ASA status

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waterbottle10

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Not the most important questions but I am curious as to what the community would give to these patients in terms of ASA score.
ESRD,
Diabetes type 1 insulin dependent

I'm curious about above because some people give ESRD an ASA 4 simply due to ESRD, because dialysis is life saving. But the diabetic type 1 patient gets an ASA 2 even though insulin is life saving. Both diseases cause significant consequences later on in life. What are your thoughts?

Otherwise healthy guy, bleeding cause he fractured his femur, causing hemodynamic instability, going into surgery to fix. Would you give this patient ASA1E since he is previously healthy, or would you give higher?
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ASA scores are intentionally vague, debatable, and open to interpretation. For my feeble brain, any time the patient stands a good chance of dying if you take away their medical therapy - that's an ASA 4. So for me, both ESRD and DM1 get an ASA 4.

That last one can be debated for days - there's no one right answer. If he's truly unstable I'd kick up his ASA score as well the "E". An ASA 1E for me would be like a non-septic appy.
 
SaltyDog said:
ASA scores are intentionally vague, debatable, and open to interpretation. For my feeble brain, any time the patient stands a good chance of dying if you take away their medical therapy - that's an ASA 4. So for me, both ESRD and DM1 get an ASA 4.

That last one can be debated for days - there's no one right answer. If he's truly unstable I'd kick up his ASA score as well the "E". An ASA 1E for me would be like a non-septic appy.
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This person gets a 4 if you believe that ESRD or DM1 is a "constant" threat to life.

Clearly without therapy, either of these would be fatal, but it would take days-weeks.

If you think that's a "constant threat to life," cool, 4.

For what it's worth, ASA goes out of its way to mention ESRD on HD as more of a 3.
 
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fakin' the funk said:
If you think that's a "constant threat to life," cool, 4.
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To me, ya, if I take away your HD or insulin you're gonna croak - that's a constant threat to life. Doesn't say anything about "has to be lethal in the next 15 minutes." But like I said, it's all real subjective. One man's 4 is another man's 3 - just like the hotness scale.
 
Asa 3. ESrd undergoing regularly scheduled dialysis.
How is that vague?

Poorly controlled dm/htn
Is a little more vague, but honestly is they have significant end organ disease that means poorly controlled.
 
I wouldn't qualify ESRD on HD, or even poorly-controlled DM, as a constant threat to life. Constant threat to life is generally somebody who not only has a severe systemic disease, but also should be/is in the hospital for it (or is barely functioning at home - you would not be surprised if you heard s/he suddenly died). That's what "constant" and "severe" imply, that's the true ASA 4 patient, not a well-controlled organ failure etc. Just because somebody is on well-functioning organ-replacement technology or medication, s/he shouldn't be an ASA 4. Ergo, 95+% of outpatients shouldn't qualify.

I must admit my scores have gone down since I started working with sicker populations. I can see how an ambulatory anesthesiologist would score as an ASA 4 a lot of of what I score as a 3. It's just that I see much worse, on a weekly basis. None of us is right or wrong, because it's such an ambiguous score (although the ASA gives examples that encourage my type of underscoring). The ASA should just drop it.

upload_2018-3-22_12-18-50.png
 
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FFP said:
I wouldn't qualify ESRD on HD, or even poorly-controlled DM, as a constant threat to life. Constant threat to life is generally somebody who not only has a severe systemic disease, but also should be/is in the hospital for it (or is barely functioning at home - you would not be surprised if you heard s/he suddenly died). That's what "constant" and "severe" imply, that's the true ASA 4 patient, not a well-controlled organ failure etc. Just because somebody is on well-functioning organ-replacement technology or medication, s/he shouldn't be an ASA 4. Ergo, 95+% of outpatients shouldn't qualify.

I must admit my scores have gone down since I started working with sicker populations. I can see how an ambulatory anesthesiologist would score as an ASA 4 a lot of of what I score as a 3. It's just that I see much worse, on a weekly basis. None of us is right or wrong, because it's such an ambiguous score (although the ASA gives examples that encourage my type of underscoring). The ASA should just drop it.

