1. DAY CASE ANAESTHESIA
Dr. Omar Mohamed Danfour
Senior Lecturer –Specialist of Anesthesia & Intensive Care
(MSU-IMS-Anesthesia Department)

2. Day Case Aneasthesia
Another Name
• Ambulatory surgery
• Day-case surgery
• Same-day surgery
• Come and go surgery
Pt. who is admitted for investigation or operation on
a planned non-resident basis. The pt occupies a bed
in a ward or unit set aside for this purpose.
Outpatient surgery allows a person to return home
on the same day that a surgical procedure is
performed.

3. Day Case Aneasthesia
 During the last 30 years, there has been rapid
expansion in the use of day-case surgery.
 In the last 25 years, the percentage of pts going
home the same day has increased from < 10% to
approximately 65% in the united states
 At the inception of day-case procedures, a case was
considered suitable if it took less than 90 min to
complete (do not cause sever haemorrhage or
produce excessive amounts of postoperative pain).

4. Day Case Aneasthesia
• because investigators have found that the operating
and anesthetic time is a strong predictor of
postoperative complications (e.g., pain, emesis)and
delayed discharge, as well as unanticipated
admission to the hospital after ambulatory surgery .
 With regard to the distance from the hospital to the
pt’s home, and a responsible adult must be at
home with the pt during first 24 h after surgery
 The growth in ambulatory surgery would have not
been possible without the development of
improved anesthetic and surgical techniques.

5. Day Case Aneasthesia
 The availability of rapid, shorter -acting anesthetic,
analgesic, and muscle relaxant drugs has clearly
facilitated the recovery process and allowed more
extensive procedures to be performed on an
ambulatory basis, irrespective of preexisting medical
conditions.
 Surgical procedures suitable for ambulatory surgery
should be accompanied by minimal postoperative
physiologic disturbances and an uncomplicated
recovery.
 Prolonged stay or unanticipated admission after day -
case surgery are related to the surgical procedure
(e.g., blood loss, pain, postoperative nausea and

6. Advantages of DCA
• Significant reduction in medical costs
• Increased availability of indoor beds
• Better comfort and greater control over the patient’s
business and personal lives
• Some protection from hospital acquired infections and
deep vein thrombosis
• Less social disruption to patients and their families and
minimal need for inpatient hospital resources
• Particularly in children short separation from parents and
family is very beneficial to the reduce separation-induced
anxiety problems
• Faster recovery, more rapid discharge and better pain relief
for outpatients.
• Less preoperative testing and postoperative medication

7. Surgical procedures commonly undertaken as
day cases
1. Gynaecology:- (Dilatation & curettage, Laparoscopy, Vaginal
termination of pregnancy colposcopy & hysteroscopy.
2. Plastic Surgery:- (Dupuytren’s contracture release, removal of
small skin lesion, nerve decompression
3. Ophthalmology:-(Strabismus correction, lacrimal duct probing,
cataract surgery & examination under G.A).
4. ENT:- (Adenoidectomy, tonsillectomy, Myringotomy, insertion of
grommets, removal of foreign body, polyp removal & submucosal
resection).
5. Urology:- (Cystoscopy, Circumcision, Vasectomy)
6. Orthopaedics:- (Arthroscopics, Carpal tunnel release, anal fissure,
Ganglion removal, Lab Cholecystectomy & Haemorroidectomy )
7. General Surgery:- (Breast lumps, Herniae, Varicose veins,
Endoscopy
8. Paediatrics:- (Circumcision, Orchidopexy, Squint, Dental
extractions)

8. Guidelines for patient selection for day-case
surgery under G.A
A- Patients should normally be ASA I , ASA II, or medically sable
ASA III only, i.e. normally healthy people & those with minor
systemic disease not interfering with normal activities a pt with
moderate to severe systemic disease & some
functional limitation
• Age: > 52 Weeks post-conception age
• Weight: BMI < 30, (31-34 discuss with anaesthetic deparment)
• Generally healthy i.e. can climb two flight of stairs
B- Patients Exclusions:
1- Cardiovascular
• M.I/TIA/CVA within 6 months
• Hypertension (persistent diastolic > 110mmhg)
• Angina and low exercise tolerance
• Arrhythmias & heart failure & symptomatic valve disease

9. 2- Respiratory:
• Acute respiratory tract infection
• Asthma requiring regular β2-agonists or steroids
3 Metabolic:
• Alcoholism/narcotic addiction
• Insulin-dependence diabetic
• Renal failure & or Liver failure
4- Neurological /Musculoskeletal
5- Drugs
• Arthritis of jaw or neck, cervical
spondylosis or Ankylosing Spondylosis • Steriods
• Myopathies, muscular dystrophies or • Monoamine
Myasthenia gravis oxidase inhibitors
• Advanced multiple sclerosis • Antocoagulants
• Epilepsy >3 fits per year • Antiarrhythmics
• Insulin

10. Facilities Available
The hazards and risks of day-surgery general anesthesia are
no less than those for in-patient surgery; indeed, in some
respects they may be greater and the facilities provided
must be comparable
There is always the possibility of a minor operation
developing into a major operation and this demands that
the theatre is well equipped to deal with this eventuality.
1- An admission area:- Reception, treatment & examination
rooms, a nurses station, lavatories, a playroom and a
discharge area.
2- An anesthetic room:- fully equipped, good lighting,
scavenging, piped gases and suction equipment, anesthetic
machine & monitoring equipment.

