FUNCTIONAL STATUS AND ASA CLASSIFICATION Nader D. Nader, MD PhD FACC FCCP Professor and Senior Vice Chair University at Buffalo, USA TARK Oct 2016

Statistically, 55 years old is the most common age for a touch-up. Does ASA classification require a new facelift? OR

Evolution of Anesthesiology 2000 BC 1846 1950 2000 2014

Added roles for an Anesthesiologist Perioperative risk assessment Preoperative cardiovascular and pulmonary assessment Optimization of medical condition Intraoperative care (Surgical Anesthesia) Postoperative critical care of patients and pain management.

Why Do We Need a Risk Assessment? Nearly 12 million per year, and one fourth of these are major surgeries. The average age of the patients in need of surgical care is in rise. Prevalence of cardiovascular disease increases with age

Medical Consult or Medical Insult? A new finding only in 3.4% 42.5% contained no recommendations More than 50% states: “clearing the patient for surgery” “proceed with case” “cleared for surgery” “continue current medications”

Newly Established Surgery Homes Establish an Anesthesiologist-run Preoperative Evaluation Clinic One stop shop Relevant History and Physical Exam Blood draw for lab, Chest-X-ray and ECG as indicated MD Anesthesiologists/Internists (Cost-effective?) Level of Insurance reimbursement Payback is on decreasing unnecessary cancellations on the day of surgery

Risk Assessment

Available Tools ASA functional class (the simplest tool) Lee-Goldman prediction model of risk. Euroscore for Cardiac risks VASQIP/NSQIP American College of Surgeons Risk assessment tool

Lee’s Independent factors for Cardiac Risk (4C-IT) Coronary heart disease Congestive HF Cerebral vascular disease Preoperative Creatinine >2 mg/dL Insulin treatment for DM High-risk Type of surgery

Lee Modified Risk The mnemonic for the Revised Coronary Risk Index considers 4C IT: none of the 4C-IT criteria 0.4% risk One risk factor  0.9% risk two risk factors  7% three risk factors  11%.

ACS Risk Calculator http://riskcalculator.facs.org/

ACS Risk Calculator http://riskcalculator.facs.org/

Cardiac Risk Stratification for Non-cardiac Surgical Procedures Procedure Examples Major or High risk (reported cardiac risk > 5%) Aortic and other major vascular Peripheral vascular Surgery Intermediate (reported risk 1% to 5%) Intraperitoneal and intrathoracic Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate Surgery Low (reported risk < 1%) Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery

Anesthesiologists are the Oldest Surgical Risk Managers!! ASA has long been used as a simple tool to determine the surgical risk 5 operative classes used since 1941 with little modification Hazard risk ratios more than double with the addition of every ASA class.

Definition by Dripps for ASA Physical Status ASA-1: Healthy person. ASA-2: Mild systemic disease UNDER CONTROL. ASA-3: Severe systemic disease UNCONTROLLED. ASA-4: Severe systemic disease that is a CONSTANT THREAT to life. ASA-5: A moribund person who is NOT expected to survive without the operation

Purpose of the ASA Classification A simple tool that is used to quickly assess the risk of death and complication after a surgical procedure. It is now adopted by non-anesthesiologist physicians who use moderate sedation for minor procedures.

Not in Vascular Surgery patients J Vasc Surg;2008;47(4):766-771 79% of patients are classified as ASA 3 4 METS cutoff ASA-3A vs. ASA-3B

Estimated Energy for the levels of activity

Difference in 30-day complications ASA 3A ASA 3B OR (CI 95%) MI 0.5% 4.6% 10.4 (1.2 - 85.4) Stroke 0% 0.7% Death 5.9% 13.6 (1.7 -108.2) MACCE 12.5% 21.5% 2.0 (1.1 – 3.4)

5-year survival

Not in Octogenarians!!

