ASA physical status classification system

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added. These are:

1. A normal healthy patient.
2. A patient with mild systemic disease.
3. A patient with severe systemic disease.
4. A patient with severe systemic disease that is a constant threat to life.
5. A moribund patient who is not expected to survive without the operation.
6. A declared brain-dead patient whose organs are being removed for donor purposes.

If the surgery is an emergency, the physical status classification is followed by “E” (for emergency) for example “3E”. Class 5 is usually an emergency and is therefore usually "5E". The class "6E" does not exist and is simply recorded as class "6", as all organ retrieval in brain-dead patients is done urgently. The original definition of emergency in 1940, when ASA classification was first designed, was "a surgical procedure which, in the surgeon's opinion, should be performed without delay."^[1] This gives an opportunity for a surgeon to manipulate the schedule of elective surgery cases for personal convenience. An emergency is therefore now defined as existing when delay in treatment would significantly increase the threat to the patient's life or body part.^[2] With this definition, severe pain due to broken bones, ureteric stone or parturition (giving birth) is not an emergency.

Limitations and proposed modifications

These definitions appear in each annual edition of the ASA Relative Value Guide. There is no additional information that can be helpful to further define these categories.^[3] It is logical to expect a missing class between ASA 2 and ASA 3 for a systemic disease which is neither mild nor severe, but is of moderate nature. It is also not clear what will be the ASA classification of a patient who is suffering simultaneously from two, three or more systemic diseases (which might be of different severity).

Different authors give different versions of this ASA definition.^[4] It is because this classification is vague and far from perfect. Many authors try to explain it on the basis of 'functional limitation' or 'anxiety' of patient which are not mentioned in the actual definition. Often different anesthesia providers assign different grades to the same patient.^[5][6][7][8] The word 'systemic' in this classification creates a lot of confusion. For example, heart attack (myocardial infarction), though grave, is a 'local' disease and is not a 'systemic' disease, so a patient with recent (or old) heart attack, in the absence of any other systemic disease, does not truly fit in any category of the ASA classification, yet has poor post-surgery survival rates. Similarly cirrhosis of the liver, COPD, severe asthma, peri-nephric abscess, badly infected wounds, intestinal perforation, skull fracture etc. are not systemic diseases. These, and other severe heart, liver, lung, intestinal or kidney diseases, although they greatly affect physical status of patient and risk for poor outcomes, cannot be labelled as “systemic disease” (which means a generalized disorder of the whole body like hypertension or diabetes mellitus). Local diseases can also change physical status but has not been mentioned in ASA classification.

This classification system assumes that age of the patient has no relation to physical fitness, which is not true. Neonates and the elderly, even in the absence of any systemic disease, tolerate otherwise similar anesthetics poorly in comparison to young adults. Similarly this classification ignores patients with malignancy (cancer). This classification system could not be improved to a more elaborated and scientific form, probably because it is often used for cost reimbursement.

Although more complex scoring systems like APACHE II exist, they are time-consuming to calculate, and do not have the same utility for ease of communication between surgeons, anesthesiologists, and insurers.

Some anesthesiologists now propose that like an 'E' modifier for emergency, a 'P' modifier for pregnancy should be added to the ASA score.^[9]

Also, the ASA classification doesn't describe the general health status of the patient when excluding the condition that indicates the surgery. In fact, there are hospitals (e.g. Uppsala University Hospital) that do exclude the condition indicating the surgery. Thus, in such hospitals, ASA 1 may still refer to a patient in a severe medical emergency, such as for example a moribund patient due to a traumatic aortic rupture (which indicates the surgery) but otherwise being healthy.

Uses

While anesthesia providers use this scale to indicate the patient's overall physical health or "sickness" preoperatively, it is regarded by hospitals, law firms, accrediting boards and other health care groups as a scale to predict risk,^[10] and thus decide if a patient should have – or should have had – an operation.^[11] To predict operative risk, age and obesity of the patient, the nature and severity of the operative procedure, selection of anesthetic techniques, the competency of the surgical team (surgeon, anesthesia providers and assisting staff), duration of surgery or anesthesia, availability of equipment, medicine, blood, implants and especially the level of post-operative care etc. are often far more important than multiple ASA classification.

