1. 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

2. 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

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

4. Limitation of ASA Grading 0 25 50 75 100 2367 ASA4ASA3ASA2ASA1 Case # Grade assigned (%) Haynes & Lawler — Anaesthesia 50: 195, 1995 910

5. 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. 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. 2 nd edn. 1994

7. 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

8. Where is the Evidence?

9. ASA & Risk Number (n)919473011143 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

10. ? After Discharge

11. Morbidity Within 1 Month 38 598 patients –45 090 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)

12. 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

13. Further Evidence Number (n) Unplanned admission Unplanned contact with GP ASA 1&2 Ansell & Montgomery — Br J Anaesth 92: 71, 2004 28,025 1.9% <1% 896 2.9% <1% ASA 3 No difference in postoperative complications

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

15. 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?

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

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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. What would be done differently with inpatient care?

25. ANY QUESTIONS ?