Day case
An overview of anaesthesia
and patient selection for
day surgery
Matthew Molyneux
Nia Griffith
Abstract
Day surgery is increasingly recognized as the best form of treatment
for a wide range of patients and procedures. As day surgery becomes
more widely available, older patients with comorbidities and patients
needing complex surgery are increasingly considered as suitable day
cases. Standards for day surgery must be the same as for inpatient
treatment and organization is the key to the successful running of a
day unit. Day surgery needs to be meticulously planned, with appropri-
ate patient selection, modern surgical and anaesthetic techniques, plus
robust discharge criteria and follow-up. Attention to detail with good
control of postoperative pain, nausea and vomiting are essential. Patient
preference and choice may dictate where day surgery is performed in
the future.
Keywords ambulatory surgery; analgesia; day surgery; investigations;
pre-assessment; postoperative nausea and vomiting; selection criteria
Anaesthesia for day surgery is an expanding subspecialty. During
the 1990s the proportion of operations performed in the UK as
day cases increased from 34% to 65%. However, the 2001 Audit
Commission Report showed that day-case units were not being
used to their maximum capacity. The NHS Plan 2000 envisages
that 75% of all elective surgery will be carried out as day cases
‘in the near future’, despite hospitals not performing at uniformly
high levels across all specialties.
Patient safety and departmental efficiency are paramount to a
successful day-case unit. An interdisciplinary team approach to
selecting and assessing patients, ordering appropriate investiga-
tions and preparing the patient for surgery is vital. Surgical and
anaesthetic techniques must be tailored to day-case patients and
discharge criteria must be robust. The incidence of major adverse
events with day surgery is low.
Matthew Molyneux, FRCA, is Specialist Registrar at Southmead Hospital,
Bristol, UK. He qualified from St George’s Hospital Medical School,
London, and is currently on the Bristol rotation. His interests include
simulation medicine and regional anaesthesia.
Nia Griffith, FRCA, is Consultant Anaesthetist at Southmead Hospital,
part of North Bristol NHS Trust. She qualified from the University
of Wales College of Medicine, Cardiff and trained in anaesthesia in
Northampton, Oxford, Reading and Lyon, France. Her main interests
are day surgery and regional anaesthesia.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Day surgery is defined as ‘the admission of selected patients
to hospital for a planned surgical procedure, who return home on
the same day’. ‘True day surgery’ patients are defined as those
who require full operating theatre facilities, with or without a
general anaesthetic, and day cases not included as outpatient or
endoscopy patients.
‘Extended’ day-case units (23-hour units) are increasingly used
to support more major surgical procedures. These units may also
assist the transfer of operations from inpatient to day case and allow
the extension of operating times into the early evening. The capac-
ity of extended day-case units needs to be planned, otherwise any
excess may be taken over by emergency medical or surgical cases
and existing day surgery will be compromised. However, when day-
case patients stay in hospital overnight they are no longer classified
as such. Some trusts arrange hotel facilities close to the day unit.
Benefits of day surgery
The benefits of day surgery are listed below.
• Patients receive treatment that is suited to their needs and
­allows them to recover in their own home.
• Cancellation of surgery due to emergency pressures is unlikely
in a dedicated day-case unit.
• The risk of hospital-acquired infection is reduced.
• Inpatient beds are released for major surgical cases.
• Junior clinicians may be released if there is an effective, nurse-
led pre-assessment service overseen by a clinical lead (ideally, an
anaesthetist).
• Trusts improve their throughput of patients and reduce
­waiting lists.
• Primary Care Trusts can commission cost-effective healthcare.
Facilities and list planning in the day-surgery unit
The most efficient day-case units are integrated and ring-fenced.
Features of an ideal day-case unit are listed in Table 1. The facili-
ties ­available at a day-case unit should include:
• preoperative assessment area
• admissions/waiting area
• changing rooms
• dedicated day-surgery theatres, with or without anaesthetic
rooms
• first-stage recovery area using day-surgery trolleys rather than
beds
• second-stage recovery/discharge area.
