occur within these autonomic units. In developing nations, majority of nursing homes and smaller hospitals function in this manner.
These operating or diagnostic units are managed in conjunction with physician's offices for the convenience of patients and health-care providers.
| Eligibility Criteria and Prerequisites for Day-Care Surgery|| |
Patient screening and selection is one of the primary important requisites for day-care anesthesia and surgery.,,, Patients are selected for such procedures based on some important guidelines such as:
- Patient must be sound to understand the delicate intricacies of day-care procedures
- During discharge from hospital, an adult person should accompany the patient with written instructions
- The domestic environment should be conducive enough for smooth postoperative period
- Besides evaluating basic minimum laboratory investigations, clinical acumen is very important in deciding the fitness for day-care surgery and anesthesia
- Comorbid diseases should be optimized satisfactorily before declaring patient fit for surgery
- Decision of day-care surgical procedures also depends on the duration, severity, and potential chances of hemodynamic instability and others
- Patient should be able to initiate oral intake within few hours of the surgical procedure
- Anesthetic drugs and techniques should be chosen in manner not to disturb the postoperative ambulation
- Patient should be able to take care of himself/herself for routine personal chores
- A good means of transport and communication should be available to the patient at home
- Availability of physician/surgeon for 24 h is an essential prerequisite in case of any emergency readmission.
| Preanesthetic Evaluation: “A Foundation of the Buildings”|| |
Preanesthetic evaluation akin to a foundation of the building when planning for day-care surgery is formulated. At this stage, a detailed history and meticulous examination can help in the identification of medical comorbidities and risks associated with surgery and initiation of appropriate measures to optimize the clinical status. To reduce anxiety and related hazards during induction, it is desirable to do counseling of the patient regarding day-care strategies and patient-controlled nature of postoperative pain relief. Day-care anesthesia has become a subspecialty of its own as increasing number of surgeries are being performed in pediatric, geriatric, and patients with various comorbid disorders.,,
Commonly associated comorbidities and risk stratification
Comorbid diseases such as hypertension, diabetes mellitus, morbid obesity, and others are not considered contraindications to day-care anesthesia in current practice. Doses of antihypertensive drugs are taken as routine on the morning of surgery except the angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists as these agents can cause severe intraoperative hypotension.,,, The optimal control of blood pressure (BP) with preoperative antihypertensive drugs helps in providing cardioprotection, preservation of renal functions, and attenuation of stress response during laryngoscopy and intubation.,
Diabetes management includes stoppage of oral hypoglycemics a night before the surgery and no insulin injection on the morning of surgery. Morning report of fasting blood glucose is extremely helpful. Patients with diabetes should be taken up as first case to avoid metabolic consequences due to fasting status. Tight glycemic control is controversial, especially in day-care surgical procedures in stable patients with diabetes., Postoperative nausea and vomiting as well as fasting status can be detrimental in diabetic surgical population. The newer anesthetic techniques and drugs, minimally invasive surgical methods, and better understanding of diabeto-anesthesia have revolutionized the ambulatory anesthesia in patients with diabetes. Careful evaluation is mandatory as diabetes is frequently associated with other comorbid diseases.,,
It is generally recommended to avoid administration of general anesthesia (GA) in patients with active respiratory infections, hyperreactive airway, and sleep apnea syndrome. Bronchospasm during induction and intubation as well as during perioperative period can be severe, especially in patients with chronic obstructive airway disease.,
Body mass index (BMI) is an independent predictor of perioperative morbidity, and an increased incidence of complications results from a progressively higher BMI. Such patients are ideal candidates for minimally invasive surgical procedures and day-care anesthesia. Equally challenging situations are encountered in patients with obstructive sleep apnea. The issues of airway management during perioperative period and difficult mask ventilation and intubation can increase the incidence of complications perioperatively. Anesthetic techniques are chosen on patient-to-patient basis and type of surgery.,,
Currently, day-care anesthesia can be administered to all age groups ranging from 1-month child to geriatric population. Children can be treated best on day-care basis as the anxiety levels due to separation from parents and unfamiliar surroundings of the hospital are minimal with this technique. Moreover, risk of nosocomial infections always looms large in such patients with minimal immunity strength. However, postoperative apnea is a matter of concern in patients with a clinical history of respiratory disease.,
A history of venous thromboembolism during the past 3 months, prosthetic cardiac valves, higher doses of anticoagulant drugs, critical or decreased platelet count, and others are not suitable for ambulatory anesthesia. Patients with neurological disorders and peripheral and autonomic neuropathies are vulnerable to develop postoperative respiratory complications. Patients with neuromuscular disorders, myasthenia gravis, and muscular dystrophies should not be discharged on the same day. Such cases are ideal for local or regional anesthesia if feasible.,
Renal and hepatic diseases are not considered as contraindications for day-care surgery. As such American Statistical Association III-IV patient can also be taken up for elective surgery provided, they meet fitness criteria laid down for the day-care anesthesia.
