Indian J. Anaesth.

CHHABRA, KIRAN,2002; 46 (5) : BHARADWAJ,

MALHOTRA, 347-352 THAKUR : RISK STRATIFICATION AND ANAESTHESIA 347

RISK STRATIFICATION IN ANAESTHESIA PRACTICE

Dr. B. Chhabra1 Dr. Shashi Kiran2 Dr. Naveen Malhotra3
Dr. Manoj Bharadwaj4 Dr. Anil Thakur5

SUMMARY
Risk stratification is of vital importance not only in carrying out day to day successful anaesthetic practice but is also essential for
development of standard procedure guidelines and/or protocols.
Various methods of perioperative risk stratification, along with risks and benefits and limitations are briefly received in this article.
Keywords : Anaesthesia risk, Risk stratification.

Risk groups under study should be as similar as possible to

The dictionary meaning of “RISK” is hazard, danger, each other thus reducing CONFOUNDING variables.
exposure to mischance or peril. Risk is a measure of
An investigator has available, for study, a specific
probability (statistical chance) of future occurrence (usually
population of patients, such as the patients treated in a
undesirable). No body is with `no risk’ as a very small but
particular hospital or practice. Frequently, it is not practical
possible chance of untoward outcome exists even for those
to study all the individuals available. A sample may be
who do not show presence of a factor known to be
drawn, of representatives, from the large population. This
associated with undesired outcome. We can grade risk as:
process is called sampling and the extent to which the
Very low risk information obtained may be extrapolated to the total
Low risk population depends in large measure on the skill with
Moderate risk which that sampling was done. Sometimes a process called
High risk stratification is used. Stratified samples are drawn to ensure
Very high risk that specified proportions of selected groups are included.
Risk factors
Methods used for risk stratification
A risk factor is a detectable characteristic or
Data Source
circumstance of individuals or groups which is
Relevant studies published are identified using
associated with an increased chance (risk) of experiencing
MEDLINE search of the English-language literature,
an unwanted outcome. Risk factors can be ‘causes’ or
followed by a mannual search of the references of all
‘signals’ of untoward outcome. They are observable or
identified articles.
identifiable before the occurrence of the undesirable
event they predict. Study collection
Dictionary meaning of Stratify All clinical studies evaluating methods used for
Stratify (verb) means arrange in strata; stratum risk stratification.
layer or set of layers of any deposited substance; (noun) Data extraction
stratification. The key data extracted from each article includes
Stratification the inclusion and exclusion criteria of the study patients,
For a trial to be valid, the degree and severity of the techniques used for testing and the corresponding
disease must be accurately characterized in order that all definitions of positive test results, and the clinical outcomes
of the tested patients. Data are analysed using Bayesian
1. D.A.,M.S., Prof. & Head conceptual framework, and pretest probabilities are
2. D.A.,D.N.B.,MD, Lecturer converted to post test probabilities using calculation of
3. M.D.,D.N.B. Lecturer likelihood ratios.
4. M.D., Lecturer
5. M.D., Lecturer Study of risk
Department of Anaesthesia and Critical Care Risk of general anaesthesia is coincident with the
Pt. B.D. Sharma P.G.I.M.S., Rohtak-124001 risks of surgical operation and the morbid condition that
Correspond to : requires this type of therapeutic intervention. In other
Prof. B.Chhabra
4/7-J, Medical Enclave, Rohtak-124001 HARYANA, INDIA.
words, the hazards of anaesthesia are never entirely
348
separate (independent) from a second procedure or
condition. The study of such risks is very difficult and
requires complex multifactorial analysis of large number
of patients. Despite these difficulties, such studies are
needed to provide objective information on the outcome
of anaesthetic and surgical care and to enable accurate
prediction of associated risks to be made (Fig.I).
Fig. I : Model of measuring anaesthetic outcomes
Risk stratification for non-cardiac surgery
Although the occurrence of life threatening cardiac
complications during and after non cardiac surgery has
long been recognized, this problem has gained increasing
attention over the past 15 years. In part, this new interest
reflects the growing numbers of complex operations in an
aging population and increased scrutiny of what were
once considered expected events. However, it is also clear
that this trend is to a significant extent driven by technology.
As methods such as multilead ST segment
monitoring and transoesophageal echocardiography have
made their way into the recovery areas, there has been
a greater appreciation of the association of myocardial
ischaemia with adverse cardiac events.1,2 More importantly,
improvements and increased availability of non invasive
imaging techniques have made it possible to detect and
quantify ischaemia before surgery. Not surprisingly, the
occurrence of preoperative, intraoperative and especially
postoperative ischaemia has proved to be a predictor or
marker of cardiac morbidity and mortality.1-4
These trends and observations, however, have not
clarified either how to best assess perioperative risk or,
more importantly, why and when such assessments are
necessary.
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002
Perioperative cardiac morbidity : the problem
Nearly 25 million patients undergo noncardiac
surgical procedures each year in the United States. Of
these, 1 million are known to have coronary artery disease,
another 2-3 million have multiple risk factors, and an
additional 4 million are at risk by virtue of being >65
years old.1 These groups account for approximately 80%
of the 1 million patients who suffer perioperative cardiac
morbidity and mortality.
The 400,000 patients undergoing vascular surgery
represent the highest risk group, both because they have
a high incidence of coronary disease and because the
operative procedures are particularly stressful.
Death, nonfatal myocardial infarction, unstable
angina pectoris, and congestive heart failure or pulmonary
oedema are the most important cardiac complications of
noncardiac surgery. Mortality rates from cardiac causes
ranges from negligible to 5% or higher for major vascular
procedures.5 Although the incidence of perioperative
myocardial infarction is <1% in the general population,
it rises to 2-8% in patients with previous myocardial
infarction and ranges from 1% to 15% in patients
undergoing vascular surgery. Coronary artery disease and/
or significant left ventricular dysfunction are the underlying
substrates for most of these complications.6
Perioperative cardiac risk :
How should it be assessed ?
Because of the magnitude of the problem of
perioperative cardiac morbidity, clinicians and investigators
have sought to identify patient at greatest risk
preoperatively. In this regard, a number of clinical factors
have been identified, including (1) Clinical evidence of
coronary artery disease from prior myocardial infarction
or angina pectoris; (2) Severe left ventricular dysfunction
as evidenced by a history of heart failure, a third heart
sound, or elevated jugular venous pressure; (3) Factors
that increase the likelihood of these conditions such as
advanced age, severe hypertension, diabetes mellitus, and
arrhythmias; and (4) instability or progression of cardiac
disease (e.g. recent myocardial infarction, unstable angina,
or refractory heart failure). Several multifactorial indices
(Fig.II) have incorporated these markers and have proved
quite helpful in identifying patients at high and low risk
for non cardiac procedures.3,4,7-9
However, when the population under evaluation
has a high prevalence of coronary artery disease, whether
apparent or silent, such as patients undergoing abdominal
aorta or peripheral vascular surgery, and even individuals
at apparently low risk may have a 5 to 10% incidence of
CHHABRA, KIRAN, MALHOTRA, BHARADWAJ, THAKUR : RISK STRATIFICATION AND ANAESTHESIA 349

