Emerging sub-speciality

More surgical operations may be performed as out-patient procedures, says DR. S. SUBRAMANYAM MUDALIAR.

DAY case surgery (or ambulatory surgery/out-patient operation) is not new. In fact, the first demonstration of anaesthesia, for dental extraction, was performed as a day case using ether on October 16, 1846 at the Massachussets General Hospital, Boston, U.S., by Dr. W.T.G. Morton. He became "the Father of anaesthesia".

In the early 1900s, Ralph Waters in Iowa, started an out-patient operation clinic. In the 1960s, the first hospital based out- patient operations were started. In future, we expect more than 70 per cent of operations to be performed as an out-patient procedure as the new millennium unfolds.

In 1984, an association called the Society for ambulatory anaesthesia was formed in the U.S.. By the end of 1985, 73 lakh elective operations were performed on an ambulatory basis.

The availability of rapid, short acting anaesthetic and pain relieving drugs has facilitated the recovery process, allowing more extensive procedures to be done on out-patients.

The meaning of day case surgery is: rapid recovery and shortened time to resume normal activities without depending on nursing or hospital care. The benefits are less expenditure (thereby the budget on health care by the government in a developing country like ours is reduced), bed strength in a hospital can be adjusted by avoiding unnecessary occupancy, patients' medical bills and sufferings are minimised, patients are ready for work the next day depending upon the surgical procedure performed, the patient's morale is boosted and attendants or the dependents are also happy.

The range of procedures done as out-patient procedures include eye surgeries (i.e. cataract), dental, gynaecological, plastic, orthopaedic, urological, dermatological and general surgery.

The quality of assurance is that this is not a sub-standard procedure and needs experienced staff, full facilities, hospital admission and experience in basic life support.

The grey areas include procedures done in dental clinics and X- ray or imaging technique rooms where facilities are much less including staff, drugs and space.

Patient selection should be appropriate. Patients should be of physical status grade I or II (that is without any other major illness), the procedure required should not take more than one or one and half hours time, the procedure should not produce excessive derangement of body physiology and excessive sedation, and immobilisation should be minimal.

The patient should be assessed by a surgeon and an anaesthesist and laboratory investigations (ECG, chest X-ray if they are aged 40 years and above) should be done preoperatively.

Preoperative preparation of the patient includes preoperative visits, psychological preparation, patient education by questionnaires or audio-visual explanations or leaflets. Administrative procedures should be minimal; consent should be had in writing from the patient as well as from the attendant.

Preoperative medication should be minimal to facilitate rapid recovery after the operation without much sedation, nausea and vomiting. Patients should "starve" for at least five hours without solid food and at least three hours without even clear fluids like water before surgery. Without any compromise, anaesthetic equipment should be state-of-the-art, with fast acting rapid recovery drugs, good post-operative pain relief and a well equipped recovery room.

Anaesthetic techniques may be either general, with the aim of facilitating rapid recovery and good pain relief, without post- operative nausea and vomiting or regional techniques like spinal anaestheisa or nerve blocks.

Discharge criteria should include stable vital signs, no evidence of respiratory depression or obstruction, normal orientation. The patient, should not drive a vehicle for at least 24 hours.

Causes of readmission include bleeding, pain, nausea, vomiting and improperly performed operations.

In conclusion, ambulatory or day case surgery has become a sub- speciality.

The writer is an anaesthetist at the Khoula Hospital, Muscat, Sultanate of Oman.

Send this article to Friends by E-Mail

Section  : Features
Previous : Nature's best dressing
Next     : Caring for baby's heart