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© DR GEETANJALI S VERMA DISCUSSION INVOLVES Definition Advantages Disadvantages Selection criteria Surgical procedures Anesthetic concerns Discharge criteria Information to pt Future developments


© DR GEETANJALI S VERMA DEFINITION Day care surgery - A patient recovers from surgery and fit to return home within a day (24 hrs.) Ambulatory surgery - A patient recovers from surgery and fit to return home in the same evening without overnight stay in the hospital. Office surgery - A patient recovers from surgery and fit to return home within couple of hours.


© DR GEETANJALI S VERMA ADVANTAGES Patient Comfort Financial burden Hospital Financial Operative list


© DR GEETANJALI S VERMA DISADVANTAGES Expensive drugs Expensive equipments Requires good monitoring & assessment Communication skills

Recent reports:

© DR GEETANJALI S VERMA Recent reports Association of Anaesthetists booklet Day Case Surgery: The Anaesthetist’s Role in Promoting High Quality Care. Royal College of Surgeons handbook Guidelines for Day Case Surgery, London. National Health Service Management Executive, Value for Money Unit. Day Surgery: Making it happen.

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© DR GEETANJALI S VERMA When patients are referred for day surgery it is essential to ensure that: ✦ the procedure is suitable ✦ the risk of complications (from surgery and anaesthetic) are minimised ✦ admission to an in-patient bed following day surgery is prevented ✦ patients are adequately supported after discharge home.

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SELECTION CRITERIA (NHS modernisation agency):

© DR GEETANJALI S VERMA SELECTION CRITERIA (NHS modernisation agency) Surgical Thoracic or abd wall cavities not involved Pain manageable with oral analgesia Continuing blood loss or need for fluid replacement unlikely No expected interruption of blood supply to major organs Social Responsible adult to accompany pt home & for 24hrs after GA / sedation Reasonable access to a telephone GP back up available Medical No upper age limit ASA 1-3 unless contraindications DM not contraind if well controlled, if on Insulin, surgery should not prevent early resumption of normal diet Contraindications Marked dyspnea on mild exertion or at rest Angina markedly limiting activity or at rest MI within 6 months Uncontrolled HTN (sys >170, dias > 100 mm Hg) Renal failure on dialysis (fistula formation & minor procedures possible) Severe hepatic disease

For children:

© DR GEETANJALI S VERMA For children ASA I or II the anaesthetic and operating time should be <1 hour procedure should have a low incidence of post-op complications NOT SUITABLE premature infants who have not reached 44 weeks post conceptual age infants < 4 weeks old or who have been on ventilatory support Royal College of Surgeons of England

Investigations :

© DR GEETANJALI S VERMA Investigations Clinically driven NOT routine

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UK Audit Commission “Basket of 25” (2001) [day care preferred option]:

© DR GEETANJALI S VERMA UK Audit Commission “Basket of 25” (2001) [day care preferred option] 1 Orchidopexy 2 Circumcision 3 Inguinal hernia repair 4 Excision of breast lump 5 Anal fissure dilatation or excision 6 Haemorrhoidectomy 7 Laparoscopic cholecystectomy 8 Varicose vein stripping or ligation 9 Transurethral resection of bladder tumour 10 Excision of Dupuytren’s contracture 11 Carpal tunnel decompression 12 Excision of ganglion 13 Arthroscopy (all arthroscopic examinations of joints) 14 Bunion operations 15 Removal of metalware 16 Extraction of cataract with/without implant 17 Correction of squint 18 Myringotomy 19 Tonsillectomy 20 Sub mucous resection 21 Reduction of nasal fracture 22 Operation for bat ears 23 Dilatation and curettage/hysteroscopy 24 Laparoscopy 25 Termination of pregnancy

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© DR GEETANJALI S VERMA 1 Laparoscopic hernia repair 2 Thoracoscopic sympathectomy 3 Submandibular gland excision 4 Partial thyroidectomy 5 Superficial parotidectomy 6 Wide excision of breast lump with axillary clearance 7 Urethrotomy 8 Bladder neck incision 9 Laser prostatectomy 10 Trans cervical resection of endometrium (TCRE) 11 Eyelid surgery 12 Arthroscopic menisectomy 13 Arthroscopic shoulder decompression 14 Subcutaneous mastectomy 15 Rhinoplasty 16 Dentoalveolar surgery 17 Tympanoplasty British association of Day Surgery (1999) trolley of procedures About 50% of each procedure should be done as day surgery

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© DR GEETANJALI S VERMA GA Isoflurane / Desflurane / sevoflurane Propofol Nitrous oxide LMA with spontaneous ventilation Tracheal intubn & controlled vent (short acting NMBA & adequate reversal ensured) Sch AVOIDED (muscle pain) Ivf – 1L crystalloid hydration (↓ drowsiness) Opioids (?)