Unfortunately, there is no convincing evidence that this

Fig. II : Use of clinical risk indices to predict postoperative
cardiac end points
is the case. There are three potential circumstances under
which RISK STRATIFICATION makes sense: (1) If the
Study Year Patients Type of Quality End Point Pretest results would alter the surgical plan, leading either to
n Surgery Rating Proba- cancellation of surgery or to an alternative procedure,
bility%
such as amputation instead of peripheral arterial bypass.
Cardiac Risk Index (2) If the results indicate a need for coronary
revascularization before non cardiac surgery, either by
General, MI,
Goldman et al 1977 1001 orthopedic, Fair Cardiac death, 6 coronary artery bypass grafting or percutaneous
urologic CHF, VT transluminal angioplasty; and (3) If the results would
MI,
alter perioperative management. Each of these potential
Jeffrey et al 1983 99 Vascular Fair Cardiac death, 11 applications warrants careful scrutiny because even if
CHF, VT preoperative testing does lead to these interventions, as is
General, MI,
now often the case, are there data to justify these
Zeldin 1984 1140 vascular, Fair Cardiac death, 3 approaches? (Fig.III).
thoracic CHF, VT

MI, Fig. III : Approach to cardiac risk stratification for

Detsky et al 1986 455 Mixed Strong Cardiac death, 10 patients having peripheral vascular surgery
CHF

