Bombay Hospital Journal EDITOR'S CHOICEContentsHomeArchivesSearchBooksFeedback

DAY CARE MEDICINE SURGERY

Day Care’ Comes of Age!

L H Hiranandani

A doctor friend of mine recently told me that he has opened a Day Care Centre. I was very excited to hear the news, not so much because it was something new, but because it was something I always felt the country needed. I saw the Centre and was highly impressed to see the state-of-the-art facilities with which it was laced. With mounting pressure on existing infrastructure in hospitals, especially in cities like Mumbai, the concept of Day Care Centre is fast gaining popularity. The practice of keeping a patient in hospital for post-operative care may now really become a thing of the past in case of a majority of operations.

As a practising ENT surgeon in Mumbai for the past 60 years, I am gladdened by this development. More so because it is beneficial to both, hospitals and patients: the hospitals, because they get more patients; and the patients, because the bill for stay in hospital is reduced drastically.

This is indeed a dream coming true for me. I had realized the importance of Day Care long before the concept actually arrived, to be precise in 1948, and always felt that we need more of such centres in India. With pardonable pride I can claim myself to be the pioneer of Day Care at least in the great city of Mumbai, if not in India.

I had worked as Registrar at KEM for two years from 1942 and had gained tremendous experience in ENT operations. The year 1947 was perhaps the most eventful year in my life. After acquiring the prestigious FRCS, I became an Honorary at Nair Hospital at the age of 30. In the same year, I started my private practice at a very small, 6 x 4 feet room in Dadar. A year later, in 1948, I moved to Amerchand Mansion on Madam Cama Road, in a rented place where I had to share my consulting room with a senior doctor. This was a single large room, divided into two, a small sitting room for patients and a relatively large consulting room, which was available to me for two hours, from 5 to 7 p.m.

I had already started receiving patients for surgery. Tonsillectomy was the commonest operation. But the main problem was to find a place to operate. I had an English lady as my secretary, Mrs Burbury, who doubled up as nurse. Her husband was Managing Director of Syncindia Airlines. Although not a trained nurse, she was very intelligent and helpful. When I discussed the idea of operating in the clinic with her, she assured me of all help. She came to Nair Hospital, saw me operate and learnt about the basics of nursing. She then told me that now we must start operating in the consulting room itself.

Mrs Burbury was living in a second floor flat in the same building. She said that she would keep the autoclave with her and also sterilize the clothes in her house. During my stay in London for the FRCS, I had bought the best of surgical instruments from the famous shop: May and Philips, on credit. These included one water sterilizer in the room. One mobile operation table was purchased. The sitting room for patients became my operation theatre. Soon, an operation was fixed. The first operation was done at 2’0 clock in the afternoon and the patient was discharged at 4’0 clock. Anaesthesia was administered in a crude form using ether and chloroform. Even though I had performed the operation with utmost courage, I was scared to think what would I do if anything went wrong with the patient. Post-operation bleeding was common in tonsil and nose operations in those days. After leaving the consulting room, I straightaway went to Vile Parle to see the patient in his house. My God, what a relief it was when I saw the patient laughing with his relatives. The relatives thanked me profusely and expressed their gratitude for discharging the patient within two hours. This was really my first brush (or should I say scissor!) with Day Care. Thus, Day Care was started out of absolute necessity, as there was no space for me to keep the patients.

Encouraged by the feel good sentiment it generated among patients and their relatives, I continued the practice of visiting every patient’s house after operation to see if he was doing well, for several years thereafter. A simple gesture like this from me created good impression about me among the patients. I performed 3 to 4 operations a day. After each operation, I used to wait for half an hour before taking up the next patient. By the time, the second operation was over; the first patient would recoup and was sent home. No overnight stay and early discharge from hospital would save a patient’s precious time and money. Soon, people began to consider me as a great doctor. My reputation grew and practice increased.

I didn’t face a single problem in following this practice of Day Care. I was alive to the problem of post-operation bleeding, but fortunately, and I should thank God for that, among the hundreds of patients I operated, bleeding occurred in only 4 cases. Not a single patient died in my operation theatre.
Doctors in far off suburban places like Thane, Bhiwandi, Borivali, etc., who came to know of my successful ‘Day Care’ story, approached me with requests to visit their place on Sundays and holidays to perform tonsil operations. I operated on patients in Thane on a wooden bench outside a tea stall! Dr GS Amberdekar, an anaesthetist, doubled up as my nurse for the operation. Sunlight made for the necessary light in the operation ‘theatre’. These were Day Care centres born out of absolute necessity.

I followed this practice at Nair, Seth Atmasingh Municipal ENT Hospital and Bombay Hospital. The speed with which I performed operations was astonishing. Once, on a single day, I had performed 35 tonsillectomies! These operations resulted in more availability of patients for these hospitals, as waiting period for such operations was brought down to nil. In those days, in England, where health service is nationalized, waiting period for tonsillectomy was 2 years and patients had to suffer much of pain.