History

In 1940-41, ASA asked a committee of three physicians (Meyer Saklad, M.D., Emery Rovenstine, M.D., and Ivan Taylor, M.D.) to study, examine, experiment and devise a system for the collection and tabulation of statistical data in anesthesia which could be applicable under any circumstances.^[1] This effort was the first by any medical specialty to stratify risk for its patients.^[12] While their mission was to determine predictors for operative risk, they quickly dismissed this task as being impossible to devise. They state:

"In attempting to standardize and define what has heretofore been considered 'Operative Risk', it was found that the term ... could not be used. It was felt that for the purposes of the anesthesia record and for any future evaluation of anesthetic agents or surgical procedures, it would be best to classify and grade the patient in relation to his physical status only."^[11]

The scale they proposed addressed the patient's preoperative state only, not the surgical procedure or other factors that could influence surgical outcome. They hoped anesthesiologists from all parts of the country would adopt their "common terminology," making statistical comparisons of morbidity and mortality possible by comparing outcomes to "the operative procedure and the patient's preoperative condition".^[13]

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They described a six-point scale, ranging from a healthy patient (class 1) to one with an extreme systemic disorder that is an imminent threat to life (class 4). The first four points of their scale roughly correspond to today's ASA classes 1-4, which were first published in 1963.^[1][5] The original authors included two classes that encompassed emergencies which otherwise would have been coded in either the first two classes (class 5) or the second two (class 6). By the time of the 1963 publication of the present classification, two modifications were made. First, previous classes 5 and 6 were removed and a new class 5 was added for moribund patients not expected to survive 24 hours, with or without surgery. Second, separate classes for emergencies were eliminated in lieu of the "E" modifier of the other classes.^[13][14] The sixth class is now used for declared brain-dead organ donors. Saklad gave examples of each class of patient in an attempt to encourage uniformity. Unfortunately, the ASA did not later describe each category with examples of patients and thus actually increased confusion.

Original definition by Saklad et al.

Class	Original
1	No organic pathology or patients in whom the pathological process is localized and does not cause any systemic disturbance or abnormality. Examples: This includes patients suffering with fractures unless shock, blood loss, emboli or systemic signs of injury are present in an individual who would otherwise fall in Class 1. It includes congenital deformities unless they are causing systemic disturbance. Infections that are localized and do not cause fever, many osseous deformities, and uncomplicated hernias are included. Any type of operation may fall in this class since only the patient's physical condition is considered.
2	A moderate but definite systemic disturbance, caused either by the condition that is to be treated or surgical intervention or which is caused by other existing pathological processes, forms this group. Examples: Mild diabetes. Functional capacity I or IIa. Psychotic patients unable to care for themselves. Mild acidosis. Anemia moderate. Septic or acute pharyngitis. Chronic sinusitis with postnasal discharge. Acute sinusitis. Minor or superficial infections that cause a systemic reaction. (If there is no systemic reaction, fever, malaise, leukocytosis, etc., aid in classifying.) Nontoxic adenoma of thyroid that causes but partial respiratory obstruction. Mild thyrotoxicosis. Acute osteomyelitis (early). Chronic osteomyelitis. Pulmonary tuberculosis with involvement of pulmonary tissue insufficient to embarrass activity and without other symptoms.
3	Severe systemic disturbance from any cause or causes. It is not possible to state an absolute measure of severity, as this is a matter of clinical judgment. The following examples are given as suggestions to help demonstrate the difference between this class and Class 2. Examples: Complicated or severe diabetes. Functional capacity IIb. Combinations of heart disease and respiratory disease or others that impair normal functions severely. 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.
4	Extreme systemic disorders which have already become an eminent threat to life regardless of the type of treatment. Because of their duration or nature there has already been damage to the organism that is irreversible. This class is intended to include only patients that are in an extremely poor physical state. There may not be much occasion to use this classification, but it should serve a purpose in separating the patient in very poor condition from others. Examples: 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. Emergency Surgery: An emergency operation is arbitrarily defined as a surgical procedure which, in the surgeon's opinion, should be performed without delay.
5	Emergencies that would otherwise be graded in Class 1 or Class 2.
6	Emergencies that would otherwise be graded as Class 3 or Class 4.

