Day Care Centre

ANKIT SINGH
Another Name
 Ambulatory surgery
 Day-case surgery
 Same - day surgery
 Come and go surgery
 Overview
 In the early 1900s, an American anesthesiologist, Ralph Waters, opened an outpatient anesthesia
clinic in Sioux City, lowa.

 This facility, which provided care for dental and minor surgery cases, is generally regarded
as the prototype for the modern freestanding ambulatory (and office-based) surgery
center.

 Interestingly, there was little ,interest in ambulatory surgical care until the late 1960s,when
the first hospital-based ambulatory surgery units were developed.
 Overview
 Over the last 3 decades, outpatient surgery has grown at an exponential rate,
progressing from the practice of performing simple procedures on healthy outpatients to
encompassing a broad spectrum of patient care in freestanding ambulatory surgery
centers.

 Development of ambulatory anesthesia as a subspecialty occurred with establishment

of the Society for Ambulatory Anesthesia (SAMBA)in 1984 and the subsequent
development of postgraduate subspecialty training programs.

 By 1985, 7 million elective operations in the United States (over 30% of all elective surgical
procedures) were performed on an ambulatory basis. Currently, more than 60% of all
elective surgery is performed in the outpatient surgical setting, and it is expected that
this number will increase to more than 70% in the near future.
 Overview

 The growth in ambulatory surgery would have not been possible without the
development of improved anesthetic and surgical techniques. 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.
Overnight admission

 An alternative to same- day surgical concept is a planned overnight admission

to the hospital after surgery.
 This approach (AM admit,23 hour, short stay, come and stay ) is often classified as
outpatient surgery and preserved many of its advantages.
 Outpatient surgery allows a person to return home on the same day that a
surgical procedure is performed.
Benefits of ambulatory surgery
 Patient preference, especially children and the elderly
 Lack of dependence on the availability of hospital beds
 Greater flexibility in scheduling operations
 Low morbidity and mortality
 Lower incidence of infection
 Lower incidence of respiratory complications
 Higher volume of patients (greater efficiency)
 Shorter surgical waiting lists
 Lower overall procedural costs
 Less preoperative testing and postoperative medication
FACILITY DESIGN AND SAFETY
Patient selection

 Characteristic of the patient

 type of operation
 psychosocial aspect of the patient
 Human and physical resource for pre & post op care
 Proximity to EMS
 Resource of skill set of both anesthesiologist and surgeon
 Surgical procedures suitable for ambulatory surgery should
be accompanied by minimal postoperative physiologic
disturbances and an uncomplicated recovery.

 The primary predictors of prolonged stay or unanticipated

admission after day-case surgery are related to the surgical
procedure (e.g., blood loss, pain, postoperative nausea
and vomiting (PONV).
Operative procedures suitable for ambulatory
surgery
 Patients undergoing procedures that are likely to be associated with
postoperative surgical complications or major fluid shifts should be
admitted to the hospital overnight. Although autologous blood transfusions
are used for more extensive outpatient plastic surgery (e.g., reduction
mammoplasty, liposuction), lengthy procedures

 Associated with excessive fluid shifts should be handled in an overnight (23-

hour) recovery facility. Similarly, operative procedures requiring prolonged
immobilization and parenteral opioid analgesic therapy are more ideally
suited to a 23-hour stay. The availability of newer analgesic therapies (e.g.,
continuous local anesthetic infusions) and ambulatory patient-controlled
analgesia (e.g., subcutaneous, intranasal, transcutaneous) may alter the
latter recommendation in the future.
 Duration of Surgery

 The duration of surgery in the ambulatory setting was originally limited to procedures
lasting less than 90 minutes 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 .
 Patient Characteristics

 Most patients seen in ambulatory surgical facilities are classified as ASA physical status I or
II. However, because of improved anesthesia and surgical care, increasing numbers of
medically stable ASA physical status III (and even some IV) patients are able to undergo
operations away from conventional medical centers.
American Society of Anesthesiologists (ASA)
Classification of Physical Status
I. A normal healthy patient
-no discernible disease; animals entered for ovariohysterectomy, castration,
declaw, cosmetic procedures
II. A patient with mild systemic disease
-skin tumor, fracture without shock, cruciate repair, uncomplicated hernia,
cryptorchidectomy, localized infection, compensated cardiac disease
III. A patient with severe systemic disease
-fever, dehydration, anemia, cachexia, moderate hypovolemia
IV. A patient with severe systemic disease that is a constant threat to life
-uremia, toxemia, severe dehydration or hypovolemia, severe anemia, cardiac
decompensation, emaciation, high fever
V. A moribund patient not expected to survive 24 hrs. with or without surgery
-extreme shock or dehydration, terminal malignancy or infection, severe trauma
 Contraindications to Outpatient Surgery

1. Serious, potentially life-threatening diseases that are not optimally managed (e.g., brittle
diabetes, unstable angina, symptomatic asthma).
2. Morbid obesity complicated by symptomatic cardiovascular (e.g., angina) or respiratory
(e.g., asthma) problems.
3. Multiple chronic centrally active drug therapies (e.g., use of monoamine oxidase inhibitors
such as pargyline and tranylcypromine) and active cocaine abuse because of the
increased risk of intraoperative cardiovascular complications, including death.
4. Ex-premature infants less than 60 weeks' post conceptual age requiring general
endotracheal anesthesia
5. Lack of a responsible adult at home to care for the patient on the evening after surgery.