Would you consider ESRD an ASA 3 or 4?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
P

Patron

Full Member
10+ Year Member
Joined
Dec 27, 2009
Messages
40
Reaction score
0
Would you consider ESRD an ASA 3 or 4
Members don't see this ad.
 
Members don't see this ad :)
I think it's technically considered a 3. But I'll argue all day that it should be a 4. Being dialyzed 3 times a week to me seems like it's a condition that "is a constant threat to life" (ASA 4 status).
 
  • Like
Reactions: 1 user
I say 4, although a few of my colleagues disagree. I think if you have an organ system in failure, you are a 4 (Hepatic, renal, pulm, c/v). There is a large difference between the ESRD patients from the well controlled compliant patient on peritoneal dialysis to the raging diabetic vasculopath here for the 15th fistula. I could probably be talked into a 3 for the former patient.
 
Patron said:
Would you consider ESRD an ASA 3 or 4
Click to expand...

I remember looking this up. If I remember, Miller says ESRD on HD is a 3. New ESRD in the process of becoming stabilized on dialysis is a 4. However I always mark them as a 4. They're usually the typical CAD, PVD, DM, ESRD, CHF patients. These pts are the sickest of the sick. Had one code to PEA on induction with nothing but 5 mg of etomidate and 25 mcg of fentanyl. Luckily 100 mcg of epi picked them right up.
 
I would say 3. They shop at Macy's and drink Starbucks like everyone else with nobody being the wiser.
 
3.

Interpret "constant threat to life" however you want, but for me the disease process has to be capable of striking you dead at any given random second. Not so much with ESRD well managed on HD.

The arguments for 4 are all reasonable, but I disagree with them.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Depends.

If my patient were Alonzo Mourning or Sean Ellicott (top
Shape NBA players who had kidney transplants).

I would consider them an ASA 2.

Usually I would consider them ASA 3. Those who constantly end up in the hospital are ASA 4

ESRD by itself is not automatic Asa classification. You have to look at the overall patient health profile.
 
proman said:
So does someone with a Heartmate II. Would you say that person is also a 3?
Click to expand...

Everybody can tell there is something not right when you are carrying a black strap on purse.

Plus, the Heart mate 2 guy might have to run for the power outlet before making the line at Starbucks.
 
  • Like
Reactions: 1 user
Last edited by a moderator:
aneftp said:
Depends.

If my patient were Alonzo Mourning or Sean Ellicott (top
Shape NBA players who had kidney transplants).

I would consider them an ASA 2.

Usually I would consider them ASA 3. Those who constantly end up in the hospital are ASA 4

ESRD by itself is not automatic Asa classification. You have to look at the overall patient health profile.
Click to expand...

ASA 4 means that you have a disease that is significant enough to be a constant threat to your life.
ESRD and dialysis are constant threats to your life because your life depends on a machine and because you are susceptible to all kinds of complications related to the disease itself or to the dialysis process.
And there is no patient with ESRD who is otherwise healthy because as you know you are never healthy on dialysis.
 
  • Like
Reactions: 1 user
hudsontc said:
I fall into the 4 camp on this. If the patient requires consistent medical intervention to keep them from dying (as in the case of systolic heart failure, for example) they're a 4 in my book--not as though that is my only criterion.

Along similar lines, many would probably give a 3 classification to this kid because of the way that he looks, preoperatively: http://www.cbs19.tv/story/16414977/austin-teen-dies-on-christmas-day-leaves-behind-touchingn-video
Click to expand...

I'm sure he had an icd....

By looks I would give him a 1. Until I found out about the icd. That bumps him up to a 4.

But dialysis? Really? Those guys live like 20 yrs.... Constant threat to life over 20 yrs....
 
Planktonmd said:
ASA 4 means that you have a disease that is significant enough to be a constant threat to your life.
ESRD and dialysis are constant threats to your life because your life depends on a machine and because you are susceptible to all kinds of complications related to the disease itself or to the dialysis process.
And there is no patient with ESRD who is otherwise healthy because as you know you are never healthy on dialysis.
Click to expand...

So, any pt on tpn is an asa4? He is dependent on the Iv pump to eat. Otherwise he will die. Right????


