ASA score
Encyclopedia
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:
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." 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. With this definition, severe pain due to broken bones, ureteric stone or parturition (giving birth) is not an emergency.
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 disease
s (which might be of different severity).
Different authors give different versions of this ASA definition. 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. 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 disease
s. 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.
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.
, 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. This effort was the first by any medical specialty to stratify risk for its patients. 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."
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. 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. 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.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
. In 1963 the American Society of Anesthesiologists
American Society of Anesthesiologists
The American Society of Anesthesiologists is an association of physicians, primarily anesthesiologists, that share a common goal of raising the standard of the medical specialty of anesthesiology and the improvement of patient care by fostering and encouraging education through research and...
(ASA) adopted the five-category physical status classification system; a sixth category was later added. These are:
- A normal healthy patientPatientA patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
. - A patient with mild systemic diseaseSystemic diseaseLife-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
. - A patient with severe systemic diseaseDiseaseA disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
. - A patient with severe systemic disease that is a constant threat to lifeLifeLife is a characteristic that distinguishes objects that have signaling and self-sustaining processes from those that do not, either because such functions have ceased , or else because they lack such functions and are classified as inanimate...
. - A moribundMoribundMoribund refers to a literal or figurative state of near-death.Moribund may also refer to:* "Le Moribond", a song by Jacques Brel which became better known for its rewritten English-language version, "Seasons in the Sun"...
patient who is not expected to survive without the operationSurgerySurgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
. - A declared brain-dead patient whose organsOrgan (anatomy)In biology, an organ is a collection of tissues joined in structural unit to serve a common function. Usually there is a main tissue and sporadic tissues . The main tissue is the one that is unique for the specific organ. For example, main tissue in the heart is the myocardium, while sporadic are...
are being removed for donorOrgan donationOrgan donation is the donation of biological tissue or an organ of the human body, from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues are removed in a surgical procedure following a determination, based on the donor's medical and...
purposes.
If the surgery is an emergency, the physical status classification is followed by “E” (for emergency
Emergency
An emergency is a situation that poses an immediate risk to health, life, property or environment. Most emergencies require urgent intervention to prevent a worsening of the situation, although in some situations, mitigation may not be possible and agencies may only be able to offer palliative...
) 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." 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. 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. It is logical to expect a missing class between ASA 2 and ASA 3 for a systemic diseaseSystemic disease
Life-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
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 disease
Systemic disease
Life-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
s (which might be of different severity).
Different authors give different versions of this ASA definition. 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. The word 'systemic' in this classification creates a lot of confusion. For example, heart attack (myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
), 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
Systemic disease
Life-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
, does not truly fit in any category of the ASA classification, yet has poor post-surgery survival rates. Similarly cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
of the liver, COPD
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...
, severe asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, peri-nephric abscess, badly infected wounds, intestinal perforation, skull fracture
Skull fracture
A skull fracture is a break in one or more of the bones in the skull usually occurring as a result of blunt force trauma. If the force of the impact is excessive the bone may fracture at or near the site of the impact...
etc. are not systemic disease
Systemic disease
Life-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
s. 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
Systemic disease
Life-threatening disease redirects here.A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. Although most medical conditions will eventually involve multiple organs in advanced stage Life-threatening disease redirects here.A systemic disease is one...
” (which means a generalized disorder of the whole body like hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
or diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
). 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
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
). 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
APACHE II
APACHE II is a severity-of-disease classification system , one of several ICU scoring systems...
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.
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
Uppsala University Hospital
Uppsala University Hospital in Uppsala, Sweden is a teaching hospital for the Uppsala University Faculty of Medicine and the Nursing School. Uppsala University Hospital is owned and operated by the Uppsala County Council in cooperation with the university and serves, together with Enköping...
) 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
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
, such as for example a moribund
Moribund
Moribund refers to a literal or figurative state of near-death.Moribund may also refer to:* "Le Moribond", a song by Jacques Brel which became better known for its rewritten English-language version, "Seasons in the Sun"...
patient due to a traumatic aortic rupture
Traumatic aortic rupture
Traumatic aortic rupture, also called traumatic aortic disruption or transection, is a condition in which the aorta, the largest artery in the body, is torn or ruptured as the result of trauma. The condition is frequently fatal due to the profuse bleeding that results from the 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, and thus decide if a patient should have – or should have had – an operation. 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 RovenstineEmery Andrew Rovenstine
Emery Andrew Rovenstine was an American anesthesiologist and a leader in the fields of anesthesiology.- Medical career :Dr. Rovenstine was born in the year 1895, in Atwood, Indiana, where he clerked at his father’s grocery store...
, 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. This effort was the first by any medical specialty to stratify risk for its patients. 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."
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".
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. 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. 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. |
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See also
- AnesthesiaAnesthesiaAnesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
- AnesthesiologistAnesthesiologistAn anesthesiologist or anaesthetist is a physician trained in anesthesia and peri-operative medicine....
- Anesthetic equipment
- Anesthetics
- BIS monitor to assess the depth of anesthesia
- Nurse anesthetistNurse anesthetistA nurse anesthetist is a nurse who specializes in the administration of anesthesia.In the United States, a Certified Registered Nurse Anesthetist is an advanced practice registered nurse who has acquired graduate-level education and board certification in anesthesia...
or Certified Registered Nurse Anesthetist (CRNA) - Operating Department Practitioners
- Perioperative mortalityPerioperative mortalityPerioperative mortality is mortality in relation to surgery, often defined as death within two weeks of a surgical procedure. An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks...
- Patient safetyPatient safetyPatient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
- Patient safety organizationPatient safety organizationA patient safety organization is a group, institution or association that improves medical care by reducing medical errors. In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable adverse health care events...
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