Anaesthesia for day surgery

Social factors

• The patient needs suitable conditions at home for postoperative care and access to a telephone in case of complications.

• A responsible adult carer is recommended to escort the patient home and remain with the patient for 24 h after a general anaesthetic.

• Travelling distance from hospital less than 60 min is recommended for operations where serious postoperative haemorrhage may be a risk, such as tonsillectomy.

• The patient (and/or carer) should understand the nature of the surgery and its implications, including complications which may occur at home.

Medical factors

Offering day surgery to patients with complex medical needs is now well established. Intense preoperative management with involvement of a consultant anaesthetist may be necessary but can produce good outcomes for same-day discharge. Anaesthetic involvement in patient selection is recommended to develop local protocols and management strategies for complex patients and communicate with other specialties including surgical consultants to improve the efficiency of the process and minimise cancellation on the day of surgery.

A detailed history and examination should determine suitability for day surgery.

• Patients who are ASA physical class 3. Patients with stable, optimised disease have no contraindication to day surgery, with no increase in the incidence of postoperative complications, unplanned admissions or unplanned contact with healthcare services. Appropriate anaesthetic techniques help to maximise the chance of discharge home. Local anaesthetic techniques may give the best outcome.

• Obesity (BMI > 30 kg m ^–2 ). Obesity does not preclude successful day surgery. Assessment of associated comorbidities, rather than BMI in isolation, will define suitability. Postoperative complications increase with central obesity and the metabolic syndrome. Case reports exist for successful day surgery in patients with a BMI greater than 60 kg m ^–2 with careful preplanning, availability of specific equipment and good team communication. Guidelines for anaesthesia in the obese surgical patient should be applied (discussed in detail in Chapter 32 ). Patients need to understand postoperative expectations and the necessary procedures for success.

• Cardiovascular disease. Stable ischaemic heart disease may be managed in day surgery. Careful review of functional capacity and symptoms is necessary preoperatively, with further investigations and optimisation of disease if appropriate (see Chapter 19 ). Preoperative assessment should aim to identify cases of severe aortic valve stenosis, cardiomyopathies, severe ventricular dysfunction, pulmonary hypertension and arrhythmias, as these may lead to perioperative critical incidents if undiagnosed. Atrial fibrillation, once rate control is achieved, is not a contra-indication to day surgery. Patients taking anticoagulants and antiplatelet therapy should be managed in the usual way (see Chapter 19 ). Patients at high risk of thrombotic events who require bridging therapy with low-molecular-weight heparin (LMWH) can often have this organised via day surgery in conjunction with primary care. Pacemakers are not a contraindication to day surgery if the team and anaesthetist are aware and a plan in case of failure is prepared.

• Respiratory disease . Patients with severe chronic obstructive pulmonary disease (COPD) may be managed in day surgery, especially if the operation is amenable to a regional or nerve block technique. Pulmonary function tests can help to quantify severity of disease and current exacerbations should be excluded preoperatively. Patients with mild obstructive sleep apnoea (OSA) and those with severe OSA on established CPAP therapy can usually be managed in day surgery.

• Endocrine disease. Patients with well-controlled diabetes mellitus, even those on insulin, can be safely managed as day cases. Diabetic control should be assessed by glycosylated haemoglobin levels; National guidance for the perioperative management of diabetes recommends that elective surgery should be postponed if HbA1 _C concentrations are greater than 69 mmol mol ^–1 . Communication with the primary care team or diabetologists may be necessary to improve control, and patients with severe hypoglycaemic attacks may not be suitable. Diabetic complications such as renal disease should be identified early. Precise patient information (verbal and written) is essential, with an individual patient plan for the perioperative management of diabetic medication and postoperative effects on blood sugars clearly documented. Many regimens are available for the perioperative management of diabetes; the simplest puts the patient first on the morning list, omitting his or her morning medication whilst fasting, then taking the usual diabetic medication with a light breakfast after the operation. Perioperative diabetic management is discussed in greater detail in Chapter 20 .

• Hepatic/renal dysfunction. Patients with cirrhosis are not suitable for day surgery because of increased perioperative mortality rates. Milder liver function test abnormalities are usually not a problem. Renal dysfunction does not prohibit day surgery, but careful assessment of associated comorbidities is required and appropriate anaesthetic agents used (see Chapters 11 and 20 ). Regional techniques have been used to allow vascular access procedures for dialysis to be done as a day case.

• Rheumatoid disease. The issues regarding preoperative assessment and cessation of disease-modifying anti­rheumatic drugs are discussed in Chapters 19 and 20 .

• Chronic pain. Patients with chronic pain (see Chapter 24 ) should be identified early in the pathway and a perioperative analgesic plan determined in conjunction with the patient.

• Dementia. Patients with dementia often make a better postoperative recovery in their own home. A perioperative plan should be agreed on during preoperative assessment so carers are clear about the proposed pathway.

• Paediatrics. Children are often suitable for day surgery. They should be aged 60 weeks and older postconceptual age without significant lung disease or apnoeas (see Chapter 33 ).

Surgical factors

Operations deemed suitable for day surgery are ever expanding. The BADS directory now contains more than 200 recommended operations, and more complex operations in specialties such as breast surgery, otolaryngology and orthopaedic and endocrine surgery are also being developed as day surgery procedures. A team approach is necessary to introduce new operations to day surgery to minimise surgical complications and produce guidelines for optimal management. The principles guiding surgical suitability are outlined in Box 34.1 .

Emergency surgery is also moving into the day surgery arena. Designated lists for abscesses or minor hand surgery are produced where patients are discharged after initial presentation but rapidly return for scheduled surgery. Other pathways are evolving for acute cholecystitis treated with day surgery laparoscopic cholecystectomy and for patients with uncomplicated laparoscopic appendectomy to be allowed home on the same day as their surgery.

General anaesthesia

Facilities for anaesthesia should be equivalent to those for inpatient anaesthesia, with standard monitoring and equipment available and the same trained anaesthetic assistance and recovery care available for any general anaesthetic, regional technique or sedation performed.

Anaesthetic agents for general anaesthesia should have rapid onset and offset for clear-headed emergence, with minimal drowsiness, nausea, vomiting or dizziness in the postoperative period. The aim is to get back to street fitness for home discharge.

Analgesia

Multimodal approaches are widely advocated for day surgery to achieve good analgesia for discharge and minimise the use of long-acting opioids. Use of multiple non-opioid drugs with diverse modes of action, including NSAIDs, paracetamol and local anaesthetics, make this possible.