DAY CARE ANESTHESIA

DR.V.SANKARASUBRAMANIAN INTRODUCTION: DAY CASE SURGERY OR AMBULATORY SURGERY PRACTICE HAS GROWN SUBSTANTIALLY OVER THE PAST TWO DECADES IN EUROPE AND U.S. BUT THE CONCEPT IS STILL IN PREMATURE STAGE WHEN IT COMES TO DEVELOPING COUNTRY LIKE US.APART FROM THE INSTITUTIONAL BACKUP,PATIENTS PREFERENCE AND SURGICAL EXPERTISE, ANESTHESIOLOGIST PLAY A VITAL ROLE IN PROMOTING AND RUNNING A SUCCESSFUL AMBULATORY SURGICAL UNIT. THE EVOLUTION OF SEPERATE SUB SPECIALITY, FELLOWSHIP PROGRAMMES IN UNIVERSITIES & SOCIETY FOR AMBULATORY ANESTHESIA IN DEVELOPED COUNTRIES REALLY SHOW THE PROMISING FUTURE FOR DAY CARE PROCEDURES. AS AN ANESTHETIST IT BECOMES VERY ESSENTIAL TO GET UPDATED IN THIS AREA. HISTORY: CRAWFORD LONG CAN BE CALLED AS THE FIRST AMBULATORY ANESTHETIST AS HE GAVE ETHER ANESTHESIA FOR REMOVING CYSTIC TUMOR ON NECK FOR THE PATIENT JAMES VENABLE ON MARCH30, 1842 BUT THE CREDIT GOES TO WALLACE REED WHO OPENED UP A SEPERATE DAY CARE UNIT IN 1970S.SINCE THEN AMBULATORY SURGERIES STARTED FLOURISHING AS A CONSEQUENCE TO SURGICAL AND ANESTHETIC ADVANCEMENTS. DEFINITION OF AMBULATORY SURGERY: IF A PATIENT SPENDS LESS THAN 4 HRS IN HOSPITAL OR ONE WHO MAY STAY OVERNIGHT BUT WHOSE TOTAL STAY IS LESS THAN 24 HRS. SELECTION CRITERIA FOR AMBULATORY SURGERIES: AS IT WAS FIRST INTRODUCED ,IT WAS MEANT ONLY FOR STRAIGHT FORWARD ASAI &II PATIENTS .BUT NOW SYSTEMIC DISEASES ARE NO LONGER A CONTRAINDICATION TO DAYCARE SURGERY.RISK OF COMPLICATIONS CAN BE REDUCED IF CO MORBIDITIES ARE STABILISED PRIOR TO ADMISSION.SO ASA III CAN ALSO BE TAKEN UP FOR AMBULATORY PROCEDURES. AGE: AGE IS NO LONGER CONSIDERED AS A RESTRAINT FOR AMBULATORY PROCEDURES. STUDIES SHOW THAT ELDERLY PATIENTS HAD LESS INCIDENCE OF COGNITIVE DYSFUNCTION AND DISORIENTATION IF DONE ON AMBULATORY BASIS.WHATEVER THE AGE, THE MOST IMPORTANT THING TO BE CONSIDERED IS A RESPONSIBLE ATTENDER. DURATION OF SURGERY: PREVIOUSLY IT WAS THOUGHT THAT SURGERY < 90 MIN ARE IDEAL, BUT NOW PROCEDURES LASTING 3-4HRS ARE ALSO DONE ON AMBULATORY BASIS.