| Surgical Factors|| |
Surgical factors are important determinants for deciding the fitness of patients for day-care ambulatory surgery. Elective and emergency surgical procedures have to be individualized on patient-to-patient basis. Surgical procedures with high propensity for cardiovascular instability, hemorrhage, postoperative nausea and vomiting, delayed start of oral intake, etc., are not suitable for day-care anesthesia. Rather, only those surgical procedures should be chosen which allows early oral intake and ambulation.
| Anesthetic Techniques|| |
Anesthetic technique has to be modified and titrated to a level so as to provide optimal anesthesia with minimal side effects. The present recommendations state that clear fluids can be administered up to 2 h before surgery without increasing the gastric volume. Routinely, administration of metoclopramide and H2 blockers is immensely useful in ensuring minimal residual gastric volume and acidity.
Newer airway adjuncts such as proSeal laryngeal mask airway, Combitube, and others have revolutionized the noninvasive airway management in day-care surgeries. GA is the most common method and can be administered either by inhalation or intravenous methods as well as a combination of both can be considered.
Inhalational anesthesia with traditional agents such as ether, nitrous oxide, halothane, isoflurane, and others is a thing of past now. With the advent of modern anesthesia workstations and development of advanced vaporizers, inhalational anesthesia has also made huge leaps of progression. Sevoflurane and desflurane have maintained the place of day-care ambulatory anesthesia in modern day anesthesia practice; however, widespread usage of these agents is somewhat limited by their high procurement cost.
Total intravenous anesthesia
Total intravenous anesthesia (TIVA) has revolutionized the ambulatory surgery in recent times. Availability of newer and better intravenous anesthetic agents such as propofol and midazolam and adjuvants such as remifentanil and dexmedetomidine has almost replaced inhalational agents in the era of day-care clinical practice. Propofol has been the major contributory anesthetic agent in the rapid evolution of day-care surgery due to its superior recovery characteristics. Infusions of propofol, remifentanil, and dexmedetomidine have galvanized the advancements made in ambulatory anesthesia, especially in short surgical procedures., TIVA is suitable for any kind of surgery but is highly useful in pediatric, geriatric, ophthalmology, and ENT surgeries. The combination of propofol, fentanyl, or remifentanil is associated with rapid recovery characteristics, but the availability of remifentanil is again a big limitation. Rocuronium, succinylcholine, atracurium, or cisatracurium remains the muscle relaxant of choice for day-care ambulatory surgeries.,
Regional anesthesia has gained a widespread popularity in day-care surgical procedures recently. However, prolonged recovery time for complete regression of the block lengthens period of postoperative period care.
Modifications of existing spinal anesthetic techniques and advent of newer drugs which are used as an adjuvant to local anesthetics have made regional anesthesia a suitable choice for day-care surgeries. Low-dose epidural or spinal analgesia is possible with reduced doses of local anesthetics when opioids and other adjuvants are added. Unilateral or low-dose spinal anesthesia techniques provide comparable recovery characteristics to general anesthesia with newer inhalational anesthetics. Increasing use of spinal needles with smaller gauge and concept of unilateral and low-dose spinal anesthesia have proved similar anesthesia and recovery characteristics when compared to general anesthesia using desflurane, sevoflurane, and nitrous oxide. Use of spinal needles with gauge smaller than 25 has significantly reduced the incidence of postdural puncture headache (PDPH) in a day-care ambulatory anesthesia patients. Introduction of newer local anesthetic agents such as ropivacaine and levobupivacaine has almost eliminated the risk of transient neurological symptoms which was frequently encountered with lignocaine, procaine, and mepivacaine. Discharge criteria during day-care surgery in such patients should include return of sensory level at S4-5 dermatome, Bromage scale equivalent to preprocedure level, and adequate return of proprioception on standing.,,
Bier's block is still the gold standard in many procedures, especially pertaining to forearm. The advent of safe local anesthetics such as levobupivacaine and ropivacaine and the reduction of dosage of these local anesthetics with adjuvants such as dexmedetomidine and clonidine have made Bier's block an extremely safer procedure in modern day anesthesiology practice.
Ultrasound-guided peripheral nerve blocks
Availability of newer ultrasound equipment in the past decade has given an impetus to peripheral nerve blocking procedures. Not only the block is administered with precision but also the dose of local anesthetic is also decreased remarkably. Even procedures such as shoulder arthroscopy have become possible to be performed on day-care basis.