Other health grading systems

• APACHE II
• Apgar score
• Barnes Akathisia Scale
• Blantyre Coma Scale
• Dolorimeter pain index
• Glasgow Coma Scale for central nervous system
• Goldman index
• Hamilton-Norwood scale
• Hoehn and Yahr scale
• Holmes and Rahe stress scale
• International Red Cross Wound Classification System
• Life-Events and Difficulties Schedule
• Ludwig scale
• Malinas score
• MEWS
• Paediatric Glasgow Coma Scale
• Pain scale
• PIM2 Children scoring system
• Psoriasis Area Severity Index
• Rancho Los Amigos Scale
• Revised Trauma Score
• SAPS II
• SAPS III
• SCORTEN scale
• SOFA score
• Tanner stage
• Tygerberg score

See also

• Anesthesia
• Anesthesiologist
• Anesthetic equipment
• Anesthetics
• BIS monitor to assess the depth of anesthesia
• Nurse anesthetist or Certified Registered Nurse Anesthetist (CRNA)
• Operating Department Practitioners
• Perioperative mortality
• Patient safety
• Patient safety organization
• Medical algorithm

References

1. ^ ^{a b c} Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941; 2:281-4.
2. ^ ASA Relative Value Guide 2002, American Society of Anesthesiologists, page xii, Code 99140.
3. ^ "ASA Physical Status Classification System". American Society of Anesthesiologists. http://www.asahq.org/For-Members/Clinical-Information/ASA-Physical-Status-Classification-System.aspx. Retrieved 2007-07-09. 
4. ^ Fehrenbach, Margaret J. "ASA Physical Status Classification System". http://www.dhed.net/ASA%20Physical%20Status%20Classification%20SYSTEM.htm. Retrieved 2007-07-09. 
5. ^ ^{a b} Little JP (1995). "Consistency of ASA grading". Anaesthesia 50 (7): 658–9. PMID 7653772. 
6. ^ Haynes SR, Lawler PG (1995). "An assessment of the consistency of ASA physical status classification allocation". Anaesthesia 50 (3): 195–9. doi:10.1111/j.1365-2044.1995.tb04554.x. PMID 7717481. 
7. ^ Owens WD, Felts JA, Spitznagel EL (1978). "ASA physical status classification: A study of consistency of ratings". Anaesthesia 49: 239–43. doi:10.1097/00000542-197810000-00003. PMID 697077. 
8. ^ Harling DW (Jul;1995). "Consistency of ASA Grading". Anaesthesia 50 (7): 659. PMID 7653773. 
9. ^ Pratt, Stephen D. "Clinical Forum Revisited: The "P" Value" (PDF). Spring 2003 newsletter. The Society for Obstetric Anesthesia and Perinatology (SOAP). pp. 9–11. http://www.soap.org/media/newsletter_spring2003.pdf. Retrieved 2007-07-09. 
10. ^ William D. Owens, M.D. American Society of Anesthesiologists Physical Status Classification System Is Not a Risk Classification System. Anesthesiology. 94(2):378, February 2001.
11. ^ ^{a b} Lema, Mark J (September 2002). "Using the ASA Physical Status Classification May Be Risky Business". ASA Newsletter. American Society of Anesthesiologists. http://www.asahq.org. Retrieved 2007-07-09. 
12. ^ Spell, Nathan O.; Lubin, Michael F.; Smith, Robert Metcalf; Dodson, Thomas F (2006). Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine. Cambridge, UK: Cambridge University Press. ISBN 0-521-82800-7. 
13. ^ ^{a b} Segal, Scott. "Women Presenting in Labor Should be Classified as ASA E: Pro". Winter 2003 newsletter. SOAP. http://www.soap.org/media/newsletters/winter2003/pro.htm. Retrieved 2007-07-09. 
14. ^ New classification of physical status. Anesthesiology 1963; 24:111

External links

• American Society of Anesthesiologists
• "Women Presenting in Labor Should be Classified as ASA E"
• "Women Presenting in Labor Should NOT be Classified as ASA E"
• "Is it true that ASA 1 excludes the very young and very old?"
• "Anesthesia History Files"