Ian Smith, MD, FRCA

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Perspectives on British Day Surgery

• Ian Smith, MD, FRCA
• Editor, Journal of One-day Surgery,
• Senior Lecturer in Anaesthesia
• University Hospital of North Staffordshire
• Stoke-on-Trent

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National Health Service
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Physician-only Anaesthesia
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Role of Nurses

• Preassessment
• similar to core skills
• consistent
• protocol based
• medical input, as needed
• Theatre
• Recovery
• Ward management

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U.K. Working Practice

• Surgeons have fixed operating lists
• Regular pattern
• Regular anaesthetist
• Always together

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Fixed ListsBenefits

• Teamwork
• Friendship
• Strengths weaknesses
• Communication
• Consultant delivered
• Efficiency

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Causes of Delays
Cause
Incidence
No consultant surgeon Patient not in
hospital Transport problem Case cancelled No
trainee surgeon No consent
9.4 6.8 6.8 6.8 5.4 5.4
Overdyk, et al. Anesth Analg 86 896, 1998
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Fixed ListsDisadvantages

• Patient delays
• social arrangements
• psychological preparation
• no clinical detriment

• Workload
• alternate weeks
• pooled lists

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Anaesthetic Practice
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Choice of Anaesthetic

• Wide variation
• All drugs available
• desflurane less popular
• TIVA common
• TCI
• volatiles popular too
• Regional anaesthesia unusual
• ? increasing

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Managing the Airway
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The LMA

• Commonly used
• most cases including laparoscopy
• sv
• Less common
• prone
• tonsils thyroid
• lap chole
• ProSeal

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Day Case Analgesia

• NSAIDs
• suppository
• oral, pre-op
• diclofenac, ibuprofen
• Paracetamol
• iv ? popularity
• Codeine preps

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Opioids

• Sufentanil not available
• Alfentanil / remifentanil for TIVA
• Fentanyl very popular
• good for rescue
• try to avoid otherwise
• Morphine still used!

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Local Anaesthesia

• Infiltration widely used
• Blocks still popular
• complications
• e.g., femoral nerve
• Surgery under LA still uncommon

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Day Surgery Activity
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Variation
Inguinal Hernia Repair
asDaySurgery
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All Acute Hospitals
Data from Audit Commission, 2002
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Variation
Laparoscopy (gynaecology)
73
asDaySurgery
All Acute Hospitals
Data from Audit Commission, 2002
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Variation
Tonsillectomy
asDaySurgery
All Acute Hospitals
Data from Audit Commission, 2002
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Variation
Laparoscopic Cholecystectomy
asDaySurgery
All Acute Hospitals
Data from Audit Commission, 2002
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Variation

• Between hospitals
• Between procedures
• Between surgeons
• Good and bad examples in most hospitals

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Promoting Day Surgery

• British Associationof Day Surgery
• Multi-disciplinary
• Useful web site
• www.bads.co.uk
• Annual meeting
• Quarterly journal

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Politics

• 75 as day surgery
• The NHS plan, 2000
• 6 months target
• 18 week target
• Payment by results
• national tariff
• Patient choice

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NHS Modernisation Agency(20002005)

• Day surgery programme
• clinical champions for each region
• Selection criteria
• Good Practice Guides
• 10 High-impact Changes

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Modern Selection Criteria
Nationalindiindi

• Pragmatic
• Evidence-based
• Functional limitation
• Suitable unless contraindications

National Good Practice Guidance on Pre-operative
Assessment for Day Surgery
Operating Theatre Pre-operative Assessment
Programme
2002
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Obesity May be a Problem

• Airway
• Breathing
• Cardiovascular
• Veins
• Handling
• Access
• Bleeding
• etc, etc...

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Day Surgery Obesity

• Most problems peri- early postoperative
• not prevented by admission
• Rapid recovery mobilisation beneficial
• Late problems start at BMI gt40
• BMI 3540
• acceptable for most procedures

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Other Selection Criteria

• Age No upper limit
• ASA 13 (unless other contraindications)
• Diabetes If well-controlled
• CVS Not if MI lt6 mo, angina on minimal effort
• Resp Not if SOB on minimal effort

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Functional Limitation
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Day Surgery 2006

• Laparoscopic cholecystectomy
• Subacromial shoulder decompression
• Lumbar microdiscectomy
• Emergency surgery abscess, ERPC, clavicle
• Thyroidectomy parathyroidectomy
• TURP
• Laparoscopic Nissen fundoplication
• Laparoscopic nephrectomy

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Expanding Day Surgery

• Clinical benefits
• Local enthusiasm
• Political drive
• Financial pressures
• Target culture
• Additional capacity

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Treatment Centres
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Treatment Centres
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British Contributions

• Teamwork
• optimum use of staff
• Simplicity
• anaesthesia
• airway management
• pain PONV
• Pragmatism

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