American Society of Anesthesiologists Classification (ASA Class)

Daniel John Doyle; Emily H. Garmon.

Last Update: October 6, 2017.

Introduction

The American Society of Anesthesiologists (ASA) physical status classification system was
developed to offer clinicians a simple categorization of a patient’s physiological status that can
be helpful in predicting operative risk. The ASAPS originated in 1941 and has seen some revisions
since that time.

Clinical Significance

The ASAPS obtained in a particular patient cannot serve as a direct indicator of operative risk
because (for instance) the operative risk for a high-risk patient undergoing cataract surgery
under topical anesthesia is quite different than the operative risk for the same patient
undergoing an esophagectomy or cardiac surgery. Also, since the ASAPS for a particular patient
is based on the extent of his or her systemic disease (as judged by the patient’s medical history,
the extent of the patient’s function limitation, etc.), technically speaking, mere physical
problems such as a the presence of a difficult airway by virtue of a very anterior larynx or artificial
constraints such as the prohibition of a clinically necessary blood transfusion in patients who are
orthodox Jehovah’s Witness do not influence the ASAPS but most definitely will
strongly impact the patient’s operative risk.

It has been shown that anesthesiologists sometimes vary significantly in the ASAPS classification
assigned to patients, especially on the influence of factors such as age, anemia, obesity, and with
patients who have recovered from a myocardial infarction. Similar problems have been
highlighted in a pediatric study.

Finally, note that the ASAPS classification system implicitly assumes that age is unrelated to
physiological fitness, an assumption which is simply not true since neonates and the very elderly,
even in the absence of disease, are far more “fragile” in their tolerance of anesthetics compared
to young adults. However, despite these and other well-known limitations, the ASAPS
classification is used ubiquitously (although sometimes uncritically) in providing a convenient
description of a surgical patient’s overall condition.

Table 1. The latest version of the American Society of Anesthesiologists (ASA) physical status
classification system (ASAPS) as approved by the ASA House of Delegates on October 15, 2014
and adapted for this presentation. Note that there is no specific classification assigned to
patients with a moderate systemic disease, just assignments for patients with mild systemic
disease (ASA 2) and those with severe systemic disease (ASA 3).

Abbreviations used: ASA: American Society of Anesthesiologists, BMI: body mass Index, CHF:
congestive heart failure, COPD: chronic obstructive pulmonary disease.

 ASA 1: A normal healthy patient. Example: Fit, nonobese (BMI under 30), a nonsmoking
patient with good exercise tolerance.
  ASA 2: A patient with a mild systemic disease. Example: Patient with no functional
limitations and a well-controlled disease (e.g., treated hypertension, obesity with BMI
under 35, frequent social drinker or is a cigarette smoker).

 ASA 3: A patient with a severe systemic disease that is not life-threatening.

Example: Patient with some functional limitation as a result of disease (e.g., poorly
treated hypertension or diabetes, morbid obesity, chronic renal failure, a
bronchospastic disease with intermittent exacerbation, stable angina, implanted
pacemaker).

 ASA 4: A patient with a severe systemic disease that is a constant threat to

life. Example: Patient with functional limitation from severe, life-threatening disease
(e.g., unstable angina, poorly controlled COPD, symptomatic CHF, recent (less than
three months ago) myocardial infarction or stroke.

 ASA 5: A moribund patient who is not expected to survive without the operation. The
patient is not expected to survive beyond the next 24 hours without surgery. Examples:
ruptured abdominal aortic aneurysm, massive trauma, and extensive intracranial
hemorrhage with mass effect.

 ASA 6: A brain-dead patient whose organs are being removed with the intention of
transplanting them into another patient.

The addition of “E” to the ASAPS (e.g., ASA 2E) denotes an emergency surgical procedure. The
ASA defines an emergency as existing “when the delay in treatment of the patient would lead to
a significant increase in the threat to life or body part.”

Examples of ASAPS Classification:

Patient 1 A 20-year-old college athlete from Brigham Young University is scheduled to undergo
an elective ACL repair. Nonsmoker, nondrinker, no medications, BMI 23. This patient would be
assigned ASAPS Class 1.

Patient 2 A 19-year-old college student from the University of California - Santa Barbara (a top
“party school”) is scheduled to undergo emergency orthopedic surgery following a fall from his
frat house roof after attending a weekly “kegger” party. The patient takes recreational
medications only (mostly cannabis) and has a BMI of 29. This patient would be assigned ASAPS
Class 2E by being a frequent social drinker and being scheduled as an emergency case. Note that
the “full stomach” status of the patient does not figure into his ASAPS yet still adds considerably
to his overall anesthetic risk.

Patient 3A 30-year-old woman is scheduled to undergo elective surgery for removal of a large
ovarian cyst. Comorbidities include anemia from menorrhagia and type II diabetes treated with
metformin. She is a non-smoker, occasional social drinker, and has a BMI of 42. This patient
would be assigned ASAPS Class 3.

Patient 4A 70-year-old woman is scheduled to undergo an emergency laparoscopic

appendectomy. Comorbidities include severe COPD as a consequence of a life-long smoking
habit, morbid obesity (BMI 46) and type II diabetes. She gets short of breath walking more than
a few meters. This patient would be assigned ASAPS Class 4E.
Patient 5A 55-year-old man is scheduled for emergency repair of a ruptured abdominal aortic
aneurysm. He is brought to the operating room with CPR in progress due to asystole. He had
been intubated earlier in the Emergency Department without the need for any drugs. This
patient would be assigned ASAPS Class 5E as he would not be expected to survive beyond the
next 24 hours with or without surgery.

Patient 6A 25-year-old man sustained a severe head injury in a motorcycle accident. He was not
wearing a helmet. After a neurosurgical decompression procedure and numerous other
interventions in the intensive care unit, it is clear that there is no hope for recovery. He is
unresponsive to all noxious stimulation. Testing for brain death is carried out according to the
American Academy of Neurology guidelines for Brain Death Determination reveals a complete
absence of central nervous system function, and his family agrees to make his organs available
for transplantation. This patient would be assigned ASAPS Class 6.

References

1. Bohnen JD, Ramly EP, Sangji NF, de Moya M, Yeh DD, Lee J, Velmahos GC, Chang DC, Kaafarani
HM. Perioperative risk factors impact outcomes in emergency versus nonemergency surgery
differently: Time to separate our national risk-adjustment models? J Trauma Acute Care
Surg. 2016 Jul;81(1):122-30. [PubMed]

2. Ehlert BA, Najafian A, Orion KC, Malas MB, Black JH, Abularrage CJ. Validation of a modified
Frailty Index to predict mortality in vascular surgery patients. J. Vasc. Surg. 2016 Jun;63(6):1595-
1601.e2. [PubMed]

3. Vargo JJ, Niklewski PJ, Williams JL, Martin JF, Faigel DO. Patient safety during sedation by
anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38
million procedures. Gastrointest. Endosc. 2017 Jan;85(1):101-108. [PubMed]

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