MODERN PERSPECTIVE
The Day Care Surgery is now gaining the attention it deserves. With hospitals facing perennial shortage of beds and private hospital charges going beyond the reach of even the upper middle class, I think the Day Care system will come to stay, mostly because of its affordability. The system is gaining popularity in India, as it has in Europe and America.

Day Care Centre could prove to be a boon for ENT patients, save those with Head and Neck disorder. Almost 95% of ENT cases can be operated at Day Care Centres. This has become possible because of better anaesthesia and good anti-biotics. In the past, infections were very common in absence of good anti-biotics and many ENT diseases required surgical procedures, which in turn needed hospitalization for a long period. Also, ear infections calling for extensive mastoid surgery have come down due to tympanoplasty. Likewise, nose operations that needed extensive surgical intervention have become lot easier, thanks to improved techniques and arrival of endoscopic nasal surgery. Minimum surgical intervention and use of microscope have not only made Day Care possible, but also improved the cure rate.

The Medical Council of India has taken cognizance of this development of Day Care and has brought down the mandatory requirement of 30 beds for the post-graduate ENT course to 15. This was a remarkable achievement.

POINT OF CAUTION
One thing needs to be borne in mind and it is that day care does not mean less care. In fact day care calls for all the more care, precision, planning and ability to take quick decisions. Even today, I do not admit patients overnight, without properly assessing the case and the need for operation.

Existing laws have made admitting patients for day care operations a risky proposition for surgeons. Doctors now come within the purview of consumer courts and can be sued even for a small negligence. Greater care needs to be exercised before admitting a patient for Day Care operations.Existing laws have made admitting patients for day care operations a risky proposition for surgeons. Doctors now come within the purview of consumer courts and can be sued even for a small negligence. Greater care needs to be exercised before admitting a patient for Day Care operations.

Day Care Surgery-Socioeconomic Need of The Hour
RD Bapat, Chetan V Kantharia
The concept of day care surgery is not new to us. The earliest reference for day care surgery was as early as the beginning of nineteenth century by James McNicoll and later in the year 1912, when Ralphwaters from usa described “The Down-town anaesthesia clinic”, at Sioux City, Iowa, usa, where he gave anaesthesia for minor outpatient surgery. However over the next two decades it lost its momentum.

advance in knowledge, improvement in the skills and increase in the technological support, has compelled us to reassess the age-old concept of “Pre-surgery” hospitalisation and “Post-operative” immobilisation, paving the way for resurgence of “Day Care Surgery”.

change in concepts from “immobilisation” to “early mobilisation”, practice of safe anaesthesia, prophylactic and per operative use of antibiotics, and above all effective and meaningful communication are responsible for the change in scenario. presently only about 20% of surgical procedures are done as “Day Care Surgeries” in our country.

in the present clinical scenario surgeries can be classified into:

1. procedures requiring day care management.
2. procedures requiring in-hospital surgical management.
3. Procedures requiring intensive management.

Most of the surgeries we perform today fall in the first category. besides surgeries in the second category too, do not require more than 48-72 hours of hospitalisation and can be managed by home visits made by efficient trained para-medical personnel. this fact is very well documented in the “Guidelines for the day care surgery” provided by the Royal College of Surgeons of England (1992), which states that: “Day care surgery is now considered the best option for 50% of all patients undergoing elective surgical procedure”.

A very important reason for the resurgence in day care surgery is recognition of the three factors by the health care providers and managers. These factors are:
- Cost containment.
- Decompression of the busy hospital beds.
- Delivery of “quality care”.
Cost containment
The audit commission in uk in19901 and Heath et al 2 have documented that day care surgery has much lower average costs than equivalent in-patient surgery. We too have published a report, that, even in a civil hospital set up of ours, practice of day care surgery helps to save the civic authorities a sum of Rupees12,50,00,000/- annually. 3 Decompression of Busy Hospital Beds At present 15% of bed occupancy is taken up by minor cases, which can be otherwise managed on day care surgery basis. This results in refusal of admission to patients needing urgent medical attention, overcrowding of the wards leading to cross infection and nosocomial infection.

Delivery of Quality Care

With the decrease in number of hospital admissions there is a corresponding decrease in the doctor / nurse-patient ratio. This leads to increased attention towards the patient resulting in delivery of quality care.

Day care surgery is a quality care that is cost effective but has not yet reached its full potential. The percentage of patients undergoing day care surgery in our country remains a dismal 20%, as compared to 70% in the usa, and 65% in uk (1998-1999), has risen from 34% (1989-1990).4 The reason for this is poor patient selection and lack of proper information to the patient.

Patient selection is not simply a matter of choosing patients with conditions that may be treated on a day basis, but also involves sifting out those patients who are unsuitable for medical and social reasons. The criteria of medical exclusions and social requirements put forward by Tuverskey5 in 1993, is as given in Table 1.

