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DAY CARE MEDICINE SURGERY

An Overview in Day Care Cosmetic Surgery
Viraj S Tambwekar, Suresh R Tambwekar, Kumkum Khadalia, Rustom P Ginwala
Day care surgery, office based surgery, ambulatory surgical services... one gets to hear these terms more and more frequently in recent times. It makes one wonder what this is all about and how safe is it for our patients? Are patients really comfortable with this format of surgical care?

This article is a brief overview on the principles that guide clinicians to undertake day care surgery, and its efficacy for both, the patient, as well as the surgeon.

INTRODUCTION
Day care surgery typically restricts itself to surgical procedures, which when performed, would allow patients to return home comfortably in the evening of the same day. This practice has been popular with surgeons for some time now and the earliest references date back to the post world war II days where rhinoplasties were performed as day care procedures.

Day care surgery will be popular, not only with insurance companies, but, also with the government as it is very cost effective; the overhead costs are much less in comparison to regular hospitalization. So much so, that in some countries the government provides incentives to patients and doctors who choose this system of surgical care.
The patient also benefits, as the overall cost is less (more so in aesthetic procedures not covered by insurance) and surgery is not delayed due to unavailability of hospital beds.
The surgeon also benefits, as he is able to attend to his regular office work in the time taken to prepare the operating room for the next patient.

There is a large plethora of procedures that can be performed as day care procedures and all of these should be considered in the light of the facilities required, patient selection and procedure selection.

FACILITIES
At present, in our country, we do not have a body that dictates guidelines, accredits centres and guides inspectors to accredit centres where day care surgery can be safely performed, as do certain western countries. However, with the formation of ‘The Indian Association of Day Care Surgeons’, we can hope to see some guidelines laid down to ensure patient safety, by addressing areas such as patient care, facilities, safety, personnel, quality assurance, and administrative documentation, amongst other things.

Day care plastic surgery can be performed in the surgeon’s office, office surgical suite, a hospital operating room, a hospital day care centre, or a multi-specialty day care centre. The emphasis is of course, on patient safety and adequate infrastructure to deal with any complications that may arise due to the procedure or anaesthesia.

Needless to say, adequate patient monitoring devices, ventilators, defibrillator, oxygen are a must. It is prudent to see to it that there is a facility close by to admit, observe and manage any patient if the need arises. It is equally important to have a well-trained nurse and a qualified assistant who can aid the surgeon in the operating room and subsequently take care of the patients in the recovery bay. It will be a great advantage if supporting services like X-rays, frozen-section, arterial blood gas analysis, etc., are available on site if required.

PATIENTSELECTION
Patients whose fitness levels satisfy ASA I / II categories, those less than 60 years of age, those who reside close by, and those who will be staying with responsible relatives after surgery are patients who can be taken up for day care procedures safely.

Day care surgery is definitely contraindicated in those patients whose fitness levels are ASA III or above and those who have serious complicating systemic diseases relating to cardiac, renal, and hepatic function, as also those who will require blood transfusion during and / or after surgery.

PATIENTPREPARATION
Pre-surgical consultation with a physician and anaesthesiologist is desirable to obtain fitness for surgery.
Pre-operative planning should include a detailed history, clinical exam and necessary lab tests and imaging. The patient must be explained and educated regarding pre-operative, intra-operative and post-operative behaviour and care. Details of any implants, splints, casts and supporting garments must also be discussed.

A mention must be made regarding pre, intra, and post-operative photography, skin marking and infiltration and consent obtained.

A special consent for day care surgery should always be obtained.
The patient must be instructed about showering, shampooing, shaving, facials, clean-ups, clothing, driving to and from surgery and the necessity of having an adult accompanying him / her.
Necessary pre-medication and anaesthesia (especially analgesic suppositories) along with antibiotics (if used), should also be discussed.

PROCEDURES
Plastic surgery is an all-encompassing field of expertise and multiple problems are treated by plastic surgeons, so much so that there is an overlap with many other specialties. Thus, to enlist the various procedures that can be performed by a plastic surgeon, as day care procedures are endless and it is beyond the scope of this article to list them all. A brief guide, if adhered to would find most plastic surgeons with satisfied and happy patients, and zero stress.
The duration of surgery should be such that the patient should be able to leave for home the same evening between five and eight pm. The rule of the thumb is ‘x’ hours of surgery needs ‘x’ hours of recovery.

On discharge, the patient should be fit to be transported home, cared for by an untrained adult and should not require any monitoring, intra-venous fluid administration or frequent dressing changes due to soakage etc.
Oral analgesia should be sufficient to alleviate any pain that the patient may experience.