11. Facilities Available
3- An operating theater:- Should be of the same
specification as the in –patient equivalent. A good
operating lighting light, air-conditioning, scrub-up and
autoclave facilities
4- A fully equipped recovery room:- must always be
equipped and staffed for the safe recovery of patient
after G.A. Piped gas supplies and resuscitation
equipment are mandatory and the full range of
monitoring and ventilation equipment must be readily
available
Other facilities that should be available include office
space, equipment store, staff room, a panty to make
drink and lavatories for patients, parents and staff.

12. O.T Preparation
Outpatient surgery Equipments:
requires the same basic – SPO2
equipment as inpatient – BP & ECG
surgery – ETCO2
Equipments: – Temperature
– Anaesthetic machine – Invasive IABP, CVP, PA
& monitors – Nerve stimulator
– Airway and intubation – BIS (Bispectral Index
adjuncts monitor)
– Suction apparatus – Gas analysis
– IVD
– Drugs
– Warming devices
– Trolley – Spinal, CVP
– Trained assistance

13. Monitor Laryngoscope
O2
Anc. Machine
IV line
Stethoscope
Defibrillator
Suction

14. • The role of anesthetists for out pt surgery is enormous
particularly regarding pt selection, preoperative evaluation
& preparation, intra-operative anesthesia management,
post operative care and safe discharge from out pt clinic. In
Unexpected adverse situations, the pt may need
hospitalization as per advice of the anesthetist concerned.
• There should be adequate number of house officers ,
nurses,& other personnel & at least one senior anesthetist.

15. Admission
• Pts should be admitted to the ward in adequate time for
history-taking and examination
• Any investigation requested as an out pts should be
available and noted.
• The surgeon should ensure the indication for surgery is still
present
• The consent form should be signed if not already done.
• The operation site should be marked
• A pregnancy test in women of fertile age
• Staggering patient admission decreases waiting times and
improve the efficiency of the unit.

16. Pre-operative Management
• Pre-operative Assessment.
• Pre-operative Preparation.
• Premedication.
The purposes of pre-operative visit.
• History taking.
• Physical Examination.
• Risk Assessment.
• Common causes for postponing Surgery.

17. ANAESTHETIC EVALUATION
Clinic
Ward
Theater

18. ANAESTHETIC EVALUATION
1- History
2- Physical examinations
3- Review investigations
 ASA classification

19. PREOPERATIVE ASSESSMENT

20. premedication
Not routinely prescribed for day cases, as it is usually
unnecessary. Drug that may be used include the following:
A- Benzodiazepines:
• Temazepam 10-20 mg is effective anxiolytic for day cases,
no delay in recovery times as measured by memory test
cards and all pts were discharged from the day unit 3 h
after administration of GA.
• Oral Midazolam has been used, but it associated with delay
in immediate and late recovery compared with Temazepam
B- Antiemetic:
• Oral or & I.V, antiemetic may administered before
operation or rectal antiemetic perioperatively if pts are at
high risk of postoperative nausea and vomiting (PONV).

21. C- Antacids:
• If there is a risk of acid reflux, H2-antagonist are
commonly prescribed as a premedication in day surgery.
D- Analgesics:
• Routine use of narcotic (opioid) analgesics for premedication is
not recommended unless the patient is experiencing acute pain
• Oral NSAIDs and paracetamol may be given preoperatively if
declines rectal route perioperatively
• Oral COX II inhibitors have better GIT side effect profiles than
NSAIDs and less antiplatelet effects
• Pt satisfaction with self- administration of rectal Diclofenac
preoperatively has been reported
• Dermal application of tetracaine over a vein has a useful role
for children & nervous adults or those with a neddle phobia.

22. TYPE OF ANAESTHESIA
GA C
RA

23. Optimal Anesthetic Techniques
• The optimal anesthetic technique in the ambulatory
setting would provide for excellent operating
conditions, rapid "fast-track" recovery without
postoperative side effects or complications, and a
high degree of patient satisfaction.
• General, local, & regional anesthesia may be
administered safely to day-case pt. The choice of
technique should be determined by surgical
requirements, anesthetic consideration, and
patient’s physical status and preference.