Patient information
Comprehensive and well-presented information using lay terminologies for patients and their relatives is essential for the success of day surgery. Day patients, unlike in-patients, do not have ready access pre-operatively and post-operatively to health care professionals to answer their questions and deal with their worries. As suggested by Baskerville et al6 , the information given to patients should commence with a brief description of the condition for which they are being treated and the procedure being undertaken. This is followed by instruction as what patients must do before coming to the unit, what will happen during their stay in the unit, the post-operative analgesic regimen, what they should do on entering home and what is expected in the days following their operation.

Finally, patients need advice on when they can return to various activities such as bathing and work. Perhaps the most important information that must be given is that, concerning problems that might arise following surgery at home and how to deal with those. These will include advice on self-treatment and when to seek professional help. It is very essential that the information patients are given is honest. A patient given different advice by different doctor and nurse becomes worried and loses confidence. Thus all surgeons working in a unit must agree on standard advice to be given to patients for each of the procedures that are undertaken.

Further increase in use of day case surgery, will require the combined efforts of anaesthetists, surgeons and nurses working together, developing and refining their skills and techniques for the benefit of the day surgery patient. Day surgery is cost effective quality care that has not reached its full potential. However we see no reason why overall day surgery should not approach 80% in the near future in our country.

REFERENCES
1. Royal College of Surgeons of England 1992. Commission on the provision of surgical services. Guidelines for Day care surgery revised edition. Rcs, London.
2. Heath pj, oqq tw, hall ca, brownlie gs. The cost of day care surgery. Health Trends 1990; 22 : 109-11.
3. Bapat RD, Cv kantharia, sr ranka et al. Day care surgery in a public hospital set up. Bombay hospital journal 2001, 249-252.
4. Jarret PEM. Day care surgery-an overview. European Journal of Anesthesiology 2001, 18 (suppl.23), 32-5.
5. Tuverskey rs. To be an outpatient or not to be - selecting the right patients for ambulatory surgery. Ambulatory Surgery 1993; 1: 5-14.
6. Baskerville pa, heddle rm, jarret pem. Preparation for surgery: Information for the patient. Practitioner 1985; 229: 677-8.

Our Experience of Day Case Laparoscopic Urological Procedures
DD Gaur
Day case surgery is now getting popular, as a result of improved surgical techniques, better postoperative pain management, better patient information and escalating hospitalization costs. We hereby, report the results of a retrospective study of the use of retroperitoneal laparoscopy for various urological procedures, where the patients were discharged from the hospital the same day or the early next day.

Of the 281 patients who underwent renal biopsy, varicocoelectomy, ureterolithotomy, renal cortical cyst decortication, pelvic lymphadenectomy, pyelolithotomy, nephropexy, Rovsing’s procedure, and simple nephrectomy using the retroperitoneal laparoscopic approach, 128 were discharged the same day or the next morning. None of them had any complications or required re-admission.

This is only a retrospective study and therefore, the figures do not reflect the actual number of patients operated on a day case basis. However, it provides enough proof that about half the patients can be discharged the same day by using the retroperitoneal laparoscopic approach.

Introduction
Though, minor urological surgical procedures are routinely being carried out as day case procedures, the feasibility of the same being carried out for the major or the supra-major procedures became apparent mainly due to the development and refinement of the endourological and laparoscopic techniques. Nevertheless, there were some other factors as well, which made it possible for this to happen to patients undergoing major and supra-major procedures. Improved surgical techniques, use of robots in urology, better postoperative pain management, better patient information and escalating hospitalization costs were also responsible for evolution of day case urological procedures.

Postoperative bleeding was the major deterrent in sending patients home the same day following endoscopic urological procedures. The development in electrosurgical and laser technology helped a lot in reducing the postoperative stay of patients undergoing transurethral resection of prostate and bladder tumours. With the use of holmium laser, patients can be sent home a few hours after prostatectomy. Larner et al have recently reported a mean hospital stay of 5 hours for patients undergoing laser prostatectomy.

1 However, even using a regular electro-surgical unit, transurethral resection of the prostate can be performed in day case surgery patients.

2 We have been pioneers in the field of urologic laparoscopy and have performed more than 500 laparoscopic urological procedures at the Bombay Hospital since 1991. We hereby, report the results of a retrospective study of the use of retroperitoneal laparoscopy for various urological procedures, where the patients were discharged from the hospital the same day or the early next day.

Material and methods
Retroperitoneal laparoscopic technique was used to assess the feasibility of reducing the hospital stay to less than 24 hours in patients undergoing some of the commonly performed urological procedures. A three-port access was used in most of these patients. A closed percutaneous 10 mm initial access was used for most patients and balloon dilatation of the retroperitoneal space was carried out in all patients. General anaesthesia was used in most patients and regional anaesthesia was used in only half a dozen patients.