View attachment 230841
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Some anesthesiologists will probably make less money if they drop ASA score . And those studies showing CRNA = anesthesiologist may come true
 
FFP said:
I wouldn't qualify ESRD on HD, or even poorly-controlled DM, as a constant threat to life. Constant threat to life is generally somebody who not only has a severe systemic disease, but also should be/is in the hospital for it (or is barely functioning at home - you would not be surprised if you heard s/he suddenly died). That's what "constant" and "severe" imply, that's the true ASA 4 patient, not a well-controlled organ failure etc. Just because somebody is on well-functioning organ-replacement technology or medication, s/he shouldn't be an ASA 4. Ergo, 95+% of outpatients shouldn't qualify.

I must admit my scores have gone down since I started working with sicker populations. I can see how an ambulatory anesthesiologist would score as an ASA 4 a lot of of what I score as a 3. It's just that I see much worse, on a weekly basis. None of us is right or wrong, because it's such an ambiguous score (although the ASA gives examples that encourage my type of underscoring). The ASA should just drop it.

View attachment 230841
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I’m with salty. I mean why are they having surgery? Seems to me like it’s usually due to blood clots, infected lines, DKA with diabetic foot and osteomyelitis, etc. With the exception of Jay Cutler, they’re rarely an otherwise healthy group.
 
FFP said:
I wouldn't qualify ESRD on HD, or even poorly-controlled DM, as a constant threat to life. Constant threat to life is generally somebody who not only has a severe systemic disease, but also should be/is in the hospital for it (or is barely functioning at home - you would not be surprised if you heard s/he suddenly died). That's what "constant" and "severe" imply, that's the true ASA 4 patient, not a well-controlled organ failure etc. Just because somebody is on well-functioning organ-replacement technology or medication, s/he shouldn't be an ASA 4. Ergo, 95+% of outpatients shouldn't qualify.

I must admit my scores have gone down since I started working with sicker populations. I can see how an ambulatory anesthesiologist would score as an ASA 4 a lot of of what I score as a 3. It's just that I see much worse, on a weekly basis. None of us is right or wrong, because it's such an ambiguous score (although the ASA gives examples that encourage my type of underscoring). The ASA should just drop it.

View attachment 230841
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I base it on this....I remember we would have entire M&Ms where people would argue over ASA status and miss the entire point of why we're having the M&M in the first place.

If you really want a debate......what's the ASA status of a laboring patient? what about a laboring patient with Gestational DM or thrombocytopenia? Are laboring patient's ever and "E"?

*these are all debates that have come up at some point in my career*
 
Twiggidy said:
I base it on this....I remember we would have entire M&Ms where people would argue over ASA status and miss the entire point of why we're having the M&M in the first place.

If you really want a debate......what's the ASA status of a laboring patient? what about a laboring patient with Gestational DM or thrombocytopenia? Are laboring patient's ever and "E"?

*these are all debates that have come up at some point in my career*
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They are only an E when I get called at 200am to do a labor epidural.
 
narcusprince said:
They are only an E when I get called at 200am to do a labor epidural.
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I don't know if you're joking or not?
Are you?

The ASA scale is so intrinsically linked to payments, insurance at this stage it will never be scrapped but also it is the ASA's own greatest publication. It makes them relevant.

I also don't think there as much ambiguity in the scale as people make out. The new examples really spell it out loud and clear. Anesthesiologists just make it difficult it inflate their wages and egos.

In Europe where I worked before payments weren't related to ASA scale and scores weew usually 1 point less
 
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All pregnant patients are automatic ASA2+. Anything I do in L&D is an E except for scheduled c sections.

Going from Asa 1 to 2 doesn’t change billing at all. Going from 2 to 3 adds a couple billing units. 3 to 4 adds more. Not sure if doing a labor epidural on a 3 pays any more than a 1 but it definitely increases units for c section.
 
ZzzPlz said:
All pregnant patients are automatic ASA2+. Anything I do in L&D is an E except for scheduled c sections.

Going from Asa 1 to 2 doesn’t change billing at all. Going from 2 to 3 adds a couple billing units. 3 to 4 adds more. Not sure if doing a labor epidural on a 3 pays any more than a 1 but it definitely increases units for c section.
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that's argument one of my attendings used to make. "they're in pain. the labor wasn't planned. it's an "E" since there's nothing scheduled about this situation". which is an interesting point. so the counter point is a planned induction an "E"?

FYI @narcusprince ....i agree with you, both jokingly and seriously. in my book, any call I get to do ANYTHING outside the hours of 7a-5p is an "E", in my book. Billing companies will likely think different
 
Twiggidy said:
that's argument one of my attendings used to make. "they're in pain. the labor wasn't planned. it's an "E" since there's nothing scheduled about this situation". which is an interesting point. so the counter point is a planned induction an "E"?