Placing inpatients and day-case patients on the same list is
inefficient, inappropriate and may increase the number of can-
cellations. However, if separate lists are not possible, day-case
patients should be placed first on an inpatient list. The use of
inpatient wards for day-case patients is not acceptable.
Patient selection
The appropriate selection of patients who are suitable for day
surgery is the basis of good practice, together with the use of
modern surgical and anaesthetic techniques. Since day surgery
started, the definition of an ‘acceptable’ patient has changed
and strictly held criteria have been relaxed. The question has
now become, ‘is there any reason why this patient should not be
treated as a day case?’ In the process of patient selection three
areas should be considered: type of surgery, the patient’s social
factors and medical conditions.
116 © 2007 Elsevier Ltd. All rights reserved.
 Day case
Features of an ideal day-case unit
• A senior manager directly responsible for day surgery only
• Preoperative assessment procedure undertaken by dedicated
day-surgery staff
• Efficient scheduling and careful planning of case-mix
• Clear policies and protocols for running the unit, focusing on
patients
• Appropriate levels of staff, who are multi-skilled
• Effective follow-up and outreach with key audit measures
• Involvement of patients, the public and community
practitioners
Table 1
Type of surgery: the Audit Commission and the British Associa­
tion of Day Surgery (BADS) have produced a list or ‘basket’ of
25 surgical procedures that are suitable for day surgery. The
pro­cedures in each hospital will vary according to local agreed
policy. Suitable procedures should:
• be short (maximum 2 hours)
• lead to minimal physiological insult
• not cause excessive blood loss or fluid shifts
• not be associated with serious postoperative complications
• involve only pain that can be controlled with oral analgesics.
As more complex procedures are added to the day-unit list,
the postoperative assessment and discharge criteria become
more important.
In 2006, BADS produced a ‘Directory of procedures’ which
­recommends the proportion of procedures for different types of
day-unit case: procedure-room surgery (e.g. banding haemor-
rhoids 100%, ‘manipulation under anaesthetic’ fractured nose
95%); traditional day surgery (e.g. primary repair inguinal her-
nia 95%, haemorrhoidectomy 65%); 23-hour stay (e.g. septo-
rhinoplasty 90%, anterior cruciate ligament repair 65%); under
72-hour stay (e.g. subtotal thyroidectomy 80%).
Procedures such as laser resection of the prostate, parathy-
roidectomies and vaginal hysterectomies are now being identi-
fied as day-surgery procedures. Surgeons are being encouraged
to review the type of operation and postoperative management
of some of the procedures they perform as ‘minimal access sur-
gery’ becomes routine and hospital stay reduces. For rapid and
seamless management of day-case patients, early access to other
healthcare facilities such as physiotherapy, plastering services
and occupational therapy is required.
Social factors: without a social support structure in place even
the healthiest patient undergoing minor surgery is not suitable
as a day case. A responsible adult needs to bring the patient to
the day-surgery unit and care for them for at least 24 hours after
discharge, or longer for more invasive procedures. Important
­factors for the social support for the day-case patient are shown
in Table 2.
Medical conditions: the general medical status of the day-case
patient (e.g. asthma, ischaemic heart disease, chronic obstruc-
tive pulmonary disease (COPD), epilepsy) should be reviewed
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Social support for the day-case patient
• The carer should be a responsible adult and a relative,
trusted friend or established carer
• Both patient and carer must be able to understand
instructions provided by healthcare staff
• The carer must know the circumstances under which the unit
should be contacted and also know who to contact
• The patient should be cared for at home, which should
ideally be less than 1 hour away from the unit
• A telephone and toilet facilities should be available and
easily accessible at the patient’s home
Table 2
and specific anaesthetic issues, such as difficult airway, reflux,
previous anaesthetic complications, noted (see below).
Patient assessment
An integrated care pathway (ICP) is ideal for day surgery. An ICP
contains all the patient information in one standardized booklet,
including assessment, relevant investigations, consent, the anaes-
thetic and surgical record, recovery, discharge and follow-up.
