Would you consider ESRD an ASA 3 or 4?

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Sorry to bump this, but just did a review question on Pass Machine for the CA-1 board coming up in July and it asked whether ESRD on dialysis was a 3 or 4- I put down 4 since that's what I've been doing on pre-ops all year long (cmon, get dialyzed or die isn't a constant threat to life??) Anyway, official answer per their reasoning from big miller is that ESRD on HD is a 3...

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ok, what about Morbid Obesity?
 
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So BMI 60 without HTN/CAD/OSA = ASA 3 ?
Definitely. There is a reason they call it (super)morbid obesity.

I seriously doubt you can find a BMI 60 without OSA or HTN.
 
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ASA classifications are so subjective, this could go on forever.

But while we're on the topic... how would you classify a 20yo, BMI 35, otherwise healthy, no meds, no OSA? I've had attendings tell me anything from 1-3, all with their own confident line of reasoning too...
 
ASA classifications are so subjective, this could go on forever.

But while we're on the topic... how would you classify a 20yo, BMI 35, otherwise healthy, no meds, no OSA? I've had attendings tell me anything from 1-3, all with their own confident line of reasoning too...
2
 
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ASA classifications are so subjective, this could go on forever.

But while we're on the topic... how would you classify a 20yo, BMI 35, otherwise healthy, no meds, no OSA? I've had attendings tell me anything from 1-3, all with their own confident line of reasoning too...
ASA 2. Some people will make it a 3, because of the obesity, but it's hard to defend, especially in the US nowadays. When about BMIs, 30 is the new 20.
 
ASA now provides examples for physical status class
BMI 30-40 ASA II
pacemaker ASA III
ESRD on dyalisis ASA III
ASA IV examples are very sick
and we have to separate minimal I / social II / alcohol abuse III

obviously these do not fit with some of our old impressions
 
Old thread brought back from the dead.

What do people consider a pt who has opiate dependence (prescribed) with chronic pain? Is uncontrolled chronic pain a ASA 3 in itself?

Also I was taught in residency that all OB pts are ASA 2's. But I notice some people still call them an ASA 1. Not sure which is correct.
 
Also I was taught in residency that all OB pts are ASA 2's.

Per ASA example pregnancy is ASA II
 
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I call uncomplicated OBs ASA 2. Although pregnancy is a natural beautiful glorious condition of joy, the physiology is altered. If the point of the ASA classification is to coarsely risk stratify patients based on coexisting conditions, and if controlled hypertension is a 2, pregnancy should be too.
 
Sorry to bump this, but just did a review question on Pass Machine for the CA-1 board coming up in July and it asked whether ESRD on dialysis was a 3 or 4- I put down 4 since that's what I've been doing on pre-ops all year long (cmon, get dialyzed or die isn't a constant threat to life??) Anyway, official answer per their reasoning from big miller is that ESRD on HD is a 3...

Forget about what Miller says. I presented all the evidence needed long ago.
I would say 3. They shop at Macy's and drink Starbucks like everyone else with nobody being the wiser.

Now, will the people calling them ASA 4 please surrender their certification?

ASA now provides examples for physical status class
BMI 30-40 ASA II
pacemaker ASA III
ESRD on dyalisis ASA III
ASA IV examples are very sick
and we have to separate minimal I / social II / alcohol abuse III

obviously these do not fit with some of our old impressions
 
Anyone place everyone on medical disability as a 3? Seems a bit excessive, but I know some that do. That was a debated topic for us recently.
 
we have a crna and md in our group who have a pacemaker but are otherwise healthy = ASA III
 
Now, will the people calling them ASA 4 please surrender their certification?

I need to wait a month until my recertification from the National Board of Physicians and Surgeons is approved. But yes, eventually I likely will.
 
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Quick quip: My grandma had ESRD and got a kidney transplant 10 years ago. She is doing fine and has not had a single complication since. She remains one of the healthiest 70-year old ladies I know. Her only issue is that she has to take 53 pills every morning to prevent rejection. She doesn't smoke. Is not overweight. Has no signs of osteoporosis. Etc.

Would you call her a ASA4?



Not trying to cause an argument. Just wondering.
 
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From asahq

ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
 
Quick quip: My grandma had ESRD and got a kidney transplant 10 years ago. She is doing fine and has not had a single complication since. She remains one of the healthiest 70-year old ladies I know. Her only issue is that she has to take 53 pills every morning to prevent rejection. She doesn't smoke. Is not overweight. Has no signs of osteoporosis. Etc.

Would you call her a ASA4?



Not trying to cause an argument. Just wondering.
ASA 3
 
Anyone dependent upon a machine is a 4 in my opinion.
 
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Anyone dependent upon a machine is a 4 in my opinion.

agree

the length of this discussion illustrates the fallacy in attempting to define the vast continuum of disease severity with a 6 point number system.

more important - how can i get one of my hospitals to stop making me wear a bouffant in the OR and give us back our caps? the elastic band in those cafeterialady hats leaves a valley in my gigantic forehead for hours...
 