Local anesthesia with sedation
Local infiltration of anesthetics at incision site is an extremely simple procedure for providing effective postoperative analgesia. This is being increasingly employed even by the nonanesthesiological fraternity as well, especially in the ophthalmological and ENT surgical patients. Infiltration of port sites with local anesthetics in laparoscopic procedures also provides pain relief to a good extent in the early postoperative period.
| Emergency Day-Care Surgeries|| |
Few procedures with acute surgical emergencies can be taken up for day-care anesthesia. These include but are not limited to close reduction of bony fractures, tendon repairs, laparoscopic procedures such as appendectomy and cholecystectomy, ectopic gestation and removal of products of conception, breast abscess drainage, wound debridement, and various other incision and drainage procedures [Table 1]. However, the decision regarding discharge has to be a combined responsibility of the attending anesthesiologist and surgeon.,
| Monitoring Essentials|| |
Huge stress has been made in the past on “3M,” that is, minimum mandatory monitoring during day-care surgery. However, there is no universal consensus on which parameters to be monitored strictly during such procedures besides heart rate, noninvasive BP, pulse oximetry, and electrocardiogram. In resource-limited settings, it is difficult to monitor end-tidal CO2 and end-tidal concentration of inhalational anesthetics. In developed nations, even bispectral index system also forms the component of minimum mandatory monitoring which is greatly helpful in maintaining the adequate depth of anesthesia, faster recovery, and minimum postoperative complications.
| Recovery Characteristics|| |
This is the most important aspect during postoperative period as the discharge of the patient from the hospital on day-care basis is decided after evaluating recovery characteristics. Major issues before discharge such as any episode of bradycardia, hypotension, hemorrhage, emergence phenomenon, PDPH, transient neurological symptoms, pain, respiratory depression, urinary retention, shivering, postoperative nausea and vomiting, and many others which can possibly defeat the goals of ambulatory anesthesia.,, Recovery is usually divided into three stages; early, intermediate, and late recovery stage. The early stage is characterized by patient getting awake with return of protective reflexes. Patients undergoing local anesthetics are considered to have fast-track recovery. Intermediate stage starts with the patient getting admitted into the postanesthesia recovery care unit till discharge of the patient. Any complication or symptoms during this stage can be easily managed as the recovery unit of day-care surgery is well equipped and staffed. The ability to take oral fluids and self-ambulation for micturition are not considered vital criteria for discharge. Regression of neuraxial blockade beyond S3 level helps in return of micturition reflex. Late stage recovery terminates when patient fully recovers from the physiological and psychological aspects of the surgical procedure. A written set of instructions and contact number of attending doctor should be handed over to the patients and the accompanying persons during discharge and should be told to contact immediately on appearance of any signs and symptoms. Ideally, such patients should be handed over summary of general details pertaining to day-care anesthesia and surgical procedure.
Numerous scoring systems such as clinical recovery score, Stewart recovery scores, Aldrete score (AS), postanesthesia discharge scoring systems (PADSSs), and others have been developed to monitor patients before being discharged safely from the hospital after ambulatory surgery., The clinical usefulness of each varies slightly with dependency on demographic and clinical factors. However, AS serves as a better method during the initial part of the recovery after ambulatory anesthesia whereas PADSSs are more useful during discharge of the patient after ambulatory anesthesia [Table 2] and [Table 3].
As a matter of fact, majority of the clinicians do not depend entirely on these rigid scoring systems. In routine practice, a mix of these scores and subjective clinical acumen is very useful in taking appropriate decisions related to discharge of the patient which include but are not limited to following factors.
- A good coordination of various sensory, motor, and psychologic functions of the body
- Correct orientation to time, place, and person
- Recovery from neuraxial anesthesia should be assessed by return of lower sensory levels and Bromage score to <1
- Stable BP reading, especially related to orthostatic mean arterial pressure
- Patient should have a good perianal sensation, ability to self-ambulate, normal flexion, and extension movements at foot
- An adult to escort the patient to home as well as supervise the patient later at home
- A good communication with the attending surgeon/anesthesiologist
- Availability of personal/reliable transportation
- Above all patients should be able to understand the requirements of postanesthesia care and should follow advice as to when to resume daily routine activities.
The scoring systems are just supportive parameters rather it is the clinical judgment and acumen of the attending anesthesiologist which is extremely useful in ambulatory anesthesia, especially in developing nations and low resource settings.
| Cost-Effectiveness|| |
The cost-effectiveness of day-care anesthesia can be derived from the fact that minimum workforce is required as the patients do not get admitted for the night and the short recovery times are translated into cost savings. Hospital resources are also spared which is hugely beneficial in resource-challenged settings of developing nations. Cost-effectiveness is further enhanced with setting up of audit of day-care anesthesia procedures which can improve the quality and efficiency of patient care.
| Conclusion|| |
Day-care anesthesia and surgeries are undergoing a phase of evolution from the traditional methods. The betterment is being guided by an increased understanding of the pathophysiological basis of the disease, advancements in anesthetic techniques, adoption of minimally invasive surgical techniques, availability of newer and short-acting anesthetic drugs, and evolution of sociobehavioral and economic factors. However, many challenges are being confronted everyday and numerous barriers have to be broken before day-care ambulatory anesthesia and surgery can make its concrete place and establishment in clinical society.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]