American Society Of Anesthesiologists Physical Status Score Research Articles

Machine Learning Algorithm to Perform the American Society of Anesthesiologists Physical Status Classification.

The American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System defines perioperative patient scores ranging from 1 to 6 (healthy to brain dead, respectively).The scoring is performed and used by physician anesthesiologists and providers to classify surgical patients based on co-morbidities and various clinical characteristics. There is potentially a variability in scoring stemming from individual biases.The biases impact the prediction of operating times, length of stay in the hospital, anesthetic management, and billing.This study's purpose was to develop an automated system to achieve reproducible scoring. A machine learning (ML) model was trained on already assigned ASA PS scores of 12,064 patients. The ML algorithm was automatically selected by Wolfram Mathematica (Wolfram Research, Champaign, IL) and tested with retrospective records not used in training. Manual scoring was performed by the anesthesiologist as part of the standard preoperative evaluation.Intraclass correlation coefficient (ICC) in R (version 4.2.2; R Development Core Team, Vienna, Austria) was calculated to assess the consistency of scoring. An ML model was trained on the data corresponding to 12,064 patients. Logistic regression was chosen automatically, with an accuracy of 70.3±1.0% against the training dataset. The accuracy against 1,999 patients (the test dataset) was 69.6±1.0%. The ICC for the comparison between ML and the anesthesiologists' ASA PS scores was greater than 0.4 ("fair to good"). We have shown the feasibility of applying ML to assess the ASA PS score within an oncology patient population. Though our accuracy was not very good, we feel that, as more data are mined, a valid foundation for refinement to ML will emerge.

Utility of the LET-IN-OUT Clinical Decision Support Tool for Medical Risk Stratification Prior to Outpatient Total Hip or Knee Arthroplasty

BackgroundMusculoskeletal care teams can benefit from simple, standardized, and reliable preoperative tools for assessing discharge disposition after total joint arthroplasty. Our objective was to compare the predictive strength of the Ascension Seton Lower Extremity Inpatient-Outpatient (LET-IN-OUT) tool versus the American Society of Anesthesiologists Physical Status (ASA-PS) score for predicting early postoperative discharge. MethodsWe retrospectively extracted sociodemographic, surgical admission, postoperative day (POD) of discharge, 90-day readmissions, and predictions of the LET-IN-OUT and ASA-PS tools from the electronic records of 563 consecutive hip or knee arthroplasty patients (mean age 65 [SD 9.6], 54% women). Included patients who underwent a total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single health system between June 2020 and March 2021. We performed descriptive statistics and analyzed predictive values of each tool, defining “early discharge” primarily as discharge before the second postoperative day (POD 2), and secondarily as before 24 hours, and on the same calendar day (POD 0) as surgery. ResultsThe LET-IN-OUT tool demonstrated superior predictive power among hip and knee arthroplasty patients compared to the ASA-PS tool for discharge prior to POD 2 (positive predictive value [PPV] 89 versus 83%, positive likelihood ratio [+LR] 2.0 versus 1.2), discharge before 24 hours (PPV 86 versus 70%, +LR 2.9 versus 1.2), and discharge on POD 0 (PPV 34% versus 30%, +LR 1.2 versus 1.1). ConclusionsThe Ascension Seton Lower Extremity Inpatient-Outpatient tool predicted patients suitable for early discharge following THA or TKA and did so more effectively than the ASA-PS score.

A population pharmacokinetic model of remimazolam for general anesthesia and consideration of remimazolam dose in clinical practice

Remimazolam besylate is a novel short-acting benzodiazepine. An appropriate pharmacokinetic model of remimazolam is desirable in anesthesia practice. The aim of the study was to develop a pharmacokinetic model using plasma samples from patients anesthetized with remimazolam. Influence of patient characteristics, context-sensitive decrement-times, and dose regimens were also examined. Data were obtained from four trials on patients, and seven trials on healthy volunteers. The characteristics of 416 male and 246 female subjects were as follows: age, 18-93years; body weight, 34-149kg; and American Society of Anesthesiologists physical status (ASA-PS), I-IV. 2231 arterial and 3200 venous samples were used for the final model. The equilibration rate constant between arterial plasma and effect-site was estimated using the concept of time to peak effect. The final model was used to generate context-sensitive decrement times and dose regimens for general anesthesia. A three-compartment model plus virtual venous compartment with allometric scaling of adjusted body weight (ABW), age, sex, and ASA-PS as covariates were selected as the final model. Elimination clearance was lower in males, and in subjects with higher ABW and ASA-PS scores. Approximately 10% or 20% higher dose rate was necessary in females than in males or ASA-PS I/II than III/IV patient. The context-sensitive half-time for effect-site concentration in a 55-year-old, 70-kg, 170-cm male or female ASA-PS I/II patient after > 6-h infusion was 16.7 or 15.9min. Remimazolam pharmacokinetic model for general anesthesia was successfully developed. ABW, ASA-PS, and sex has a considerable impact on the remimazolam concentration.