I guess once you paralyze pt they become asa4 intra op. they are dependent on the vent. They can die too. Right???
 
Planktonmd said:
ASA 4 means that you have a disease that is significant enough to be a constant threat to your life.
ESRD and dialysis are constant threats to your life because your life depends on a machine and because you are susceptible to all kinds of complications related to the disease itself or to the dialysis process.
And there is no patient with ESRD who is otherwise healthy because as you know you are never healthy on dialysis.
Click to expand...

The ASA classification system is imperfect. I've done so many renal patients, I can tell which patients have diseases that "are a constant threat to their lives...asa 4...who end up in the hospital with graft clots, missed dialysis,, chf etc".

But I've done many cases on young renal patients who do peritoneal dialysis and they are active, work full time.

We can debate the ASA classification till the end of time. I believe there needs to be a revision like adding a "+" sign to the ASA 2, 3. What about the 24 year old female otherwise healthy who has a BMI above 50? They don't have a severe systamic disease but they are considered "super morbidly obese" They can run a 5K with no problems? Are they are 2 or a 3?

For 99% of patients on ESRD, I write down ASA 3 or 4. But there are always exceptions. There are exceptions to anything.

Like I was covering a surgery center last week and this 300 pound dude with diabetes had 48 ounces of black coffee 2 hours before his colonscopy. Does he meet the NPO guidelines for 2 hours for MAC?
 
urge said:
So, any pt on tpn is an asa4? He is dependent on the Iv pump to eat. Otherwise he will die. Right????


I guess once you paralyze pt they become asa4 intra op. they are dependent on the vent. They can die too. Right???
Click to expand...

Actually the ASA classification during anesthesia depends on who is at the head of the table, which means I would classify all your patients as ASA 5 :D
 
aneftp said:
The ASA classification system is imperfect. I've done so many renal patients, I can tell which patients have diseases that "are a constant threat to their lives...asa 4...who end up in the hospital with graft clots, missed dialysis,, chf etc".

But I've done many cases on young renal patients who do peritoneal dialysis and they are active, work full time.

We can debate the ASA classification till the end of time. I believe there needs to be a revision like adding a "+" sign to the ASA 2, 3. What about the 24 year old female otherwise healthy who has a BMI above 50? They don't have a severe systamic disease but they are considered "super morbidly obese" They can run a 5K with no problems? Are they are 2 or a 3?

For 99% of patients on ESRD, I write down ASA 3 or 4. But there are always exceptions. There are exceptions to anything.

Like I was covering a surgery center last week and this 300 pound dude with diabetes had 48 ounces of black coffee 2 hours before his colonscopy. Does he meet the NPO guidelines for 2 hours for MAC?
Click to expand...

In addition, the ASA class is being used for many things it was never intended to be used for in the periop arena. Since it can be so subjective, I find it not to be real reliable in some instances. It can also vary quite a bit as a patient gets better or worse. I have always had trouble with classifying the previously healthy ASA I type who is now septic from a perforated viscous. If they are on death's doorstep, they are suddenly now a 4 or 5 E. If they then improve and come back for a washout and are now stable, are they then a 3? If they return 2 months later for an unrelated surgery and have completely gotten over their near death experience, are they now an ASA I again? I am certain that Urge's comments (about the patient after induction of anesthesia) above are somewhat tongue in cheek, but his point is well taken in that patients seem to fluctuate at times between ASA Class levels, and it is tough to know the exact point where a patient crosses from one class to the next in either direction.
So I guess for the young motorcyclist, at the point of impact with the back of an 18 wheeler at 120 mph, he may proceed rapidly from ASA 1 all the way to ASA 5E or even 6 in a matter of microseconds entirely skipping classes 2,3, and 4.
It is hard to find a system that will take every situation into account.
 
