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ASA III & Above in Ambulatory Surgery. Ian Smith , MD, FRCA Editor , Journal of One-day Surgery Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent. ASA Classification. . ASA I Healthy patient ASA II Mild systemic disease; NO limitation

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asa iii above in ambulatory surgery

ASA III & Abovein Ambulatory Surgery

Ian Smith, MD, FRCA

Editor, Journal of One-day Surgery

Senior Lecturer in Anaesthesia

University Hospital of North Staffordshire

Stoke-on-Trent

asa classification
ASA Classification

  • ASA I Healthy patient
  • ASA II Mild systemic disease; NO limitation
  • ASA III Disease limits function or activities
  • ASA IV Disease is constant threat to life
  • ASA V Moribund

  • ASA III Disease limits function or activities
  • ASA IV Disease is constant threat to life
origin of asa
Origin of ASA
  • Simple identification of
    • “high risk” or
    • “complex” patient
  • Intended for billing purposes
  • Useful shorthand
  • Limitations
limitation of asa grading

9

10

Limitation of ASA Grading

100

ASA1

ASA2

ASA3

ASA4

75

Grade

assigned

(%)

50

25

0

2

3

6

7

Case #

Haynes & Lawler —

Anaesthesia 50: 195, 1995

text book advice
Text Book Advice
  • “No longer restricted to ASA 1 & 2
    • 3 & 4 appropriate if medically stable ”
      • Wetchler In: Barash et al. Clinical Anesthesia 2nd edn. 1992
  • “ASA 3 may safely undergo day surgery
    • if stable & well-controlled for >3 mo”
      • Smith & White In: Whitwam. Day-case Anaesthesia 1994
  • “Medically-stable ASA 3 patients acceptable”
      • Smith & White In: Nimmo et al. Anaesthesia. 2nd edn. 1994
latest recommendations
Patients of ASA 1–3 should be suitable

unless there are other contraindications

Some ASA 4 patients may be acceptable

under local anaesthesia

Gudimetla & Smith —Chapter 5, 2006

Latest Recommendations
asa risk
ASA & Risk

ASA 1 ASA 2 ASA 3

Number (n) 9194 7301 1143

Any theatre event 1.6% 4.9% 8.1%

Any recovery event 9.9% 7.4% 5.5%

Any DSU event 6.8% 5.4% 2.9%

More complex to manage

Chung, et al. —

Br J Anaesth 83: 262, 1999

Do well after

morbidity within 1 month
Morbidity Within 1 Month
  • 38 598 patients
    • 45 090 procedures
  • Approx 1/4 ASA 3
  • Major morbidity in 31 (8 ASA 3)
  • 2 Deaths from MI (ASA 2)
  • (+ 2 died as car passengers)

Warner, et al. —

JAMA 270: 1437, 1993

need for admission
Need for Admission
  • 9616 patients
    • 100 admitted
    • pain, bleeding & emesis
  • Risk increased if >ASA 1
    • BUT
    • no association with ASA if age-corrected

Gold, et al. —

JAMA 262: 3008, 1989

further evidence
Further Evidence

ASA 1&2

ASA 3

Number (n)

Unplanned admission

Unplanned contact with GP

28,025

1.9%

<1%

896

2.9%

<1%

  • No difference in postoperative complications

Ansell & Montgomery —

Br J Anaesth 92: 71, 2004

remember
Remember
  • ASA is a crude grading
  • Evaluate:
    • specific disease(s)
    • whole patient
    • functional limitation
    • current status
medical fitness
Medical Fitness
  • Is the condition optimally treated?
    • if not
      • unsuitable for elective surgery
      • optimise first
  • Would management of the condition be improved by hospitalisation?
  • Is the patient at risk at home?
widening the criteria

Available from

www.bads.co.uk

Widening the Criteria
  • Day case spinals
    • 5 mg bupivacaine
    • 10 µg fentanyl
    • 3 ml volume
slide17

TheASA 4 Patient

Disease is a “constant threatto life”

asa 4 patients
ASA 4 Patients
  • Evidence?
    • rare & unique
  • Consider as individual
  • Risks AND benefits
  • Minimal disruption
    • local anaesthesia
    • regional analgesia
    • (rarely GA)
example
Example
  • 65 year old male
    • CABG x2, maximum medical therapy
    • not candidate for further op or stenting
    • angina at rest, breathless on talking
    • SpO2 85% on air (no home oxygen)
    • very limited mobility (arthritis)
  • Well as normal!
  • Intolerable perianal pain (? fissure)
      • House & Smith — J One-day Surg 17: 24, 2007
risks benefits
Severe disease

symptoms at rest

Hypoxic

No further treatment options

Poor quality of life

Potentially curable

simple surgery

Stable (!)

Coping

Maximally treated

Risks & Benefits

House & Smith —J One-day Surg 17: 24, 2007

further considerations
Further Considerations
  • Unlikely to deteriorate further after low dose spinal
  • Should cope as before (less pain)
  • Risk of
    • dehydration & immobility
    • poor pain management
    • hospital-acquired infection
    • over zealous treatment

House & Smith —J One-day Surg 17: 24, 2007

ambulatory surgery in asa 4
Ambulatory Surgery in ASA 4
  • Excellent pain relief
    • local, regional, non-opioid
  • Short-acting techniques
    • rapid recovery
    • enhanced mobility
    • minimal disruption
  • Hospitalisation ONLY if beneficial
summary
Summary
  • ASA 3 suitable if no other contraindications
  • ASA 4 may be suitable
    • assess on individual basis
  • Must be stable & well-controlled
  • Nature of disease
    • effect on surgery
    • effect of surgery
slide25

ANY

QUESTIONS

?