How do you incorporate American Society of Anesthesiologists Physical Status (ASA PS) classification, Duke Activity Status Index (DASI), and Revised Cardiac Risk Index (RCRI) into a SOAP note for preoperative evaluation?

Incorporating ASA PS, DASI, and RCRI into Preoperative SOAP Notes

Subjective Section

Document functional capacity using DASI questionnaire responses directly in the patient's own words, calculating the total score (0-58.2 points) by summing weighted activities the patient can perform. 1

• Record specific activities: ability to climb stairs (5.5 points), walk blocks (2.75 points), perform household work (2.7-8.0 points), and engage in recreational activities (6.0-7.5 points) 1
• A DASI score ≤34 identifies patients at significantly increased risk (1.63 times higher rate of death, MI, acute heart failure, or life-threatening arrhythmias), while scores >34 indicate reduced odds of complications 2, 3
• Document inability to perform ≥4 METs of activity (equivalent to climbing one flight of stairs or walking 4 blocks), as this threshold predicts perioperative cardiac events even after adjusting for other risk factors 1, 2

Objective Section

Assign ASA Physical Status classification based on the patient's systemic disease burden, documenting the specific rationale for the grade assigned. 1, 4

ASA PS Classification Documentation:

• ASA I: Normal healthy patient 4
• ASA II: Mild systemic disease without functional limitation 4
• ASA III: Severe systemic disease with definite functional limitation 4
• ASA IV: Severe systemic disease that is a constant threat to life 4
• Higher ASA grades correlate directly with perioperative mortality and ICU length of stay, with ASA IV patients having substantially elevated risk 5, 6
• The ASA PS scale demonstrates moderate inter-rater reliability (κ 0.61) but shows closer correlation with perioperative mortality than cardiac risk indices alone 5, 7

Vital Signs and Physical Examination:

• Document blood pressure, heart rate, and focused cardiac examination within 2 hours of surgery for all patients 1
• For intermediate- and high-risk patients: document pulmonary auscultation findings and cardiovascular examination abnormalities 1

Laboratory and Diagnostic Testing:

• For intermediate- and high-risk patients (RCRI ≥2): obtain preoperative troponin, complete blood count, renal function (creatinine), and coagulation profile (PT, platelet count) 1
• Obtain 12-lead ECG for patients with known coronary disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or diabetes undergoing intermediate- or high-risk procedures 1, 8

Assessment Section

Calculate and document RCRI score by assigning 1 point for each of 6 risk factors present: ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, chronic kidney disease (creatinine >2.0 mg/dL), and high-risk surgery. 1, 2, 8

Risk Stratification Algorithm:

RCRI 0-1 (Low Risk, <1% MACE):

• Proceed directly to surgery without additional cardiac testing 2, 9
• Continue chronic beta blockers and statins if already prescribed 9
• Consider 12-lead ECG only if symptomatic or established cardiovascular disease 9

RCRI 2 (Moderate Risk, ~7% MACE):

• If DASI >34 or functional capacity ≥4 METs: proceed to surgery without further testing 2, 8
• If DASI ≤34 or functional capacity <4 METs: consider pharmacological stress testing only if results would change management (coronary revascularization, medication changes, or surgical cancellation) 2, 8
• Initiate beta blockers preoperatively if not contraindicated, preferably >1 day before surgery to assess tolerability 9
• Consider preoperative NT-proBNP and/or troponin for enhanced risk prediction (improves discrimination by median delta c-statistic of 0.12) 2, 8

RCRI ≥3 (High Risk, 14.4% complication rate):

• Comprehensive cardiac monitoring with troponin measurements preoperatively and at 24 and 48 hours postoperatively 1
• Functional capacity assessment mandatory 2
• Consider pharmacological stress testing if results would alter management 2
• For non-urgent high-risk surgery: obtain echocardiography within 3 months if not recently performed 1

Alternative Risk Calculators:

• For vascular surgery patients, use NSQIP MICA calculator or Gupta score instead of RCRI, as RCRI performs poorly in this population 2, 8
• The NSQIP calculator uses 21 patient-specific variables and demonstrates median delta c-statistic 0.11 higher than RCRI for predicting MI and cardiac arrest 2, 8

Special Populations:

• Patients >70 years: assess frailty using a validated tool preoperatively 1
• Emergency surgery: focus on immediate perioperative medical optimization rather than extensive testing, as cardiac risk is elevated regardless of RCRI score 2, 8

Plan Section

Document specific perioperative management based on combined ASA PS, DASI, and RCRI assessment:

• Continuation of guideline-directed medical therapy (beta blockers, statins, ACE inhibitors/ARBs) 9
• VTE prophylaxis for high-risk orthopedic or abdominal surgery 1
• Postoperative troponin monitoring schedule for high-risk patients 1
• Timing and type of any additional cardiac testing required 2, 8
• Anesthesia technique considerations based on ASA PS classification 4

Important Caveats:

• Combining ASA PS with surgeon risk estimates improves prediction accuracy (AUC 0.84) to match clinical data-based models 4
• The inter-rater reliability of ASA PS is moderate (κ 0.61), with 67% of patients receiving identical scores between preoperative clinic and operating room 7
• RCRI has modest discrimination (AUC ~0.79) and should be supplemented with functional capacity assessment for optimal risk stratification 2, 8
• Routine preoperative coronary angiography is not recommended regardless of risk score 8, 9