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Rapid recovery and a minimum of residual effects are factors of utmost importance when handling the day-case patient. Prolonged preoperative fasting should be avoided. Many countries have adopted revised fasting guidelines that allow patients without risk factors to eat a light meal up to 6 hours and to ingest clear fluids up to 2 hours prior to the induction of anesthesia. Postoperative fatigue can be reduced by fluid intake up to 2–3 hours prior to surgery.
Perioperative intravenous fluid therapy should be instituted on the basis of the case profile. In general, fluid infused during minor surgery may not exert a major effect, but during intermediate surgery, such as laparoscopic cholecystectomy, a liberal fluid program has been shown to improve recovery and reduce postoperative fatigue. Administration of about 1 liter isotonic electrolyte solution to compensate for the fasting, and a further 1 liter during surgery, improves the postoperative course. Liberal fluid administration also reduces the risk for postoperative nausea and the risk vs. benefit seems to be in favor for its routine use in ASA 1–2 patients. The potential benefit in adding dextrose to the intravenous fluid during the early postoperative phase has been assessed, but the benefit seems to be very minor.
Resumption of oral intake, drinking, and eating are traditional variables for the assessment of eligibility for discharge and thus an essential part of day surgery. However, there is no need for patients to drink before discharge; intake of fluid and food should be recommended but not pushed.*
Day surgery is expanding. More patients and procedures are transferred from traditional in-hospital care to day-case or short-stay logistics. This trend – to shorten the hospital stay – affects the preparation and planning of patient care. The concept of fast tracking has become well established in a variety of surgical settings and is a most fundamental part of day surgery.[1] Rapid recovery and a minimum of residual effects are factors of utmost importance for the handling of the day-case patient. Resumption of oral intake, drinking, and eating are traditional variables for the assessment of eligibility for discharge and thus an essential part of day surgery.
Most surgical specialities are today performing day-case surgery, and the proportion of traditional in-hospital vs. day surgery is, in many disciplines, much in favor of the day cases. However, the proportion of day-case surgery for one and the same procedure varies considerably between countries and may also vary considerably within nations between different institutions. Explanations for these differences include tradition and economical factors.
Day surgery calls for vigilant assessment and preparation. The patient, the procedure, institutional resources, anesthesia, and a structured and quality-assured plan are needs to be considered. A structured anesthesia and analgesia protocol is fundamental. Multimodal analgesia should include a combination of local anesthesia and non-opioid analgesics (para-cetamol and non-steroidal anti-inflammatory drugs, NSAIDs), then add on a weak opioid, and, as further rescue, oral strong opioids in an escalating fashion. These factors are cornerstones in the widely accepted standard of care.[1]
The adoption of day surgery must not jeopardize safety. However, the experience of day surgery as of today is reassuring. The outcomes at 30 days in large cohorts of patients show very low mortality and incidences of major morbidity. Classical follow-up studies, such as the ones by Warner et al. [2], and Mezei and Chung,[3] and the 60-day follow up of day surgery in Copenhagen,[4] have all documented most reassuring safety. On the other hand, the increasing numbers of more complex procedures and acceptance of patients with more extensive medical history for day-case surgery must be acknowledged, and surveillance of outcome is of great importance in order to evaluate the maintenance of safe practice.
More elderly patients
The number of elderly patients undergoing day surgery increases. A positive result of this trend is that avoidance of hospitalization and change in environment reduces the risk of postoperative cognitive impairment. However, further effort to evaluate the outcome of day surgery in the growing elderly population is warranted. Alternatively, the experience from cataract surgery in office-based or day-surgery practice is most reassuring and has gained wide acceptance as a cost-effective approach with high patient satisfaction.
Elderly patients are also, in increasing numbers, scheduled for day surgery that requires general anesthesia. The elderly are prone to have somewhat more minor perioperative cardiovascular events, the most frequent being hypertension and dysrhythmias. Hypotension and hypovolemia are relatively less frequent in this patient group compared with patients of all ages; hypotension constitutes about one-tenth of all cardiovascular events seen.[5]
Preoperative fasting routines
One important part of patient care is proper preparation with regard to intake of food and fluid in order to minimize the risk of regurgitation and aspiration in conjunction with the anesthesia.