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more important - how can i get one of my hospitals to stop making me wear a bouffant in the OR and give us back our caps? the elastic band in those cafeterialady hats leaves a valley in my gigantic forehead for hours...

We try to play nice, but our unwritten standard is "Do you make the surgeons do it?" If the answer for them is basically "they can do or wear whatever they want" or "we tried, but they wouldn't do it", then that same standard will apply to us. If these standards don't apply to everyone and aren't enforced uniformly for everyone (which in my experience is a rarity) then they're unenforcable.

But I digress - ESRD is a 4.
 
Forget about what Miller says. I presented all the evidence needed long ago.


Now, will the people calling them ASA 4 please surrender their certification?
The ASA classification is unfortunately made and refined by the ASA, which is not known for coming up with many useful or meaningful definitions, that is the issue!
 
Penis pump?
102-Austin-Powers-quotes.gif
 
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I've actually done this question multiple times on various a qbanks, startprep being one, and it's ASA 3 IF they're on HD. This question was actually on the ITE this year too
 
Forget about what Miller says. I presented all the evidence needed long ago.


Now, will the people calling them ASA 4 please surrender their certification?
In my book, ESRD on HD (and any machine-dependent patient) has always been closer to a 4 than to a 3. No machine, no life (hence the constant threat). If ESRD on HD is an ASA 3, so should be a CHF patient on LVAD. :p

ESRD by itself is clearly an ASA 3. ESRD dependent on HD is debatable. It's what I call an ASA 3.5 when talking to my colleagues (almost a 4, but not quite). I don't think this should be a board-level question. It's like asking whether a psych problem is an ASA 1 or 2.
 
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Pregnancy is always a 2 for me. I agree with ESRD on HD, ie major organ failure, geez that sure sounds like a constant threat to life.... Asa 4 for me. Usually they had significantly uncontrolled HTN or DM To get to ESRD- I call renal insufficiency a 3. Chronic pain on narcs is a 3 for me. Great point about CHF and LVAD.... I don't think anyone would call that a 3. How about ESLD....? 4. Now - status post transplant doing well on immunosuppressives sounds like a three to me. But seriously do these arbitrary numbers really mean anything to any of us? No. We don't make a decision or judgement based on Asa. You never treat numbers right? No, it's for the billing people and maybe to help justify post-op complications in some committee somewhere. Put three on the boards but I have to respectively disagree with the Asa - critical chronic organ failure is a constant threat to life imho.... Not to mention all the complications that go along with HD.
 
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Pregnancy is always a 2 for me. I agree with ESRD on HD, ie major organ failure, geez that sure sounds like a constant threat to life.... Asa 4 for me. Usually they had significantly uncontrolled HTN or DM To get to ESRD- I call renal insufficiency a 3. Chronic pain on narcs is a 3 for me. Great point about CHF and LVAD.... I don't think anyone would call that a 3. How about ESLD....? 4. Now - status post transplant doing well on immunosuppressives sounds like a three to me. But seriously do these arbitrary numbers really mean anything to any of us? No. We don't make a decision or judgement based on Asa. You never treat numbers right? No, it's for the billing people and maybe to help justify post-op complications in some committee somewhere. Put three on the boards but I have to respectively disagree with the Asa - critical chronic organ failure is a constant threat to life imho.... Not to mention all the complications that go along with HD.
Excellent input Amyl
 
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agree

the length of this discussion illustrates the fallacy in attempting to define the vast continuum of disease severity with a 6 point number system.

more important - how can i get one of my hospitals to stop making me wear a bouffant in the OR and give us back our caps? the elastic band in those cafeterialady hats leaves a valley in my gigantic forehead for hours...

I couldn't agree more. They are most uncomfortable things ever.
 
What about someone on suicide precautions and no other medical problems? Would that qualify for an ASA 4?
 
What about someone on suicide precautions and no other medical problems? Would that qualify for an ASA 4?
Definitely not. More like a 2, and that's because he's probably loaded with antipsychotics.

There is no systemic disease present that would affect the anesthesia plan at an ASA 4 level.
 
Would you consider ESRD an ASA 3 or 4

3- systemic disease thats out of control

Which is interesting because you could argue someone who is compliant with 3x per week dialysis could be a "2", systemic disease thats well controlled

My easy way to think of it
is:

1- healthy and better walk out of hospital
2- has something in PMH but shouldnt keep them from walking out in one piece
3- an affliction thats a problem for them and likely my anesthetic
4- this person may die from affliction soon
5 - #dead

"E": you got me out of bed for this
 
Pregnancy is a 2 for me, and get this, I had an attending in training convince me labor epidurals are 2E

(Back to the wholr 'gets me out bed' quote)
 
What about a pt with cad coming for a cabg?

ASA 3 or 4?
 
What about a pt with cad coming for a cabg?

ASA 3 or 4?

I had another cardiac attending that said everyone getting heart surgery is a 4. Now, he was very old school and I picked up both his good and annoying habits, but I still do that classification myself.

Yes, it's barbaric, but most cardiac anesthesiologists are barbarians :) (tongue and cheek for the sensitive-types)
 
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