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ASA III & Above in Ambulatory Surgery

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

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  1. 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

  2. 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

  3. Origin of ASA • Simple identification of • “high risk” or • “complex” patient • Intended for billing purposes • Useful shorthand • Limitations

  4. 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

  5. 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

  6. 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

  7. Where is theEvidence?

  8. 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

  9. After Discharge ?

  10. 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

  11. 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

  12. 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

  13. Remember • ASA is a crude grading • Evaluate: • specific disease(s) • whole patient • functional limitation • current status

  14. 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?

  15. Available from www.bads.co.uk Widening the Criteria • Day case spinals • 5 mg bupivacaine • 10 µg fentanyl • 3 ml volume

  16. TheASA 4 Patient Disease is a “constant threatto life”

  17. ASA 4 Patients • Evidence? • rare & unique • Consider as individual • Risks AND benefits • Minimal disruption • local anaesthesia • regional analgesia • (rarely GA)

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. What would be done differently with inpatient care?

  24. ANY QUESTIONS ?

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