FYI @narcusprince ....i agree with you, both jokingly and seriously. in my book, any call I get to do ANYTHING outside the hours of 7a-5p is an "E", in my book. Billing companies will likely think different
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What is your attending talking about? They've been scheduled for months but they may have come a bit early for their appointment.
 
Psai said:
What is your attending talking about? They've been scheduled for months but they may have come a bit early for their appointment.
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That was how he rolled. I was a resident. Didn't matter to me whether he made them ASA 1, 5, or 7s....I just wanted to finish the epidural so I could get some sleep
 
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I look at ASA 4 as "would I be surprised if you die tomorrow"? If you have something that's a daily, constant threat to life.

Throughout residency, every dialysis patient was a 4. Patients on dialysis, even who adhere to dialysis properly, have much higher mortality rates, particularly sudden cardiac death. (Risk Assessment for Sudden Cardiac Death in Dialysis Patients)

Then the ASA specifically comes out and calls them a 3, so that's what I do. But I still really believe them to be a 4.
 
I have well-controlled hypertension controlled by an ACE-inhibitor and single digit body fat. I'm considered ASA 2 and it freakin' pisses me off to no end...
 
facted said:
I look at ASA 4 as "would I be surprised if you die tomorrow"? If you have something that's a daily, constant threat to life.

Throughout residency, every dialysis patient was a 4. Patients on dialysis, even who adhere to dialysis properly, have much higher mortality rates, particularly sudden cardiac death. (Risk Assessment for Sudden Cardiac Death in Dialysis Patients)

Then the ASA specifically comes out and calls them a 3, so that's what I do. But I still really believe them to be a 4.
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that's pretty much my criteria

ASA 1: you better go home in one piece
ASA 2: you SHOULD go home in one piece
ASA 3: you COULD go home in one piece
ASA 4: you're NOT going home in one piece
ASA 5: you're not going home
 
Twiggidy said:
that's pretty much my criteria

ASA 1: you better go home in one piece
ASA 2: you SHOULD go home in one piece
ASA 3: you COULD go home in one piece
ASA 4: you're NOT going home in one piece
ASA 5: you're not going home
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ASA 6: you're going to homes in several pieces

Sent from my SM-G930V using SDN mobile
 
DM I in DKA--ASA IV
ESRD w/ significant hyperkalemia, heart failure, uremia, etc.--ASA IV
 
I had E explained to me once as someone who you would ignore NPO status on. The only caveat to that is laboring patients. Not sure how to classify that.
 
Ronin786 said:
I had E explained to me once as someone who you would ignore NPO status on. The only caveat to that is laboring patients. Not sure how to classify that.
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The same way. A labor epidural is never an E, except as a main anesthetic for an emergent C-section. E is an emergent life, limb or organ-saving surgery.

Non-emergent C-sections should follow NPO rules, or wait. I know that some of us cut corners there, I don't.
 
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narcusprince said:
Totally joking. Here if you speak to a l and d nurse labor pain is an emergency.
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lawl. I've actually had one particular midwife at my place meet me halfway to L+D and then turn around and literally start running back and waving at me to hurry up... for an epidural... at 3 am... that was 5 cm dilated.

Um, no.
 
DocVapor said:
lawl. I've actually had one particular midwife at my place meet me halfway to L+D and then turn around and literally start running back and waving at me to hurry up... for an epidural... at 3 am... that was 5 cm dilated.

Um, no.
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We all know this is true.....but let me tell you, if I have a kidney or urethral stone, in my head it's gonna be an emergency. But yes, letter of the law, labor epidurals are not emergencies.
 
Twiggidy said:
We all know this is true.....but let me tell you, if I have a kidney or urethral stone, in my head it's gonna be an emergency. But yes, letter of the law, labor epidurals are not emergencies.
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I can certainly empathize with this, but I was on my way even before I hung up the phone. It's not like I sat around playing on my phone another 15 minutes and chuckling to myself about it before going.
 
At our annual meeting with our billing company I asked about labor epidurals being "E" or not and was told that labor epidurals are not E, and that if E is added, it is rejected by the payors.

