Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (15 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Precise patient selection should ensure that postoperative morbidity is minimised, but complications do occur and can be classified into major and minor problems.
63
Major complications occur less often than anticipated in the day surgery patient population with an incidence of 1 in 1455
64
and are independent of ASA status. Mortality is low and varies between 1 in 66 500 and 1 in 11 273.
Minor complications are more common and may precipitate unplanned overnight admission; these range from 0.1% to 5% depending on case mix.
65
Postoperative morbidity is usually related to the procedure undertaken and the anaesthetic agent used rather than the ASA status, which predicts complications in major inpatient surgery but not in day surgery patients. Surgical causes account for 60–70% of unplanned admissions and are usually the result of the surgeon embarking on a more extensive procedure than planned rather than surgical misadventure. Day surgery lists require careful planning, with the more major surgical procedures performed earlier in the day to allow adequate recovery time. Failure to adhere to this policy often leads to unplanned admissions.
66
The more lengthy and invasive surgical procedures tend to increase postoperative pain, PONV and drowsiness, and preclude safe discharge. Even once the patient has returned home, PONV may return and last up to 5 days in 35% of patients
67
and is often severe. Readmission rates are similar to unplanned admission rates (0.7–3.1%) and again are most often from surgically related causes.
Children find surgery and hospital visits a daunting and stressful prospect, and are therefore treated both separately and differently from adults. In 1991, the National Association for the Welfare of Children in Hospital published quality standards for care of paediatric day cases and suggested that children should be managed by staff trained in their care, in a child-safe and child-friendly environment with open access to the conscious child for the parents.
68
As a result, excellent results have been reported from non-specialised District General Hospitals as long as regular auditing of quality is practised.
69
Most children are fit and healthy ASA class I patients. ASA class II and III patients are not excluded but an anaesthetist with paediatric expertise is recommended.
15
Procedures for children with respiratory infections should be postponed for 2–4 weeks depending on severity, but after measles or whooping cough this should be extended to 6 weeks because of irritability of the respiratory tract.
70
In many units, children under the age of 6 months are considered unsuitable for day surgery, but if specialist facilities are available, full-term neonates are acceptable provided inpatient neonatal care is available. Premature babies are excluded up to 60 weeks after conception because of the risk of postoperative apnoea.
71
Many units also exclude children who are less than 5 kg because of the risk of hypothermia or hypoglycaemia associated with their physical status.
Psychosocial factors also determine a child's suitability for day surgery, and may limit access to day surgery especially in single parents with many children and little support, or very timid children with overly anxious parents.
Therefore, while the range of surgical procedures undertaken is similar to adult day surgery, in children it is often confined to a more restricted list (
Box 3.4
). In the anaesthetic room, venous access is obtained after the application of topical local anaesthetic 1 hour before; parental presence in the anaesthetic room is useful, especially in the preschool group. Postoperative pain relief is obtained first through adjunctive local or regional anaesthesia. NSAIDs cannot be given to children under 1 year of age or 10 kg in weight because of their immature kidneys, but paracetamol is effective if given in a premedication dose of 20 mg/kg. Before discharge, the parents require clear instructions regarding pain control, wound care, mobilisation and resumption of normal activities.
Box 3.4
Paediatric day surgery procedures
General surgery
Herniotomy, hydrocele excision, examination under anaesthesia, anal stretch, excision of minor lumps and bumps, ingrowing toenail treatment, endoscopy, biopsy (rectal, skin, lymph node)
Urology
Circumcision and associated procedures, orchidopexy
ENT
Myringotomy/grommets, adenoidectomy, tonsillectomy
Dental
Extractions
Ophthalmology
Correction of squint
Orthopaedic
Change of plaster cast
The shift of elective surgery from the inpatient setting to short stay and eventually day care is now inexorable and will continue to be driven by three factors. The first and most important is the natural dislike in most people of in-hospital stays, accelerated by the growing fear of hospital-acquired infections; most people prefer to be at home, and as soon as a day surgery procedure can be shown to be performed as safely and effectively as in the traditional inpatient setting, most of us will opt for the former.
The second drive for change is the continued growth of minimal access techniques, including the use of robotics and the development of natural orifice transluminal endoscopic surgery (NOTES).
72
These techniques are associated with less surgical trauma and reduced postoperative pain both in the short and medium term, and have led to the concept of ‘fast-track’ surgery for inpatient procedures.
54
The concomitant development of better anaesthetic and pain-relieving techniques will further reduce the need for inpatient postoperative care.
The third and greatest factor currently driving change is that of healthcare costs. By dispensing with inpatient hotel costs including staffing, procedures performed as day cases offer significant cost savings to healthcare providers and purchasers, and the impact of this can be seen in many areas:
Emergency surgery.
There has been a significant growth in emergency and urgent surgery now being performed in the ambulatory setting, which reduces costs as well as avoiding the reported postponements that occur in the inpatient setting. Recent studies have shown that care of these patients in the day unit can be preferable to inpatient care.
73
,
74
Short stay and enhanced recovery.
New research and developments in enhanced recovery are enabling the performance of more complex and advanced day surgery in patients who are anaesthetically more challenging.
54
–
59
,
75
This allows the high standards of care explicit in day surgery to be applied to early recovery and mobilisation, and discharge in these cases can usually take place in under 72 hours.
Tariffs and commissioning.
We have seen how much variability in day case rates persists across the UK.
13
New funding rules are likely to have beneficial effects on this ‘postcode lottery’. The impact of payment by results is already changing the way in which hospital trusts perceive day surgery, and its role in the delivery of elective care.
76
The added impact of both primary care commissioning
77
and tariffs that financially penalise organisations performing inpatient rather than day case procedures is accelerating the shift to day care.
78
,
79
Key points
The UK government targeted 75% of all elective surgery to be performed on a day case basis by the end of 2005.
All elective surgical patients should be pre-assessed by a nurse-led pre-assessment team who make the decision to allocate the patient to 12-hour, 23-hour or inpatient surgery.
Day surgery should be independent and separate from the inpatient infrastructure as successful day surgery depends on day of surgery admission, pre-assessment and nurse-led discharge.
Regional and local anaesthetic block techniques are ideal for day surgery but are currently underutilised.
Major surgical procedures, such as laparoscopic cholecystectomy, TURP, bilateral varicose vein surgery and arthroscopic procedures, can now be performed safely and routinely as day cases.
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