The ICP ensures that the patient is screened for surgical, social
and anaesthetic factors and that the information is immediately
available to the anaesthetist on the day of surgery. This avoids
repetition of the history, examination and investigations and
allows the anaesthetist to focus on specific issues of concern. An
ICP is also beneficial for audit purposes.
Nursing staff who are trained in day-surgery assessment
screen patients for any medical pathology and potential anaes-
thetic problems according to locally developed guidelines. If
concerned, the nurses can discuss any issues with a designated
consultant anaesthetist and seek advice on the suitability of a
patient for day surgery or referral to appropriate specialties. Gen-
erally, treatment of underlying medical conditions needs to be
optimized before surgery by the patient’s general practitioner.
This interdisciplinary team approach is key to an efficient, safe
unit and reduces the number of cancellations on the day of sur-
gery. Telephone assessments of patients may be used, but face-
to-face interviews give better patient satisfaction, reduce anxiety
and improve the patient’s understanding of the procedure. Writ-
ten information about the procedure and admission process may
also be given to the patient at an interview to reinforce verbal
information. Preoperative assessment also provides an opportu-
nity for the patients to familiarize themselves with the day unit
and be given information about preparation for admission.
Medical background and history
Generally, patients of American Society of Anesthesiologists
(ASA) grades 1 and 2 are suitable for day surgery. ASA grade 3
patients should also be considered and may well benefit from
day surgery. However, there are no strict rules. Experience and
­common sense applied to the surgical and anaesthetic require-
ments are very important. Careful pre-admission screening, op­­
timization of fitness before admission, consideration of local or
regional anaesthesia and skilled anaesthesia with identification of
117 © 2007 Elsevier Ltd. All rights reserved.
 Day case
those who need overnight admission postoperatively is important
in those less fit patients.
Age is not a contraindication to day surgery; however, it increases
the likelihood of other diseases, especially hypertension and car-
diac disease. Children benefit from being treated as day cases.
Airway: patients with known or likely difficulties in tracheal
intubation should be excluded because of the lack of specialist
equipment and expertise readily available, especially in a stand-
alone unit. Planning and turnover of the list is also disrupted.
Reflux is not a contraindication to day surgery. It should be
screened for in the assessment, treated preoperatively if possible,
and a safe anaesthetic technique applied (i.e. a rapid-sequence
intubation if required).
Respiratory disease: asthma, chronic obstructive pulmonary
disease and smoking are common. Provided these conditions
are well controlled, patients are suitable for day surgery. Poor
control, recent exacerbation of symptoms or severe exercise
limitation in these patients requiring general anaesthesia is an
­indication for postponement of day surgery (pending investi-
gations and therapy) or exclusion from day surgery in favour
of inpatient treatment. Obstructive sleep apnoea is contra­
indicated for general anaesthesia as a day case, although local
and regional anaesthetic techniques may be considered for this
group.
Cardiovascular disease: absolute contraindications to day sur-
gery comprise:
• myocardial infarction within the past 6 months
• angina causing marked limitation in daily activity
• congestive cardiac failure
• symptomatic valvular disease
• cardiomyopathy
• tachyarrhythmias
• second- or third-degree heart block.
Relative contraindications for cardiovascular disease comprise:
• myocardial infarction more than 6 months previously
• untreated mild angina
• high blood pressure (systolic >175 mm Hg or diastolic
>100 mm Hg)
• cerebrovascular accident in the past 6 months
• controlled atrial fibrillation
• previous deep vein thrombosis or pulmonary embolism.
Patients with relative contraindications should have their
treatment optimized before surgery. If the patient is able to climb
at least one flight of stairs (equivalent to 4 metabolic equivalents
(METs); 1 MET is the oxygen consumption of healthy man at
rest −3.5 ml/kg/min) the perioperative cardiac risk is low and
day surgery is suitable. Patients at risk of thrombosis risk will
need compression stockings, clexane and early mobilization.
