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Daycare surgery.pptx

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Daycare surgery.pptx

  1. 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
  2. 2. Daycare Surgery
  3. 3. Daycare Surgery • The patient undergoes surgery in the morning and discharged on the same day in less than 24 hours. • Effective pre-operative preparation and protocol-driven, nurse-led discharge are fundamental to safe and effective day and short stay surgery.
  4. 4. Types
  5. 5. Types • Office procedures • True Ambulatory Surgery -This is where patients are admitted, operated on and discharged during the time frame of one working day (6 to 8 hours). There is no overnight stay. • Ambulatory Surgery with Extended Recovery-This is where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours).
  6. 6. Indications
  7. 7. Indications • In recent years, the complexity of procedures has increased with a wider range of patients now considered suitable for day surgery.
  8. 8. Selection of patients
  9. 9. Selection of patients Factors Affecting- • Social • Medical • surgical.
  10. 10. Social factors
  11. 11. Social factors • The majority of patients are appropriate for day surgery unless there is a valid reason why an overnight stay would be beneficial. • responsible adult should escort the patient home; • responsible adult should escort the patient home; • Presence of a carer for 24 h postoperatively
  12. 12. Medical factors
  13. 13. Medical factors • Fitness for a procedure should relate to the patient’s functional status as determined at pre-anaesthetic assessment, and not by ASA physical status, age or body mass index • Patients with a stable chronic disease such as diabetes are often better managed as day cases because there is minimal disruption to their daily routine.
  14. 14. Medical factors • Obstructive sleep apnoea (OSA) is not an absolute contraindication to day surgery in adults, • If postoperative pain can be managed predominantly with non-opioid analgesic techniques’
  15. 15. Surgical factors
  16. 16. Surgical factors • The procedure should not carry a significant risk of serious postoperative complications requiring immediate medical attention, for example, haemorrhage or cardiovascular instability. • Postoperative symptoms (such as pain and nausea) must be controllable by the use of a combination of oral medication and local anaesthetic techniques
  17. 17. Surgical factors • The procedure should not prohibit the patient from resuming oral intake within a few hours of the end of surgery. • Patients should be able to mobilise before discharge
  18. 18. Operations covered
  19. 19. Operations covered The target is that 75% of elective surgery should be performed as day cases • .Excision of breast lump • Incision and drainage of abscess • Laparoscopic appendicectomy • laparoscopic cholecystectomy • Thyroidectomy • Temporal artery biopsy • Eversion of hydrocele sac • Inguinal hernia repair • Circumcision. • Laparoscopic sterilisation • tonsillectomy The list is endless
  20. 20. Management Aspects
  21. 21. Management Aspects Components of an emergency day surgery pathway are: 1. Identification of appropriate procedures 2. Identification of a theatre list that can reliably accommodate the procedure (e.g. a dedicated day surgery list or a flexibly run emergency theatre list) 3. Ensuring clear pathways are in place 4. Determining whether the condition is safe to be left untreated for up to 24 h and manageable at home with oral analgesia 5. Providing clear pre-operative patient information, ideally in writing.
  22. 22. Facilities
  23. 23. Facilities • Day surgery works best when it is provided in a selfcontained unit that is functionally and structurally separate from inpatient wards and operating theatres. • It should have its own reception, consulting rooms, ward, theatres and recovery area, together with administrative facilities. • Stand alone day surgery units- not part of a hospital have been started in several developed countries.
  24. 24. Admission process
  25. 25. Admission process • Patients should be admitted to the day surgery unit as close as possible to the time of their surgery.
  26. 26. Fasting
  27. 27. Fasting
  28. 28. Change • Pre-operatively, patients should be allowed to stay in their ‘street clothes’ for as long as possible in order to maintain dignity, warmth and comfort. • At a suitable time, they should change into theatre gowns and wait in a single sex area. • They should walk to theatre and ideally transfer themselves onto the operating trolley in the anaesthetic room. • They can remain on this trolley throughout their day surgery pathway until ready for transfer to a chair in the postoperative ward.
