Dumb semantic question about ASA classification

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shepardsun

shepardsun

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ASA 5- moribund patient not expected to survive without the operation. Doesn't that automatically make the case an "E" designation as well? In other words, can you give an example of an ASA 5 case that's not time sensitive?
 
shepardsun said:
ASA 5- moribund patient not expected to survive without the operation. Doesn't that automatically make the case an "E" designation as well? In other words, can you give an example of an ASA 5 case that's not time sensitive?
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Probably not. But the ASA classification system is so archaic and poorly-representative of the overall health of a patient (your outpatient 3 days a week HD patient is the same ASA 4 as a septic, intubated 3 pressor dude or dudette?) that it is almost meaningless to me. That being said, our malpractice company says it is very important to note which patients are high risk and which aren't, which they view as ASA 3 and above - my partners tell stories of them calling with complications followed by a sigh of relief over the phone when they report an ASA 4.

N.B. Really don't want to get into the "your healthy outpatient dialysis person isn't an ASA 4" argument here. Had it enough with obnoxious academic attendings in residency, and it drove me up the damn wall.
 
shepardsun said:
ASA 5- moribund patient not expected to survive without the operation. Doesn't that automatically make the case an "E" designation as well? In other words, can you give an example of an ASA 5 case that's not time sensitive?
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Patient with cardiogenic shock on ecmo coming for let’s say limb amputation, maybe a cath, maybe head mri.

Patient is in the process of dying but the procedure is booked for the next day at 7am.

I think people get too fixated on the part that the patient has to die with/without the surgery.

Oh, And the dialysis patients are ASA 3 unless you are a very weak anesthesiologist.
 
AdmiralChz said:
Probably not. But the ASA classification system is so archaic and poorly-representative of the overall health of a patient (your outpatient 3 days a week HD patient is the same ASA 4 as a septic, intubated 3 pressor dude or dudette?) that it is almost meaningless to me. That being said, our malpractice company says it is very important to note which patients are high risk and which aren't, which they view as ASA 3 and above - my partners tell stories of them calling with complications followed by a sigh of relief over the phone when they report an ASA 4.

N.B. Really don't want to get into the "your healthy outpatient dialysis person isn't an ASA 4" argument here. Had it enough with obnoxious academic attendings in residency, and it drove me up the damn wall.
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Yeah, but your healthy outpatient dialysis patient isn’t an ASA 4... weird example when there are so many true examples you could choose.
 
nolagas said:
Yeah, but your healthy outpatient dialysis patient isn’t an ASA 4... weird example when there are so many true examples you could choose.
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Patients on dialysis are NOT healthy.

This is the definition of an ASA IV.

ASA IV A patient with severe systemic disease that is a constant threat to life.

If you need a machine to get rid of K every two days, that is severe systemic disease - and constantly a threat...because the machine is a machine.

People (not the ASA) have tried to use the classification system for things it was never meant for. That doesn't mean it is a bad classification...it just means people use it wrong.

Please note - ASA classification says nothing about functional status, how well a disease process is managed, how well the other systems are working, etc.

Based on the very simple definition, someone could be a marathon runner, the best max VO2 in the word, be pescatarian (best mortality rates), and have known large aneurysms systemically that are very tenuous and could rupture at any second - that would be an ASA IV.
 
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epidural man said:
Patients on dialysis are NOT healthy.

This is the definition of an ASA IV.

ASA IV A patient with severe systemic disease that is a constant threat to life.

If you need a machine to get rid of K every two days, that is severe systemic disease - and constantly a threat...because the machine is a machine.

People (not the ASA) have tried to use the classification system for things it was never meant for. That doesn't mean it is a bad classification...it just means people use it wrong.

Please note - ASA classification says nothing about functional status, how well a disease process is managed, how well the other systems are working, etc.

Based on the very simple definition, someone could be a marathon runner, the best max VO2 in the word, be pescatarian (best mortality rates), and have known large aneurysms systemically that are very tenuous and could rupture at any second - that would be an ASA IV.
Click to expand...

Actually, the ESRD patient getting dialysis 3x/week would be an ASA III according to the ASA's own examples.

aBtlDih.png
 
@26B is right.

The ASA has "lightened" its classification ~5 years ago, because of the sicker general population. So, what used to be an ASA 4 is, many times, a 3 nowadays. Etc. For example, a BMI of 39 used to be a 3; not anymore. See above.

It makes sense. As medicine progresses, it takes more and more for a disease to be a constant threat to life, or have severe systemic impact.
 