Hypertension: hypertensive patients should have their blood
­ ressure controlled before selection for day surgery. Once
p infections)
­identified at pre-assessment the patient should return to their
GP’s care for blood pressure control with a delay of surgery for
at least 2–4 weeks for adjustment. An ECG is essential as cardiac
disease is an association.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Diabetes: patients with well-controlled diabetes are suitable for
day surgery. The assessment should ensure:
• no history of repeated hypoglycaemic attacks or recurrent
­admissions to hospital with complications of diabetes
• HbA1c lower than 8%
• patient and carer are able to measure blood glucose at home
• patient and carer understand hypoglycaemia and its treatment.
Special consideration must be given to patients with diabetes
who have a history of postoperative nausea and vomiting (PONV)
or those having surgery likely to result in reduced oral intake
postoperatively. These patients should be treated as ­inpatients.
Patients with non-insulin-dependent diabetes that is well con-
trolled should omit their oral hypoglycaemic agents on the morn-
ing of surgery and restart with the first meal after surgery. Blood
glucose should be recorded 1 hour before, during and at 2-hourly
intervals after the procedure until the patient’s first meal.
Patients with insulin-controlled diabetes are more susceptible
to hypo- or hyperglycaemia. These patients should be scheduled
first on a morning list. Local guidelines on perioperative insulin
dosing regimens should be followed. Typically, the dose of long-
acting insulin the night before is reduced by one-third and the
morning dose of insulin is omitted. Subcutaneous, short-acting
insulin is resumed with the first meal. Blood glucose needs to be
checked hourly perioperatively.
Obesity: comorbidities, anaesthetic problems and postoperative
complications are all more common in obese patients. Compli­
cations associated with obesity are summarized in Table 3. In
addition, healthcare staff are also at risk when moving obese
patients and the weight limit of trolleys, theatre tables and beds
may be exceeded. Patients with a body mass index (BMI) of less
than 35, with limited comorbidities are usually suitable for day
surgery and those with a BMI between 35 and 40 may be suit-
able for minor procedures provided an experienced anaesthetist
is present. In practice, obese patients may provide intraopera-
tive challenges but rarely fail to reach the criteria required for
discharge.
Complications associated with obesity in day surgery
• Sleep apnoea
• Ischaemic heart disease
• Hypertension
• Diabetes
• Gastrointestinal reflux
• Difficult intravenous access
• Difficult intubation
• Problems with monitoring (blood pressure cuffs)
• Difficult placing of regional blocks
• Perioperative hypoxia
• Prolonged surgery
• Postoperative wound complications (delayed healing and
• Postoperative chest infections
• Increased risk of deep vein thrombosis or pulmonary embolism
Table 3
118 © 2007 Elsevier Ltd. All rights reserved.
 Day case
Renal system: day surgery is generally not suitable for patients
undergoing haemodialysis or chronic ambulatory peritoneal dia­
lysis because of practical difficulties and comorbidity. However,
some simple procedures can be undertaken (e.g. fistula forma-
tion, carpal tunnel decompression and other local anaesthetic
procedures).
Liver disease: patients with advanced liver disease are unsuit-
able for day surgery.
Neurological disease: epilepsy is not a contraindication to day
surgery. Patients who have well-controlled epilepsy and infre-
quent fits are suitable. Patients with neuromuscular disorders,
myasthenia gravis, or myotonias are not suitable. Those with
multiple sclerosis or myalgic encephalopathy may be suitable for
minor procedures.
Psychiatric patients and patients with learning difficulties:
many of these patients benefit from a short stay in hospital and
rapid return to their normal environment. The patient’s usual
medication should be given. A carer familiar to the patient should
be present while the patient is on the ward and also at induction
and recovery.
Pregnancy: all women of childbearing age should be asked
about the possibility of pregnancy. Anaesthesia at any stage
carries some risk for the mother and fetus.
Recreational drug use: the risk of using recreational drugs
within 24 hours of general anaesthesia should be discussed
with the patient and recorded. Particular caution should
be taken with patients using Ecstasy or cocaine because
­cardiovascular instability is more common. Cannabis use is
not a ­contraindication but it should be stopped 2 weeks before
­surgery.