  29. 29. Change • Pre-operatively, patients should be allowed to stay in their ‘street clothes’ for as long as possible in order to maintain dignity, warmth and comfort. • At a suitable time, they should change into theatre gowns and wait in a single sex area. • They should walk to theatre and ideally transfer themselves onto the operating trolley in the anaesthetic room. • They can remain on this trolley throughout their day surgery pathway until ready for transfer to a chair in the postoperative ward.
  30. 30. Pre-operative preparation
  31. 31. Pre-operative preparation 1. To educate patients and carers regarding day surgery pathways 2. To impart information regarding planned procedures and postoperative care to help patients make informed decisions; important information should be provided in writing. 3. To identify medical risk factors, promote health and optimise the patient’s condition
  32. 32. Contraindications
  33. 33. Contraindications • The only patients routinely not included in day surgery are those with unstable medical conditions.
  34. 34. Anaesthetic management
  35. 35. Anaesthetic management • Dedicated anesthetist. • Anaesthetic techniques should ensure minimum stress and maximum comfort for the patient. • Avoid Isoflurane. • Analgesia is paramount and must be long acting, but, as morbidity such as nausea and vomiting must be minimised, the indiscriminate use of opioids is discouraged • Prophylactic oral analgesia with long-acting non- steroidal anti-inflammatory drugs (NSAIDs) should be given to all patients, unless contraindicated.
  36. 36. Regional anaesthesia
  37. 37. Regional anaesthesia • Local infiltration and nerve blocks can provide excellent anaesthesia and pain relief after day surgery. • Patients may safely be discharged home with residual motor or sensory blockade, provided the limb is protected and appropriate support is available for the patient at home. • Infusions of local anaesthetics may also have a role • Use of a ‘block room’ improves efficiency and allows confirmation of adequate nerve blockade before surgery commences
  38. 38. Spinal anaesthesia
  39. 39. Spinal anaesthesia • Concerns regarding post-dural puncture headache have previously limited the use of spinal anaesthesia in day surgery patients, but the use of smaller gauge (25 G) and pencil-point needles has reduced the incidence to < 1%. • Low-dose local anaesthetic techniques and newer shorter acting local anaesthetics such as hyperbaric prilocaine 2% and 2- chloroprocaine • Appropriate spinal anaesthetic dosing targeted to surgical site, for example, lateral for a unilateral knee arthroscopy or sitting for peri-anal procedures, can minimise side-effects such as hypotension and prolonged motor blockade
  40. 40. Spinal anaesthesia
  41. 41. Spinal anaesthesia • Restricting i.v. fluids to no more than 500 ml should reduce the incidence of urinary retention. Patients should be encouraged to drink postoperatively in order to allow their own body to correct fluid balance.
  42. 42. Safe mobilisation after spinal anaesthesia
  43. 43. Safe mobilisation after spinal anaesthesia • Return of sensation to the peri-anal area (S4–5) • Plantar flexion of the foot at pre-operative levels of strength • Return of proprioception in the big toe.
  44. 44. Post op management
  45. 45. Post op management • Venous thromboembolism risk assessment and prophylaxis should be followed.. • management of postoperative nausea and vomiting (PONV) – Prophylactic anti-emetics are recommended in patients with a history of PONV, – motion sickness and those undergoing certain procedures such as laparoscopic sterilisation/cholecystectomy or tonsillectomy.. – Routine use of intravenous (i.v.) fluids and maintenance of body temperature can enhance the patient’s feeling of wellbeing and further reduce PONV
  46. 46. Post op complications
  47. 47. Post op complications • Common postoperative problems – PONV (Postoperative Nausea And Vomiting) – Pain • Emergencies – Haemorrhage – Cardiovascular events
  48. 48. Discharge: Assessment
  49. 49. Discharge: Assessment Who should assess fitness for discharge? • Surgeon and/ or anaesthetist • Senior nurse against a medical approved printed protocol. • Surgeon and/ or anaesthetist only involved in cases of doubt or when there is a problem
  50. 50. Discharge Process and Criteria
  51. 51. Discharge Process and Criteria • There are 3 phases of recovery following anaesthesia: 1. Early recovery - awakening and recovery of vital reflexes. 2. Intermediate recovery - recovery to point of 'home readiness‘ 3. Late recovery - recovery to point of 'street fitness'. • Patients are fit for discharge from the day unit when they have completed the intermediate phase of recovery .
