A poorly controlled diabetes with retinopathy would be placed under ASA 3. ASA grade IIIA patient with severe systemic disease. + Poorly controlied diabetes mellitus or hypertension or complicated diabetes Is included under ASA + Retinopathy is a complication due to DM and also a substantive functional limitation due to poor vision oF lose of vision, Note: Ir the question was about well-controlled diabetes or mild diabetes without any complications then the answer would be ASA Pearl #411; American Society of Anesthesiologists’ Physical Status ‘Classification of Patiants American Society of Anesthesiclogists'(A 5A) classification is used to define relative risk prior to ‘conscious sedation and surgical anesinesia Its simple, reproducible and stronaly correlates to perioperative risk ASAPS Examples, including, but not limited to: Classitication & Derinition ASAI: Anomal Healthy, non-smoking, no or minimal alconol use healthy patient Without substantive functional imitations. Eg: current smoker. social alcono! drinker, pregnancy. obesity (20 ~ BM ~ 40), well-controlled DM/HTN, mild lung systemic disease alsease. ASAI: 4 patient Substantive functional limitations; One or more moderate to severe diseases. Eg with severe poorly contiolled DM or HTN. COPD, morbid obestly (BMI =40), active hepatit's, aystemic disease leona dependence or abuse, implanted pacemaker. moderate reduction of gection fraction, ESRD uncergoing regulary scheduled dialysis, premature inrant PCA = 60 weeks, nistory (=3 months) ef Ml, CVA, TIA, or CADystents. ASA IV: A patient Eg: recent ( « 8 monins) Mi, GVA. TIA. or CADysients. ongoing cardiac Ischemia or with severe severe valve dysfunction. severe reduction of ejection fraction, sepsis, DIC ARO systemic disease or ESRD not undergoing regularly scheauled dialysis ASAV:A Eg: ruptured abgominavinoracie aneurysm, massive trauma, intracranial bleed with moribund patient mass effect, ischemic bowel in the face of significant cardiac pathology or Multiple who is not organ/system dysfunction expected to the operation whose organs are being: removes for donor purposes ‘Thyromental distance >7em with neck extension Is net an Indieater of dimcult intubation. Pearl #412: Predictors of Difficult Airway ‘Obstructive sleep apnea History of snoring Obe: Facial and neck deformities from previous surgery Previous head and neck radiation ‘Congenital abnormalities of the head and neck Bown syndrome Cervical spine alsease or previous cervical spine surgery Specific tests for assessment Mallampati scores (Il! and IV) Thyromental distance <6.8 em with head in maximum extension Increased neck circumference (717 Inches in men or =16 inches In women) Upper Up bite test : Inability to protrude the mandible or lower teeth in front of the upper teeth (Cormack and Lenane (laryngoscopie view) - Grade Ill ana IV Altnougn the presence of these risk factors may net be sensitive in detecting a alricult intubation, the absence or these inaings Indicates an ease with intubation.bleeding proceaure (hernia surgery) Only Ir risk of bleeding Is very high, aspirin should be discontinued An earlier recommendation was to discontinue aspirin was 7-10 days or 5-4 days before surgery because It increases bleeding. ‘The 7 to 10 days winarawal period Is excessive and it can Increase the risk of Ischemia from caraiac But if a patient on a coronary stent taking aspirin is posted for surgery. aspirin should be continued even on the day of surgery to avold the risk of stent or thrombosis, myocardial infarction or death Anupiaeiers: wanting perioa Eptnpanae ene If patient on a coronary stent taking aspirin is posted for surgery. aspirin should be continued even on the day of surgery to avold the risk of stent re thrombosis, myocardial infarction or death Antiplatelet drugs should net be Interrupted in patients with coronary stents without consultation with cardiologist, + Drug-eluting coronary stents require antiplatelet administration for at least one year Iaeally, elective surgery Is avoided ror one month in patients with bare coronary stents and one year for those with drug-eluting stents. But in the question, it is an emergency surgery and so cannet be postponea. Use of heparin may paradoxically Increase platelet aggregation and Is not recommended, Stents nave a risk of thrombosis until endothelial tissue grow to line the stent surface. The arug-eluting stents delay this endothelial growth by eluting drugs like sirolimus/paciitaxel etc and thereby reduce the risk of endothelial overgrowth causing occlusion. But this prolonged lack of endothelial lining causes an Increased risk of thrombosis and nence a longer duration of antiplatelet therapy is requires with arug- eluting stents Contrary to what one may expect. it is the drug-eluting stents that require longer antiplatelet therapy land ft is essential to understand why its 50 Pearl #2124: Drugs that should be discontinued on