24. General Anesthesia 2
For many ambulatory
procedures, general
anesthesia remains the
most popular technique
with both patients and
surgeons.
3

25. General Anesthesia
Any induction agents used in day-case anesthesia
should ensure a smooth induction, good immediate
recovery and a rapid return to street fitness.
• Propofol is now used widely as the primary
induction agent which has advantage of rapid
recovery & low incidence of PONV.
• Thiopental (3 to 6 mg/kg) is the prototypical
intravenous induction drug with a rapid onset and
a relatively short duration of action as a result of
redistribution of the drug . However, thiopental
impairs fine motor skills for several hours after
surgery and can produce a "hangover“ sensation

26. • ketamine compares unfavorably with both the
barbiturates and propofol for minor gynecologic
procedures because of its prominent psychomimetic
effects and higher incidence of PONV during the
early postoperative period
• Although midazolam (0.2 to 0.4 mg/kg IV) has
been used for induction of anesthesia in outpatients,
its onset of action is slower and recovery is
prolonged in comparison to the barbiturate
compounds and propofol.
• Sevoflurane is the agent of choice for inhalational
induction with advantage of Non irritant to the
airways, rapid induction in both children & adults,
minimal cardiovascular side effects. However,
sevoflurane causes more PONV than propofol.

27. Maintenance of anesthesia:
• Both sevofurane & desflurane are ideal agents for day-
case anesthesia
• Volatile anesthetics are associated with a higher incidence of
vomiting in the early recovery period than propofol based
anesthetic techniques
• Nitrous oxide increase the risk of PONV, but it reduce the
requirements for volatile agents & risk of intraoperative
awareness.
• Target-controlled infusion (TCI) of propofol with or
without the ultra-rapid-acting opioid remifentanil are
techniques which have minimal risk of PONV & short
recovery time.

28. • Morphine, hydromorphone, oxymorphone, and
meperidine have all been used in outpatient anesthesia
However, these opioid compounds are less popular
than the more potent, rapid, and shorter-acting opioid
analgesics (e.g., fentanyl, sufentanil, alfentanil, and
remifentanil).
• The laryngeal mask airway (LMA) is used widely &
avoids for intubation & extubation, which improves
turnaround time between cases.
• The incidence of postoperative sore throat after
ambulatory surgery was 18% with an LMA versus 45%
with a tracheal tube and 3% with a face mask.
• Patient at risk of aspiration still require a rapid-
sequence induction technique with tracheal intubation
or in these situations to minimize the risk of gastric
distention and ensure adequate ventilation in the
Trendelenbmg posinduction .

29. • Many superficial outpatient surgical procedures do not
require the use of neuromuscular relaxants.
• When remifentanil is used in combination with propofol
for induction of anesthesia, tracheal intubation can be
performed without any muscle relaxants .
• The choice of MR depends on the anticipated duration of
surgery. Succinylcholine is associated with muscle pains,
especially in ambulant patients and it is not ideal in the
day-case setting.
• NDMRs: Use of the short- and intermediate-acting
nondepolarizing muscle relaxants (e.g., cisatracurium,
mivacurium) allows reversal of neuromuscular blockade
even after brief surgical procedures
• Mivacurium may be advantageous for use during the
maintenance period because reversal is seldom required if
the drug is properly titrated

30. Antagonist (Reversal) Drugs
• Antagonists may also produce unwanted side
effects (e.g., dizziness, headaches, PONV) that
should be considered before routinely using these
drugs.
• In addition, because their duration of action is often
shorter than the agonist (e.g., naloxone,
flumazenil), a "rebound“ of the agonist effect may
occur.

31. Regional Anesthesia
Regional anesthesia can offer many advantages for the
ambulatory patient population .
 Spinal anesthesia has been used for day-case
anesthesia, but the side effects of post-dural puncture
headache & motor weakness, dizziness, urinary
retention, and impaired balance may delay ambulation
& discharge. Smaller-gauge pencil spinal needles have
reduced the incidence of PDPH
• Shorter-acting local anesthetics may increase the use of
day-cases. Prilocaine, Mepivacaine with or without opioid
(pethidine, fentanyl), have also been used for out
patient.
• Bupivacaine (3ml 0.17%) + 10μ Fentanyl has been used
successfully for knee arthroscopy

32. Epidural anesthesia is technically more
difficult to perform, it has a slower onset of action,
the potential for intravascular or intra-thecal
injection exists, and it is associated with a greater
chance of an incomplete sensory block than spinal
anesthesia.
Caudal block is used to reduce pain in paediatric
pts for circumcision, herinorraphy, hypospadias or
orchidopexy using 0.25% plain bupivacaine; this
provides excellent post operative analgesia.
Local anesthetic block are an excellent choice
for day-case pts because of the low incidence of
PONV & good post operative analgesia