  52. 52. Discharge: Essential invariable criteria
  53. 53. Discharge: Essential invariable criteria • Stable vital signs • Orientated to preop. stage • Minimal nausea and vomiting • Controllablel pain by oral drugs. • No significant bleeding from operative site.
  54. 54. Discharge: Variable criteria
  55. 55. Discharge: Variable criteria • Micturition prior to discharge. Essential following epidural or spinal anaesthesia. May be deemed essential following certain surgical procedures. • Fixed length of stay in day unit following surgery plays no part in the generality of surgical procedures. May be deemed necessary after certain procedures to minimise the risk of reactionary haemorrhage at home eg: tonsillectomy, thyroidectomy.
  56. 56. Discharge: Disputed criteria
  57. 57. Discharge: Disputed criteria • The ability to take and retain oral fluids prior to discharge is increasingly disputed. It may in fact provoke nausea and vomiting.
  58. 58. Discharge: Non-medical criteria Non-medical criteria to be met prior to discharge from the day unit. • An adult to accompany the patient home and to be with them at home for the first 24- hours following surgery . • Access to a functioning telephone at home.
  59. 59. Discharge: Patient to be given
  60. 60. Discharge: Patient to be given • Printed post-operative instructions • Printed information on whom to contact in case of emergency . • Appropriate discharge drugs • Follow-up information. • A summary of the treatment they have received.
  61. 61. Post-operative instructions
  62. 62. Post-operative instructions • Not to drink alcohol, operate machinery or drive for 24 h after a general anaesthetic. • Patients should not drive until the pain or immobility from their operation allows them to control their car safely and perform an emergency stop • Recent guidance for driving following isoflurane anaesthesia recommends refraining from driving for four days after its use.
  63. 63. Patient satisfaction
  64. 64. Patient satisfaction • Good post-operative pain control is achieved • There is no post-operative nausea and vomiting • Good pre and post-operative information is delivered ; • Increased surgery availability and short waiting time before surgery are achieved; • A courtesy and a friendliness environment are given by the operating and day surgery staff; • Patients do not feel that they are being discharged too early or in a rushed way; • A telephone follow-up contact on the next day is established.
  65. 65. Advantages
  66. 66. Advantages • Quicker recovery • Less disruption to patients and family life • Cost effective • Reduces the risk of hospital-acquired infections and • venous thromboembolism
  67. 67. Disdvantages • .
  68. 68. Disdvantages • Low acceptance • Need for a responsible caregiver at home. • Anxiety • Readmission • Stand alone units must collaborate with a regular hospital to manage complications.
  69. 69. Day surgery for children
  70. 70. Day surgery for children Lower age limit and medical comorbidities of children • Lower age limit of 44 weeks ‘post- menstrual age’ (defined as gestational age plus chronological age). • Ex-premature infants (those born at less than 37 weeks gestational age) not accepted for day surgery < 60 weeks postmenstrual age. • Obstructive sleep apnea (OSA)not suitable for day surgery
  71. 71. Day surgery for children • The home environment • distance from the hospital • Parents’ access to transport and a telephone • Parents must be able to understand instructions, recognise complications that would require a return to hospital.
  72. 72. Day surgery for Older patients
  73. 73. Day surgery for Older patients • Is ideal for older patients • Older patients are less likely to admit to feeling unwell, uncomfortable or distressed. • They are often already partially dehydrated • Prone to hypoglycaemia. • Prone to hyponatremiain
  74. 74. Take home messages • The International Association for Ambulatory Surgery (IAAS)
  75. 75. Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
  76. 76. Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
  77. 77. Get this ppt in mobile
  78. 78. Get my ppt collection • https://www.slideshare.net/drpradeeppande/ edit_my_uploads • https://www.dropbox.com/sh/x600md3cvj8 5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl =0 • https://www.facebook.com/doctorpradeeppa nde/?ref=pages_you_manage

Notas do Editor

  • drpradeeppande@gmail.com
  • https://anaesthetists.org/Portals/0/Images/Guidelines%20cover%20images/Guideline_day_case_surgery_2019.pdf?ver=2019-05-05-075731-563
  • https://anaesthetists.org/Portals/0/Images/Guidelines%20cover%20images/Guideline_day_case_surgery_2019.pdf?ver=2019-05-05-075731-563