ASA physical status classification system

From Wikipedia, the free encyclopedia Jump to: navigation, search 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. 2. 3. 4. 5. 6. A normal healthy patient. A patient with mild systemic disease. A patient with severe systemic disease, that limits function, but is not incapacitating. A patient with severe systemic disease that is a constant threat to life. A moribund patient who is not expected to survive without the operation. 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, anesthetists, and insurers. Some anesthetists now propose that like an 'E' modifier for emergency, a 'P' modifier for pregnancy should be added to the ASA score.[9]

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.