The American Society of Anesthesiologists (ASA) physical status is a tool commonly used to classify a patient's physical fitness before surgery. Since its introduction in 1941 it has undergone very few modifications to improve its reliability and to eliminate subjectivity, despite vast changes in both surgical and anaesthetic technique. We present the history of the ASA physical status and review the literature on its applicability to contemporary anaesthetic practice.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.14569

A review of ASA physical status – historical perspectives and modern developments

Background:
5% of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. We hypothesized that the choice of neuromuscular blockade reversal (neostigmine versus sugammadex) may be associated with a lower incidence of major pulmonary complications.

Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.

The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System.

Importance Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results. Objective To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year. Design, Setting, and Participants Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020. Interventions Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon’s discretion. Main Outcomes and Measures The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score. Results Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, −2.6 to 3.1;P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%;P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%). Conclusions and Relevance Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach. Trial Registration ClinicalTrials.gov Identifier:NCT02076113

/pdf/effect-of-ventral-vs-dorsal-spinal-surgery-on-patient-1etk5717qa.pdf

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial.

Background The American Society of Anesthesiologists physical status (ASA-PS) is a grading system adopted worldwide by anesthesiologists to classify the overall health status of patients. Its importance is demonstrated not only by its routinely use in clinical practice, but also by its deployment in other healthcare-related environments. However, a weak/moderate inter-observer agreement for ASA-PS has been previously shown and, although definitions and clinical examples of each class were provided by ASA, doubts remain on the individual factors influencing the assignment to an ASA-PS class. The aim of this study was to investigate whether and how an anesthesiologist's experience conditions the classification into a specific ASA-PS class. Methods An online survey presenting 8 fictitious patients was administered to a group of Italian anesthesiologists and residents of different experience. Respondents were asked to assign each one of the 8 patients to a specific ASA-PS class. For the comparisons, anesthesiologists were subdivided into 5 classes according to the experience as anesthesiologists. Results Six hundred one surveys were correctly completed. The highest mean number of correct answers was obtained by residents, and this number decreased progressively with increasing work experience. The lowest value was recorded in the most experienced group (≥ 20 years of experience). Conclusions Low inter-reliability and experience-dependence of ASA-PS must be taken into account when evaluating a patient, particularly in settings where wide differences in experience are present.

/pdf/assignment-of-asa-physical-status-relates-to-3h11fk9ufu.pdf

Assignment of ASA-physical status relates to anesthesiologists' experience: a survey-based national-study.

Background:Despite its widespread use, the American Society of Anesthesiologists (ASA)-Physical Status Classification System has been shown to result in inconsistent assignments among anesthesiologists. The ASA-Physical Status Classification System is also used by nonanesthesia-trained clinicians an

Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients.

A successful anesthesia pre-assessment clinic needs to identify patients who need further testing, evaluation, and optimization prior to the day of surgery to avoid delays and cancelations. Although the ASA Physical Status Classification system (ASA PS) has been used widely for over 50 years, it has poor interrater agreement when only using the definitions. In 2014, ASA-approved examples for each ASA physical status class (ASA PS). In this quality improvement study, we developed and evaluated the effectiveness of institutional-specific examples on interrater reliability between anesthesia pre-anesthesia clinic (APAC) and the day of surgery evaluation (DOS). A multi-step, multi-year quality improvement project was performed. Step 1, pre-intervention, was a retrospective review to determine the percentage agreement of ASA PS assignment between APAC and DOS for adult and pediatric patients. Step 2 was a retrospective review of the step 1 cases where the ASA PS assignment differed to determine which medical conditions were valued differently and then develop institutional-specific examples for medical conditions not addressed by ASA-approved examples. Step 3 was to educate clinicians about the newly implemented examples and how they should be used as a guide. Step 4, post-intervention, was a retrospective review to determine if the examples improved agreement between APAC and DOS ASA PS assignments. Weighted Kappa coefficient was used to measure of interrater agreement excluding chance agreement. Having only ASA PS definitions available, APAC and DOS agreement was only 74% for adults (n = 737) and 63% for pediatric patients (n = 216). For adults, 20 medical co-morbidity categories and, for pediatric patients, 9 medical co-morbidity categories accounted for > 90% the differences in ASA PS. After development and implementation of institutional-specific examples with ASA-approved examples, the percentage agreement increased for adult patients (n = 795) to 91% and for pediatric patients (n = 239) to 84%. Weighted Kappa coefficients increased significantly for all patients (from 0.62 to 0.85, p < .0001), adult patients (from 0.62 to 0.86, p < .0001), and pediatric patients (from 0.48 to 0.78, p < .0001). ASA-approved examples do not address all medical conditions that account for differences in the assignment of ASA PS between pre-anesthesia screening and day of anesthesia evaluation at our institution. The process of developing institutional-specific examples addressed the medical conditions that caused differences in assignment at one institution. The implementation of ASA PS examples improved consistency of assignment, and therefore communication of medical conditions of patients presenting for anesthesia care.

/pdf/improving-agreement-of-asa-physical-status-class-between-pre-afzibai3dj.pdf

Improving agreement of ASA physical status class between pre-anesthesia screening and day of surgery by adding institutional-specific and ASA-approved examples: a quality improvement project

Adding Examples to the ASA–Physical Status Classification Improves Correct Assignment to Patients

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Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients.

Improving agreement of ASA physical status class between pre-anesthesia screening and day of surgery by adding institutional-specific and ASA-approved examples: a quality improvement project

Adding Examples to the ASA–Physical Status Classification Improves Correct Assignment to Patients