A Single-Center Retrospective Study of Selected Clinical Parameters and Intraoperative Fluid Management of Patients Undergoing Pancreatoduodenectomy.

BackgroundPancreatoduodenectomy is an extensive procedure with a very high risk of complications. Appropriate intraoperative fluid therapy is a subject of ongoing debate. The aim of this retrospective study was to analyze the relationship between selected preoperative parameters, intraoperative fluid therapy, and catecholamines administration during pancreatoduodenectomy.Material/Methods: From 2011 through 2017, among pancreatoduodenectomies performed at a single university hospital, 192 patients met the inclusion criteria of the study: 105 (54.7%) males and 87 (45.3%) females with a mean age of 60.06 (±11.63) years. Correlations were assessed between sex, age, body mass index (BMI), selected comorbidities, surgery duration, American Society of Anesthesiologists (ASA) Physical Status (PS) scale, preoperative endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative catecholamine administration, intraoperative fluid supply, red blood cell (RBC) concentrate and fresh frozen plasma (FFP) supply, blood loss, and diuresis.ResultsA need for catecholamines has been shown to be more frequent in smokers (P=0.01), patients with cardiovascular comorbidities (P=0.037), high ASA PS scores (P=0.003), and preoperative ERCP (P=0.011). The need for intraoperative transfusion of RBC concentrate was more frequent in smokers (P=0.005). Surgical time was significantly longer in males (P=0.014). Among females, liberal intraoperative fluid therapy (>7.9 ml/kg/h) was more frequent in patients with thyroid comorbidities (P=0.003).ConclusionsThe findings of this retrospective study demonstrate the influence of comorbidities, ASA PS class, and catecholamine use on fluid therapy during pancreatoduodenectomy.

Perioperative Cardiac Arrest: A 3-Year Prospective Study from a Tertiary Care University Hospital.

PurposePerioperative cardiac arrests (CAs) are a rare but catastrophic perioperative complication. Much about incidence, risk factors, and outcomes of such events are still unknown. This study investigated anesthesia-related CAs at a tertiary teaching hospital.MethodsCA incidence within 24 hours of anesthesia administration was prospectively identified from May 1, 2016 to April 31, 2019. Each CA was matched by four other cases without CA receiving anesthesia on the same date and under similar operating conditions. The CA cases were reviewed and assigned to one of three groups: anesthesia-related, anesthesia-contributing, and anesthesia not related.ResultsA total of 58,303 patients underwent 73,557 procedures under anesthesia during the study period. In sum, 27 CAs were reported for incidence of 3.7 per 10,000 anesthesia administrations (95% CI 2.3–5.1). Eleven CA were anesthesia-related for incidence of 1.5 per 10,000 anesthesia administrations. Four CA cases were anesthesia-contributing for incidence of 0.5 per 10,000 anesthesia administrations, while 53% of the anesthesia-related and -contributing CAs were due to respiratory problems. American Society of Anesthesiologists (ASA) physical status score, cardiovascular surgery, emergency surgery, and increased duration of surgery were significantly correlated with CA incidents when compared to the control group. ASA physical status score is an independent risk factor of the occurrence of perioperative CA (OR 7.6, 95% CI 2.6–22.4; P<0.001).ConclusionIdentifying factors associated with increased risk for anesthesia-related CA is of great importance in risk stratification for surgical patients. ASA physical status score was found to be a major factor in predicting perioperative CA, since patients with higher ASA scores had a statistically significant increased risk of CA. Therefore, extra precautions must be taken when dealing with unprepared patients who have uncontrolled medical illnesses, especially those who will be undergoing emergency surgery.

Does operative treatment of geriatric pelvic ring injuries lead to a high risk of one-year mortality?