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© DR GEETANJALI S VERMA LA Spinal analgesia Low dose tech (5mg bupivacaine + 10mcg fenta diluted to vol of 3ml) Wound infiltration 0.5% bupivacaine / levobupivacaine in volume approp to size of wound Regional nerve blocks Extensive shoulder/ knee surgery

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© DR GEETANJALI S VERMA Sedoanalgesia Small dose of Midazolam (1-2mg) Boluses / low dose infusion of Propofol (1-2mg/kg/hr) Small doses of short acting Opioids

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Post Anaesthesia Recovery Score modified for Day Surgery (Aldrete ’95):

© DR GEETANJALI S VERMA Post Anaesthesia Recovery Score modified for Day Surgery (Aldrete ’95) Activity Able to move 4 extremities voluntarily or on command 2 Able to move 2 extremities voluntarily or on command 1 Unable to move extremities voluntarily or on command 0 Respiration Able to breathe deeply and cough freely 2 Dyspnoea or limited breathing 1 Apneic 0 Circulation BP ± 20% of preanaesthetic level 2 BP ± 20 to 49% of preanaesthetic level 1 BP ± 50% of preanaesthetic level 0 Consciousness Fully awake 2 rousable on calling 1 Not responding 0 Oxygen saturation Able to maintain saturation >92% on room air 2 Needs oxygen to maintain saturation >90% 1 SpO2 <90% even with oxygen 0

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© DR GEETANJALI S VERMA Dressing Dry and clean 2 Wet but stationary or marked 1 Growing area of wetness 0 Pain Pain free 2 Mild pain handled by oral medication 1 Severe pain requiring parenteral medication 0 Ambulation Able to stand up and walk straight 2 Vertigo when erect 1 Dizziness when supine 0 Fasting-feeding Able to drink fluids 2 Nauseated 1 Nausea and vomiting 0 Urine output Has voided 2 Unable to void but comfortable 1 Unable to void and uncomfortable 0 SCORE >= 18 FIT FOR DISCHARGE

Post anesthesia Discharge Scoring System (PADSS) (Marshall and Chung):

© DR GEETANJALI S VERMA Post anesthesia Discharge Scoring System (PADSS) (Marshall and Chung) Vital signs: vital signs must be stable and consistent with age and preoperative baseline. BP and pulse within 20% of preoperative baseline 2 BP and pulse within 20-40% of preoperative baseline 1 BP and pules >40% from preoperative baseline 0 Activity level: Patient must be able to ambulate at preoperative level. Steady gait, no dizziness (or meets preoperative level) 2 Requires assistance 1 Unable to ambulate 0 Nausea and Vomiting : The patient should have minimal nausea and vomiting prior to discharge. Minimal: successfully treated with oral medication 2 Moderate: successfully treated with intramuscular medication 1 Severe: continues after repeated treatment 0

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© DR GEETANJALI S VERMA Pain: Minimal or no pain prior to discharge. The level of pain that the patient has should be acceptable to the patient. Pain should be controllable by oral analgesics. The location, type and intensity of pain should be consistent with the anticipated postoperative discomfort. Acceptability: Yes 2 No 0 Surgical Bleeding Postoperative bleeding should be consistent with expected blood loss for the procedure Minimal: does not require dressing change 2 Moderate: up to two dressing changes required 1 Severe: more than three dressing changes required 0 SCORE >= 9 FIT FOR DISCHARGE

Regional anesthesia (neuraxial):

© DR GEETANJALI S VERMA Regional anesthesia (neuraxial) Assess Return of anal tone Passage of urine (bladder fn) Power of limbs Recovery of proprioception, sympathetic tone Plantar flx of foot

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© DR GEETANJALI S VERMA Medication - specific instructions regarding prescribed analgesia, antiemetics or antibiotics Wound care & when patient is able bathe or shower arrangements for dressing renewal and suture removal (if appropriate) Resuming normal activities What ‘normal’ symptoms may be expected and their duration What would be abnormal symptoms and what to do if they occur Contact telephone numbers for information or in an emergency Arrangements for follow -up (telephone and out-patients) PROCEDURE SPECIFIC INFORMATION


© DR GEETANJALI S VERMA FUTURE DEVELOPMENTS Sending pts with catheter Drains in situ 2 incision hip replacement Single compartment knee replacement

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© DR GEETANJALI S VERMA REFERENCES 1. Aldrete JA. The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia. 1995;7:89-91 2. Marshall S, Chung F. Assessment of ‘home readiness’: discharge criteria and postdischarge complications. Current Opinions in Anesthesiology 1997;10:445-50 3. Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anesthesia & Analgesia. 1999:88;508-17 4. NHS modernisation agency. National good practice guidelines on pre operative assessment of day surgery. Modernisatin agency; london 2002 5. Audit commission. Day surgery: review of national findings. Londo: audit commission publications, 2001 6. Cahill Cj Basket cases and trolleys. Day surgery proposals for the millenium. Journal of one day surgery 1999; 9:11-12

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