Lundquist et al 1989 78 Vascular Fair MI, 17

Cardiac death

Lette et al 1991 360 Mixed Weak MI, 10

major Cardiac death

Modified Cardiac Risk Index

MI,
Detsky et al 1986 455 Mixed Strong Cardiac death, 10
CHF

Lette et al 1991 360 Mixed Weak MI, 10

major Cardiac death

cardiac complications. Therefore, a number of additional

diagnostic tests have been evaluated for their potential to
further stratify risk. Approaches that have been used are
resting and exercise ECG, measurements of left ventricular
ejection fraction at rest or with exercise, ambulatory ECG
assessments of arrhythmias and ischaemia, exercise and
pharmacological stress myocardial scintigraphy, and stress
echocardiography.3,4

Perioperative risk stratification

Why or why not ?
Although experience with approaches of
perioperative risk stratification continues to evolve,
relatively little thought has been given to the rationale for
such assessments. The fiscal impact would increase
substantially if more patients at risk were studied or
Perhaps the clearest application of risk stratification
multiple tests were performed. In addition, the results of
is the first of these interventions. However, cancellation
these tests are likely to lead to additional procedures,
of surgery or the selection of a different procedure are
morbidity, and mortality. It is possible that these costs
decisions that are usually based on clinical factors. Age,
and risks are warranted, if they result in improved long-
co-morbidity and general poor condition and unstable or
term outcomes for patients undergoing non-cardiac surgery.
350
refractory cardiac disease are the usual reasons, rather
than the results of additional diagnostic tests.
Prophylactic coronary artery vascularization to
reduce perioperative cardiac morbidity is the most
controversial intervention.
The risk of coronary revascularization in these
patients is not cited. Those at highest risk for non cardiac
surgery are also often at very high risk for coronary
artery bypass surgery. Many surgeons would be
circumspect in undertaking coronary revascularization in
individuals with diffuse vascular disease, poor left
ventricular functions, multiple associated diseases and no
potential for symptomatic benefit, with the sole goal being
to reduce the risk of a subsequent surgical procedure.
The third potential application for risk stratification
is to use the results to modify perioperative management.
Careful intraoperative and postoperative monitoring are
standard procedures for those with important clinical risk
factors. The ability of additional monitoring by
transoesophageal echocardiography or prolonged intensive
care unit observation to prevent complications remains
unproven. Whether additional risk stratification would lead
to safer or more cost-effective perioperative care is a
hypothesis that requires testing.6 Several medical
interventions are potentially attractive. These include the
use of ß blockers to minimise haemodynamic fluctuations
and the effect of excess catecholamines, central
sympatholytic agents for much the same objectives,
antithrombotic therapy, and other investigational agents
that increase myocardial adenosine levels. However, each
of these therapies has the potential to increase
complications as well as to reduce them. Therefore, the
use of these approaches is also not an adequate justification
for risk stratification until trials demonstrating their efficacy
have been performed.
Risks and benefits of perioperative risk stratification
If successful, cardiac risk stratification separates
patients into various risk categories so that their
management can be tailored to their needs. Low risk
patients may be spared further testing, and postoperative
management may be changed for patients at higher risk.
The goal of risk stratification is to reduce overall mortality
and morbidity. Clarification of risk status allows the
clinician to provide better informed consent. From a
societal perspective, reducing perioperative complications
and avoiding unnecessary testing could result in substantial
cost savings. The major harms of stratification arise from
the use of potentially unnecessary preoperative testing
and the consequent possibility of ineffective or harmful
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002
interventions. Harm may also result from delay of the
planned non cardiac surgery.
Area of future research
Further well-designed studies are needed if we are
to determine which non invasive tests can improve risk
stratification among intermediate risk patients undergoing
non vascular surgery. Study of the optimal stratification
strategy should consider not only therapeutic benefit but
also the cost-effectiveness of different pathways, given
the high prevalence of this problem and the potentially
large financial implications of screening numerous patients.
Risk stratification for airway assessment
Maintenance of a patent patients airway is a primary
responsibility of the anaesthesiologists. Interruption of
gas exchange, for even a few minutes, can result in
catastrophic outcomes such as brain damage or death.
Closed claims analysis has found that the vast majority
(85%) of airway-related events involve brain damage or
death, and as many as one third of death attributable
solely to anaesthesia have been related to inability to
maintain a patent airway.10,11
The difficulty of achieving a patent airway varies
with anatomic and other individual patient factors, and
identification of the patient with a difficult airway is vital
in planning anaesthetic management so that endotracheal
intubation can be achieved safely.
Several clinical criteria can be routinely assessed
on patients prior to anaesthesia including mouth opening,
Mallampati classification, head/neck movements, ability
to prognath, thyromental distance, body weight, and
previous history of difficult intubation.
Accurate preoperative prediction of potential
difficulty with intubation can help reduce the incidence of
catastrophic complications by alerting anaesthesia personnel
to take additional precautions before beginning anaesthesia
and establishing an artificial airway. In addition, more
accurate prediction of difficulty with intubation might
reduce the frequency of unnecessary maneuvers (e.g.
awake intubation) related to false positive predictions.
While several studies have evaluated such predictive criteria
individually or in arbitrary combinations, there has been
no sufficiently powered systematic multivariate analysis
of readily available clinical variables in a large general
population to determine a method of accurately
STRATIFYING the risk of encountering difficulty with
intubation. Since reliability of risk stratification using
multivariate models requires more than 10 outcomes events
per independent variable included in such analyses, this
CHHABRA, KIRAN, MALHOTRA, BHARADWAJ, THAKUR : RISK STRATIFICATION AND ANAESTHESIA 351