The urological procedures performed using the retroperitoneal laparoscopic approach included renal biopsy, varicocoelectomy, ureterolithotomy, renal cyst decortication, pelvic lymphadenectomy, pyelolithotomy, nephropexy, Rovsing’s procedure and simple nephrectomy. A total of 281 patients were included in this study and the Table shows the distribution for the various procedures.

Results
Fourty two of the 48 renal biopsy patients, 25 of the 30 varicocoelectomies, 36 of the 100 ureterolithotomies, 6 of the 10 renal cyst decortications, 2 of the 5 pelvic lymphadenectomies, 4 of the 43 pyelolithotomies, 1 of the 5 nephropexies, 1 of the 2 Rovsings procedures and 11 of the 38 simple nephrectomies were discharged from the hospital the same day or the next morning. None of the patients developed any complication due to early discharge from the hospital and none of them required any re-admission. The bar diagram shows the percentage of the patients treated as day case procedures in the different categories.
All the patients were satisfied with the operative results. They were happy, as they did not require any parenteral analgesia or fluids after they were discharged. They had a greater psychological satisfaction as even for major procedures like pyelolithotomy and nephrectomy, they were discharged or promised to be discharged within 24 hours.

Table 1 showing break-up of day case laparoscopic urological procedures:

TABLE 1
Laparoscopic urological procedures

Total Day case

Renal biopsy 48 42
Varicocoelectomy 30 25
Cyst decortication 10 6
Rovsing’s procedure 2 1
Pelvic lymphadenectomy 5 2
Ureterolithotomy 100 36
Nephrectomy 38 11
Nephropexy 5 1
Pyelolithotomy 43 4

Total 281 128


Discussion
Laparoscopy has been established as a minimally invasive modality for the treatment of various urological disorders. Transperitoneal laparoscopy is more invasive compared to the retroperitoneal technique, as the latter does not transgress the peritoneal cavity. Therefore the incidence of complications like paralytic ileus, vascular and visceral damage are less by the retroperitoneal approach compared with the transperitoneal approach. Nevertheless, these are operator related and in experienced hands the complication rates are quite comparable by both the approaches.
Postoperative bleeding is one of the common complications in urology, which can delay the discharge of the patient from the hospital. Laser coagulation and ultrasound knife incision can be of great help during laparoscopic urologic surgery. In their absence, meticulous dissection and the use of electro-surgical units can solve the problem of bleeding during laparoscopy, as was used in all our patients. General anaesthesia, can sometimes also delay the discharge of the day case patients. Though, sedo-analgesia, midazolam and local anaesthesia can be used with advantage for non-laparoscopic urological procedures, they don’t have much role in laparoscopic surgery.

3,4 Day case surgery is fairly safe but patients may have to be re-admitted due to paralytic ileus, severe pain, bleeding or urinary retention. The re-admission rate recently reported by a large centre practising day case surgery was 9.3%.5,6 However, in our retrospective study there were no re-admissions.
Our present series show that almost half of the patients operated by the retroperitoneal laparoscopic approach could be discharged the same day or the early next day and there were no complications. The fact that all the procedures were performed using the extra-peritoneal approach shows that it is safer than the transperitoneal approach for day case surgery. However, they should be kept under surveillance of a trained nurse or a family physician for the next couple of days. This is important as any postoperative complication detected early can always be better managed.

We did not have any supra-major day case procedures performed laparoscopically. However, the review of the literature shows that laparoscopic adrenalectomy and even laparoscopic radical retropubic prostatectomy have been performed as day case surgical procedures.7,8
Bar diagram showing percentage of laparoscopic urological procedures performed as day case surgery (Fig. 1)
Conclusions

1. Day case laparoscopic urological surgery is good for patients as apart from saving the hospital cost they are also less apprehensive and have greater psychological satisfaction.
2. Retroperitoneal laparoscopy is comparatively less invasive for these patients, as it does not transgress the peritoneal cavity.
3. All day case patients should be under close surveillance of a trained nurse or a family physician for the next couple of days after their discharge.

References
1. Larner trg, agarwal d, costello aj. Day-case holmium laser enucleation of the prostate for gland volumes of < 60 ml: Early experience. Bju intl 2003; 91: 61-64.
2. Perera nd, nandasena ac. Early catheter removal after transurethral resection of the prostate. Ceylon med j 2002; 47 : 11-2.
3. Birch br, anson k, gelister j, parker c, miller ra. The role of midazolam and flumazenil in urology. Acta Anaesthesiol Scand Suppl 1990; 92 : 25-32.
4. Birch br, anson km, miller ra. Sedoanalgesia in urology: A safe, cost-effective alternative to general anaesthesia. A review of 1020 cases. Br J Urol 1990; 66 : 342-50.
5. Bain j, kelly h, snadden d, staines h. Day surgery in scotland: Patient satisfaction and outcomes. Qual Health Care 1999; 8 : 86-91.
6. Crew jp, turner kj, millar j, cranston dw. Is day case surgery in urology associated with high admission rates? Ann R Coll Surg Engl 1997; 79 : 416-9.
7. Gill is, hobart mg, schweizer d, bravo el. Outpatient adrenalectomy. J urol 2000; 163 : 717-20.
8. Menon m. Robotic radical retropubic prostatectomy. Bju intl 2003; 91 : 175.

