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

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

3. Evolution of Anesthesiology
2000 BC

4. 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.

5. 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

6. 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”

7. 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

8. Risk Assessment

9. 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

10. 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

11. 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%.

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

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

14. 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

15. 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 with little modification
Hazard risk ratios more than double with the addition of every ASA class.

16. 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

17. 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.

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

19. Estimated Energy for the levels of activity

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

21. 5-year survival

22. Not in Octogenarians!!

24. 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

25. 30-day Complications for ASA 3 (A versus B)

26. Survival analysis of ASA3A vs. ASA3B

27. 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): , doi: /ANE , PMID:

28. 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

29. 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)

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

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

32. 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

33. 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)

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

35. 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% %
5.0% %
Current pneumonia (%)
0.9%
6.1%
Sepsis (%)
1.1%
8.6%

36. 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)

37. Modifying ASA based on functional capacity

38. ASAa Class-Subclass Hazard Ratios for Mortality
Comparisons
Hazard Ratio
95% CIb
P-Value
ASA-1: ASA-2Ac
0.18
<0.001
ASA-2A: ASA-2Bd
0.14
ASA-2B: ASA-3A
1.92
0.004
ASA-3A: ASA-3B
0.29
ASA-3B: ASA-4A
1.29
ASA-4A: ASA-4B
0.50
ASA-4B: ASA-5
2.03
0.034

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

40. 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

41. Proposed modification

42. 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.

43. Thank you.