Patients using narcotics (e.g. diamorphine) may experience
difficulties with pain control postoperatively. It may be necessary
to admit these patients for pain management under the guidance
of a pain team.
Prescribed drugs: patients should be asked to bring all their
regular drugs in to hospital with them. Most drugs should be
taken as normal on the day of surgery, including cardiac, anti-
hypertensive, anticonvulsant and antireflux medication. Spe-
cific advice should be given to patients taking warfarin and
clopidigrel. The contraceptive pill and aspirin (the latter for
prevention of myocardial infarct or cerebrovascular accident)
should be continued unless instructed otherwise by the sur-
geon. Very few patients are still taking monoamine oxidase
inhibitors; ­ however, for patients taking this type of drug,
ephedrine, metaraminol and pethidine should be considered
unsafe. Noradrenaline, phenylephrine, fentanyl, morphine and
alfentanil are safe alternatives.
Anaesthetic history: patients with a history of malignant hyper-
pyrexia, previous anaphylaxis, suxamethonium apnoea or
­significant morbidity after anaesthesia should have their notes
reviewed by an anaesthetist. These patients may be suitable as
day cases, depending on the nature of the surgery.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
Investigations
Preoperative tests: ‘Preoperative tests, The use of routine pre-
operative tests for elective surgery’, developed by consensus of
expert opinion and issued by the National Institute of Clinical
Excellence (NICE) in June 2003, is a useful guide for investiga-
tions in all elective surgery (see Further Reading).
The following tests should be performed where appropriate:
• full blood count in patients who are likely to have anaemia
• clotting screen in patients with liver disease, those who con-
sume excessive alcohol or those who are taking anticoagulants
• sickle cell test in patients of Afro-Caribbean origin
• electrolytes and creatinine in patients aged more than
70 years, those with renal or cardiac disease or diabetes, or
those taking diuretics, digoxin or steroids
• ECG in all patients aged more than 60 years and those ­younger
patients with a cardiac history or risk factors (hypertension,
dysrhythmias, diabetes, hyperlipidaemia)
• thyroid-function test to ensure euthyroid if the patient is
­taking thyroxine
• Chest radiograph, lung function tests and arterial blood gases
are rarely indicated.
Patient information
Patients should be informed at their first outpatient meeting with
their doctor that their procedure will be done in the day-case unit.
Ideally, a day-case pre-assessment nurse will also be present at this
first meeting. This affirms that their procedure is normally done as
day surgery and allows treatable conditions to be identified at an
early stage. Information leaflets specific to each procedure should
be given to the patient and carer. These leaflets contain instructions
on preoperative fasting time, which drugs to take on the morning
of surgery and advice on the time that they will be absent from
work, as well as what to expect in the perioperative period and
the level of pain and discomfort to expect postoperatively. Well-
informed patients will be less anxious and more motivated.
To reduce the incidence of non-attendance, patients should
be contacted in the week before admission to the unit to confirm
that there are no changes in their medical condition. Cancella-
tions for any reason impact significantly on the efficiency of a
day-surgery service. Nationally, more than two-thirds of cancel-
lations are initiated by the patient, with less than 10% due to
clinical reasons. This highlights the importance of patient infor-
mation and motivation in the selection process.
Anaesthetic technique
Good day-case anaesthetic management includes the following
criteria:
• patient safety as the main priority (as for inpatient anaesthesia)
• optimal conditions for the surgeon
• a rapid patient recovery
• good postoperative analgesia
• minimal nausea and vomiting.
Preoperative factors: after reviewing the nurse assessment in
the ICP and the current routine observations, the anaesthetist
should visit the patient before the list begins. At this visit the
­following should be considered or confirmed.
• Fasting guidelines should be adhered to, with 6 hours fasting
for solid food and 2 hours for clear fluids. Patients for routine
119 © 2007 Elsevier Ltd. All rights reserved.
 Day case
­ inor local anaesthetic procedures should not be expected to
m journey home, which delays their return to normal activity and
fast.
• All routine medications should have been taken if appropri-
ate, with H2-blockers or proton-pump inhibitors given if needed.
