Lecture #1: ASA Classifications
"E" was added to which ASA classifications? What does this mean?
"E" for emergency was added to Classes 5 & 6 Emergency was thought of "as an operation" that needed to occur immediately
ASA 2 Description Examples
A moderate/mild but definite systemic disturbance. Patients have mild to moderate systemic disease or are healthy ASA I patients who demonstrate a more extreme anxiety and fear toward dentistry. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop after completion of the exercise because of distress since they do not have substantive functional limitations. Minimal risk during dental treatment. - This classification represents a "yellow flag" for treatment, with a slight t warning flag indicating to proceed with caution with all dental care ===================== Examples: History of well-controlled disease states - Well controlled DM or HTN without systemic effects - Mild diabetes (Non-insulin dependent) - Functional capacity I or IIa. - Prehypertension - Current cigarette smoking/social drinking - Pregnancy - Mild lung disease but without COPD - Epilepsy - Asthma - Thyroid conditions - Psychotic patients unable to care for themselves. - Mild acidosis - Anemia moderate - Septic or acute pharyngitis - Chronic sinusitis with postnasal discharge - Acute sinusitis
ASA 4 Description Examples
A patient with severe systemic disease that is constant threat to life Patients have severe systemic disease that limits activity. Patients are unable to walk up one flight of stairs or two level city blocks. Patient has very severe functional limitations. Distress is present even at rest. Patients pose significant risk since patients in this category have a severe medical problem of greater importance to the patient than the planned dental treatment. Whenever possible, planned dental treatment should be postponed until such time as the patient's medical condition has improved to at least an ASA III classification. - This classification represents a "red flag", with a strong warning flag indicating that the risk involved in treating the patient is too great to allow planned dental care to proceed. If emergency treatment is needed, medical consultation is still indicated. ====================== Examples: - History of less than 3 months of unstable angina pectoris, myocardial infarction, cerebrovascular accident, severe congestive heart failure, coronary artery disease with stents - Ongoing ischemia or severe valve dysfunction - Severe reduction of ejection fraction - Sepsis - Disseminated intravascular coagulation - Moderate to severe chronic obstructive pulmonary disease - Uncontrolled diabetes, hypertension, epilepsy, or thyroid condition - Renal failure with refractory ascites and end-stage renal disease not undergoing regularly scheduled dialysis. - Functional capacity III (Cardiac Decompensation). - Severe trauma with irreparable damage. - Complete intestinal obstruction of long duration in a patient who is already debilitated. - A combination of cardiovascular-renal disease with marked renal impairment. - Patients who must have anesthesia to arrest a secondary hemorrhage where the patient is in poor condition associated with marked loss of blood.
Brief overview/description of each ASA Classification (1-6)
ASA 1 - A normal healthy patient ASA 2 - A patient with mild systemic disease ASA 3 - A patient with severe systemic disease ASA 4 - A patient with severe systemic disease that is constant threat to life ASA 5 - A moribund patient not expected to survive without the operation ASA 6 - A brain-dead patient whose organs are being removed for donation
What are some things that can make a normally ASA 1 patient be categorized as ASA 2?
ASA I with: - a mild respiratory condition - pregnancy - active allergies - current smoker and/or social alcohol drinker - Class I and II fObesity (30 < BMI < 40). Patients who demonstrate a more extreme anxiety and fear toward dentistry have a baseline of ASA 2 even before their medical history is considered; that situation can raise the classification system for that patient. May need medical consultation before all dental care.
What is the ASA status of a healthy pregnant patient?
ASA II
Classify Patient AB's current ASA status Patient AB is a 42 year old white female crossing guard Demographics: • Height: 5' 5" • Weight: 145 lbs. • BMI (Body Mass Index): 24.1 • Vital signs: Pulse/P, Respiration Rate/RR, Blood Pressure/BP, all WNL Health & Social History: • Patient AB has no medical conditions & feels totally healthy • She is a smoker • She does not drink nor does she use any recreational drugs
ASA II This is because she is a smoker. Everything else looks good.