To the OP's original question. I have never had an ASA-5 patient that I did not also add the "E" classification to. You are likely right that in basically all scenarios a 5 is also an E because the definition of a 5 precludes something being elective or time-sensitive. The only real scenario I can think of at the moment would be a moribund septic patient maxed on 3 pressors urgently going to the OR for an ex-lap, but is first having a face lift to look good for their funeral and it's being billed as two separate anesthetics.
 
SaltyDog said:
Well by that definition aren’t we all ASA 5’s?
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There are so many ways to prolong the death of a sick patient that death within 24hrs is not really a marker of sickness.
 
My rule of thumb:

1 healthy
2 mild disease but basically healthy
3 moderate disease
4 disease that needs icu level care at some point in the recent year.
5 someone who is currently very sick in the icu and might not be discharged alive.
 
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On a somewhat similar vein. For what types of cases are residents checking "life threatening pathology" when logging things on the ACGME website? I feel like I could easily attribute it to many of the cases I've done in the past.

The open chest on Central VA ECMO going to OR for chest washout or decannulation. The open belly with ischemic bowel in septic shock (or any infection with septic shock requiring source control) The symptomatic critical aortic stenosis.

Just curious about people's thoughts.
 
abolt18 said:
On a somewhat similar vein. For what types of cases are residents checking "life threatening pathology" when logging things on the ACGME website? I feel like I could easily attribute it to many of the cases I've done in the past.

The open chest on Central VA ECMO going to OR for chest washout or decannulation. The open belly with ischemic bowel in septic shock (or any infection with septic shock requiring source control) The symptomatic critical aortic stenosis.

Just curious about people's thoughts.
Click to expand...

Yes yes no
 
I dont know if case logs changed since I graduated, but I rarely clicked the box for it and somehow when I graduated it had automatically counted nearly half of my cases that way.
 
What do you make an infant for pylormyotomy? On one hand they are (presumably) otherwise healthy, but then again their pyloric stenosis is a constant threat to life.
 
btbam said:
What do you make an infant for pylormyotomy? On one hand they are (presumably) otherwise healthy, but then again their pyloric stenosis is a constant threat to life.
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It's a medical "emergency" not a surgical one. Patient is going to sit on a med ward until their lytes are corrected. Not an ASA 5 by any stretch.
 
btbam said:
What do you make an infant for pylormyotomy? On one hand they are (presumably) otherwise healthy, but then again their pyloric stenosis is a constant threat to life.
Click to expand...

I think of constant threat to life as meaning it wouldn’t really be a complete, total surprise if they dropped dead or had significant morbidity under anesthesia. It wouldn’t surprise me if a pt with an MI less than 3 months ago reinfarcted or if a pt with severe sepsis had refractory hypotension. It would surprise me if stable ESRD on dialysis or a medically optimized pyloromyotomy coded.
 
btbam said:
What do you make an infant for pylormyotomy? On one hand they are (presumably) otherwise healthy, but then again their pyloric stenosis is a constant threat to life.
Click to expand...
Not a constant threat to life unless some ***** takes the patient to surgery without fixing his lytes first. Just an ASA 2.

ASA 5 is an E by definition. Just look at the examples the ASA gives.
 
btbam said:
What do you make an infant for pylormyotomy? On one hand they are (presumably) otherwise healthy, but then again their pyloric stenosis is a constant threat to life.
Click to expand...
1. Maybe 2. That's it.
 
anbuitachi said:
It's debatable. I think pyloric stenosis can easily be higher. The baby can't survive unless it's fixed. It won't die immediately but it won't live that long
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What would you call Lance Armstrong if he went for emergency surgery after being hit by a car?
 
anbuitachi said:
It's debatable. I think pyloric stenosis can easily be higher. The baby can't survive unless it's fixed. It won't die immediately but it won't live that long
Click to expand...

Yea that was my point, you'd think to make them a 1 or 2 without any thought, but how are they any different than an ESRD patient who needs dialysis? If they go more than a couple days without intervention they'll die. My original point was more about making them a 3 or 4, not a 5.
 
btbam said:
Yea that was my point, you'd think to make them a 1 or 2 without any thought, but how are they any different than an ESRD patient who needs dialysis? If they go more than a couple days without intervention they'll die. My original point was more about making them a 3 or 4, not a 5.
Click to expand...

I disagree. As someone stated before, this is a medical, not surgical, emergency. These patients should never be an “E”. If they aren’t appropriately optimized, they don’t get surgery. By the time we see them, they should be tanked up with normal lytes. No “serious systemic” disease there....
 