IntroductionNon-operative management of pelvic ring injuries in the elderly is associated with a high risk of one-year mortality. The majority of these injuries are the result of a low-energy mechanism, however, due to the multiple medical comorbidities in this patient population the injuries are associated with a high degree of morbidity. The purpose of this study was to determine the one-year mortality risk after operative treatment of pelvic ring injuries in a geriatric patient population and the effect of patient and injury characteristics on the risk of mortality. Patients and methodsWe performed a retrospective review of patients over the age of 70 who underwent operative fixation of a pelvic ring injury at two Level 1 trauma centers between January 2016 and June 2019. Medical records were reviewed for patient and injury characteristics including: Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) physical status score or Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). The primary outcome of interest was the one-year mortality risk following operative treatment. Secondary outcomes included the effect of patient and injury characteristics on the one-year mortality risk and the hospital LOS. ResultsNinety patients were included with an average age of 79.8 ± 6.5 years. The overall mortality was 8.9% (n = 8) and was significantly associated with the CCI. There was no significant effect related to the ASA physical status score or ISS. The average hospital LOS was 9.2 ± 7.3 days and was associated with the CCI, ASA physical status score, and ISS. DiscussionNon-operative management of pelvic ring injuries in geriatric patients is associated with a high risk of one-year mortality. Our findings suggest operative treatment of these fractures is associated with an acceptable risk of one-year mortality that falls below the commonly reported range for non-operatively managed injuries. Furthermore, the risk of mortality was significantly associated with the patient's pre-injury state as determined by the CCI.

Developing a Simpler Prognosticating Tool: Comparing the Combined Assessment of Risk Encountered in Surgery Score with Deyo-Charlson Comorbidity Index and The American Society of Anesthesiologists Physical Status Score in Predicting 2 years Mortality after Hip Fracture Surgery

Background: The use of risk stratification tools in identifying high-risk hip fracture patients plays an important role during treatment. The aim of this study was to compare our locally derived Combined Assessment of Risk Encountered in Surgery (CARES) score with the the American Society of Anesthesiologists physical status (ASA-PS) score and the Deyo–Charlson Comorbidity Index (D-CCI) in predicting 2-year mortality after hip fracture surgery. Methods and Material: A retrospective study was conducted on surgically treated hip fracture patients in a large tertiary hospital from Jan 2013 through Dec 2015. Age, gender, time to surgery, ASA-PS score, D-CCI, and CARES score were obtained. Univariate and multivariable logistic regression analyses were used to assess statistical significance of scores and risk factors, and area under the receiver operating characteristic (ROC) curve (AUC) was used to compare ASA-PS, D-CCI, and CARES as predictors of mortality at 2 years. Results: 763 surgically treated hip fracture patients were included in this study. The 2-year mortality rate was 13.1% (n = 100), and the mean ± SD CARES score of surviving and demised patients was 21.2 ± 5.98 and 25.9 ± 5.59, respectively. Using AUC, CARES was shown to be a better predictor of 2-year mortality than ASA-PS, but we found no statistical difference between CARES and D-CCI. A CARES score of 23, attributable primarily to pre-surgical morbidities and poor health of the patient, was identified as the statistical threshold for “high” risk of 2-year mortality. Conclusion: The CARES score is a viable risk predictor for 2-year mortality following hip fracture surgery and is comparable to the D-CCI in predictive capability. Our results support the use of a simpler yet clinically relevant CARES in prognosticating mortality following hip fracture surgery, particularly when information on the pre-existing comorbidities of the patient is not immediately available.

Assignment of pre-event ASA physical status classification by pre-hospital physicians: a prospective inter-rater reliability study

BackgroundIndividualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient’s condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene.MethodsThe study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen’s kappa (κw).ResultsFor most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κw 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κw 0,77 to 0.85). When all physicians had access to the same information, κw increased (κw 0,65 to 0,93).ConclusionsPre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

An automated machine learning-based model predicts postoperative mortality using readily-extractable preoperative electronic health record data

BackgroundRapid, preoperative identification of patients with the highest risk for medical complications is necessary to ensure that limited infrastructure and human resources are directed towards those most likely to benefit. Existing risk scores either lack specificity at the patient level or utilise the American Society of Anesthesiologists (ASA) physical status classification, which requires a clinician to review the chart. MethodsWe report on the use of machine learning algorithms, specifically random forests, to create a fully automated score that predicts postoperative in-hospital mortality based solely on structured data available at the time of surgery. Electronic health record data from 53 097 surgical patients (2.01% mortality rate) who underwent general anaesthesia between April 1, 2013 and December 10, 2018 in a large US academic medical centre were used to extract 58 preoperative features. ResultsUsing a random forest classifier we found that automatically obtained preoperative features (area under the curve [AUC] of 0.932, 95% confidence interval [CI] 0.910–0.951) outperforms Preoperative Score to Predict Postoperative Mortality (POSPOM) scores (AUC of 0.660, 95% CI 0.598–0.722), Charlson comorbidity scores (AUC of 0.742, 95% CI 0.658–0.812), and ASA physical status (AUC of 0.866, 95% CI 0.829–0.897). Including the ASA physical status with the preoperative features achieves an AUC of 0.936 (95% CI 0.917–0.955). ConclusionsThis automated score outperforms the ASA physical status score, the Charlson comorbidity score, and the POSPOM score for predicting in-hospital mortality. Additionally, we integrate this score with a previously published postoperative score to demonstrate the extent to which patient risk changes during the perioperative period.

