ASA Classification

DR.DEEPAK SOLANKI M.D. ANAESTHESIA dr.dsolanki@gmail.com

Whats New

Introduction
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As we all know that any operation or surgical intervention has its own risk complications. And if patient has any type of ds. (systemic) the risks & chances of intraop. & Postop. Complications are much higher. So there must be some system by which we can assess the patient preoperatively, so that we can access the operative and anaesthetic risk that we and patient can face during the operation and postoperative period. And prepare ourselves according to that and manage them in a better way.

Introduction

There are many system designed to access the patient based on there status like :-APACHE II -Goldman Index for Cardiac Patient -Childs Criteria for Liver disease -Glasgow Coma Scale for Head injury patient Etc. The main problem with these that they have their limitations. One classification that is universal and is used to assess any patient is ASA scores or ASA Physical Status class.

History
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In 1940-41 ASA (American Society of Anaesthesia form a Committee of 3 Anaesthesiologist. .Dr. Meyer Saklad .Dr. Ivon Taylor .Dr. Emery Rovenstine To make a system of collection and tabulation of statistical data of patient by which the physical status of patient can be accessed. But they could not able to make such system. Instead of that they have proposed a grading system to access the patient.

According to them : the grading is :I Normal healthy patient II Mild systemic disease with no function limitation III Moderate to severe systemic disease with some functional limitation (Not incapacitation) IV Severe systemic disease with incapacitating and constant threat to life. V Grade I & II with emergency. VI Grade III & IV with emergency. The definition of Emergency (According to Saklad et al.) Was a surgical procedure which in surgeons opinion should be performed without delay.

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But ASA did not accepted this grading system. In 1961-62 Drippes et al. reassess this system and made two modification in this. The modifications are :Grade I-IV (same as old) V VI Moribund patient who can not live more than 24hr. with or without the operation. brain dead patient whose organs are being used for donation purpose In 1963 ASA accepted this classification with one more addition :i.e. the World E for Emergency. Emergency is when delay in treatment would significantly increase the threat to patient life or body part.

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So the New ASA classification i.e. used now a days is :I II III IV V VI E Normal healthy patient Mild systemic disease with no function limitation Moderate to severe systemic disease with some functional limitation but not incapacitating. Severe systemic disease with incapacitating and constant threat to life. Moribund patient who can not live more than 24hr. without the operation. . Brain dead patient organs being havested. For Emergency.

The Mortality risk according to this classification :Grade I II III IV V Mortality Risk 0.06 0.08% 0.24 0.47% 1.8 4.3% 7.8 21% 9.4 53%

The advantages of this classification : The biggest advantage of this classification is

UNIVERSAL

It is used worldwide and in same manner so the physical status or condition of patient graded by ASA classification is judged same by any Doctor and everywhere. It has no limitations so can be used for any type of patient. Very simple to use this classification.

Limitations
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Local disease is not included in this classification like perinephric abscess. (which affects patients physical status badly). Age is not included in this classification Neonate and geriatric patient have more risk for any surgical intervention. Asymptomatic systemic disease is not included like Old MI, old COPD. Malignancy not included in this class. Patient who has 2 or 3 systemic disease. Not clear what is his ASA scores. Also in ASA classification Grade-II & III have very big and wake criteria of patient so the risk can not be accessed properly.

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Because of all these limitations the assessment of physical status of patient according to ASA classification sometimes (infact many times) is not correct or not fulfill the right criteria. So many attempts are made to modify or adding in this classification.

Some of them are

In 1996 (2) modifications are made in ASA classification and made it a 7 grade class :I Ia Normal Healthy patient Ib Normal health patient with operation & Anaesthetic Risk II IIa Mild systemic disease with operative & Anaesthetic risk Moderate systemic disease. IIb Moderate systemic disease with operative and anaesthetic risk. Severe systemic disease without function limitations III Severe systemic disease with some functional limitation but not incapacitating. IV Severe systemic disease with incapacitating and constant threat to life. V Moribund patient who can not live more than 24 hr. without surgery.

Grading of this classification has point system for accessing the risk :Ia Ib IIa IIb III IV V 1 1.5 2 2.5 3 4 5 No risk to life. Almost no risk to life. Mild risk to life Middle risk to life. Severe risk to life. Very dangerous to life. Almost death risk to life.

According to this modified classification in 2005-06, 1933 patients accessed preoperative and their post operative complication percentage are compared.

This shows that with modified classification , We can access patient physical status more accurately and access the complication chances much better by placing them in right grading.

The factors that are excluded while we access the physical status of the patient are :(B) Anaesthetic factors Difficult intubation. Difficult I/V line cannulation Special position. Full stomach. One lung ventilation. Refusal of B.T. Not in operating room.

(A) Surgical Factors Cardiac surgery Theracotomy Operation in Airway Suspecting time taken surgery. Suspecting more bleeding. Operation in brain stem. Pregnancy (except caesarean).

One other modification which is tried in U.K. is that :They access the physical status of the patient and grading them on the basis of :

* ASA classification + CEPOD grading.

CEPOD confidential enquiry report of perioperative death. CEPOD grading is

Elective Operation at time to suit both surgeon and patient Scheduled Operation within 24 hours. Delayed operation after resucitation Urgent Operation between 1- 3 hours. Early surgery perferred, but not life saving Emergency Operation within 1 hour. Immediate operation or resuscitation simultaneous with surgical treatment

Grade 1 Grade 2

Grade 3

Grade 4

The American dental association use ASA classification in a different manner.

Patient normal and healthy. Little or no anxiety. Little or no risk. Able to climb stairs without distress. Mild to moderate systemic disease More anxiety. Able to climb stairs but stop after because of distress. Exp-well controlled NIDDM, Epilepsy, thyroid. ASA-I with pregnancy.

II

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Severe systemic disease limit activity but not incapacitating. Able to climb stairs but stop in between because of distress. Exp. H/O Angina, MI, cerebrovascular acc. (CHF>6 mth) (COPD>6 mth.) Cont. IDDM. Contant threat to life and incapacitating. Unable to climb stairs. Distress even at rest. Exp.-Unastable angina, MI, CVS, within 6 mth, severe COPD, CHF, Uncontrolled DM, thy. Moribund not survive >24 hr. with or without operation.

IV

Conclusion
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ASA classification is a very-very unique and useful classification (because of its universility & simplicity) to access the physical status of patient preoperatively, so we can prepare ourselves for the complications and risks with we can face in intra and postoperative phase. But the assessment of physical status according to this classification is not always gives us accurate grading & chances of misjudgment in accessing the risk.

*THANKS*