Anaesthesia in Day Care Surgery
Paras S Jain, Sudarshan Somani
Day Care Surgery is growing worldwide at an exponential rate, progressing from the practice of performing simple procedures in a physician’s office to a broad spectrum of patient care in a freestanding ambulatory surgery centres. This rapid growth in ambulatory surgery is possible due to the changing role of the anaesthesiologist and development of new drugs. The anaesthesiologist is responsible for screening, evaluating, informing and preparing the patient both physically and psychologically for surgery.

Factors contributing to the popularity of Day Care Surgery:
1. Patient comfort and convenience
2. Cost consideration
3. Development of new drugs
4. Modification of anaesthetic techniques suitable to outpatient
5. Reduced risk of wound infection, deep vein thrombosis and pulmonary embolism and pneumonia
Types of surgical procedures, which can be performed on an outpatient basis
Many types of operations can be performed as Day Care Surgery including general surgical procedures, paediatric, ophthalmic, gynaecologic, orthopaedic, ENT, diagnostic and reconstructive procedures.

Criteria for preoperative screening in Day Care Surgery cases
It is common practice for relatively healthy ASA I and II patients to return home on the day of surgery, provided complications from surgery or anaesthesia do not arise. More controversial are geriatric and ASA III patients scheduled for Day Care Surgery. Well controlled ASA III patients are accepted on day care basis, but three important points must be kept in mind:
1. The degree to which the systemic disease is under control,
2. The complexity of the surgery, and
3. The level of postoperative care and availability of assistance at home.
Patients who do not have the resources to care for themselves should not be discharged home, if they meet discharge criteria.

Contraindications to Day Care Surgery
Medical contraindications
1. Unstable ASA physical status II or III patients
2. Morbidly obese with other systemic disease
3. Uncontrolled epilepsy
4. History of susceptibility to malignant hyperthermia
5. Patients on Mono Amine Oxidase Inhibitor (MAOI) treatment
6. Infant at risk
a. Premature infant less than 50 weeks post conceptual age
b. Infant with apnoeic episodes, difficulty with feeding or failure to thrive
c. History of respiratory distress syndrome
d. Bronchopulmonary dysplasia
Social contraindications
1. Patient refusal
2. Patient unwilling to comply with instructions
3. Lack of responsible person at home

Preoperative Laboratory Tests

A thorough history and physical examinations should be the guide for deciding which, if any Lab tests are necessary. The trend is to order fewer tests, basing such evaluations on strong anticipation of abnormal findings from the history and physical exam. Chronic medical conditions require a baseline evaluation. For example, diabetes require assessment of glucose level, and renal patients require: electrolyte profile, blood urea nitrogen, creatinine and haematocrit.
Preoperative medications for Day Care surgery Medications that patients must take for chronic conditions should be continued the morning of surgery and include beta-adrenergic blockers, angiotensin converting enzyme inhibitors, central acting antihypertensives, beta-agonists, anticonvulsants, H2 blockers, corticosteroids, bronchodilators and the other cardiac drugs, such as antianginal or anti-dysrhythmic agents.

Non-insulin dependant diabetics should be told not to take oral hypoglycaemic agents in the hope of preventing preoperative hypoglycaemia. Insulin dependant diabetics can hold morning insulin dose or take one half of the usual morning insulin dose depending on blood sugar levels.
Routine aspiration prophylaxis is recommended for high-risk patients and obstetrics and may include a nonparticulate antacid, an H2 blocker, and metoclopramide.

The other indications for preoperative medications include anxiolysis, sedation (especially for paediatric patients), analgesia, amnesia, vagolysis.
Children In children oral Midazolam (0.5 - 0.75 mg/kg) provides good sedation. Intranasal and rectal Midazolam are also highly effective routes of administration.
Non-injection options for paediatric premedication include oral, rectal or nasally administrated Midazolam (0.5 -1.0 mg/kg1), rectal Ketamine etc. Nasal Midazolam avoids the unpleasant taste, but can cause a burning sensation that children dislike. The bitter taste of oral Midazolam can be disguised with a small amount of fruit drink and administer in a cup or syringed in increments into the mouth.

Adults
Benzodiazepines (BDZ): Midazolam’s rapid onset of action and water solubility offer a number of advantages for outpatients. Midazolam may be given intramuscularly 30 to 60 minutes before surgery or intravenously in the induction room. Midazolam does not delay recovery after ambulatory surgery because of its relatively short elimination half-life. Midazolam (2 mg) given intravenously immediately prior to a propofol infusion reduces anxiety and increases amnesia without prolonging the recovery room stay.

