With an aging and increasingly obese population, patients with significant comorbidities present for surgery. Although age per se is not a factor in determining candidacy for ambulatory procedures, each patient must be considered in the context of his or her comorbidities, the type of surgery to be performed, and the expected response to anesthesia. First developed in 1963, the American Society of Anesthesiologists’ (ASA) physical status classification system (Table 65-1) summarizes the physiologic fitness of each patient prior to surgery. It serves as a means of communication between health-care providers and is used for record-keeping.
TABLE 65-1ASA’s Physical Status Classification of Patients1 ||Download (.pdf) TABLE 65-1 ASA’s Physical Status Classification of Patients1
|Class ||Definition |
|1 ||Normal healthy patient with no organic, physiologic, biochemical, or psychiatric disturbances |
|2 ||Patient with mild-to-moderate systemic diseases that have no functional limitations and may not be related to the reason for surgery |
|3 ||Patient with severe systemic diseases with some functional limitations that may or may not be related to the reason for surgery |
|4 ||Patient with severe systemic disturbances that have incapacitated functions and are a constant threat to life (functionality incapacitated) with or without surgery |
|5 ||Moribund patient who has little chance of survival but undergoes surgery as a last resort (resuscitative effort) |
|6 ||Brain-dead patient whose organs are removed for donor purposes |
|E ||For an emergency operation, the physical status is followed by “E” (eg, “2E”) |
In general, ambulatory surgeries should be of a complexity and duration such that one could reasonably assume that the patient will make an expeditious recovery. Assessment of the patient’s ASA physical status and completion of a thorough history and physical examination are crucial in the screening of patients selected for ambulatory or office-based surgery. ASA 4 and 5 patients normally would not be candidates for ambulatory surgery, whereas ASA 1 and 2 patients would be prime candidates for such surgery. ASA 3 patients with diabetes, hypertension, and stable coronary artery disease would not be precluded from an ambulatory procedure, provided their diseases are well controlled. Ultimately, the surgeon and anesthesiologist must identify patients for whom an ambulatory or office-based setting is likely to provide benefits (eg, convenience, reduced costs, and charges) that outweigh risks (eg, the lack of immediate availability of all hospital services, such as a cardiac catheterization laboratory, emergency cardiovascular stents, assistance with airway rescue, and rapid consultation).
Criticism of the ASA physical status scale is primarily due to its exclusion of age and difficulty of intubation. A study of 1095 patients undergoing total hip replacement, prostatectomy, or cholecystectomy found that both age and ASA physical status accurately predicts postoperative morbidity and mortality. Although it does not predict operative risk, the ASA physical status scale remains a useful application for all patients during the preoperative ...