GAnoAW said:
I disagree. As someone stated before, this is a medical, not surgical, emergency. These patients should never be an “E”. If they aren’t appropriately optimized, they don’t get surgery. By the time we see them, they should be tanked up with normal lytes. No “serious systemic” disease there....
Click to expand...

its not an emergency in teh sense that it doesn't have to go in the next 24 hours. theres no serious system disease because you corrected it with interventions. A patient can get dialyzed to have all electrolytes normal, doesn't mean the patient is healthy and have no serious systemic disease.
 
I like to code ECT patients as ASA5s if they're suicidal since they would die without the operation/procedure to fix their psychiatric issues.

It's generally not an E though.

:corny:
 
btbam said:
Yea that was my point, you'd think to make them a 1 or 2 without any thought, but how are they any different than an ESRD patient who needs dialysis? If they go more than a couple days without intervention they'll die. My original point was more about making them a 3 or 4, not a 5.
Click to expand...

If you can find me an otherwise perfectly health ESRD patient I’ll make him an ASA 2.
 
Pyloric stenosis is treated with TPN until the kid outgrows it in some countries.
 
GravelRider said:
If I have to miss dinner or the sun has set, the case gets an “E” designation.
Click to expand...

Not sure how much of that is facetious, but at our shop we're told that anything that is not elective gets the E designation, which I think pushes the ASA's definition of "significant threat to life or body part" a little much.
 
I rarely see ASA 1s... young athletes that get injured. But even most of the kids I see have something going on like asthma. Essentially if you're on scheduled meds, you're a 2. Pyloric stenosis is a 2 (non-E) in my books. All my T+As are 2s unless have other issues that might make them more high-risk then they become a 3. The biggest debate I have is often classifying between 2 and 3... Ever since the ASA updated their classification it's a little easier to separate patients.
 
The renal pt question is always interesting to me. I always consider ASA IV to be "would i be surprised if you died tomorrow?" There is plenty of evidence that even "healthy" pts in HD have higher mortality rates than general population. Why aren't they ASA IV now? Their condition is certaintly a constant, daily threat to life.
 
facted said:
The renal pt question is always interesting to me. I always consider ASA IV to be "would i be surprised if you died tomorrow?" There is plenty of evidence that even "healthy" pts in HD have higher mortality rates than general population. Why aren't they ASA IV now? Their condition is certaintly a constant, daily threat to life.
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I had been told by attendings that they were a 4. I just checked and you have nailed it. I had no idea.
 
WholeLottaGame7 said:
They're a 3 when they walk out of the dialysis center on Monday. They're a 4 when they walk back in on Wednesday.
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And gods know what they become once they get constipated. With all due respect, guys, nobody gives a crap (pun intended).

Both the septic ICU patient on 2 pressors and the one not on pressors are ASA 4. Not every detail can/should be codified, especially if it has no prognostic or therapeutic value. Patients are humans, not machines. It's a 50 year-old classification; let it rest.
 
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epidural man said:
Patients on dialysis are NOT healthy.

This is the definition of an ASA IV.

ASA IV A patient with severe systemic disease that is a constant threat to life.

If you need a machine to get rid of K every two days, that is severe systemic disease - and constantly a threat...because the machine is a machine.

People (not the ASA) have tried to use the classification system for things it was never meant for. That doesn't mean it is a bad classification...it just means people use it wrong.

Please note - ASA classification says nothing about functional status, how well a disease process is managed, how well the other systems are working, etc.

Based on the very simple definition, someone could be a marathon runner, the best max VO2 in the word, be pescatarian (best mortality rates), and have known large aneurysms systemically that are very tenuous and could rupture at any second - that would be an ASA IV.
Click to expand...

Have you read the ASA classification and it examples?
Regular scheduled dialysis is asa3 unless you got something else isnt it?

Where do you get 4 from?
 
anbuitachi said:
It's debatable. I think pyloric stenosis can easily be higher. The baby can't survive unless it's fixed. It won't die immediately but it won't live that long
Click to expand...

Got called to the ED the other night to help with an airway on a lethargic 1mo. old. pH was 7.7 with a bicarb of 66. 😱 That was an impressive pyloric.
 
anbuitachi said:
What did you do? That's impressive
Click to expand...

Ended up not having to do anything. ER doc was able to get the airway just before I walked into the room. Only thing I did after hearing the labs (they had drawn twice to confirm) was look that the RT squeezing the bag and said “SLOWER”.
 
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