mandates a study of about 10,000 patients, assuming an
estimated frequency of truely difficult intubation of 1%.12
Recently Arne et al (1998) have given a “Clinical
predictive index.” Its clinical use is easy, as one uses
only seven risk factors and the “points” as shown in the
table (Fig.IV). Difficult intubation can be predicted if the
score exceeds 11. When a score less than 11 is found, a
difficult intubation can be excluded, with a risk of false
prediction of 1-2%.13
Fig. IV: Risk factors retained by the multivariate analysis
for predicting difficult tracheal intubation and the
corresponding points of the exact and simplified score. The
points of simplified score were obtained by multiplying the
points of the exact score by 3.15 and then rounding the
results to the nearest whole number.
Risk factor Point of the
simplified score
Previous knowledge of difficult intubation
No 0
Yes 10
Pathologies associated with difficult intubation
No 0
Yes 5 Class II
Clinical symptoms of airway pathology
No 0
Yes 3 is not incapacitating
patients, easy to perform, reproducible and inexpensive.
Although there has been considerable effort directed
recently into preoperative risk screening, only the ASA
grading is applied widely at present.
ASA grading
The concept of physical status classification was
suggested in 1941 by a committee of the American Society
of Anesthetists, the predecessor of the American Society
of Anaesthesiologists. This Committee had the task of
devising a system for collection and tabulation of statistical
data in anaesthesia. Although the term operative risk was
initially considered, this was deemed unsuitable because
it was altered by the magnitude of the surgical procedure.
The system was intended to describe the patient, and not
the specific anaesthetic or surgical risk. Instead the term
‘physical state’ was adopted. Initially six categories were
described, a seventh being added after the ASA published
the classification. In 1961, Dripps et al proposed the
current classification.
The ASA physical status scale
Class I A normally healthy individual
A patient with mild systemic disease
Class III A patient with severe systemic disease that

