Ian Smith, MD, FRCA Editor, Journal of One-day Surgery Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent ASA III & Above in Ambulatory Surgery

ASA Classification ASA I Healthy patient ASA IIMild systemic disease; NO limitation ASA IIIDisease limits function or activities ASA IVDisease is constant threat to life ASA VMoribund ASA IIIDisease limits function or activities ASA IVDisease is constant threat to life

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

Limitation of ASA Grading ASA4ASA3ASA2ASA1 Case # Grade assigned (%) Haynes & Lawler — Anaesthesia 50: 195,

Text Book Advice “No longer restricted to ASA 1 & 2 –3 & 4 appropriate if medically stable ” –Wetchler In: Barash et al. Clinical Anesthesia 2 nd edn “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. 2 nd 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

Where is the Evidence?

ASA & Risk Number (n) Any theatre event1.6%4.9%8.1% Any recovery event 9.9%7.4%5.5% Any DSU event6.8%5.4%2.9% ASA 1 ASA 2 ASA 3 Chung, et al. — Br J Anaesth 83: 262, 1999 More complex to manage Do well after

? After Discharge

Morbidity Within 1 Month patients – procedures Warner, et al. — JAMA 270: 1437, 1993 Approx 1 / 4 ASA 3 Major morbidity in 31(8 ASA 3) 2 Deaths from MI(ASA 2) (+ 2 died as car passengers)

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 Number (n) Unplanned admission Unplanned contact with GP ASA 1&2 Ansell & Montgomery — Br J Anaesth 92: 71, , % <1% % <1% ASA 3 No difference in postoperative complications

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

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 Day case spinals –5 mg bupivacaine –10 µg fentanyl –3 ml volume Available from

The ASA 4 Patient Disease is a “constant threat to life”

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

Example 65 year old male –CABG x2, maximum medical therapy –not candidate for further op or stenting –angina at rest, breathless on talking –SpO 2 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 House & Smith — J One-day Surg 17: 24, 2007

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 Excellent pain relief –local, regional, non-opioid Short-acting techniques –rapid recovery –enhanced mobility –minimal disruption Hospitalisation ONLY if beneficial

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

What would be done differently with inpatient care?

ANY QUESTIONS ?