EXERPT from Nagelhout/Plaus

American Society of Anesthesiologists Physical Status Classification System

With the conclusion of the preanesthesia assessment, assignment of an ASA physical status classification is made for each patient. The classification
ideally represents a reflection of the patient's preoperative status and is not an estimate of anesthetic risk. For greater accuracy to be attained from its
interpretation, the ASA status should also remain independent of the proposed surgical procedure.285-288

Advent and Purpose

In 1940 the ASA developed a system “to classify the physical condition of a patient requiring anesthesia and surgery.” This six-category
classification was then revised by the ASA in 1961 to the current system of five categories (Table 19-15).289 The purpose of the ASA classification,
then and now, is to provide a consistent means of communication to anesthesia staff, within and among institutions, about the physical status of a
patient.289 Furthermore, it allows for a standardized interpretation of anesthesia outcome based on one criterion.

Despite rough correlations between patient physical status and postoperative outcome, the ASA classification system does not represent an estimate of
anesthesia risk.285-288 Although a patient in poor physical health is known to be at greater risk for negative outcome, this does not account for other
factors that influence perioperative morbidity and mortality. These factors include the duration and involvement of the surgical procedure, the degree
of perioperative monitoring, and unfortunate circumstances, such as human error or equipment failure.

TABLE 19-15 American Society of Anesthesiologists Physical Status Classification

Classification Physical Status
ASA Class I No organic, physiologic, biochemical, or psychiatric disturbance
Example: Healthy patient
ASA Class II Mild to moderate systemic disturbance
Examples: Heart disease that slightly limits physical activity, essential hypertension, diabetes mellitus, chronic bronchitis, anemia,
morbid obesity, age extremes
ASA Class III Severe systemic disturbance that limits activity
Examples: Heart or chronic pulmonary disease that limits activity, poorly controlled essential hypertension, diabetes mellitus with
vascular complications, angina pectoris, history of previous myocardial infarction
ASA Class IV Severe systemic disturbance that is life threatening
Examples: Congestive heart failure; persistent angina pectoris; advanced pulmonary, renal, or hepatic dysfunction
ASA Class V Moribund patient undergoing surgery as a resuscitative effort, despite a minimal chance for survival
Classification Physical Status
Example: Uncontrolled hemorrhage from a ruptured abdominal artery aneurysm
ASA Class E Emergency surgery is required
Example: An otherwise healthy 30-year-old woman who requires a dilation and curettage for moderate but persistent hemorrhage is
classified as ASA IE
Modified from American Society of Anesthesiologists. New classification of physical status. Anesthesiology. 1963;24:111.
ASA, American Society of Anesthesiologists.

Definition
The current ASA classification system ranges from class I through V, with E denoting an emergent procedure. At some institutions, a classification
of ASA status VI also may be assigned to postmortem patients undergoing organ procurement procedures. By definition, a patient classified as ASA
status I is a healthy individual except for the condition that has necessitated surgery. A healthy young woman about to undergo an emergency dilation
and curettage for vaginal bleeding, for example, is classified as ASA status IE. At the other end of the spectrum, a 74-year-old man with
hypertension, uncontrolled diabetes, and unstable angina who is scheduled for a coronary artery bypass graft procedure is classified as ASA status
IV.289

Limitations of the Current System

Despite the numerous benefits of the ASA classification system, it has its shortcomings. Namely, the current system is not explicit enough in its
categorization to account for every patient, and this can result in patient misclassification.290 If the physical status classification system is used for
statistical or reimbursement purposes within a department, overclassification is often the consequence. Overclassification of a patient also occurs
when the proposed surgical procedure is incorporated into the assignment of ASA physical status. This improper classification, or overclassification,
of patient status thereby limits the degree of accuracy attained from its original interpretation. As a result, correlations between preoperative status
and postoperative outcome are skewed. Despite the shortcomings of the system, ASA physical status continues to be assigned to each patient as a
summary of the preoperative evaluation.