Many countries have adopted revised fasting guidelines that allow patients without risk factors to eat a light meal up to 6 hours and to ingest clear fluids up to 2 hours prior to the induction of anesthesia.[6] The safety of a more liberal fasting regime in patients without obvious risk factors for delayed gastric emptying receives support from a recent Cochrane systematic meta-analysis review.[7] The acceptable safety of intake of clear fluid up to 2 hours prior to surgery has also been shown in obese patients and in children.[8–10]
Avoiding prolonged fasting and fluid restriction has beneficial effects on patient satisfaction, and may also have positive effects on outcome, reduced fatigue, postoperative nausea and vomiting (PONV), and glucose intolerance.[11]
Adherence to the new more physiological fasting guidelines is not yet well adopted. For simplicity, it may be easier to inform a patient not to take food or fluids after midnight.
Elective day-case surgery should allow proper planning and timing and, thus, information about intake of clear fluids up to 2–3 hours prior to anesthesia should be promoted in patients without risk factors. Shortening the preoperative fasting and promoting intake of clear liquid for up to 2 hours prior to anesthesia is today considered to be well established and evidence-based.
The authors’ conclusion in the Cochrane meta-analysis is clear; there was no evidence to suggest that a shortened fluid fast results in an increased risk of aspiration, regurgitation, or related morbidity compared with the standard “nil by mouth from midnight” fasting policy. Permitting patients to drink water preoperatively resulted in significantly smaller gastric volumes.
Clinicians should be encouraged to appraise this evidence for themselves and, when necessary, adjust any remaining standard fasting policies (nil-by-mouth from midnight) for patients who are not considered “at risk” during anesthesia.[7]
Preoperative nutrition: correction of deficits
Correction of malnutrition and specific nutritional or vitamin deficits should always be assessed before elective surgery and, as far as possible, substituted. The typical day-surgery patients are rarely those exhibiting a more extensive degree of malnourishment but, if present, it should be handled in accordance with general nutritional routines.
Preoperative testing of the clinically healthy patient has been questioned in recent years.[12] Patients showing signs or symptoms of being malnourished should be identified and possibly supported in order to restore proper nutritional status before surgery. Likewise, in patients with severe obesity, proper preoperative diet preparations have become standard care in most bariatric centers. Fluid deficits, low plasma/blood volume, and/or a low hematocrit should be evaluated and corrected whenever there are any signs, symptoms, or history raising suspicion about its occurrence.
Preoperative nutrition: “energy loading”
There are reports from studies evaluating the effects of preoperative nutritive fluid intake suggesting potential benefits without risk.[13] An increasing amount of evidence indicates that instead of being operated on in the traditional overnight fasted state, undergoing surgery in the carbohydrate-fed state has many clinical benefits. Many of these clinical effects can be related to the reduced postoperative insulin resistance by preoperative carbohydrate loading.
In many centers, preoperative carbohydrates have become established for use before major surgery. Those who advocate preoperative energy support suggest that carbohydrate loading should be considered for all patients who are scheduled for elective surgery and are allowed to drink clear fluid.[14] The value of such efforts in minor intermediate elective day surgery in ASA 1–2 patients may be debated.
Perioperative fluid therapy: anesthetic considerations
Perioperative fluid therapy in day surgery should be instituted on the basis of the case profile.
The benefit of fluid therapy can be questioned in minor surgical procedures of short duration (less than 15–20 min) and without any substantial fluid losses during the procedure.
Fluid therapy is more clearly beneficial in intermediate surgery, and administration of more liberal volumes probably leads to better recovery compared with lower volumes. Study design, fluid administered, and variables used for evaluation of effects vary between studies, and thus it is hard to provide clear, explicit guidelines (Table 20.1). The administered fluid has, in most studies, consisted of crystalloid fluid solutions such as lactated Ringer’s solution.