the day of surgery Drugs that should be discontinued on the day of surgery Topical medications Diureties except thiazides ‘Oral hypoglycemic agents: Sidenafl NSAIDs - Discontinue 48 hours before the day of surgery Wartann - Discontinue 4 days before surgery, except for patients naving cataract surgery without a ular block + Short acting insulins except when given by a continuous pump + Thienopyridines (e.9.. clopidogrel, ticlopidine) except in cataract surgery, patients with metallic/arug eluting stents + Aspirin in selected cases where reversal of platelet inhibition is necessary + MAG Inhibitors - 2 weeks prior (MAO Inhibitors are usually continued. They should be discontinued if the patient and anesthesiologist factors are not favorable to continue them) All antihypertensive medications like amlodipine are continued at the same dose. Exception: Due to the risk of intraoperative hypotension, angiotensin-converting enzyme innipitors and angiotensin receptor blockers are discontinued 12-24 hours preoperatively for patients undergoing procedures with major fluid shifts or for patients with medical conditions in which hypotension is dangerous.Clopidogrel is an antiplatelet drug and is stopped 1 week prior to surgery to avoid the risk of increased surgical bleeding Do not discontinue antipiatelets in patients with + Drug-eluting stents until they have completed 12 menths of dual antiplatelet therapy + Bare metal stents until they nave completed 1 month of dual antiplatelet therapy. Pearl #2093: Drugs that can be continued on the day of surgery Drugs that can be continued on the day of surgery = Antinypertensive medications: continuation of ACE inhibitors and ARB - Contraversial. Accaraing to Gavel of evicence:5) Cardiac medications (e.g., p-blockers, digoxin) ‘Thyroig meaications Eye srops Anticonvulsants, Steroids (oral ana innate) Mono Amine Oxidase inhibiters : MAG Inhibitors generally should be continued when two criteria are met. (1) the anesthesiologist is comfortable with use of MAO_sate procedures; ana (2) the Synarome: + Levedopa Since the patient nas increased thromboembolic risk (AF, stroke), warfarin Is stopped 4-5 days pre- operatively and LMWH Is bridged till ine time ot surgery. Interruption of anticoagulation temporanily increases thromboembolic risk, while continuing anticoagulation increases the risk of bleeding associated with invasive procedures, Decisions to use bridging therapy with unfractionated heparin (UFH) or LMWH must be individualized ‘depenaing on thromboembolic risk. bleeding risk and timing of anticoagulant interruption. In patients at high risk for thrombosis (¢.9., tnose with certain mechanical neart valve Implants or with atrial fibrilation and a prior thromboembolic stroke), warfarin should be stopped and replaced by UFH or LMWH to minimize the risk. Patients at lower risk for thrombosis may have warfarin discontinued 4-5 days preoperatively and then reinitiatea aner successful surgery. Wariarin may be continued in patients posted for cataract surgery without a bulbar block Oral anticoagulants are aiscontinued prior to surgery. Anticoagulant Minimum interval between the last dose and tne surgery wartann 4-9 days Untractionated neparin 6 nours LMWH - prophylactic cose 12 hours, LMWH - therapeutic dose 24 nours ‘The following drugs ean be continued on the day of surgery Antinypertensive meaications: except ACE Innibitors ana ARBS Cardiac medications (e.9., B-blockers, cigoxin) Antigepressants, anxiolyties, and otner psyeniatric medications ‘Thyroid meaications Eye arops Heartburn or reflux medications Narcotic medications. Anticonvulsant medications, Asthma medications. Steroids (oral and inhaled) stauns LeveaopaRecommended preoperative fasting periods for all above 1 year of age are + 2 nours for clear liquias + 5 hours for light meavmitk + 8 nours for tried. tatty Tood Recommended preoperative fasting period for neonates and infants are + 4 nours for breast milk + 6 hours for solids/formula feeds/cow's milk Preoperative fasting Is intended to reduce the risk of pulmonary aspiration Note: Clear liquids include, but are not limited to - water, tea & coffee without milk, fruit juices without pulp, carbonated drinks & carbohydrate-rieh nutritional drinks. Recommended preaperative fasting period for neonates and inrants are = 6 hours fer sollas/formula Teeas/cow's milk = 4 hours for breast milk Recommended preoperative fasting periods for all above 1 year of age are = 2 hours for clear fluids + 6 hours for lignt meal = 8 nours for tea, tatty tooa (As per 2017 gurceunes) Herbals should be discontinued at least 2 weeks before surgery. Herbal medications may have effects that could be deleterious in the perioperative period, including clotting abnormalities and interactions with anesthetics, Commomly used herbal medicines include echinacea, ephedra, garlic, ginger, Ginkgo biloba, ginseng, green tea, and St. Jonn’s wort