TYPES OF SURGERY: EVENTHOUGH AMBULATORY ANAESTHESIA GOT ITS ROLE IN UROLOGY & GYNAEC SURGERIES, NOW ALMOST EVERY SPECIALITY CASES CAN BE DONE AS A DAYCARE SURGERY.FEW SURGERIES TO BE MENTIONED ARE: DENTAL EXTRACTION, HERNIORRHAPHY, HAEMARRHOIDECTOMY D&C, DIAGNOSTIC LAPAROSCOPY, LAP.STERILISATION, LAVH CATARACT SURGERIES, ARTHROSCOPY PROCEDURES MASTOIDECTOMY, MYRINGOTOMY, TONSILLECTOMY CYSTOSCOPY, ESWL, CIRCUMCISION, CLEFT LIP REPAIR CONTRAINDICATION TO AMBULATORY SURGERY: BRITTLE DM, UNSTABLE ANGINA, SYMPTOMATIC ASTHMA MORBID OBESITY PATIENT ON POLYPHARMACY PREMATURE BABIES. NO RESPONSIBLE ATTENDER AT HOME. PREOP.ASSESSMENT, TESTING AND PREPARATION: AMBULATORY SURGERIES SHOULD NOT BE CONSIDERED AS MINOR SURGERIES AND ANESTHETIST SHOULD AVOID ON TABLE VISIT. IDEALLY ALL PATIENTS SHOULD HAVE A PREOP. VISIT AS IT AVOIDS CANCELLATIONS AND MISHAPS.IF THEY HAVE COMORBIDITIES, THE VISIT SHOULD BE ATLEAST 2 WEEKS PRIOR TO THE SURGERY. A BATTERY OF INVESTIGATIONS WILL NEVER SUBSTITUTE A PROPER HISTORY TAKING. ALL ROUTINE LAB. TEST CAN BE AVOIDED AND SPECIFIC TESTS ARE WARRANTED ONLY IN PATIENTS WITH SYSTEMIC DISEASES. SYSTEMATIC REVIEWS HAD SHOWN THAT ROUTINE TESTS NEITHER IMPROVE NOR WORSENS THE OUTCOME. THE PATIENT SHULD BE WELL INFORMED ABOUT THE NATURE OF SURGERY, TECHNIQUE OF ANESTHESIA, AND NIL PER ORAL INSTRUCTIONS.WRITTEN INSTRUCTIONS WORK WELL THAN A WORD BY MOUTH.REASSURANCE HELPS IN ALLAYING THEIR ANXIETY AND RESUMING TO NORMAL LIVING AFTER SURGERY SHOULD BE DISCUSSED. PREMEDICATION: SHORT ACTING BENZODIAZEPINES LIKE MIDAZOLAM, ALPROZOLAM CAN BE SAFELY USED AS IT DOESNT DELAY THE DISCHARGE. ROUTINE USE OF ACID PROPHYLAXIS MEDICATIONS ARE NOT RECOMMENDED. ANALGESIA CAN BE GIVEN IN FORM OF NSAIDS AND CONTINUED POSTOP. FACILITATING EARLY RECOVERY.

ALPHA AGONISTS DEXMEDETOMIDINE IS AVALUABLE ADJUNCT IN DAY CASE SURGERY AS IT REDUCES ANESTHETIC REQUIREMENTS,DECREASE EMERGENCE DELIRIUM,DECREASE EMESIS AND FACILITATE GLYCEMIC CONTROL IN DM PATIENTS. CHOICE OF ANESTHESIA FOR AMBULATORY SURGERY: IT IS NOT THE CHOICE OF ANESTHESIA BUT THE JUDICIOUS AND TITRATED DRUG USAGE WITHIN THAT SELECTED ANESTHESIA,WHICH IS MORE IMPORTANT . ALL TECHNIQUES ARE BEING USED FOR DAY CASE SURGERIES. REGIONAL TECHNIQUE: THE ADVANTAGES ARE MINOR SYSTEMIC SIDE EFFECTS,OPTION OF BEING AWAKE,SUPERIOR PAIN CONTROL. SPINAL ANESTHESIA IS REGULARLY USED WITH SOME MODIFICATIONS.USE OF WHITACRE NEEDLE, FINE GAUGE NEEDLE WILL MINIMISE THE INCIDENCE OF PDPH & READMISSION.SHORT ACTING OPIOIDS CAN BE GIVEN INTRATHECALLY WITH DRUGS TO ABOLISH PRURITUS.MINI DOSE SPINAL TECHNIQUE- ACOMBINATION OF LOW DOSE LA & OPIOID IS BECOMING POPULAR AS IT PROVIDES SUPERIOR ANESTHESIA & EARLY DISCHARGE FEASIBLE. DELAYED RECOVERY FROM MOTOR BLOCK,URINARY RETENTION CAN DELAY THE DISCHARGE OF PATIENT. PERIPHERAL NERVE BLOCKS ARE ROUTINELY USED IN AMBULATORY SETTINGS AS IT FACILITATE PAIN RELIEF .IN PEDIATRIC POPULATION, IT HELPS IN EARLY AMBULATION AND DISCHARGE.ALL TYPES OF BLOCK CAN BE DONE .DISCHARGING A PATIENT WITH INSENSATE EXTREMITY REMAINS CONTROVERSIAL AS EXCELLENT ANALGESIA COMES WITH A COMPROMISE OF LOSS OF PROPRIOCEPTION.PROPER WRITTEN INSTRUCTIONS WILL AVOID UNEXPECTED FALLS& ACCIDENT. EPIDURAL TECHNIQUE CAN ALSO BE DONE ON AMBULATORY SETUP AND ANALGESIA CAN BE CONTINUED IN HOME WITH ELASTOMERIC PUMPS AND PATIENT CONTROLLED ANALGESIA. LOCAL INFILTRATION, SEDATION WITH MAC IS ALSO USED. GENERAL ANESTHESIA REMAINS THE PATIENTS FIRST CHOICE AND BECAUSE OF SHORT ACTING OPIOIDS, INDUCTION AGENTS & VOLATILE AGENTS IT IS SAFE .ADVANTAGES ARE AIRWAY CONTROL,TITRATED DRUGS USE BUT DISADVANTAGES ARE INADEQUATE PAIN RELIEF,PONV,DELAY IN DISCHARGE. USE OF LMA,HUMIDIFIED HEAT INSUFFLATED GAS DURING LAPAROSCOPY OFFERS BENEFIT OF EARLY AWAKENING, LESS AIRWAY IRRITATION & MAINTAINANCE OF BODY TEMPERATURE. PROPOFOL, ETOMIDATE, FENTANYL, REMIFENTANYL, ROCURONIUM, ATRACURIUM REMAINS THE DRUGS OF CHOICE IN AMBULATORY SETTINGS.