Opioid analgesics
The routine use of opioid analgesics for premedication has been criticized unless the patient is experiencing acute or chronic pain. Use of traditional opioid premedicant combinations (e.g. pethidine-atropine) may increase the incidence of post operative nausea and vomiting.

The use of small dose of the potent opioid analgesics (e.g. fentanyl 1-3 mg/kg, sufentanil (0.1-0.3 mg/kg ) prior to induction of general anaesthesia reduces the intravenous anaesthetic requirement and may shorten early recovery times. However, the use of these potent, rapid acting opioids increases the incidence of post operative nausea and vomiting.

Criteria for preoperative fasting in Day Care Surgery
Since prolonged fasting does not guarantee an empty stomach at the time of induction, several investigators have questioned the value of even a 4-5 hour fast prior to elective surgery. About 50% of outpatient complains of hunger or thirst following an overnight fast. This may increase preoperative anxiety.
The length of fasting has no effects, gastric fluids volume and pH were similar when intervals of less than 3 hours, 3-4.9 hours , 5-8 hours and nil by mouth after midnight were compared. Similarly, in children, preoperative administration of apple juice (3 ml/kg) decreased gastric volume, thirst and hunger furthermore, administration of ranitidine (2 mg/kg) with orange juice (5 mg/kg) 2-3 hours preoperatively resulted in a decrease in both volume and acidity of gastric contents. Thus the arbitrary restriction of fluids after midnight prior to an elective operation appears to be unwarranted.

Only those patients suspected, or known, to be at risk or delayed gastric emptying require a prolonged fast which otherwise causes discomfort to outpatients without any apparent benefit.

Prevention of aspiration
To minimise the probability of aspiration, the airway should not be manipulated while the central reflux pathways are functioning (i.e. the patient is not adequately anaesthetised and /or neuromuscular paralysis is not present). The volume of gastric contents can be decreased by fasting and medications (H2 blockers). The pH of gastric acid can be decreased with antacids and H2 receptor antagonists. Unfortunately many anaesthetists feel compelled to use these drugs as routine premedicants because of prevailing environment for malpractice litigation. However, in patient with predisposing factors for pulmonary aspiration (i.e. pregnancy, scleroderma, hiatal hernia, obesity) these medications may be indicated.

The H2-receptor antagonists cimetidine and ranitidine are both effective in decreasing gastric acid secretion. Patients who received coffee or orange juice with oral ranitidine 2-3 hours prior to induction of anaesthesia had lower residual gastric volumes, higher pH.

Prevention of nausea and emesis
Factors that increase the incidence of postoperative nausea and vomiting include:
1. The patient’s body habitus and medical condition,
2. The type of surgery performed (laparoscopy, orchidopexy, strabismus surgery)
3. Assisted ventilation using a face mask,
4. Anaesthetic and analgesic medications (e.g. fentanyl, etomidate, isoflurane and nitrous oxide), and postoperative hypotension.
This can delay discharge and may result in unplanned hospitalisation. It has been suggested that the anaesthetic agent, the type of surgery and opioid analgesics can influence postoperative nausea and vomiting.

In certain patient population Ondansetron seems more efficacious alone than a combination of several other anti-emetics.
Metoclopramide (‘M’) and Domperidone are gastrokinetic agents that facilitate gastric and bowel motility, ‘M’ seem to be especially effective in prevention of nausea and vomiting in patients who received opioid based anaesthetic. The combination of ‘M’ 10-20 mg IV and low dose droperidol (0.5-1mg IV) appears to be more effective than droperidol alone.

Anticholinergic drug (glycopyrolate, atropine) have been used because of their anti-sialogogue and vagolytic action. Central anticholinergic action may produce antiemetic activity as seen with atropine and scopolamine.
Ondansetron, Granisetron are highly selective 5HT3 right antagonists and work by blocking both central and peripheral 5HT3 receptor. Ondansetron is highly effective alone or in combination with Ranitidine, small dose (1 mg) also appear to be effective in nausea and vomiting prophylaxis. However the costs of these drugs limits against their routine use.

Unless sedation is desirable, antihistaminic drug like prochlorperazine, perphenazine should not be used routinely in outpatients. BZD like lorazepam, is effective against chemotherapy induced nausea and vomiting.

Non-pharmacological preparation
The sense of control has been shown to reduce psychological stress. Information in the form of booklets, audiovisual information and relaxation training has been used successfully in the reduction of anxiety and post operation pain.

Monitoring the Day Care Surgery patient
The American Society of Anaesthesiologist standards for basic intra-operative monitoring do not distinguish between inpatient or outpatient procedures and consist of appropriate monitoring of oxygenation, circulation, ventilation and body temperature. Advances in quantitative monitoring such as pulse oximetry and capnography are advantageous to the anaesthesia practitioner to reduce the often-quoted large percentage of critical anaesthesia incidents that are airway related.