When should ASA grading system be done?
ASA Status assessment should be done prior to starting Dentistry Prior to selecting the local anesthetic (LA) for dental care Prior to using any sedation for stress management when needed
What does each mean? ASA-E ASA-P
ASA-E - Emergency operation of any variety; used to modify one of the above classifications, i.e., ASA III-E. ASA-P - Pregnant patient; used to modify one of the above classifications, i.e., ASA III-P.
ASA classification: Pulmonary status Absence of COPD Presence of COPD Intermittent symptoms COPD Continuous symptoms COPD
Absence of COPD: ASA II Presence of COPD: ASA III Intermittent symptoms COPD: ASA III Continuous symptoms COPD: ASA IV
What is emergency surgery? What would it be called if an ASA 1 patient was having an emergency surgery?
An emergency operation is arbitrarily defined as a surgical procedure which, in the surgeon's opinion, should be performed without delay. ====================== An ASA 1 patient having an emergent procedure would be ASA 1E
Classify Patient AB's current ASA status Patient CD is a 58 year old librarian of Hispanic decent Demographics: • Height: 5' 3". Weight: 178 lbs. • BMI: 31.5 • Pulse & RR: WNL • BP: 138/89 mmHg Health History: • Diabetes & Hypertension since age 32 • Diagnosed with diabetic nephropathy & diabetic retinopathy at age 50 Treatment/Medications: • q6 month check-ups at renal clinic & at eye clinic for photocoagulation laser therapy • Hypoglycemic drug, Metformin (Glucophage): 1,000 mg bid • Hypoglycemic drug, Insulin (Tresiba Flex Touch pen): U-200 10 units SC, OD • ACE-I, Lisinopril (Zestril): 20 mg OD • Angiotensin receptor blocker, Losartan (Cozaar): 100 mg OD
BMI = Obese Class 1 BP = Stage 1 Hypertension Diabetes is progressing (has had it since age 32, at 50 was diagnosed with diabetic nephropathy and retinopathy) ASA III due to a condition (diabetes) that is not well controlled.
Lorazepam (Ativan) Type of drug Adult oral dose
Benzodiazepine ============== Adult oral Dose: - 1-2 mg PO hs the night prior - 1-2 mg PO 30 mins-1 h prior to Rx
Diazepam (Valium) Type of drug IV doses - Increments given - Healthy elderly people Oral doses - Oral Dose under age 50 - LEAN & PETIT patient or healthy person above age 50 - Maximum dose for each
Benzodiazepine =============== IV Dose: - Initial dose: 2.5-5 mg. - Titrate in 1.5mg increments till desired effect ================ Healthy Elderly IV Dose: - 1.25-2.5 mg. - Titrate in increments of 1.0 mg ================= Oral Dose < age 50: - 5-10 mg hs; 5-10 mg PO 1h prior to Rx. - Maximum dose 10 mg PO ================== LEAN & PETIT patient or healthy person above age 50 - 2-5 mg hs; 2-5 mg PO 1h prior to Rx. - Maximum dose 5 mg or less
ASA 6 Description
Clinically dead patients being maintained for harvesting of organs.
ASA classification: Hepatic status Compensated Cirrhosis Decompensated Cirrhosis
Compensated Cirrhosis: ASA III Decompensated Cirrhosis: ASA IV
Cirrhosis Classification System Stages of Cirrhosis and findings Death % at each stage What is the ASA status of a patient with cirrhosis?