• An anaesthetic plan should be made, with appropriate patient
discussion and consent.
• Sedative premedication should be avoided. If necessary, oral
midazolam (0.5 mg/kg; maximum 15 mg) in cordial may be
given to children or temazepam (10–20 mg) to adults for severe
anxiety. Distraction techniques such as music, TV or magazines
are preferable.
• Paracetamol, 1 g for adults or 40 mg/kg load for children, with
or without non-steroidal anti-inflammatory drugs (NSAIDs) (e.g.
diclofenac or ibuprofen) given orally at least 1 hour pre-induction
is a useful adjunct to anaesthesia, has few side effects and pro-
vides intra- and postoperative analgesia. Nurses on some units
may prescribe and give simple analgesics such as paracetamol
pre- and postoperatively, following local guidelines. In practice,
slow-release ibuprofen 1600 mg provides effective, long-lasting
analgesia.
Induction and maintenance
• Total intravenous anaesthesia is widely used because of its
anti-emetic properties and the rapid emergence profile of propo-
fol. Target-controlled infusion allows smaller doses of propofol
to be given. Propofol induction and isoflurane/sevoflurane/­
desflurane maintenance are suitable alternatives; however, the inci-
dence of PONV may be higher than with intravenous ­anaesthesia.
• The use of short-acting opioids (fentanyl, alfentanil, remifen-
tanil) reduces the incidence of PONV compared with morphine
and improves recovery times.
• NSAIDs, paracetamol and local anaesthetic blocks or infiltra-
tion should be used whenever possible.
• A laryngeal mask airway is quicker and smoother than tra-
cheal intubation, but patient safety must not be compromised.
When intubating, short-acting neuromuscular blocking agents
(atracurium, mivacurium) are useful.
• Suxamethonium should be avoided (unless specifically indi-
cated) because it causes significant postoperative muscular pain
in those who mobilize early.
• Anti-emetics can be used (see below).
• Forced air warming prevents hypothermia during long pro­
cedures or when the patient undergoes greater exposure.
Postoperative anaesthesia
• Pre- and intraoperative inclusion of paracetamol, NSAIDs,
opioids and local anaesthetics should provide early analgesia.
• Fentanyl bolus (20 μg) every 5 minutes provides fast-onset
­analgesia in recovery whilst awaiting the onset of local anaesthe-
sia and simple analgesics.
• Morphine may be required but increases PONV and delays
discharge.
• Simple oral analgesics may be given in recovery to patients
once awake with mild-to-moderate pain.
Postoperative nausea and vomiting
PONV continues to be a challenge for day surgery. Up to 30%
of patients experience PONV at some point after surgery. It can
delay discharge, cause a hospital stay or distress a patient on the
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
work. The choice of anaesthetic technique affects the prevalence
of PONV, with total intravenous anaesthesia achieving the best
results. Anti-emetics are not routinely indicated and should be
reserved for treatment of PONV or as prophylaxis in high-risk
patients. The surgical risk factors for PONV include:
• oral or ENT surgery
• squint surgery
• laparoscopic surgery.
Patient risk factors include:
• female gender
• not smoking
• history of PONV or motion sickness.
When the preoperative risk factors have been identified, a
multimodal approach to prevent PONV should be used, with the
reduction of avoidable triggers. Prophylaxis can be aimed at low
(0 or 1 risk factors), medium (2–3) or high (>3) risk factors and
treated accordingly. The following should be considered when
attempting to reduce the risk of PONV:
• general anaesthesia can be avoided by using regional or local
anaesthesia
• total intravenous anaesthesia is preferable to inhaled anaes-
thetic agents
• good perioperative hydration reduces PONV
• nitrous oxide should be avoided
• morphine analgesia triples the incidence of PONV
• medium-risk patients (2–3 risk factors) should be given
­ondansetron or dexamethasone
• high-risk patients (>3 risk factors) should be given two anti-
emetic drugs after induction of anaesthesia (e.g. ondansetron
4 mg and dexamethasone 4–8 mg)
• metoclopramide in its usual dose is probably an ineffective
anti-emetic in the immediate postoperative period.