Standard intra-operative monitoring equipment for outpatient operations includes an electrocardiogram, a non-invasive blood pressure machine, a pulse oximeter and a capnograph. The major risk factor, hypoxaemia during outpatient general anaesthesia include obesity, age greater than 35 years, lithotomy position, manual ventilation and light anaesthesia. Temperature monitoring is useful for young adults, adolescents and children undergoing general anaesthesia with known triggering agents of malignant hyperthermia.

Anaesthesia Techniques for Day Care Surgery
Quality, safety, efficiency and the cost of drugs and equipment are important consideration in choosing anaesthesia technique. The ideal outpatient anaesthetic should have a rapid and smooth onset of anaesthesia; produce intra-operative amnesia and analgesia, good surgical condition with a short recovery period and no side effects.

General anaesthesia (GA) - The ability to deliver a safe and cost-effective GA with minimal side effect and rapid recovery is critical in a busy outpatient surgery unit.

Procedures lasting < 15 min. do not require an IV line. However for longer cases or situations in which patient has been without oral intake for an excessive period of time (> 15 hrs) an IV line is useful to maintain fluid balance and glucose homoeostasis.

a. Airway Management - Endotracheal Intubation (ETI) results in a higher incidence of airway related complaints (sore throat, hoarseness) and a greater morbidity after surgery. Thus ETI is not needed nor desirable for all outpatients GA.

The Laryngeal Mask Airway (LMA) can be used instead of an ET tube or facemask. Some anaesthetists have suggested that success in easily maintaining an adequate airway makes LMA superior to face mask. But LMA should not be used in patients with high risk of aspiration.
b. Intra-operative suggestion - Patients are exposed to suggestion of relaxation, well being comfortable feeling, lack of nausea , vomiting, pain and rapid recovery and ambulation played via a tape repeatedly throughout operation.

c. Anaesthetic Drugs - Induction of GA is accomplished by rapid acting IV anaesthetic. Propofol has replaced barbiturates and BZD. For maintenance of anaesthesia, a volatile agent in combination with Nitrous Oxide is most popular.

Propofol is preferable drug due to its shorter half-life and early recovery. Followed by Ketamine (side effect of psychominetic which can be reduced by Midazolam) and Etomidate (disadvantage of pain at injection, nausea and vomiting, myoclonic movement).

Inhalation agents - Sevoflurane / Desflurane / Isoflurane in order of their efficacy are preferably inhalation agent for maintenance of anaesthesia.
Analgesics - Opioids can reduce the requirement for sedative - hypnotic drugs thereby shortening recovery time. Potent, rapid and shorter acting narcotic analgesics (e.g. fentanyl, sufentanil and alfentanil) can effectively attenuate cardio-respiratory stimulatory response to laryngoscopy and intubation.
Muscle relaxants - Many Day care Procedures do not require muscle relaxants. With the availability of shorter acting non depolarising muscle relaxants (atracurium, mivacurium), prompt reversal of NM Blockade can be achieved after brief surgical procedure.

Paediatric anaesthetic consideration
In unruly, frightened or mentally retarded children, methohexital can be administered (20-30 mg / kg rectally) prior to taking patient in OT.
Rectal Etomidate (6 mg/kg) or Ketamine (50 mg/kg) can also produce a rapid onset of hypnosis (<4 min.) without cardio-respiratory depression. IM Ketamine (2-6 mg/kg) can also be very useful. In children, an inhaled induction of anaesthesia is a useful alternative.

Regional Anaesthesia: In addition to limiting the anaesthetised area to surgical site, common side effects of GA can be avoided; risks of aspiration pneumonitis, and side effects of tracheal intubations, patient recovery time decreases and analgesia is provided in early post-operative period.
a. Epidural and Spinal:- less widely used in Day Care setting but can be used for out-patient, lower extremity, urology and herniorraphy procedures.
b. IVRA (Intra Venous Regional Anaesthesia):- this procedure can be used either for upper or lower extremity.

c. Peripheral nerve blocks:- used for more prolonged surgeries of extremities.
Local Infiltration technique: This is the simplest and safest for Day Care. This method can reduce the cost. Local Anaesthesia (LA) supplementation will reduce incidence of pain in the recovery room. The use of topical LA techniques can also provide acceptable post operation analgesia for carefully selected procedures. A retrospective analysis revealed that patients receiving LA had significantly shorter recovery time. The injection of LA is often associated with significant discomfort, hence the use of IV sedation and analgesic drug during LA injection has been popularised.

Recovery and Discharge Criteria
Criteria for home readiness-
1. Stable vital signs for > 30 min
2. No new signs or symptoms after operation
3. No active bleeding or oozing
4. Minimal nausea or emesis for > 30 min
5. Intact neuro-circulatory function without evidence of swelling or impaired circulation after extremity surgery
6. Ability to void after cystoscopic examination
7. Orientation to person, time and place
8. Minimal Dizziness after changing clothes and sitting for > 10 min
9. Pain controllable with oral analgesics
10. A responsible escort for transport and at home
Postoperative complications
The most common early side effect is blurry vision, dizziness, nausea and vomiting, headache and weakness. Complications persisting for more than 24-28 hours include drowsiness, headache, sore throat, myalgias and weakness / fatigue.

