Is ASA Grading Out-dated?

Transcription

1 Sedation For Medically-Compromised Patients Is ASA Grading Out-dated? 2016 Dr Yusof (Joe) Omar MBBCh, DA, MRCA, PDD (Pain & Sedation) Sedationist Senior Teaching Fellow, Eastman CPD, UCL

2 ASA I ASA II A normal healthy patient A patient with mild systemic disease ASA III A patient with severe systemic disease ASA IV A patient with severe systemic disease that is a constant threat to life

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4 Mrs X 66years old, retired, smoker, Alcohol 8-10u/w Lung disease, emhysema, usual Sats 87-89% Depression, under psychiatrist s care. Steroids in the past Excessive thirst, pt thinks she may have Diabetes. Drugs: Inhalers only

5 ASA I A normal healthy patient Healthy non-smoking, no or minimal alcohol use ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, (<14 u/w ) pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease

6 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.

7 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

8 Mrs X 66years old, retired, smoker, Alcohol 8-10u/w Lung disease, emhysema, usual Sats 87-89% Depression, under psychiatrist s care. Steroids in the past Excessive thirst, pt thinks she may have Diabetes. Drugs: Inhalers only Minor Surg Procedure. At Induction P 64/min BP 140/70 O2Sats 87% Midazolam 0.5 mg Total time 45min Total Midaz 1.5mg Total Propofol 20mg Uneventful Sedation

9 Mrs X Escort took Mrs X back to Devon by car, no problems reported. How many of you would be happy with that? Mrs X was found dead the next morning. Did the Sedation contribute towards her Demise Post Mortem: No cause of death found.

10 RETIRE NOW

11 Is there an Alternative to ASA APACHE II Acute Physiology and Chronic Health Evaluation II It is a severity-of-disease classification system (Knaus et al., 1985)

12 The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please A conceptual model for outcome after surgery. Gary Minto, and Bruce Biccard Contin Educ Anaesth Crit Care Pain 2013;bjaceaccp.mkt020

13 Surgery Specific Estimates Of Risk High risk (cardiac risk >5%) Eg Open aortic Intermediate risk (1 5%) Eg Elective abdominal Low risk (cardiac risk <1%) Eg Dental (Cardiac Risk) (adapted from The Royal College of Surgeons of England/Department of Health3). The Royal College of Surgeons of England. Taken from The Higher Risk Surgical Patient, Reproduced with permission.

14 Risk Factors in Dental Sedation Age Fitness Fear and anxiety of Pt Nature of procedure Duration of procedure Training of sedationist Experience of sedationist Gut Feeling

15 The age & fitness of the Pt Risk / Safety Assessment Experience of the sedationist Risk/ Safety The fear & anxiety level Nature & duration of the treatment

16 The age & Fitness of the Pt The fear & Anxiety Level Nature & Duration of the Treatment Experience of the Sedationist 0 Normal Easy Ext >10y Exp 0 Safe Grey-Area Unsafe 5 Extremes of Age Phobic Zygomatic Implants Beginner 5

17 Safe Grey-Area The age & fitness of the Pt Normal 0 ASA1 ASA2 ASA Age: -Within the experience & comfort zone of the sedationist 16-59y treat as adults years: 5-12 years: Individual assessment 2-4 years: Is conscious sedation really possible in a frightened child? Unsafe ASA4 Phobic 4 5

18 Safe Grey-Area The age & fitness of the Pt ASA Fitness: RISK ASSESSMENT ASA 1= 0 ASA 4 = 5 L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue) E=Evaluate the rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths) M=Mallampati (Mallampati score 3 ) O=Obstruction (presence of any condition that could cause an obstructed airway) N=Neck mobility (limited neck mobility) Unsafe ASA

19 The fear & anxiety level Phobics 4 1 Safe Normal Difficult venipuncture They expect Oblivion Increased movements Increased Tremor Increased likelihood of vagal effects Undiagnosed problems Neglected OH Loose Teeth Unsafe 5 Phobic 5

20 Safe Grey-Area Unsafe Nature & duration of the treatment Easy Ext 5 Zygomatic Implants 1 Lowest Risk: Short, dry, procedure Anterior extractions Endo with Rubber dam Moderate Risk Duration of 2 hours or more Two-Quad Restoration Scaling Sensitive Teeth without LA High risk Four Quad Surgery Complex Surgery Social reasons Public Transport Living alone 3 4 2

21 Safe Experience of the Sedationist Grey-Area Unsafe Training Formal Training PGCert or Grand-Father Skill in Venipuncture Communication skills In simple CBT Experience Suggestions <20 cases/year = score cases/y score cases/year = score 3 Up-to-Date: minimum ADA or SAAD annually

22 Safe Experience of the sedationist Grey-Area Training No Training Anaesth Training Skill Venipuncture Communication skills In simple CBT Experience Suggestions 0 4 <20 cases/year = score cases/y score cases/year = score 3 Unsafe 4 5 Up-to-Date: minimum ADA or SAAD

23 Score High Score and High Risk 6 0 Low Score and Safety A 4y old fallen off his Scooter, broken 2 teeth, and cut lip. Distraught mother, frightened child. Child wheezing but mum says it s because he s crying. Young dentist Sedates once /month Learnt to do it at Dental school and as SHO No PGC in Sedation

24 Age Fitness Fear Level x x x Total Score = 30 4y old Asthma Crying Nature of procedure x? Difficult Duration of procedure x? Training of sedationist Experience of sedationist x x Week-end Course Low Gut Feeling: Under Pressure

25 Mr MS aged 64y, BMI 33.5 PMH Anaemia of unknown origin Asthma Knee probs Benign tumors of chest Diabetes Carpel tunnel release Heavy snorer MEDICATIONS : 1. Pravastatin 2. Dosulepin 3. Bumetanide 4. Meformin 5. Irbesartan 6. Tamsulosin 7. Novomix 8. Cocodomol 9. Amitriptyline 10. Ventolin 11. Omeprazol

26 Mrs PP 95y old, mobile, lives independently PMH Angina, uses GTN very occasionally Pacemaker 2005 and 2014 Tripple CABG 2004 Hypertension L knee replacement 2010 Surgery to lower back 2014 Small cell Ca lunging remission Untreated Aortic Aneurism Cataracts Bunions Appendectomy MEDICATIONS : Aspirin Bendroflumethiazide 2.5mg Ramipril 1,25mg Isosorbide 10mg Bisoprolol 2.5 mg Lansoprazole Ferrous Sulphate Quinine Co-codomol

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28 Poswillo Report no deaths eight deaths Of which five were children. Critical of the standard of care provided in: Pre-operative assessment Monitoring Start of resuscitation and transfer to specialist critical care. General Anaesthesia, Sedation and Resuscitation in Dentistry, Report of an expert working party prepared for the Standing Dental Advisory Committee March 1990 (AKA The Poswillo Report).

29 Thank you THE ULTIMATE IGNORANCE IS THE REJECTION OF SOMETHING YOU KNOW NOTHING ABOUT YET, REFUSE TO INVESTIGATE Dr Wayne Dyer