SEVOFLURANE AND DESFLURANE ARE EQUIVALENT TO PROPOFOL IN RECOVERY ASPECT BUT THEY HAVE THE SIDE EFFECT OF EMERGENCE DELIRIUM & PONV WHICH WILL DELAY THE DISCHARGE. SO THE CHOICE OF ANESTHESIA IN AMBULATORY SURGERY SHOULD BE BASED ON SAFETY, QUALITY AND COST EFFICACY. ANALGESIA: PAIN STILL REMAINS THE MAJOR CAUSE FOR READMISSION.INCREASED DURATION OF ANESTHESIA AND BMI ARE THE TWO PREDICTVE FACTORS FOR SEVERE PAIN. EVEN THOUGH OPIOIDS ARE IDEAL ANALGESICS, THEY CANNOT BE USED LIBERALLY IN DAY CASE SURGERIES AS IT CAUSES PONV & URINARY RETENTION. SO A MULTIMODAL ANALGESIA TECHNIQUE WORKS WELL IN AMBULATORY SETUP. IT CAN BE DONE WITH LOCAL INFILTRATION, BLOCKS, NSAIDS, DEXTROPROPOXYPHENE, And PARACETAMOL & CODEINE IN VARIOUS COMBINATIONS. PONV: UNANTICIPATED ADMISSION AND DELAY IN DISCHARGE CAN HAPPEN WITH THIS COMPLAINTAND AS SUCH WE CANNOT ELIMINATE COMPLETELY THIS .IDENTIFICATION OF RISK FACTORS IN PREOP, AVOIDING DRUGS CAN MINIMISE THE PONV.PROPHYLAXIS IS NOT ROUTINELY RECOMMENDED AND THERAPY DEPENDS ON COMBINATION DRUGS RATHER THAN A SINGLE MAGIC BULLET. FORCEFUL FEEDING, INADEQUATE HYDRATION, PREMATURE AMBULATION ARE SOME OF THE PROVOKING FACTORS FOR PONV DISCHARGE CRITERIA: ANY PATIENT AFTER AMBULATORY ANESTHESIA WILL UNDERGO THREE PHASES OF RECOVERY. EARLY PHASE:IT HAPPENS AT THE END OF ANESTHESIA.THE PATIENT STARTS OPENING EYES AND RESPONDS TO VERBAL COMMANDS.IT CAN HAPPEN IN O.R /PACU. THIS PHASE REQUIRES CONTINOUS MONITORING OF VITALS INTERMEDIATE: PATIENT BECOMES FULLY ORIENTED, THEY CAN DRINK, AMBULATE OR VOID.ANESTHETIC TECHNIQUE CHOSEN HAS A MAJOR IMPACT ON THIS PHASE. LATE: IT OCCURS IN HOME AND SURGICAL FACTORS HAS A MAJOR IMPACT. NUMEROUS SCORING SYSTEMS LIKE MODIFIED ALDRETE, PADS, WHITE CRITERIA ETC ARE AVAILABLE FOR DETERMINING THE PATIENTS FITNESS FOR DISCHARGE. CONCLUSION: AS INDIAN HEALTHCARE INDUSTRY IS BOOMING AND THERE IS ALWAYS SHORTAGE OF INFRASTRUCTURE, AMBULATORY ANESTHESIA OFFERS NEW HOPE FOR BETTER PATIENT MANAGEMENT.SELECTION OF CASES,SAFE CONDUCT OF SURGERY, MINIMAL USE OF HOSPITAL RESOURCES,SKILLED SAFE SURGEON ARE THE ESSENTIAL PREREQUSITE FOR SUCCESSFUL AMBULATORY UNIT. BUT THE MOST IMPORTANT MEMBER WILL BE THE PERIOPERATIVE PHYSICIAN ALIAS ANESTHETIST!