Clinical trials of fluid therapy in intermediate-sized day surgery
| Reference | Surgery | Active | Control | Fluid | No. of patients | Results |
|---|---|---|---|---|---|---|
| Yogendran et al. 1995 [29] | Ambulatory surgery | 20 ml/kg | 2 ml/kg | Isotonic electrolyte solution | 2 × 100 | Significant positive thirst, drowsiness, and dizziness |
| Elhakim et al. 1998 [30] | Termination of pregnancy | 1,000 ml | 0 | Sodium lactate | 2 × 50 | Significant positive PONV |
| Bennett et al. 1999 [31] | Dental surgery | 17 ml/kg | 2 ml/kg | Isotonic solution | 2 × 77 | Significant positive feelings of well-being |
| McCaul et al. 2003 [20] | Gynecological laparoscopy | 1.5 ml/kg ± glucose | Sodium lactate ± glucose | 3 × 40 | Glucose; higher blood glucose and more thirst | |
| Ali et al. 2003 [32] | Laparoscopic cholecystectomy/gynecological surgery | 15 ml/kg | 2 ml/kg | Hartmann’s solution | 2 × 40 | Significant positive PONV |
| Holte et al. 2004 [15] | Laparoscopic cholecystectomy | 40 ml/kg | 15 ml/kg | Lactated Ringer’s | 2 × 24 | Significant positive pulmonary function, dizziness, drowsiness, and fatigue |
| Magner et al. 2004 [33] | Gynecological laparoscopy | 30 ml/kg | 10 ml/(kg h) | Sodium lactate | 2 × 70 | Significant positive PONV |
| Maharaj et al. 2005 [34] | Gynecological laparoscopy | 2 ml/(kg h) | 3 ml/kg | Sodium lactate | 2 × 40 | Significant positive PONV and pain |
| Chohedri et al. 2006 [35] | Ambulatory surgery | 20 ml/kg | 2 ml/kg | Isotonic electrolyte solution | 2 × 100 | Significant positive PONV and thirst |
| Goodarzi et al. 2006 [36] | Strabism | 30 ml/(kg h) | 10 ml/(kg h) | Lactated Ringer’s | 2 × 50 | Significant positive PONV and thirst |
| Chaudhary et al. 2008 [19] | Open cholecystectomy | 12 ml/kg | 2 ml/kg | Lactated Ringer’s hetastarch | 2 × 30 | Significant positive PONV, no diff. crystalloid vs. colloid |
| Dagher et al. 2009 [16] | Thyroid surgery | 30 ml/kg | 1 ml/kg | Sodium lactate | 2 × 50 | No effect |
| Lambert et al. 2009 [37] | Gynecological laparoscopy | 1,000 ml | 2 ml/kg | 2 × 23 | Significant positive PONV |
PONV, postoperative nausea and vomiting.
Administration of about 1 liter of isotonic electrolyte solution to compensate for the fasting, and a further 1 liter during surgery seems to improve the postoperative course of laparoscopic cholecystectomy. The group of Holte et al. has conducted several studies of the effects of perioperative fluid on outcome. They showed that administration of 30–40 ml/kg compared with 10–15 ml/kg lactated Ringer’s solution for laparoscopic cholecystectomy improves recovery of organ functions and reduces hospital stay.[15] In contrast, a benefit from using a liberal fluid regime during thyroid surgery was not supported in a study of similar design.[16]
Administration of crystalloids i.v. has been shown to influence the occurrence of PONV. Apfel et al. found in a quantitative review that a more liberal use of crystalloid infusion reduced nausea and need for rescue antiemetics, supporting a liberal approach in day-case patients without history of cardiac disease.[17]
The effects of high volume (30–40 ml/kg) perioperatively should also be put into perspective. Infusion of 40 ml/kg of lactated Ringer’s solution in volunteers with a mean age of 63 years decreased pulmonary function for 8 hours and also resulted in a significant weight gain that lasted for 24 hours [18]. Therefore, a more restricted fluid therapy should be adopted in the elderly. The risk of reduced lung function and edema must be acknowledged in the elderly, and fluid volume be adjusted accordingly.
Large volumes of crystalloid and colloid fluid have been compared in one study showing no difference in outcome with regard to the variables studied.[19]
The independent effect of adding glucose to the infused fluid has been studied by McCaul et al.[20] They could see no major benefit in adding glucose, which rather increased thirst and the incidence of pain besides elevating the blood glucose concentration.
The expansion of day-case surgery is moving rapidly, and there are reports of successful bariatric surgery performed on an ambulatory basis. Some institutions perform transurethral prostatectomy in day-case practice. The fluid management for these special procedures is addressed in other chapters. Procedure-specific fluid protocols should be used regardless of whether the patient is operated on in ambulatory practice or as an in-patient.
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