You are right, the ASA classification is not a very accurate predictor of anything.
I tend to think of it as a snap shot of someone's current likelihood to die:
ASA1 Not going to die
ASA2 Unlikely to die
ASA3 Will die but not soon
ASA4 Will die soon
ASA5 On the launching pad


Gern Blansten said:
In addition, the ASA class is being used for many things it was never intended to be used for in the periop arena. Since it can be so subjective, I find it not to be real reliable in some instances. It can also vary quite a bit as a patient gets better or worse. I have always had trouble with classifying the previously healthy ASA I type who is now septic from a perforated viscous. If they are on death's doorstep, they are suddenly now a 4 or 5 E. If they then improve and come back for a washout and are now stable, are they then a 3? If they return 2 months later for an unrelated surgery and have completely gotten over their near death experience, are they now an ASA I again? I am certain that Urge's comments (about the patient after induction of anesthesia) above are somewhat tongue in cheek, but his point is well taken in that patients seem to fluctuate at times between ASA Class levels, and it is tough to know the exact point where a patient crosses from one class to the next in either direction.
So I guess for the young motorcyclist, at the point of impact with the back of an 18 wheeler at 120 mph, he may proceed rapidly from ASA 1 all the way to ASA 5E or even 6 in a matter of microseconds entirely skipping classes 2,3, and 4.
It is hard to find a system that will take every situation into account.
Click to expand...
 
Planktonmd said:
You are right, the ASA classification is not a very accurate predictor of anything.
I tend to think of it as a snap shot of someone's current likelihood to die:
ASA1 Not going to die
ASA2 Unlikely to die
ASA3 Will die but not soon
ASA4 Will die soon
ASA5 On the launching pad
Click to expand...

The way I look at it as the ASA status refers to the next 48 hours; ESRD which is well-controlled means ASA-3. Of course, there many ESRD patients with numerous co-morbidities which push them to ASA4 or 4+ plus category.

If a patint has a pacemaker and is pacemaker dependent (If the device fails he dies) does this automatically make him an ASA 4? What if he has no other co-morbidities? Would you make that patient an ASA 3?

The renal failure patient and this pacemaker patient both depend on mechanical devices to keep them alive.
 
Hawaiian Bruin said:
Interpret "constant threat to life" however you want, but for me the disease process has to be capable of striking you dead at any given random second. Not so much with ESRD well managed on HD.
Click to expand...

Agreed. I think the potential lethality of CKD Stage 5 (that's what it's called, y'know) isn't an acute enough threat to qualify as "constant." If their dialysis access fails, they're good for at least 3-5 days.

Contrast this with anyone with any kind of heart-sustaining device (pacer, AICD, VAD). Now that's "constant."
 
aneftp said:
Like I was covering a surgery center last week and this 300 pound dude with diabetes had 48 ounces of black coffee 2 hours before his colonscopy. Does he meet the NPO guidelines for 2 hours for MAC?
Click to expand...

Man, that fat diabetic loves him some coffee.
 
aneftp said:
What about the 24 year old female otherwise healthy who has a BMI above 50? They don't have a severe systamic disease but they are considered "super morbidly obese" They can run a 5K with no problems? Are they are 2 or a 3?
Click to expand...

I do believe she does have severe systemic disease, because there is adipose tissue severely invading all of her organ systems.

Or another way to look at it, I wouldn't call a BMI of 50 "mild" anything.
 
BLADEMDA said:
If a patint has a pacemaker and is pacemaker dependent (If the device fails he dies) does this automatically make him an ASA 4? What if he has no other co-morbidities? Would you make that patient an ASA 3?

The renal failure patient and this pacemaker patient both depend on mechanical devices to keep them alive.
Click to expand...

The ESRD patient on dialysis is NOT comparable to the pacemaker patient!
A patient on dialysis is a very sick patient, chronically uremic, hypercoagulable, with chronic electrolyte imbalance, chronic anemia who has an invasive procedure every 2 days (hemodialysis) where he is subject to all kinds of complications: Infection, bleeding, volume overload, volume depletion, acid-base imbalance...to name a few!
If you think that patients between dialysis sessions become healthy patients then I suggest you review the pathophysiology of chronic renal failure and the effects of dialysis.
So, IMHO ESRD is NOT equivalent to having a pacemaker my friend.
 
Last edited:
Planktonmd said:
The ESRD patient on dialysis is NOT comparable to the pacemaker patient!
A patients on dialysis is a very sick patient, chronically uremic, hypercoagulable, with chronic electrolyte imbalance, chronic anemia who has an invasive procedure every 2 days (hemodialysis) where he is subject to all kinds of complications: Infection, bleeding, volume overload, volume depletion, acid-base imbalance...to name a few!
If you think that patients between dialysis sessions become healthy patients then I suggest you review the pathophysiology of chronic renal failure and the effects of dialysis.
So, IMHO ESRD is NOT equivalent to having a pacemaker my friend.
Click to expand...