I am called all the time for non-emergent C-sections that they want to do in 20 minutes, such as someone laboring and there are a few decelerations, but not sustained, or even simple failure to progress. For the OB department, they have a strict criteria for "emergencies", so they do not want me to label them as "emergencies" in my notes, though they want me right away. I label them "urgent C-sections" in my notes, but still give them an E.
 
FFP said:
E is an emergent life, limb or organ-saving surgery.
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(I'm not singling you out FFP. I just like this quote)

The thing is, if "E" really is a threat to life, limb, or organ, then a strong argument can be made that any C-section that isn't scheduled can get an E because it's basically a threat to the baby. But I guess technically we're taking care of the mother so maybe that's why we can't label it an E. But a prolapsed cord is an E, and I don't think anyone would argue that, but that doesn't affect the mother. This is interesting.
 
ZzzPlz said:
All pregnant patients are automatic ASA2+. Anything I do in L&D is an E except for scheduled c sections.

Going from Asa 1 to 2 doesn’t change billing at all. Going from 2 to 3 adds a couple billing units. 3 to 4 adds more. Not sure if doing a labor epidural on a 3 pays any more than a 1 but it definitely increases units for c section.[/QUOTE
Add all the “billing units” you want, how many third party payers do you think pay for risk modifiers any more?
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I’ll disagree with @FFP that an “E” has to be a life/limb/organ saving surgery. To me an “E” is anytime I’m asked to provide an anesthetic that cannot wait for optimization etc.

So ya, that labor epidural is an “E”. Of course her labor pain isn’t life threatening or even dangerous, but I can’t exactly walk into the room and say:

“Hi, I’m Dr. Dog the anesthesiologist on today. I know you’re dilated 6 cm and in the worst pain you've ever experienced in your life and desperately want an epidural, but you had 1/2 a burrito on your way in. I’ll be right back in 6hrs.”

Actually, scratch that - she’s in labor so she won’t be “NPO” till after delivery. Sorry - No Epidural For You!!
 
Arch Guillotti said:
Let me get this straight - you make the OB wait when you have an urgent c/s that doesn't meet NPO requirements?
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This sounds like someone new in practice. I was dogmatic like this after several years practicing I have relaxed on this guideline. The reality is c/s vomit all the time that are npo. Difference is you have an awake patient that you can suction and make awake interventions to reduce aspiration risk.
 
narcusprince said:
This sounds like someone new in practice. I was dogmatic like this after several years practicing I have relaxed on this guideline. The reality is c/s vomit all the time that are npo. Difference is you have an awake patient that you can suction and make awake interventions to reduce aspiration risk.
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I love when people assume that a neuraxial anesthetic will never turn into a GA, or that an awake patient never needs ketamine or fentanyl or some sedation. I guess that's where some of those nice multimillion OB anesthesia awards come from.

Don't misunderstand me: if the OB declares a section emergent, it's happening NOW. But I won't anesthetize a non-NPO patient electively just so that both of us can go to bed.

Last time I read the joint OB anesthesia NPO guidelines, a year ago, they were saying that women in labor need AT LEAST the same NPO time as the general population, if not more. There's some "dogma" for you guys:

upload_2018-3-26_18-48-29.png


http://www.asahq.org/~/media/sites/...ctice-guidelines-for-obstetric-anesthesia.pdf
 
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Arch Guillotti said:
Let me get this straight - you make the OB wait when you have an urgent c/s that doesn't meet NPO requirements?
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Obviously not. But I have the OB document why he can't wait another x hours, despite the patient not being properly NPO. This way I don't get the "urgent" C-section which is just a frivolous elective one, when the surgeon just doesn't want to come back later. The OB is king, but he has to document it (if not clearly emergent), so it's clear that the OB benefits far outweighed the aspiration risks. The patient becomes an E, and to the OR we go.

As I said, I have very little incentive to risk ignoring the guidelines. If anything does happen, that will be the first thing any lawyer worth his salt will rub into the wound.

I know perfectly the probabilities game here. If I were to bet money systematically on this, in a casino, I would bet against waiting and make a lot of money. But it's not a casino, where I can only lose the amount I bet, it's a Russian roulette, and if I get the bullet it will cost me much more than the sum of all the times I won. Change the guidelines and I'll happily change my practice.

Charlie Munger is so right about the power of incentives. My benefits for keeping the OB happy at any price? Minimal. My risks? Disproportionate. Very easy decision.
 