Compensated: ASA III Decompensated: ASA IV
ASA classification: Renal status ESRD undergoing dialysis ESRD not undergoing dialysis
ESRD undergoing dialysis: ASA III ESRD not undergoing dialysis: ASA IV
Diabetes Tests & associated Status: Severely uncontrolled DM - FBS - Random BS - eAG - HbA1C
FBS - >250 mg/dL Random BS - >300 mg/dL eAG - >250mg/dL HbA1C - >10%
Diabetes Tests & associated Status: The Well Controlled Diabetic - FBS - PPBS - eAG - A1C
FBS: - <120mg/dL PPBS: - <180mg/dL eAG: - <160 mg/dL A1C: - <7% ================== *eAG: Estimated average glucose
ASA Status: GFR & End Stage Renal Disease (ESRD) What is GFR used for? 5 stages of severity of kidney disease using GFR
GFR is used to determine the severity of kidney disease ======================= The 5 Stages of severity are: Stage 1: - GFR ≥ 90mL/min/1.73m2 Stage 2 (Mild) - GFR 60-89mL/min/1.73m2 Stage 3 (Moderate) - GFR 30-59mL/min/1.73m2 Stage 4 (Severe) - GFR 15-29mL/min/1.73m2 Stage 5 (Kidney Failure) - GFR <15mL/min/1.73m2
ASA Classification: Heart failure At what LV EF % does heart failure occur? - Mild - Moderate/Severe
Heart failure (HF) occurs when the EF is < 40% ======================= Mild HF/CHF: - LV EF 35%-39%: - ASA III Moderate-Severe HF/CHF: - LV EF <35% - ASA IV
ASA classification: Cardiac status MI, CVA, TIA, CAD or stents <3 months MI, CVA, TIA, CAD or stents >3 months
MI, CVA, TIA, CAD or stents <3 months: ASA IV MI, CVA, TIA, CAD or stents >3 months: ASA III
ASA classification: Congestive Heart Failure (CHF) Mild/Controlled CHF Moderate-severe/uncontrolled CHF
Mild/Controlled CHF: ASA III Moderate-severe/uncontrolled CHF: ASA IV
ASA classification: Ejection fraction Moderate reduction Severe reduction
Moderate reduction: ASA III Severe reduction: ASA IV
ASA 1 Description
No organic pathology or patients in whom the pathological process is localized and does not cause any systemic disturbance or abnormality. Patients are considered to be healthy, non-smoking, with no or minimal alcohol use. All major organs and organ systems appear in good health. Patients are able to walk up one flight of stairs or two level city blocks without distress. Little or no anxiety. Little or no risk during dental treatment. - This classification represents a "green flag" for all dental treatment, usually not needing a medical consult unless other flags go up about patient hiding medical concerns when presented with an unhealthy general physical assessment
Ejection fraction (EF) %s and ASA Classifications Normal and borderline Mild reduction Moderate reduction Severe reduction
Normal LV EF - 55%-70% Borderline LV EF - 50-55% ================== Mild reduction of LV EF: - 40%-50%: - ASA III ================== Moderate reduction of LV EF: - 35%-39% - ASA III ================== Severe reduction of LV EF: - <35% - ASA IV
ASA classification: COPD Status - What are the PO2, PCO2 levels in each case? What are the normal values? Mild COPD Moderate COPD Severe COPD Very Severe COPD
Normal PO2: 80-100 mmHg Normal PCO2: 35-45 mmHg ===================== MILD COPD: ASA III PO2: Close to 75mmHg PCO2: normal - Low risk, less symptoms ======================= MODERATE COPD: ASA III PO2: < 60mmHg PCO2: normal - Low risk, more symptoms ====================== SEVERE COPD: ASA IV PO2: ≤ 50mmHg PCO2: ≥50mmHg - High risk, less symptoms, CO2 retention ======================= VERY SEVERE COPD: ASA IV PO2: ≤ 50mmHg PCO2: >50mmHg - High risk, more symptoms, CO2 retention - Respiratory Failure: O2 added
ASA Classifications: BMI What is the ASA status for each level of obesity?