33. Peripheral nerve blocks facilitate the recovery
process by minimizing the need for postoperative opioid
analgesics.
Therefore, an increasing number of ambulatory cases are
being performed with a combination of local anesthetic
nerve blocks and intravenous sedation (so-called
monitored anesthesia care [MAC])
• Femoral & sciatic N B give superior analgesia after
complex knee surgery
• L.A blocks e.g. ilioinguinal Nerve Block for inguinal hernia
repair, Brachial plexus block for hand & arm
Intra-articular local anesthetics are useful following
arthroscopy of the knee or shoulder.
intravenous regional anesthesia (Bier’s block) For
short superficial surgical hand & forearm procedures «60
minutes) limited to a single extremity, technique with
0.5% Lidocaine is a simple and reliable technique

34. Monitored Anesthesia Care
Cerebral Monitoring
• Monitoring patient vital signs remains the most
common method for determining the "depth of
anesthesia" during surgery.
• Recent studies have suggested that the use of
cerebral monitoring improves early recovery after
general anesthesia in the ambulatory setting
because of its ability to minimize both
"overdosing" and "underdosing “ with both
intravenous (e.g., propofol) and inhaled anesthetic
(e.g., sevoflurane and desflurane) drugs during the
maintenance period.

35. Recovery and Post operative care
• The recovery area should be provided with the same range
of monitoring equipment and resuscitation facilities as
available in an inpatient facilities.
• Post operative pain control should be started pre-or intra-
operatively by IV or inhalational anesthesia with
combination of NSAIDs, Paracetamol, shorter acting opioid
and local/regional block
• For routine antiemetic prophylaxis, the most cost-effective
combination consists of low dose droperidol (0.5 to 1 mg)
and dexamethasone (4 to 8 mg).
• PONV may be treated with IV 5HT3 antagonist,
dexamethasone, or cyclizine & IM prochloroperazine as
well as adequate analgesia & hydration.

36. Recovery
• The three stages of recovery after ambulatory
surgery are the early, intermediate, and late
recovery periods .
• The early and intermediate recovery stages occur
in the ambulatory surgical facility, whereas
• The late recovery refers to the resumption of
normal daily activities and occurs after discharge
home

37. Early recovery
• The time interval during which patients emerge
from anesthesia, recover control of their
protective reflexes, and resume early motor
activity.
• During this phase of recovery, patients are cared for
in the post anesthetic care unit PACU, where their
vital signs and oxygen saturation are carefully
monitored and supplemental oxygen, analgesics, or
anti emetics can be readily administered.

38. Intermediate recovery
• During the intermediate recovery period, patients
are usually cared in a reclining chair and
progressively begin to ambulate, drink fluids, void,
and prepare for discharge.
• Most ambulatory surgical facilities have a separate
area for the intermediate recovery of outpatients to
a home-ready state

39. late recovery
• The late recovery period starts when the patient is
discharged home and continues until functional
recovery is achieved and the patient is able to
resume normal activities of daily living.
• The anesthetics, analgesics, and anti emetics can
also have an effect on the patient's recovery during
the post-discharge period.
• However, the surgical procedure itself has the
highest impact on the patient's full functional
recovery.

40. Factors that predict a more prolonged stay in the
day-surgery unit include female gender, advanced age,
longer operations, large fluid or blood loss and opioid use,
nondepolarizing muscle relaxants, postoperative pain and
PONV, and spinal anesthesia.

41. DISCHARGE CRITERIA
Discharge after General Anesthesia
and Monitored Anesthesia Care
Guidelines for safe discharge from an ambulatory
surgical facility include stable vital signs, return
to baseline orientation, ambulation without
dizziness, minimal pain and PONV, and
minimal bleeding at the surgical site.

42.  Patients who achieve a score of 9 or greater and have an
adult escort are considered fit for discharge (or home ready).

43. Discharge After Regional Anesthesia
With spinal or epidural anesthesia,
• It is generally accepted that motor and sensory
function returns before sympathetic nerve function.
• Residual blockade of the sympathetic nerve supply to
the bladder and urethra may cause urinary
retention.
• Before ambulation, these patients should have
normal perianal (S4-5) sensation, the ability to
plantar-reflex the foot, and proprioception of the
big toe.
• Thus, discharge criteria after spinal and epidural
anesthesia should include the return of normal
sensation, muscle strength, and proprioception, as
well as the return of sympathetic nervous function.

44. General Advises
• Pts should be advised against driving, Operating power
tools, making important decisions, and ingesting
alcohol for at least 24 hrs after the procedure.
• Pts should be advised that they may experience pain,
headache, nausea, vomiting, dizziness, and skeletal
muscle aches and pains that can’t be attributed to the
surgical incision
• It must be confirmed that a responsible adult will
accompany (drive) the pt home and if appropriate
remain with the pt for some period of time
• At some facilities, staff members telephone the pt the
next day to determine the progress of recovery.