In Octogenarians 1670 patients over the age of 80. ASA 3A those who were functional independent ASA 3B those who were either partially or fully dependent for their daily chores

30-day Complications for ASA 3 (A versus B)

Survival analysis of ASA3A vs. ASA3B

Addition of functional status to ASA classification to better predict the surgical outcome Visnjevac O, Davari-Farid S, Lee J, Pourafkari L, Arora P, Dosluoglu HH, Nader ND,, Anesth Analg, (Article of the Month), July 2015; 121(1): 110-116, doi: 10.1213/ANE.0000000000000740, PMID: 26086512

Frailty Scale It can be used to recognize high risk patients Validated by studies Simple Incorporated into pre-operative template Only 5 questions Each question scores 0 or 1, minimum score 0 and maximum score 5

How often over the past 4 weeks have you felt tired? All of the time (1 point) Most of the time (1 point) Some of the time (0 point) A little of the time (0 point) None of the time (0 point)

By yourself and not using walking aids, do you have any difficulty walking up 10 steps without resting? Yes (1 point) No (0 point)

By yourself and not using walking aids, do you have any difficulty walking several hundred yards? Yes (1 point) No (0 point)

Did a doctor ever tell you that you have? Hypertension Cancer (other than a minor skin cancer) Heart attack Asthma Arthritis Kidney disease Diabetes Chronic lung disease Congestive heart failure Angina Stroke 0-4 diseases = 0 points. > 5 diseases = 1 point

Weight Loss 5a. How much do you weigh with your clothes on but without shoes? _______________ 5b. One year ago at this time, how much did you weigh with your clothes on but without shoes? <5% weight loss = 0 points > 5% weight loss = 1 point (weight gain = 0 points)

Frailty & Dependence Robust (score 0) Prefrail (Scores 1 and 2) Frail (Score 3 or higher) Independent Partially dependent Fully dependent

Preoperative Co-morbidities   GROUP A N=10,533 GROUP B N=1,791 P Value Hypertension (%) 64.4% 75.8% <0.0001 Diabetes Mellitus (%) 19.2% 33.6% Angina (%) 2.7% 6.0% CHF (%) 1.9% 8.0% AMI(%) 0.5% 3.8% Cardiac revascularization (%) 6.9% 14.3% COPD (%) 21% 33.7% CVA(%) 10.6% 29.7% PAD (%) 7.7% 32.7% Hemodialysis (%) 1.0% 11.0% Alcoholism -- Smoker (%) 7.8% -- 38.2% 5.0% -- 31.0% Current pneumonia (%) 0.9% 6.1% Sepsis (%) 1.1% 8.6%

Early (30-day) post-operative complications Group A N=10,533 Group B N=1,791 P Value Stroke (%) 0.4% 0.7% 0.029 AMI(%) 0.6% 1.5% <0.0001 Cardiac Arrest (%) 3.7% Pulmonary Embolization (%) 0.2% 0.5% 0.116 Pneumonia (%) 2.2% 8.0% Mechanical Ventilation (%) 2.4% 11.0% UTI (%) 2.1% 6.1% AKI (%) 1.1% 3.1% Wound infection (%) 4.4% 5.6% 0.023 30 days Mortality (%) 1.8% 12.9% Return to OR 9.4% 21.5% LOS (days) 5 (4-5) 8 (7-8)

Modifying ASA based on functional capacity

ASAa Class-Subclass Hazard Ratios for Mortality Comparisons Hazard Ratio 95% CIb P-Value ASA-1: ASA-2Ac 0.18 0.10-0.31 <0.001 ASA-2A: ASA-2Bd 0.14 0.09-0.22 ASA-2B: ASA-3A 1.92 1.23-2.99 0.004 ASA-3A: ASA-3B 0.29 0.25-0.33 ASA-3B: ASA-4A 1.29 1.06-1.57 ASA-4A: ASA-4B 0.50 0.40-0.63 ASA-4B: ASA-5 2.03 1.06-3.91 0.034

Multivariate Regression Analysis for 30-day mortality α=0.05 Parameter Estimate P- value Odds Ratio 95% CI Low High Intercept -1.8493 0.0023 - Group B1 -0.7605 <0.000 1 4.566 2.237 9.346 Emergency -0.4541 0.0038 2.481 1.340 4.587 Albumin (g/dL) -0.5657 0.0017 0.568 0.399 0.809 BUN (mg/dL) 0.0256 <0.000 1 1.026 1.013 1.039

Proposition Between ASA 2 through 4 If the patient is functional dependent add one to their ASA class Dependent ASA-2  ASA-3 Dependent ASA-3  ASA-4 Dependent ASA-4  ASA-5

Proposed modification

Take home message ASA classification has survived all new risk assessment tools because of its simplicity It should remain simple and easy to do By adding functional status to ASA classification, we improve the predictive value while Keeping It Simple.

Thank you.