Patients should be able to use the toilet comfortably on returning home, and not require any professional help for the same.

A plastic surgeon should be able to carry out any post-operative management in his office on an out patient basis.
Procedures can roughly be divided into emergencies and scheduled surgeries. Emergencies can range from suturing of minor cuts to procedures like tendon repairs and the reduction and fixation of various fractures of the facial skeleton.
Scheduled surgeries are usually aesthetic procedures such as rhinoplasties, body contouring, face-lifts, blepharoplasties, abdominoplasties, breast augmentations, hair transplant, etc. Also, some complex reconstructive procedures such as cleft lip and palate surgery, tendon transfers for hand function in cases of nerve injury/ dysfunction amongst others can also be performed.

Some procedures are gaining popularity as office based surgery especially with the advent of lasers, Botox, collagen fillers, and micro-dermabrasion. Facial rejuvenation procedures have now got an altogether different meaning with a combination of the above procedures being used separately and in conjunction with face-lifts and / or blepharoplasties.

CONCLUSION
Day care plastic surgery has its detractors and doubters, people who say that it is risky, however a well planned and organized set-up under the leadership of a well-trained plastic surgeon who chooses his patients and procedures judiciously, has proved to be beneficial to the patient, plastic surgeon and the insurance companies / government. It is win-win situations all the way, adopt it and experience its benefits.

REFERENCES
1. Ronald E. Iverson and the ASPS task force on patient safety in office-based surgery. Patient Safety in office-based surgery facilities: I. Procedures in an office-based surgery setting. Plastic and Reconstructive Surgery Oct. 2002; 110(5) : 1337-45.
2. Ronald E. Iverson and The ASPS task force on patient safety in office-based surgery. Patient safety in office-based surgery facilities: II. Patient selection. Plastic and Reconstructive Surgery Dec. 2002; 110(5) : 1337-45.
3. William C Trier, Gustavo A Colon, David A Gilbert, Ray A Elliot, Edward S Truppman, Richard H Walden. Chapter 16 Plastic and Reconstructive Surgery. In Davis JE editor. Major Ambulatory Surgery. Ist edition. 1986; 333-66.

Interventional Pain Management (Ivpm) : A Day Care Procedure
DK Baheti
INTRODUCTION
IVPM (i.e. neural blockade, ablative procedure, electric stimulation, epiduroscopy etc.), although invasive, remains an important modality in management of acute and chronic pain. There have been many advances in understanding its usefulness, and intervention at right time, in selective patients, produces excellent results.
ADVANTAGES OF IVPM AS DAY CARE PROCEDURE
• It produces immediate pain relief.
• It can be performed with ease and with minimum equipment.
• Adequate duration of pain relief obtained.
• Minimum or no hospitalization is required.
• Procedure can be repeated.
• Suitable in aged and debilitated patients.
• Reduces health care cost.
ACUTE PAIN CONDITIONS
Postoperative Pain
Infiltration block - Infiltration of local anaesthetic agent such as Inj. Sensorcaine 0.25% or Inj. Lignocaine 1% in and around the surgical incision provides pain relief for 1-3 hours.
Regional analgesia - Intrathecal, Epidural (caudal, lumbar) for lower abdominal surgeries such as inguinal hernia, haemorrhoidectomy, urological procedures, minor gynaecological procedures,
= Intercostals- chest tube insertions,
= Brachial plexus block- reduction of fractures.
ChronicPain
The modalities can be classified as follows:
• Neural Blockade (Nerve Block).
• Electric Stimulation.
• Spinal Endoscopy / Epiduroscopy.
• Ablative Procedures.
• Miscellaneous.

NeuralBlockade
A procedure room should be equipped with monitoring of pulse, NIBP, SaO2, and the resuscitation equipment and emergency drug trolley and C-arm fluoroscopy machine is mandatory to perform any interventional pain management procedure. A stand by anaesthesiologist is a must.
Following blocks can be performed either with local anaesthetic agent or neurolytic agent depending upon the pain problem.

1. Peripheral Blockade- The para vertebral and subarachnoid blocks are commonly done; especially upper intercostal nerve blocks are technically difficult to perform. However, regeneration of peripheral nerves is sometimes associated with neuritis or neuroma formation.

2. Cranial Nerve Block of Trigeminal and Glossopharyngeal nerves provide excellent pain relief in malignancy of head and neck.

3. Sympathetic Block - It can be of diagnostic, prognostic and therapeutic purpose.
Coeliac plexus block (NCPB) provides excellent pain relief in upper abdominal malignancy patients. Infiltration of 50% Alcohol 40-50 ml around coeliac plexus produces excellent pain relief.

