Chapter 7: Anesthesia
A 40-year-old male status post kidney transplant 2 years ago with history of diabetes mellitus and hypertension presents to an ambulatory surgery center for debridement of an atrioventricular (AV) fistula that was used in the past for dialysis. Despite tight glycemic control, the patient has diabetic retinopathy and neuropathy. His preoperative blood pressure is 172/95 mmHg. His renal function is normal, and he no longer requires hemodialysis. What is this patient’s American Society of Anesthesiologists (ASA) physical status?
(D) The American Society of Anesthesiologists (ASA) classification was developed in an effort to ensure that adequate comparisons between patient populations can be made between institutions for morbidity and mortality statistics. Notice the ASA classification is independent of the surgical procedure. Accordingly, it does not imply preoperative risk. Table 7-1 describes the different ASA classes.
Table 7-1 Summary of ASA Physical Classes
|Class ||Definition |
|1 ||Normal healthy patient |
|2 ||Patient with mild systemic disease (no functional limitations) |
|3 ||Patient with severe systemic disease (some functional limitations) |
|4 ||Patient with severe systemic disease that is a constant threat to life (functionality incapacitated) |
|5 ||Moribund patient who is not expected to survive without the operation |
|6 ||Brain-dead patient whose organs are being removed for donor purposes |
|E ||If the procedure is an emergency, the physical status is followed by “E” (e.g., “2E”) |
The patient in Question 1 is considered ASA class 3 because his diabetes is causing functional limitations (vision and nervous system), and his hypertension is not controlled.
Butterworth JF IV, Mackey DC, Wasnick JD. Preoperative assessment, premedication, and perioperative documentation. In: Butterworth JF IV, Mackey DC, Wasnick JD (eds.), Morgan & Mikhail’s Clinical Anesthesiology, 5th ed. New York, NY: McGraw-Hill; 2013:Chapter 18.
Butterworth JF IV, Mackey DC, Wasnick JD (eds.). Morgan & Mikhail’s Clinical Anesthesiology, 5th ed. New York, NY: McGraw-Hill; 2013:297.
The patient in Question 1 is brought to the operating suite and preoxygenated. General anesthesia is induced with fentanyl, propofol, and rocuronium. The anesthesiologist makes an initial attempt at laryngoscopy but is unsuccessful. The patient is repositioned, and a different type of laryngoscope blade is used without success. The patient is unable to be mask ventilated. Oxygen saturation is 96%. What is the best approach at this juncture according to the emergency airway algorithm?
(A) Attempt to reverse the rocuronium with neostigmine