Obese Class I (BMI 30-34.9) - ASA II Obese Class II (BMI 35-39.9) - ASA II Obese Class III (BMI equal or greater than 40) - ASA III
A patient has chronic kidney disease when GFR is ______________ for _____ months
Patient has chronic kidney disease when GFR is < 60 mL/min/1.73 m2 for 3 months
ASA 5 Description Examples
Patients are moribund and are not expected to survive more than 24 hours with or without an operation. These patients are almost always hospitalized, terminally ill patients. Elective dental treatment is definitely contraindicated; however, emergency care, in the realm of palliative treatment may be necessary. This classification represents a "red flag" for dental care and any care is done in a hospital situation. ======================== Examples: - History of ruptured abdominal or thoracic aneurysm - Massive trauma, intracranial bleed with mass effect - Ischemic bowel in the face of significant cardiac pathology or multiple organ or system dysfunction.
Ejection fraction (EF) What is it? Where is it measured?
Percentage of oxygen-rich blood pumped out of a filled ventricle with each heartbeat EF is usually measured only in the left ventricle (LV)
ASA 3 Description Examples
Severe systemic disturbance Patients have one or more moderate to severe systemic diseases that limits activity, but is not incapacitating. Patient has significant functional limitations. There is NO immediate danger to life Patients are able to walk up one flight of stairs or two-level city blocks but will have to stop enroute because of distress and thus have substantive functional limitations. If dental care is indicated, stress reduction protocol and other treatment modifications are indicated. Frightened, worried or teary eyed patient - This classification represents a "yellow flag" for treatment, with a slight to strong warning flag indicating to proceed with extreme caution during dental treatment. Will need medical consultation before all dental care ========================= Examples: - Poorly controlled DM or HTN with systemic effects - Complicated or severe diabetes. Poorly controlled insulin dependent diabetes - Functional capacity IIb. - Combinations of heart disease and respiratory disease or others that impair normal functions severely. - History of more than 3 months of angina pectoris, transient ischemic attack, myocardial infarction, cerebrovascular accident, congestive heart failure, coronary artery disease with stents - Poorly controlled hypertension - Slight chronic obstructive pulmonary disease - Complete intestinal obstruction that has existed long enough to cause serious physiological disturbance. - Pulmonary tuberculosis that, because of the extent of the lesion or treatment, has induced vital capacity sufficiently to cause tachycardia or dyspnea. - Patients debilitated by prolonged illness with weakness of all or several systems. - Severe trauma from accident resulting in shock, which may be improved by treatment. - Pulmonary abscess - Morbid obesity (BMI equal or greater than 40) - Active hepatitis - Alcohol dependence or abuse - Implanted pacemaker - Moderate reduction of ejection fraction - End-stage renal disease undergoing regularly scheduled dialysis
ASA Status: GFR & End Stage Renal Disease (ESRD) What is the ASA status for a patient with stage 5 kidney failure before undergoing dialysis? Once undergoing dialysis?
Stage 5 (Kidney Failure) - GFR <15mL/min/1.73m2 Once DIALYSIS BEGINS: ASA III Prior to/PRE-DIALYSIS: ASA IV
For an ASA 4 patient, at what ejection fraction % is there a threat of sudden cardiac death?
Threat of sudden cardiac death with EF <15%
Which choice would be incorporated in to the assessment of ASA status of a patient? a.) Jovial disposition b.) With/without dialysis c.) Multiple pregnancies d.) Elderly
b.) With/without dialysis ** See GFR
Which best describes an ASA III patient? a.) Wheel chair bound b.) Multiple controlled diseases c.) Always needs to be propped up in the dental chair d.) Can climb a flight of stairs, but needs to stop at the top
c.) Always needs to be propped up in the dental chair
Which choice is not associated with the assessment of ASA status? a.) Smoking b.) BMI c.) Cardiac status d.) Age
d.) Age Being older does not affect the ASA status of a patient
Diabetes Tests & associated Status: Mild-Moderate uncontrolled DM - eAG - A1C
eAG: - 200 mg/dL A1C: - <8.5%
Diabetes Tests & associated Status: Moderate-Severe uncontrolled DM - eAG - A1C
eAG: - 200 to <250 mg/dL A1C: - 8.5% to <10%