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FFP said:
Obviously not. But I have the OB document why he can't wait another x hours, despite the patient not being properly NPO. This way I don't get the "urgent" C-section which is just a frivolous elective one, when the surgeon just doesn't want to come back later. The OB is king, but he has to document it (if not clearly emergent), so it's clear that the OB benefits far outweighed the aspiration risks. The patient becomes an E, and to the OR we go.

As I said, I have very little incentive to risk ignoring the guidelines. If anything does happen, that will be the first thing any lawyer worth his salt will rub into the wound.

I know perfectly the probabilities game here. If I were to bet money systematically on this, in a casino, I would bet against waiting and make a lot of money. But it's not a casino, where I can only lose the amount I bet, it's a Russian roulette, and if I get the bullet it will cost me much more than the sum of all the times I won. Change the guidelines and I'll happily change my practice.

Charlie Munger is so right about the power of incentives. My benefits for keeping the OB happy at any price? Minimal. My risks? Disproportionate. Very easy decision.
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Agree with this. But I don’t make a stink about the OB documenting anything, I just write in my record “to OR 2/2 non reassuring ... or non reassuring remote from delivery. The reason for this is that I think it is far more likely that you will be blamed for “delaying” a C/S and then the baby has a bad outcome then the unlikely event that the very rare failed spinal will have an aspiration under GA on top of it.
 
We put people to sleep with full stomachs all the time. RSI and keep it moving. The dogma of the obstetric airway has been way over blown. Yes they are a risk for airway complications. I used to be very dogmatic no repeat spinals no general anesthesia for c sections unless strict emergencies. Yes when you do a spinal a general anesthetic is an option if the spinal fails.
 
dannyboy1 said:
Agree with this. But I don’t make a stink about the OB documenting anything, I just write in my record “to OR 2/2 non reassuring ... or non reassuring remote from delivery. The reason for this is that I think it is far more likely that you will be blamed for “delaying” a C/S and then the baby has a bad outcome then the unlikely event that the very rare failed spinal will have an aspiration under GA on top of it.
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Non-reassuring fetal tracing is easy. I am talking about cases like "this has been taking too long, she's tired, we can section her now, or wait till midnight when she is NPO according to your guidelines". Guess what? Half of these cases end up taking a long nap, waking up rested hours later and delivering naturally.

Everybody seems to need a C-section at 5-6 pm, when the office hours end, and before primetime and dinner, never earlier. Really?
 
narcusprince said:
We put people to sleep with full stomachs all the time. RSI and keep it moving. The dogma of the obstetric airway has been way over blown. Yes they are a risk for airway complications. I used to be very dogmatic no repeat spinals no general anesthesia for c sections unless strict emergencies. Yes when you do a spinal a general anesthetic is an option if the spinal fails.
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I am not dogmatic. I just practice the "standard of care". I don't piss on guidelines unless proven wrong again and again (e.g. Surviving Sepsis Campaign), or I have a good reason to. The NPO stuff hasn't changed for years, despite the EM guys pushing us again and again. I can't just ignore that without good reason, just to be liked by surgeons.

Not having to cover OB... priceless.
 
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Arch Guillotti said:
Do you consider this emergent?
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Yes. If the OB tells me the fetal tracing is non-reassuring (and it's usually not the first bad one) and he doesn't want to take chances, I am going. I am not an OB, so it's his call to say "we need a C-section within X minutes". All I do is ask what X is (i.e. how much time do we have?), and either document it myself or have him document it. I just don't cut corners when there is no medical urgency. The proof is in the FHR tracing, and the OB can explain at the trial why he risked the patient's life by going early. It is not my role to contradict an OB about a FHR tracing, the same way he doesn't get to decide when a patient is NPO "enough" for elective surgery.
 
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FFP said:
I am talking about cases like "this has been taking too long, she's tired
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Wait a minute, so you've got a laboring patient who's been deemed "failure to progress" or whatever term they're using these days, and you're gonna make them wait for NPO status?? While pregnancy itself has essentially no effect on gastric emptying, labor profoundly effects gastric emptying. That laboring patient will be no more NPO at midnight than they are right now. Give 'em shot of bicitra and do the damn section. Waiting in this case is just plain wrong.

Now if you think your OB's are scheduling unnecessary sections out of convenience and you're just trying to teach them a lesson, that is another issue entirely and probably needs to be taken up on a higher level.
 
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