AMERICAN SOCIETY OF ANESTHESIOLOGISTS ANESTHESIA PRE OPERATIVE SCREENING ASA PHYSICAL STATUS CLASSIFICATION ANESTHESIOLOGISTS

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1 ANESTHESIA PRE OPERATIVE SCREENING CAPA S 37 TH ANNUAL CONFERENCE PALM SPRINGS OCTOBER 5, 2013 ROBERT F. KOPEL, MD, FACP, FCCP HOAG HOSPITAL ASSISTANT CLINICAL PROFESSOR UCLA SCHOOL OF MEDICINE AMERICAN SOCIETY OF ANESTHESIOLOGISTS Anesthesiology 2012: 116: Practice Advisory for Preanesthesia Evaluation An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Practice Advisories are not supported by scientific literature to the same degree as standards and guidelines because of lack of sufficient numbers of adequately controlled studies The literature does not provide a standard definition for preanesthesia evaluation AMERICAN SOCIETY OF ANESTHESIOLOGISTS ASA PHYSICAL STATUS CLASSIFICATION A minimum directed physical examination should include an assessment of the airway, lungs, and heart Routine preoperative tests do not make an important contribution to the process of perioperative assessment and management of the patient by the anesthesiologist Specific tests and their timing should be individualized and based upon information obtained from sources such as the medical record, history, physical examination and type of planned procedure The evaluation should be performed at least before the day of surgery Physical Status PI A normal healthy patient Physical Status P2 A patient with mild systemic disease Physical Status P3 A patient with severe systemic disease Physical Status P4 A patient with severe systemic disease that is a constant threat to life Physical Status P5 A moribund patient not expected to survive without the operation Physical Status P6 A declared brain dead patient whose organs are being removed for donor purposes 1

2 HISTORY MAJOR PREDICTORS HISTORY MINOR PREDICTORS MAJOR PREDICTORS CAD, MI, EKG evidence of infarct or ischemia Congestive heart failure CVA, TIA Diabetes mellitus Renal insufficiency MINOR PREDICTORS Age >70 EKG abnormalities such as LVH, BBB, arrhythmias Non sinus rhythm or paced rhythm Poorly controlled hypertension Low functional capacity (<4 METS) 3 minors predictors are equal to 1 major predictor SURGICAL PROCEDURE RISK SURGICAL PROCEDURE TIMING LOW RISK (<1%) Breast, knee arthroscopy, cataracts, superficial, peripheral INTERMEDIATE RISK (1 5%) Intraperitoneal, laparoscopy, orthopedic, head and neck HIGH RISK (>5%) Aortic, major vascular, emergency surgery, prolonged surgery with large fluid shifts ELECTIVE Cosmetic, chronic conditions such as amputation for degenerative joint disease SEMI URGENT Cholecystectomy for chronic cholecystitis, laminectomy for spinal stenosis URGENT Mastectomy and prostatectomy for cancer, colectomy for recurrent diverticulitis, dialysis access EMERGENT Appendectomy, craniotomy for hemorrhage, aortic dissection 2

3 SPECIFIC CONCERNS PREOPERATIVE EVALUATION SPECIFIC DETAILED ASSESSMENT Angioplasty with stent during the past year The indication for surgery must be evaluated by the anesthesiologist Anticoagulation therapy The plan for drug holding parameters must be discussed by the prescribing physician and surgeon The surgeon must document this on the PAS form RED FLAGS = ACTIVE CARDIAC CONDITIONS Unstable angina, recent MI (6 months), decompensated CHF, significant arrhythmias, severe valvular disease Recent coronary artery angioplasty with stent Uncharacterized or undocumented cardiac findings such as chest pain that has not been evaluated, murmur of unknown etiology, new EKG abnormalities, LBBB GRAY AREAS THE ART OF MEDICINE CARDIOLOGY EVALUATION Should this patient be seen by a cardiologist as part of their routine medical care? If yes, please refer them for cardiology evaluation. EXAMPLE An obese 75 year old woman with a history of hypercholesterolemia, hypertension, type 2 diabetes mellitus for 10 years, minor abnormalities on EKG and low functional capacity should be referred for cardiology evaluation as part of her routine medical care. The patient must be seen before undergoing general anesthesia for a semi elective procedure. 3

4 HOAG PREOPERATIVE ANESTHESIA SCREENING (PAS) CLINIC EVALUATION EVALUATION FLOW CHART Patient history questionnaire and medication list Labs, EKG, radiography according to pre surgical patient standardized procedure Physician notes, reports of cardiac procedures, studies, other diagnostic testing Surgeon's documentation Major cardiac considerations including angioplasty/stent, pacemaker/aicd Nature of surgery: emergency or elective? If elective then active cardiac conditions or red flags? What is the risk of surgery? What is the patient's functional capacity? Consider major and minor clinical predictors. PATIENT QUESTIONNAIRE NURSING ASSESSMENT GRID 4

5 PREOPERATIVE TESTING GUIDELINES HOAG PREOPERATIVE CARDIAC EVALUATION FOR PATIENTS UNDERGOING NON CARDIAC SURGERY HOAG GUIDELINES FOR PERIOPERATIVE MANAGEMENT OF PATIENTS WITH RECENT PERCUTANEOUS CORONARY INTERVENTIONS HOAG PRE SURGICAL PATIENT TESTING PER STANDARDIZED PROCEDURE 5

6 HOAG ANTICOAGULANT THERAPY DOCUMENTATION PRE OPERATIVE PLANNING PHYSICIAN EVALAUTION The PAS nurse review determines if an anesthesiologist review is required The PAS anesthesiologist reviews relevant data and may contact the surgeon, primary care physician, cardiologist, or specialist The PAS Clinic evaluation process is associated with a very low day of surgery cancellation rate CANCELLATION DATA EVALUATION BEDSIDE CANCELLATION PREVENTION Bedside cancellations can be prevented! Hoag facilities had 35,765 surgical procedures in 2010 with 88 bedside cancellations. The Hoag Hospital surgical cancellation rate is very low compared to national averages All cancellations are reviewed to determine if it was preventable. 6

7 RESULTS Patient satisfaction Surgeon satisfaction Cost savings Avoiding adverse perioperative events 7