Yes. I fully understand. I think Stable Renal failure on dialyis means a 3 and after their transplant I might even down grade them to a 2 (if no other co morbidities).

A Pacemaker dependent patient with no other co-morbidities is an ASA 2 or 3.
 
At our place, for every 1 person who is young with renal failure, without other comorbidities, we have 20+ people who have the seemingly standard combination of HTN, DM, vasculopathy, 20-40 year smoking history, +/- COPD, and BMI's between 30 and 45. And there are a lot of them too. Must be something in the south Georgia water.
 
While we're at it, it's been a while since we've argued if a healthy uncomplicated pregnancy makes an otherwise healthy woman a 2 because of all the physiologic changes, or if she's still a 1 because pregnancy is a natural process. :)


As for ESRD - the whole ASA classifcation system exists, as I understand it, to facilitate two things: communication and billing.

If there's poor communication because an ESRD patient gets handed off with just the ASA 3 number and no further history, and the receiving party doesn't get tipped off about how severe the patient's condition really is, the failure isn't the ASA classification system, it's the person speaking. ASA # is just a PART of the info that should be related; we don't need stricter definitions or +/- modifiers. It was never intended to be comprehensive.

When it comes to billing, nothing wrong with recording the highest # you can reasonably defend. Calling a 20 year old healthy appy an ASA 4E for the extra 2 units is fraud ... but calling a stable ESRD patient an ASA 4 isn't.

It's just a tool, like Mallampati ... use it for what it is, don't sweat the details.
 
According to the Cleveland Clinic's ASA status page, which lists examples for each class:

ASA PS 2 - Patients with mild systemic disease - No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy

I know it's still subjective, but I would agree with them. Too many physiologic derangements.

ASA PS 1 - Normal healthy patient - No organic, physiologic, or psychiatric disturbance.
 
pgg said:
While we're at it, it's been a while since we've argued if a healthy uncomplicated pregnancy makes an otherwise healthy woman a 2 because of all the physiologic changes, or if she's still a 1 because pregnancy is a natural process. :)


As for ESRD - the whole ASA classifcation system exists, as I understand it, to facilitate two things: communication and billing.

If there's poor communication because an ESRD patient gets handed off with just the ASA 3 number and no further history, and the receiving party doesn't get tipped off about how severe the patient's condition really is, the failure isn't the ASA classification system, it's the person speaking. ASA # is just a PART of the info that should be related; we don't need stricter definitions or +/- modifiers. It was never intended to be comprehensive.

When it comes to billing, nothing wrong with recording the highest # you can reasonably defend. Calling a 20 year old healthy appy an ASA 4E for the extra 2 units is fraud ... but calling a stable ESRD patient an ASA 4 isn't.

It's just a tool, like Mallampati ... use it for what it is, don't sweat the details.
Click to expand...

What we need is an ASA4+ designation. We are all seeing so many more of them these days in our hospitals. The ASA3s are going to the surgicenters more and more.
 
pgg said:
Why? So you could bill more for them? Would an ASA 4+ be worth 1 unit more than an ASA 4?
Click to expand...



malpractice-lawyers.jpg
 
ASA classification criteria is often used to protect patients because providers choose to do procedures in their own facility to collect the facility fees.

Of particular interest is the explosive growth of office based procedures. Depending on state laws, many states prohibit certain procedures in an office base setting (often Level 3 from being done ASA 3 and above patients)

http://www.doh.state.fl.us/mqa/medical/osr_faq.html

Let's just say there are still a lot of shady stuff going down in the State of Fraud (oops, I meant Florida).
 
S/p lung transplant? You guys would call it a 4? Even if they are doing awesome? I'm asked to document an ASA grade prior to bronchoscopy because we use conscious sedation.
 
Endee said:
According to the Cleveland Clinic's ASA status page, which lists examples for each class:

ASA PS 2 - Patients with mild systemic disease - No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy

I know it's still subjective, but I would agree with them. Too many physiologic derangements.