Inter-incisor gap (IG) and mandible luxatum (ML) Class IV A patient with incapacitating systemic
IG > 5 cm or ML >0 0 disease that is a constant threat to life
IG 3.5-5cm and ML=0 3
IG<3.5 cm and ML<0 13 Class V A moribund patient who is not expected to
survive 24 hour with or without operation.
Thyromental distance
>6.5cm 0 Class E Added to any patient for emergency
< 6.5cm 4
operation.
Maximum range of head & neck movement
Above 100° 0 This classification is now used throughout the
About 90° (90° ± 10°) 2 world to indicate physical status having become part of
Below 80° 5 the routine “shorthand” in assessing patients prior to
Mallampati’s modified test surgery. Virtually all clinical research papers related to
Class 1 0 aspects of human anaesthesia published in journals of
Class 2 2
Class 3 6
anaesthesia refer to the physical status of the patients
Class 4 8 under study.
Total...... 48 The advantage of the ASA physical status
classification is its simplicity. The authors of the system
ASA physical status scale intended only to improve communication and hoped to be
Preoperative risk assessment able to compare results. They clearly stated that this
classification was not an estimate to operative risk. Despite
Main goals of preoperative assessment are Risk
this ASA classification has been widely utilized as an
Stratification and potential reduction of the risk by various
index of risk. The reason for this is simple, it is the only
interventions. Ideally, any method of predicting before
expression of the overall pre-operative condition which is
operation the subsequent operative and postoperative course
widely recorded.
of a patient should be applicable to a large number of
352
No other preoperative risk assessment scheme has
achieved the same widespread use. Other internationally
known patient scoring systems outside the field of
anaesthesia include APACHE II, used widely in intensive
care, but the need for a 24-h sampling period of 12
routine physiological measurements, age and previous
health status underlines the unsuitability of this system
for anaesthesia. In contrast, the ASA classification
represents a simple estimation of physiological status
without the need for clinical resources and can be applied
to every patient before operation. The simplicity of the
ASA system is its strength. It is also its weakness.
Multifactorial risk indices have been developed linking
severity of the disease and the operative procedure, in
patients with cardiac disease undergoing non cardiac
surgery. It is possible that with sufficient effort, a
multifactorial index could be devised which considers
both the category of operation and to nature of intercurrent
disease for a wide range of disorders in the same way
that the APACHE II system for intensive care has linked
the physiological severity of illness with its nature. Such
linkage would result in a more accurate assessment of
operative risk. However, the very complexity of such a
system would make it unlikely that it would be as widely
utilized as the ASA classification.
Conclusions
Comparisons between institutions are already
occurring, and comparisons between individual providers
may also become a reality. Inspite of the negative views
of such comparisons, they are likely to be mandated
because of pressure from health care regulators, insurers,
and patients. Despite awareness of the importance of
demographic variables and concurrent medical problems
in influencing outcome valid comparisons are presently
difficult to conduct.
Current methods of risk stratification each have
limitations. A method for risk assessment based on
multivariate analysis from a large group of patients that
can be prospectively validated at multiple institutions would
be valuable, not only for mortality rate comparisons but
also for patient counseling, research and hospital
management. Caution must be applied when using risk
assessment in individual patients. Physician need to be
involved in the development of such severity stratifying
systems, since inclusion of inappropriate or medically
irrelevant data can influence the outcome of multivariate
analysis.
Ongoing research and evaluation of scoring systems
also need to occur since therapy changes overtime. It is
likely that models will need to be developed for application
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002
preoperatively, at ICU admission and for the complex,
long term patient at 7 days or beyond, in order to fully
inform medical decision-making.
The potential utility of health status measures needs
to be explored in anaesthesia, given the current trend in
delivering cost-effective, customer-focused and evidence
based practice.
References
1. Mangano D, Browner W, Hollenberg M, London M, Tubau J,
Tateo I. Association of perioperative myocardial ischaemia
with cardiac morbidity and mortality in men undergoing
non-cardiac surgery. N Engl J Med 1990; 323: 1781-8.
2. Raby K, Barry J, Creager M, Cook F, Weisberg M,
Goldman L. Detection and significance of intraoperative and
postoperative myocardial ischemia in peripheral vascular
surgery. JAMA 1992; 268: 222-7.
3. Abraham S, Coles N, Coley C, Strauss H, Boucher C,
Eagle K. Coronary risk of non cardiac surgery. Prog
Cardiovasc Dis 1991; 34: 205-34.
4. Wong T, Detsky A. Perioperative cardiac risk assessment of
patients for peripheral vascular surgery. Ann Intern Med 1992;
116: 743-53.
5. Mangano D. Perioperative cardiac morbiidity (review).
Anesthesiology 1990; 72: 153-84.
6. Massie BM, Mangano DT. Risk stratification for non-cardiac
surgery. How (and why)?. Editorial comment. Circulation
1993; 87(5): 1752-5.
7. Goldman L. Multifactorial index of cardiac risk in non-cardiac
surgery: Ten-year status report (review article). J Cardiothorac
Anesthesiol 1987; 1: 237-44.
8. Eagle K, Coley C, Newell J, et al. Combining clinical and
thallium data optimizes preoperative assessment of cardiac
risk before major vascular surgery. Ann Intern Med 1989;
110: 859-66.
9. Hollenberg M. Predictors of postoperative myocardial ischemia
in patients undergoing non cardiac surgery. JAMA 1992; 268:
205-9.
10. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse
respiratory events in anesthesia: a closed claims analysis.
Anesthesiology 1990; 72: 828-33.
11. Benumof JL, Scheller MS. The importance of transtracheal jet
ventilation in the management of the difficult airway.
Anesthesiology 1989; 71: 769-78.
12. Ganzouri ARE, McCarthy RJ, Tuman KJ, Tanck EN,
Ivankovich AD. Preoperative airway assessment: Predictive
value of multivariate risk index. Anesth Analg 1996; 82:
1197-1204.
13. Arne J, Descoins P, Fusciardi J, et al. Preoperative assessment
for difficult intubation in general and ENT surgery: Predictive
value of a clinical multivariate risk index. Br J Anaesth 1998;
80: 140-6.