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From healthy to seriously ill: Do you know how ASA classification accurately assesses patient status?
The ASA physical condition classification system is a tool for evaluating a patient's health prior to surgery. Under the system established by the American Society of Anesthesiology (ASA) in 1963, patients are divided into five categories based on their physical condition, and later an additional category was added, for a total of six categories. These categories are: healthy people, mild systemic disease, severe systemic disease, severe systemic disease that poses a continuing threat to life, patients who are not expected to survive without surgery, and brain-dead patients. Its organs were removed for donation.
If the surgery is an emergency, an "E" (for urgent) will be added after the medical condition classification, such as "3E".
For example, category 5 is usually a medical emergency and so is usually recorded as "5E". Category "6E" does not exist and is recorded only as category "6" because organ removal from brain-dead patients is always performed urgently. The ASA's original definition in 1940 was "a surgical procedure that, in the opinion of the surgeon, should be performed without delay," but is now defined as "a procedure in which delay would significantly increase the risk of endangering the patient's life or limb."
Limitations of the system and suggestions for improvement
These definitions are listed annually in the ASA relative value guidelines, but there is a lack of additional information to further define these categories. Some dental professionals may take into account, for example, "functional limitations" or "anxiety", which is not mentioned in the formal definition but may be helpful when dealing with certain complex cases. Different anesthesia providers often give different grades to the same case. Some anesthesiologists are now proposing adding a "P" modifier to the ASA score to indicate pregnancy.
Although anesthesia providers use this scale to indicate a patient's overall health prior to surgery, hospitals, law firms, and other medical institutions may misinterpret it as a measure of risk.
To predict procedural risk, other factors—such as age, presence of comorbidities, nature and extent of surgery, choice of anesthetic technique, competence of the surgical team (surgeon, anesthesia provider, and support staff), surgical or anesthetic Duration, availability of equipment, medications, blood, implants, and appropriate postoperative care—are often more important than the physical condition of the ASA.
History of ASA Classification
Between 1940 and 1941, the ASA commissioned three physicians (Meyer Sackrad, Emory Lowenstein, and Ivan Taylor) to research, examine, experiment, and design a system for collecting data on anesthesia. and statistical systems. This was the first effort by any medical specialty to attempt to stratify risk. Although their initial assignment was to identify predictors of surgical risk, they quickly abandoned this task because it was too difficult.
They argue that for anesthesia records and future anesthetic or surgical evaluations, it is best to classify and score the patient based solely on their physical status.
The rating they proposed is limited to the patient's preoperative status, not the surgical procedure or other factors that might have affected the outcome. They hope that anesthesiologists across the country will adopt their "common terminology" to make it possible to statistically compare morbidity and mortality rates. The original six-point scale ranged from healthy people (category 1) to those with extreme systemic disease that was imminently life-threatening (category 4). The four categories roughly correspond to the current ASA categories 1 to 4, which were first published in 1963.
When the current classification was published in 1963, two changes were made to the system. First, previous categories 5 and 6 were removed and a new category was added for patients who were not expected to survive within 24 hours. Second, the separate category for emergency situations was abolished and replaced with an “E” modifier for the other categories. Category 6 is currently used for organ donors who have been declared brain dead. Sackrad provides examples of each type of patient to promote uniformity. Unfortunately, the ASA did not describe each category in detail afterwards, which exacerbated the confusion.
Conclusion
As the ASA physical condition classification system becomes more widely used, its role in the medical community becomes increasingly important. However, whether in clinical practice or in medical research, is the association between a patient's health status and surgical outcomes fairly clear?