ASA PS 1 - Normal healthy patient - No organic, physiologic, or psychiatric disturbance.
Click to expand...

This is interesting.

So how does one know if the patient does NOT have COPD while pt has, say, 90 pack-year history of smoking (assuming you cannot find PFTs but pt has all the clinical features of COPD)?

And what is 'mild obesity'? Is it BMI > 30? Or is it BMI > 25 since technically it is 'overweight'? At what point does obesity becomes mild? Say a patient of BMI 40 and he comes in for RYGB but otherwise 'healthy' (define healthy with whatever you think is reasonable) - would RYGB automatically qualify him as ASA 3 instead of ASA2? Or would a patient of BMI 40 automatically becomes ASA3 even if he is here for I&D of the big toe with local anesthetics only?

I feel that ASA classification is just a number - some basic common ground that one can use to communicate with another professional but it is never the full picture.
 
Planktonmd said:
The ESRD patient on dialysis is NOT comparable to the pacemaker patient!
A patient on dialysis is a very sick patient, chronically uremic, hypercoagulable, with chronic electrolyte imbalance, chronic anemia who has an invasive procedure every 2 days (hemodialysis) where he is subject to all kinds of complications: Infection, bleeding, volume overload, volume depletion, acid-base imbalance...to name a few!
If you think that patients between dialysis sessions become healthy patients then I suggest you review the pathophysiology of chronic renal failure and the effects of dialysis.
So, IMHO ESRD is NOT equivalent to having a pacemaker my friend.
Click to expand...

I would like to see a few preops by plank.

esrd pt who walked to the hosp on his Nike's> asa4
esrd septic patient on pressors> asa4
pacemaker pt who jogged to the hosp on his Puma's> asa4
pacemaker pt with traumatic brain injury all gorked out> asa4

:confused:
 
I see people quoting various non-ASA sources, but I think the ASA itself is intentionally vague about its classification system, permitting a range of interpretations: "There is no additional information that will help you further define these categories."

The way I see it:

ASA 1-2: I would be surprised if the patient died in the next ten years
ASA 3: I would not be surprised if the patient died in the next ten years as a result of something related to a current diagnosis
ASA 4: I would not be surprised if the patient died in the next year as a result of a current diagnosis
ASA 5: I would not be surprised if the patient died tomorrow
ASA 6: I would not be surprised if the patient died yesterday
 
Last edited:
:thumbup:
lord_jeebus said:
I see people quoting various non-ASA sources, but I think the ASA itself is intentionally vague about its classification system, permitting a range of interpretations: "There is no additional information that will help you further define these categories."

The way I see it:

ASA 1-2: I would be surprised if the patient died in the next ten years
ASA 3: I would not be surprised if the patient died in the next ten years as a result of something related to a current diagnosis
ASA 4: I would not be surprised if the patient died in the next year as a result of a current diagnosis
ASA 5: I would not be surprised if the patient died tomorrow
ASA 6: I would not be surprised if the patient died yesterday
Click to expand...

That's pretty good.:thumbup:
 
urge said:
I would like to see a few preops by plank.

esrd pt who walked to the hosp on his Nike's> asa4
esrd septic patient on pressors> asa4
pacemaker pt who jogged to the hosp on his Puma's> asa4
pacemaker pt with traumatic brain injury all gorked out> asa4

:confused:
Click to expand...

Correct!
I actually have a partner who makes every one ASA 2 !
And I have seen patients who came to the OR 3 different times during the same hospitalization and got 3 different ASA scores by 3 different anesthesiologists!
But I still think your Pent/Sux/Tube patients should all be ASA 5 at least. ;)
 
You must log in or register to reply here.
Next unread thread

Similar threads

F
Would 10m liquid assets and being under 50 be enough for you to walk away or would you miss it too much?
2 3 4 5
Replies
209
Views
9K
doctalaughs
D
G
MOCA without ASA?
Replies
7
Views
905
Leinie
L
P
Would you risk your license?
Replies
9
Views
2K
IMGASMD
I
O
How many days of the ASA conference would benefit a med student?
Replies
16
Views
2K
Twiggidy
Twiggidy
linkin06
Sugammadex now recommended per ASA
2 3
Replies
107
Views
5K
narcusprince
narcusprince
Top