ambulatory

anaesthesia
- extended criteria for daycare patients -
 Day care services is a multidisciplinary service
catering for diagnostic and therapeutic procedures
which may require local, regional or general
anaesthesia which do not carry the risk of post
operative complication, but require a short period of
observation in the hospital.

MOH, BRITISH ASSOC. OF DAY SURGERY -

 - objectives -
To reduce waiting time for elective surgery

To reduce inpatient admission

To make surgery convenient and comfortable for the

patient

To reduce disruption of personal lives

To reduce hospital-acquired infection

To encourage early recovery and mobilization in a home

environment with their family
To reduce cost of surgery
 - setup -

totally independent stand alone unit

separated but integrated complex but within hospital

compound
 - facilities -
Registration counter
Waiting room
Assessment room
Changing rooms
Procedure rooms
Pre and post- operative wards
Operating theatres
Recovery room
Pharmacy
patient selection
criterion
 - patient criteria -
Patient must be willing for Day Care Surgery.

Patient must be able to understand and cooperate with

instructions.

Patient must live within one hour from Day Care

facility.

Patient must have suitable transport and must not take

public transport.

Patient must have an escort to accompany patient

back home.
pre operative assessment

At least 2 weeks before the procedural date.

Pre-anaesthesia Assessment Form should be completed

by the surgeon in-charge and sent to the Anaesthetic
Clinic together with the patient. ******

Suitability for day care case shall be made at pre

assessment.
 - anaesthetic criteria -

Patient must be ASA 1 or 2

Age must be more than 6 months and less than 70

years old

Patient is not obese with BMI less than 35

No significant anaesthetic risks or alerts.

Choice of agents depends on requirements of pt and preference of anaesthetist.

Induction agent:

i.v. Propofol is used widely (easy &quick recovery, clear head, little PONV).

gas: Sevoflurane is non-irritant to airway, rapid induction, minimal side-effects.

Maintainance:

N2O: higher incidence PONV, but lower requirements for volatiles.

TIVA: Propofol +/- Remifentanilhigh cost.

Airway: GA mask, LMA, or even ETT.

Muscle-relaxants:

Succinylcholine muscle pains.

NDMR Atracurium, Mivacurium, Vecuronium, Cisatracurium, Rocuronium.

 Regional anaesthesia
TIVA
Monitored sedation
 - surgical criteria -
Uncomplicated surgery which takes less than 90
minutes.

Procedures than have minimal risk of bleeding or other

surgical complications.

Procedures that have minimal post op pain and need no

special post op care.

Patient will not be immobilised in the post op period.

Procedure with no significant nausea and vomiting and

patient can resume orally rapidly post op.
 GENERAL SURGERY GYNAECOLOGY ORTHOPAEDICS ENT

Orchidopexy Circumcisio
n Inguinal Hernia
Repair Excision of Breast
Lump Wide Excision of Excision of Dupuytrens
Division of Tongue Tie
Breast Lump with Axillary Contracture Carpal
Myringotomy Submucous
Clearance Anal Fissure Tunnel Decompression
Resection Reduction of
Haemorrhoidectomy Vari Excision of Ganglion
Nasal Fracture Nasal
cose Vein Stripping or
Dilatation and Polyps
Ligation Meatotomy Mino
Curettage/Hysteroscopy Arthroscopy (all Suction Clearance
r Repair of
Laparoscopy arthroscopic examinations including Removal of
Hypospadias Hypospadia
Sterilization Termination of joints) Bunion Foreign Bodies Aural
s Fistula Removal of JJ
of Operations Polypectomy Change of
Stents Gastroscopy
Pregnancy Examination Removal of Metalware Mastoid
Biopsy Oesophageal
under Anaesthetic and Manipulations Dressing Endoscopy
Dilatation Change of
Vaginoscopy Separation Cautery Dilatation of
Tracheostomy Proctosco Change of Plaster
of Labial Adhesions Choanae Antral
py, Sigmoidoscopy Release of Trigger Thumb
Washouts Drainage of
Biopsy Excision of Local Serial Casting for
Septal Haematoma
Skin Lesions Lymph Scoliosis
Tonsillectomy (some)
Node Biopsy Excision of Partial or Complete
Adenoidectomy (some)
Sebaceous Removal of Toenails
Cysts Branchial Tenotomy
Sinus/Fistula Thyroglossa
l Cysts
 - discharge criteria -
Patient awake, alert and orientated