Local anaesthesia
Regional anaesthesia is widely used in Europe and America and
is increasingly popular in the UK. The advantages of regional
anaesthesia include less risk of PONV, less CNS dysfunction,
postoperative pain relief and low cost. The main disadvantage
of regional anaesthesia is the time taken to establish suitable
anaesthesia for the surgical requirements, resulting in a reduced
patient throughput. Units that regularly use regional techniques
have separate ‘block rooms’ and extra staff so that a high turn-
over is maintained.
Spinal anaesthesia should be performed with short-acting
local anaesthetics and minimal opioid to avoid urinary retention.
The patient must pass urine and show full recovery of motor
power and proprioception before discharge. Post-dural puncture
headache is more common in the day-case than in the hospital
setting. Epidurals are rarely indicated in day surgery because of
the time required to establish the block.
Peripheral nerve blocks in cooperative patients, with or with-
out sedation, are useful techniques in skilled hands. Discharge
of these patients requires their compliance with instructions spe-
cific to the block (e.g. after brachial plexus block, keeping the
arm elevated in a protective sling). Written information should
be given to the patient. Femoral nerve blocks limit mobiliza-
tion after surgery, but ankle blocks are very useful after forefoot
­surgery.
120 © 2007 Elsevier Ltd. All rights reserved.
 Day case
Recovery
After day surgery, recovery can be divided into two Phases.
Phase 1 involves the emergence from anaesthesia and the recov-
ery of protective reflexes and motor function. Phase 2 involves
the recovery of coordination and return of normal physiology.
With modern anaesthesia, Phase 1 recovery is becoming more
rapid and patients can be transferred straight from the operating
­theatre to Phase 2 recovery (fast tracking). This transfer can result
in an early discharge home. Consequently, there is no minimum
stay requirement for day surgery for most simple procedures.
Discharge
Discharge from the day-case unit should be nurse-led when cer-
tain criteria are met. Reliable discharge tools such as the Post-
­anaesthesia Discharge Scoring System can be used (see page 124).
Overnight admissions occur in approximately 1–5% of day
cases depending on the unit and the rigidity of the selection
criteria. These admissions are most frequently caused by sur-
gical factors (bleeding, perforated viscus, extensive surgery).
Anaesthesia-related causes are more common with general anaes-
thesia than with regional anaesthesia and frequently include
PONV and uncontrolled pain. Social factors may change, making
an overnight stay necessary.
Patients should be given an adequate supply of suitable
oral analgesics to take home. These usually include regular
paracetamol and ibuprofen, plus codeine phosphate or tramadol
for breakthrough pain. An anti-emetic can be given to those at
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:3
risk of PONV or to those with nausea at discharge. These should
be pre-packed, available for dispensing from the day-case unit
and be accompanied by an information leaflet on how to take the
medication. Sick notes should be issued to all day-case patients
by the surgeon to reduce the need for attending primary care.
Post-discharge telephone calls made the morning following
surgery to specific patient groups by nursing staff are appreciated
by patients and are effective at enhancing patient’s overall treat-
ment experience and satisfaction levels.
Outcome measures such as cancellations, admissions, morbid-
ity, mortality, re-admissions and patient satisfaction are impor-
tant and should be reviewed regularly. ◆
Further reading
British Association of Day Surgery (BADS). www.bads.co.uk
(accessed 23 November 2006).
Day surgery – a good practice guide 2004. www.wise.nhs.uk/cmsWISE/
HIC/HIC1/HIC1.htm (accessed 23 November 2006).
Day surgery: operational guide, waiting, booking and choice, 2002.
www.publications.doh.gov.uk (accessed 23 November 2006).
National Institute of Clinical Excellence: investigations in elective
surgery 2003. www.nice.org.uk/page.aspx?o=56818
(accessed 12 December 2006).
Smith I, ed. Day case anaesthesia. London: BMJ Books, 2000.
121 © 2007 Elsevier Ltd. All rights reserved.