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Chapter 13 – Day case surgery

General principles
A surgical day case is a patient who is admitted for investigation or operation on a planned non-resident basis and who nonetheless requires facilities for recovery.
–Royal College of Surgeons Guidelines 1992
Organization is the key to efficient good-quality day surgery and requires close cooperation between all agencies involved, including surgeons, anaesthetists, day case unit staff, general practitioners, and patients themselves.
An efficient organization requires ‘ring fenced’ theatres and ward space. Day cases on inpatient wards or theatres will suffer cancellation when there are bed shortages and emergency operations. Self-contained units with their own facilities, within an acute hospital, probably offer the best option.
Senior staff should perform day case anaesthesia and surgery. Much of the surgery and anaesthesia may be viewed as routine or simple, but it must be performed to a high standard for day units to operate efficiently.
Patient selection
In theory all patients should follow a sequential pathway. All patients should be preassessed by specially trained nurses, according to set day case criteria. However, preassessment should be approached flexibly as different methods work for different patient groups.
  • With short waiting times, patients can be reviewed at the hospital on the day of their surgical outpatient appointment.
  • Some patient groups can be telephone assessed; in particular those who have direct access surgery (not seeing a surgeon until the day of surgery).
  • Older patients need earlier preassessment at the hospital so that tests can be performed and the results reviewed prior to surgery.
  • In some hospitals surgeons book day cases after reviewing them and instructions are sent out by clerical staff. This can work well as long as the surgeon is senior and is fully conversant with the requirements of day surgery.


Preassessment nurses will discuss with the patients their health, details concerning their admission, and give written instructions about the day of surgery. It is important that patients read the advice and sign a patient agreement.
Some patients who fall outside the guidelines need to be discussed on an individual basis and may include:
  • Some ASA 3 patients who would do better in a day case environment rather than as an inpatient, e.g. chemotherapy patients, stable diabetics.
  • Many paediatric anaesthetists will anaesthetize babies as young as 6 weeks on a day case basis (provided infant was not premature).
  • Moderate obesity in itself does not preclude day stay surgery, but does cause unpredictable problems in terms of length of surgery and anaesthesia. BMI is not the ideal tool for assessing fitness for day surgery, but provides preassessment nurses with guidance. Obese patients should be scheduled mid morning to allow preoperative antacid therapy time to work and still allow time for recovery. Remember that obesity may cause as many problems to the surgeon as to the anaesthetist. In general a BMI >35 is not suitable (BMI = weight (kg)/height2 (m)).
Common coexisting disease
  • Stable asthmatics are suitable for day surgery. Regular hospitalization, oral steroid therapy, and poor control of symptoms would suggest unsuitability.
  • Stable epileptics on medication are suitable for day surgery. Avoid propofol if they have a driving licence (see p. 171).
  • Well-motivated, well-controlled diabetics having operations with a low incidence of postoperative nausea can be managed as day cases, with either general or local anaesthesia.


Cancellations and DNAs (did not attend)
Most cancellations on the day of surgery can be avoided by careful patient selection by experienced staff. It is often unavoidable to cancel patients who have an acute illness, i.e. a heavy cold, or an exacerbation of previously well controlled asthma. However, diseases such as undiagnosed hypertensive disease or uncontrolled atrial fibrillation should be discovered by preassessment at the day surgery unit.
Starvation instructions
  • Morning lists: no solid food after midnight and free clear fluids up to 0630 h.
  • Afternoon lists: no solid food after 0630h and free clear fluids up 1130h.
Preoperative verbal and written instructions are important so that milky drinks are avoided. In practice, accept drinks with 1 to 2 teaspoons of milk but treat any more as solid food and require a 6 h fast.
Patients should not drive for at least 24 h postoperatively because of residual effects of the anaesthetic. Remember that some operations themselves will preclude driving for longer because of pain and limited movement, e.g. arthroscopy and inguinal hernia repair. This advice must be contained in the preoperative verbal and written instructions given to the patient.
Preoperative investigation
The following tests should be performed when appropriate:
  • FBC only in patients with the possibility of anaemia, e.g. menorrhagia.
  • Sickle cell test in patients of Afro-Caribbean origin.
  • Electrolytes and creatinine in patients on diuretics.
  • Blood sugar in patients who are diabetic or have a urinalysis positive for glucose.
  • ECG in all patients over the age of 55 and younger patients if they have a cardiac history or signs (hypertension, dysrhythmias, diabetics).
  • Chest radiograph only for patients with COAD, breathlessness, severe chest or cardiac history. Also patients with unexplained or unexpected chest problems or signs. Very few day surgery patients should need a preoperative chest radiograph.
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