Many institution require patients to drink fluids prior to discharge, forcing of oral fluids is often followed by nausea and vomiting.
Common surgically related problems necessitating admission to the hospital include intractable pain, excessive bleeding, surgical misadventures, errors in diagnosis and parenteral drug therapy. Pain is often associated with nausea and vomiting and the adequate treatment of pain (even with opioids) can reduce nausea and vomiting.

Infiltration with local anaesthetic during surgery may effectively decrease postoperative discomfort following inguinal hernia repair, circumcision, and tubal ligation. After discharge from the recovery room, most patients can be given oral pain medications (e.g. acetaminophen) if they have regained their appetites. Headache is a common postoperative problem and appears to be increased following administration of volatile anaesthetic agents.

Urinary retention can follow GA as well as spinal or epidural blockade. This is especially a problem in elderly man with prostatic hypertrophy. Sore throat and hoarseness are common complaints following ETI, but they can also occur after mask ventilation or regional anaesthesia with sedation.

Discharge criteria
The accurate assessment of the recovery of cognitive and psychomotor function is important in determining appropriate time for discharge after ambulatory surgery. Tests of cognitive function, such as processing (mental arithmetic, reaction time), integration (critical flicker fusion test), memory (digit span) and learning (word lists) have been used to assess recovery after outpatient anaesthesia
Pain control is an important factor in determining when a patient can be discharged from an outpatient facility. Prior to ambulation, patients should have normal perianal (S4-S5) sensation, the ability to plantar flex the foot, and proprioception of big toe.

Prior to leaving outpatient facility, patients should have their dressings checked and be given both verbal and written instructions regarding their postoperative care and should leave with a reliable responsible escort.

Summary
There is clearly much to learn regarding anaesthesia for ambulatory surgery. Increased evidence exists that arbitrary limits placed on the type of surgery, age of patient, duration of operation, pre-operation fasting period, and use of premedication may be unwarranted. Many controversies remain unresolved. The scope of ambulatory surgery and anaesthesia will not expand significantly unless the anaesthetist improves upon the post-operative pain management techniques in home environment. The availability of high-quality home health care services will be critically important in the future expansion of outpatient surgery practices.

• Successful anaesthetic management of patient undergoing outpatient surgery requires that the anaesthesiologist be actively involved in all aspects of management.
• The psychological evaluation and preparation of the patient and use of the pharmacological premedication when indicated will ensure a pleasant experience for all involved.
• The anaesthesiologist should choose a specific anaesthetic agent and techniques that is appropriate for each individual patient.
• Early ambulation and discharge are very desirable in outpatients.
• Long-acting drugs and techniques that are associated with excessive drowsiness or nausea and vomiting should not be used.
• Special attention should be paid to the analgesic requirements of the patient.
• Regional blocks should be used whenever possible to supplement general anaesthesia and to limit the need for narcotics during recovery.
• Specific criteria for discharge should ensure the safety and protection of the patient and staff.

Conclusion
In conclusion, the rational use of available combination of anaesthetic drugs will provide for a rapid and smooth, induction, excellent intra-operative condition and a rapid recovery with minimal side effect. The incidence of anaesthetic related side effect may be altered depending on the premedication, anaesthesia techniques, and skill of anaesthesiologist.

With the availability of more rapid and shorter acting anaesthetics, analgesics and muscle relaxants as well as improved techniques for administering these drugs; anaesthesia and pain management care provided to the expanding outpatient population will continue to improve in the future.

ReferenceS
1. Othersen HB, Jr.Clatworthy HW, Jr. Outpatient herniorraphy for infants. AM J Dis Children 1968; 116 : 78.
2. Fahy A, Marshall M. Postanaesthetic morbidity in outpatients. Br J Anaesth 1969; 41 : 433.
3. McLeanne GJ, Cooper R. The nature of perioperative anxiety Anaesthesia. 1990; 45 : 153.
4. Johnston M. Anxiety in surgical patients. Psycho Med 1980; 10 : 145.
5. Ghignone M, Quintin I, Duke PC et al. Effects of clonidine on narcotic requirements and haemodynamic responses during induction of fentanyl and endotracheal intubation. Anaesthesiology 1986; 64 : 36.
6. Rao TIK, Madhavareddy S, Chinthagada M. et al. Metoclopramide and Cimetidine to reduce Gastric pH and volume. Anaesthesia Analg 1984; 63: 1014.
7. Sengupta P, Skacel M, Planterin OM. Post-operative morbidity associated with the use of atracurium and vecuronium in Day case Laparoscopy. Eur. J. Asaesthesiology 1987; 4 : 93.
8. White PF. Pain management after day case surgery. Curr. Opin. Anaesthesia. 1988; 1 : 70.



To Section TOC
Sponsor-Dr.Reddy's Lab