Vital signs stable

Able to tolerate orally

Pain manageable with oral analgesics

Minimal nausea, vomitting and dizziness

No bleeding
Should start pre- or intraoperative by:

Opioids: Short-acting opioids (Fentanyl, Alfentanil), avoid

Morphine if possible if high risk of PONV.

LA/regional blocks (i.e. Caudal block in kids; Ropivacaine

more selective sensory block than Bupiv.).

Acetaminophen: 25-40 mg/Kg orally or rectally.

Cox-2 inhibitors: Parecoxib 20-100 mg Iv or IM. No GIT side

effects of other NSAIDs.
 - BENCHMARK -

DEVELOPED COUNTRIES >70%

MALAYSIA 5-15 %
can ASA 3 considerable
for day care surgery?
 With good preassessment and adequate preparation ASA
III patients can be treated safely in the day surgery setting.

Br J Anaesth 2004; 92: 714

ASA III (and possibly IV should not be excluded if their diseases

are under controlled

[Dunn PF. Clinical Anesthesia Procedures of the Massachusetts

General Hospital, 7th ed. LWW (Philadelphia) p. 563, 2007])
advanced age??
 A cohort study with over 15,000 patients reveals that
age is not predictive of hospitalization after outpatient
surgery.

Medicina Universitaria, Volume 18, Issue 71,

AprilJune 2016, Pages 130-133
 association between an age over 65 and a rise in
the risk of intraoperative complications, especially
cardiovascular ones

chung et al.-
 Age > 80 years is an indicator of increased
perioperative risk

Whippey A, et al: Can J Anesth 2013; 60: 675-83

Fleischer LA, et al: Arch Surg 2004; 139: 67-72
 death and hospitalization risk factors after an
outpatient surgery. For death risk or hospital
readmission within seven days after surgery, the most
significant factors related to the patient, were an age
over 85 years and a hospitalization in the months
previous to surgery .

Fleisher et al.
BMI > 35??
 The literatures do indicate that the super obese (BMI >50 kg/ m2) do
present an increased risk for perioperative complications, while patient
with lower BMIs do not seem to present any increased risk as long as any
comorbidities are minimal or optimized before surgery.

- Anesth Analg 2013;117:108291

- samba guidelines
SAMBA Guidelines 2012
1,905 studies 7 studies

Wide variety of ambulatory procedures

2 prospective cohort trials

5 retrospective chart reviews

1,491 OSA patients

2,036 low risk OSA patients

2,095 non-OSA patients
Majority of OSA patients used CPAP
1,905 studies 7 studies

Surgical airway
Anoxic brain injury
Death
Delayed discharge
Unanticipated hospital admission
Intra and Post Operative Complications

Difficult airway

Desaturation

Supplemental oxygen

Need for additional monitoring

Atelectasis
 MINIMIZE OPIOIDS
MULTIMODAL ANALGESIA
Optimize systemic disease
Avoid CNS depressants
Short acting anesthetics
Anticipate difficult airway
Consider regional anesthesia
 references
1. MOH, www.moh.gov.my 1. Day Care Surgery HRPB Ipoh. Protocols and Guidelines.

2. Policy of Daycare Complex, and Your Guide to Day Care Surgery in Hospital
Selayang

3. Assessment and Selection Criteria for Day Surgery in Ambulatory Care Center,
Hospital Pulau Pinang

4. openanaesthesia.org

5. BJA: British Journal of Anaesthesia

6. sambahq.org

7. iaas-med.com