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Day of admission

The patient should be admitted to the unit and a check made to ensure there have been no changes in their health and home circumstances. Patients should be reviewed by both the surgeon and the anaesthetist who will be looking after them.

Perioperative Management

Pain control

Success of ambulatory surgery is dependent on the management of postoperative pain. Pain should be assessed throughout the patients stay. This is usually performed in adults by using a Visual Analogue Scale (VAS) which consists of a 10cm line with words ‘no pain’ at the start and ‘worst imaginable pain’ at the end. The patient is asked to put a cross in a position on the line which represents how much pain they are experiencing at the moment. The distance along the line is measured and recorded. A measurement of less than 3 cm is often accepted as indicating acceptable analgesia. Pain control requires a multimodal or balanced approach using local anaesthesia, Non Steroidal Ant-inflammatory Drugs (NSAIDs), paracetamol, short acting opioids (alfentanil, fentanyl) and the avoidance of long acting opioids (morphine) where possible.
Pain management requires a team approach involving the surgeon, anaesthetist and the nursing staff. For example pain at the end of laparoscopic surgery can be minimised by
  • infiltration of local anaesthesia into the port sites before they are inserted
  • letting out as much carbon dioxide as possible from the abdomen
  • using normal saline peritoneal lavage at the end of the procedure

Infiltration anaesthesia

Infiltration of the operative site with local anaesthetic is simple, safe and provides satisfactory analgesia after most operations. There is evidence that the infiltration of local anaesthesia prior to skin incision provides better postoperative analgesia and may reduce the intra-operative analgesic requirements. Topical local anaesthetic as eye drops or local anaesthetic creams e.g. EMLA cream also provide effective postoperative analgesia for procedures such as squint surgery and circumcision.

NSAIDS

NSAIDS should be given whenever there are no contra-indications. The use of the intravenous or PR routes of administration is not necessary and there is evidence that giving the first dose orally about 1-hour preoperatively produces better and longer lasting pain relief.

Paracetamol

Paracetamol has well established safety and analgesia profile and it reduces the need for more potent opioids with their unwanted side effects. Intravenous paracetamol is available in many countries but is expensive – appropriate oral dosage given preoperatively should form part of the multimodal approach to pain relief.

Regional Anaesthesia

Peripheral nerve blocks can provide excellent conditions for ambulatory surgery. Patients may be discharged home with residual sensory or motor blockade, provided the limb is protected and assistance is available for the patient at the home.
The introduction of low dose spinal anaesthesia has increased the suitability of central neural blockade for ambulatory surgery. This can be useful for lower limb, perineal and lower abdominal procedures and may allow more problematic patients to be done as a day case. The use of small gauge pencil point needles has reduced the incidence of post dural puncture headache to less than 1%.