Perioperative Management of ASA III Patients

Understanding ASA III Classification

The American Society of Anesthesiologists (ASA) classifies ASA III patients as having severe systemic disease with substantive functional limitations, including conditions such as poorly controlled diabetes or hypertension, COPD, active hepatitis, alcohol dependence, implanted pacemaker, moderate reduction of ejection fraction, and morbid obesity (BMI ≥40 kg/m²) 1

The American Society of Anesthesiologists (ASA) recommends preoperative initiation of continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA), particularly if severe 2
The American Society of Anesthesiologists (ASA) suggests considering preoperative use of mandibular advancement devices or oral appliances and preoperative weight loss for patients with OSA when feasible 2
The American Heart Association, as published in Circulation, recommends preoperative evaluation to exclude severe coronary artery disease with CT or angiographic imaging for patients with severe aortic stenosis (AS) 4

The American Society of Anesthesiologists (ASA) advises considering the potential for postoperative respiratory compromise when selecting intraoperative medications, especially in patients with OSA who are susceptible to respiratory depressant effects 2, 3
The American Society of Anesthesiologists (ASA) recommends using general anesthesia with a secure airway instead of deep sedation without a secure airway, particularly for procedures that may mechanically compromise the airway 2, 3
The American Heart Association, as published in Circulation, suggests maintaining sinus rhythm and normotension for patients with severe AS, and using phenylephrine or norepinephrine to increase blood pressure in patients without significant coronary artery disease 4

The American Society of Anesthesiologists (ASA) recommends extubating patients at increased perioperative risk while awake, unless contraindicated 2, 3
The American Society of Anesthesiologists (ASA) advises verifying full reversal of neuromuscular block before extubation 2, 3
The American Society of Anesthesiologists (ASA) suggests providing continuous pulse oximetry monitoring for hospitalized patients at increased risk of respiratory compromise after discharge from the recovery room 2

The American Heart Association, as published in Circulation, recommends optimizing loading conditions and avoiding hypotension and tachycardia for patients with severe AS and normal left ventricular ejection fraction undergoing noncardiac surgery 4
The American Heart Association, as published in Circulation, suggests using periprocedural hemodynamic monitoring with a right-heart catheter or intraoperative transesophageal echocardiography for continuous optimization of loading conditions in patients with valvular heart disease 4