FRCA Notes

The main aims of anaesthesia for day surgery are to facilitate:

Rapid return to normal conscious state

By avoiding long-acting drugs in general
Use anaesthetic techniques which promote clear-headed emergence e.g. TIVA, short-acting volatile or avoid GA altogether

Effective, multi-modal, peri-operative, opioid-sparing analgesia to promote a rapid return to normal mobilisation

Avoidance of PONV, dizziness and drowsiness to facilitate a rapid return to normal oral intake

Regional techniques can provide excellent anaesthesia and analgesia, be it simple wound infiltration, single-shot blocks or catheter-based techniques
The advent of longer-acting agents may increase use e.g. liposomal bupivacaine is now licensed in the USA and has a long effect profile than standard bupivacaine
Unfortunately, regional anaesthesia accounts for 40% of complaints following day surgery despite accounting for <25% of anaesthetic techniques used

Patients may be safely discharged with residual sensorimotor blockade from a regional technique, so long as:

The limb is protected
The patient is educated on the expected duration of the blockade
The patient receives written instructions about conduct until sensation/power normalises
Support is available if required

Spinal anaesthesia has become accepted for day surgery, especially with the advent of newer, shorter-acting local anaesthetic agents

Benefits

Reduced post-operative pain scores and analgesic requirements
Lower rates of PONV
Improved patient engagement
Suitability for more comorbid (cardiac, pulmonary, obese) patients in whom GA may be less preferable
Faster discharge

Technique

Appropriate targeting of spinal anaesthetic can minimise side effects such as hypotension or prolonged motor blockade, e.g.

Using the minimum dose required to provide sufficient anaesthesia (as duration of block is proportional to dose)
Lateral lying for unilateral knee arthroscopy
Sitting position for peri-anal procedures

Use a 25G pencil point needle, as it reduces PDPH risk to <1%
Information on PDPH should be given with discharge instructions

Restricting IV fluids to ≤500ml should reduce the incidence of urinary retention

If intra-operative hypotension occurs, vasopressors should be used preferentially
Patients need to have voided in order to fulfil discharge criteria

There should be a robust analgesic plan in order to prevent significant pain when the block wears off
Criteria for safe mobilisation post-operatively should be followed, including

Return of S4-5 (peri-anal) sensation
Ability to plantarflex foot
Return of big toe proprioception

Local anaesthetic choices

Local anaesthetic options

Heavy prilocaine 2%

2-chloroprocaine 1%

Heavy bupivacaine 0.5%

Levobupivacaine 0.25 - 0.75%

Choice ultimately depends on factors such as required block height, required duration of block and nature of the surgery proposed
NB lidocaine not recommended owing to prevalence of transient neurological symptoms (1 in 7) with its use in a dose-/concentration-independent manner

Neuraxial opioids

Short-acting opioids such as fentanyl and sufentanil have been used as adjuncts
They may provide more effective post-operative analgesia but suffer from classic opioid-associated side-effects including PONV, urinary retention and pruritus
Typically avoided for ambulatory surgery

Complications

Delayed mobilisation; less common with shorter-acting agents
Urinary retention

Requires regression of sensory blockade to below S3
Keeping IV fluid to <500ml can reduce risk
Avoiding IT opioids can reduced risk
No reported cases with 2-chloroprocaine

The usual complications of neuraxial anaesthesia

Post-operative pain after day surgery is common

The incidence of moderate-to-severe pain may be as high as 25 - 30%
The frequency of inadequate post-operative pain relief varies according to surgical type

It is associated with negative sequelae including being psychologically unpleasant, increased incidence of PONV, sleep disturbance, delayed mobilisation and failed discharge
Protocolised evaluation and evidence-based analgesic regimens can improve pain management and patient satisfaction

Pre-operative

Identify patients at high risk of difficult perioperative pain management e.g. high anxiety, chronic pain, opioid tolerance
Patient education, preparation and expectation management
Premedication with oral paracetamol and NSAID

Intra-/Post-operative

Minimally invasive surgical techniques are preferred to reduce pain
Multi-modal analgesic regimen is mandatory

Simple analgesia

Paracetamol
NSAID if not contraindicated; slow-release ibuprofen may be beneficial to avoid missed doses

Opioids

Must balance analgesic benefits with side-effects
Use short-acting opioids e.g. fentanyl intra-operatively and IR-morphine immediately post-operatively
Use of long-acting opioids is discouraged

Non-opioid adjuncts can reduce opioid requirements but the optimal dosing is not known and can themselves cause discharge-delaying side-effects

Gabapentinoids
Ketamine
ɑ₂-agonists
IV lidocaine

Discharge

Include written information on pain management to improve compliance and understanding
Pain often worse on the day post-operatively as the patient mobilises
In general require regular analgesia for three days post-operatively

PONV

Risk-assess patients and stratify anti-emetics accordingly
Manage PONV as standard

VTE

The growing range & complexity of surgery performed as day cases may increased the risk of VTE
National guidelines for the assessment and prophylaxis of VTE should be followed
Interventions include:

Use of TEDs peri-operatively
Early mobilisation
Patient education
Adequate hydration
Prolonged course chemical VTE prophylaxis for patients at higher risk inc. obese patients

Anaesthesia and Analgesia for Day Surgery