Stellate or Cervico- thoracic ganglion is very useful in Chronic Regional Pain Syndrome (CRPS), peripheral vascular disease or ischaemic limb pain of upper extremities. Inj. Alcohol 100% 8-10 ml or Inj. Phenol 6% 10 ml around Stellate
ganglion produces good pain relief.

Lumbar sympathetic chain L1 to 5 with Inj. Phenol 10% 10-15 ml or Inj. Alcohol 100% 10-15 ml produces excellent pain relief in peripheral vascular diseases such as Burgers disease.

4. Epidural (cervical, lumbar, caudal):

Non neurolytic block- A combination of 0.125% sensorcaine 10-15 ml + Inj. Hylaluronidase 500 to 1000 I.U. + Inj. Depomedrol 80 mg is very useful in low backache, radiculopathy and post laminectomy patients.
Subarachnoid and Epidural block -Neurolytic block- is useful in malignancy of lower extremities, pelvic, vaginal and rectal origin. The position of the patient is crucial while using alcohol in the affected area it should be directed upwards. Whereas, with phenol, being hyper baric, the affected part should be kept down, so the phenol will gravitate along the
nerve roots.

The dose per dermatome is Inj. alcohol 1ml and Inj. Phenol 1 ml is sufficient.
Saddle block - Inj. phenol 5% 3-6 ml is injected through lumbar puncture in a modified sitting position tilted by 45 degrees posteriorly, for 15-30 minutes. This produces good pain relief in perineal and pelvic malignancies.
5. Superior Hypogastric Block and ganglion of Imus block - Intractable pelvic pain syndrome from rectum, vagina, cervix poses challenge to pain physician. The neurolytic block of superior hypogastric plexus with Inj. Phenol 5% 10 - 15 ml or Inj. Absoulte alcohol 8-10 ml produces excellent pain relief.

ImplantableDevice
It is used for continuous intrathecal drug infusion, which blocks pain by administering small doses of morphine directly in to the spinal cord. The advantages are: smaller dose, lesser side effects and greater pain relief. It is used in patients with severe and chronic pain in broad areas of the body, either from cancer or other cause.

Once the implantation of the device is over the titration of dosage can be done on out patient basis. The top up of the drug is done as day care procedure.

ElectricalStimulation
Spinal Cord Stimulation (SCS) : SCS stimulates the spinal cord with tiny electrical signals to interfere with the transmission of pain signals to the brain, thus reducing the sensation of pain. The affected area feels gentle tingling. SCS is a reversible procedure that does not damage the spinal cord or nerves.

SCS is an effective modality in relief of pain in peripheral vascular diseases; post laminectomy pain and neuropathic tic pain especially in diabetic neuropathy.

Brain Stimulation : The facility of stereotaxic procedure along with the trained, experienced medical team is mandatory to perform this specialized technique. Intracerebral stimulation can be of sensory thalamic stimulation and periaqueductal periventricular stimulation. Some forms of naturopathic pain of supraspinal aetiology can be treated by sensory thalamic stimulation.

Epiduroscopy
The Epiduroscopy helps in visualization and exact location of pathology in post laminectomy pain or failed back syndrome patients. The procedure is done in operating room and under fluoroscopic control. The presence of anaesthesiologist is necessary to provide light sedation and monitoring of vital signs during the procedure
The comparison of pre and post procedure epidurogram will confirm the extent and success of adhesiolysis. The degree of pain relief confirmed by patient also acts a guide of adequate adhesiolysis.

At the end of the epiduroscopy Inj. Depomedrol 80 mg along with 0.5% Lignocaine 20-40 ml plus normal saline 25 ml is injected. A total of 40-50 ml is usually adequate to cause volumetric adhesiolysis.

Epiduroscopy is effective in the treatment of failed back syndrome or post lamincetomy pain and radicular pain.

RadioFrequencyCoagulation (RFC)
The neurolysis is produced by coagulation with the help of controlled heat generated by Radiotome. RFC is being used in treatment for trigeminal neuralgia, coeliac plexus block, para vertebral nerve blocks and cervical plexus block.
Laser Discectomy : The application of laser to perform discectomy is definitely a new procedure. Although laser has another uses such as to treat trigger points.

Laser probe is passed through spinal needle in to the disc, and disc is dissolved with the help of laser under fluoroscopic control. This procedure is done under local anaesthesia and as one-day surgery procedure.

REFERENCES
1. Textbook of Pain- by Melzack and Wall- Third edition. 2000.
2. Pain-1999- An updated review-IASP Press. 1999.


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