American Society of Anesthesiologists physical status score as a predictor of long-term outcome in women with endometrial cancer.

To study the association of the American Society of Anesthesiologists (ASA) physical status score with long-term outcome in endometrial cancer. Overall, disease-specific and non-cancer-related survival were estimated using simple and multivariable Cox regression analyses and the Kaplan-Meier method. A total of 1166 patients were included in the study. Median follow-up time was 76 (range 1-136) months. All-cause and non-cancer-related mortality were increased in patients whose ASA physical status score was III (HRs 2.5 and 8.0, respectively) or IV (HRs 5.7 and 25, respectively), and cancer-related mortality was increased in patients whose score was IV (HR 2.7). Kaplan-Meier analyses demonstrated a worse overall, disease-specific and non-cancer-related survival for patients whose score was ≥III (p<0.0001 for all). Disease-specific survival was also separately analyzed for patients with stage I and stage II-IV cancer. Compared with patients whose score was ≤II, the survival was worse for patients whose score was ≥III in both subgroups of stages (p=0.003 and p=0.017 for stage I and stages II-IV, respectively). ASA physical status score remained an independent predictor of all-cause mortality (HR 2.2 for scores ≥III), cancer-related mortality (HRs 1.7 and 2.2 for scores ≥III and IV, respectively) and non-cancer related mortality (HR 3.1 for scores ≥III) after adjustment for prognostically relevant clinicopathologic and blood-based covariates. ASA physical status score also remained an independent predictor of cancer-related mortality after exclusion of patients who were at risk for nodal involvement based on features of the primary tumor but who did not undergo lymphadenectomy, and patients with advanced disease who received suboptimal chemotherapy (HRs 1.6 and 2.5 for scores ≥III and IV, respectively). ASA physical status score independently predicts overall survival, disease-specific survival, and non-cancer-related survival in endometrial cancer.

Tumor Resection May Improve Survival in Patients With Soft Tissue Sarcoma Aged 75 Years and Older.

This study aimed to analyze the decision-making process of treatment and the clinical outcomes of patients with STS aged 75 years and older. Overall, 72 patients were reviewed. The mean and median ages were 82 and 81 years, respectively. Of the 72 patients, 17 did not undergo surgical resection. Age was related to the decision to pursue surgical treatment. Resection was performed in 55 patients. The 5-year overall survival was 51.8%. Patients with an American Society of Anesthesiologists physical status (ASA-PS) score of 3 had a worse survival. Twenty-five patients developed metastasis. The median survival time after metastasis in 12 patients who received metastasectomy and/or lung radiofrequency ablation was superior (18.2 months) to that of the remaining 13 patients without any treatment (3.2 months). Surgical treatment should be considered in elderly patients if their physical condition is not poor. ASA-PS score may be a tool to indicate physical condition.

The ASA Physical Status Classification: What Is the Evidence for Recommending Its Use in Veterinary Anesthesia?-A Systematic Review.

Background: The effectiveness of the American Society of Anesthesiologists (ASA) Physical Status (PS) classification to identify the animals at a greater risk of anesthesia-related death and complications is controversial. In this systematic review, we aimed to analyze studies associating the ASA PS scores with the outcome of anesthesia and to verify whether there was any evidence for recommending the use of the ASA PS in veterinary patients.Methods: Research articles found through a systematic literature search were assessed for eligibility, and data were extracted and analyzed using random-effects analysis.Results: A total of 15 observational prospective and retrospective studies including 258,298 dogs, cats, rabbits, and pigs were included. The analysis found consistency between the studies showing that dogs, cats and rabbits with an ASA-PS ≥III had 3.26 times (95% CI = 3.04–3.49), 4.83 times (95% CI = 3.10–7.53), and 11.31 times (95% CI = 2.70–47.39), respectively, the risk of anesthesia-related death within 24 h (dogs) and 72 h (cats and rabbits) after anesthesia compared with those with an ASA PS <III. In addition, the analysis showed that dogs and cats with ASA PS ≥III had 2.34 times the risk of developing severe hypothermia during anesthesia (95% CI = 1.82–3.01).Conclusions: The simple and practical ASA PS was shown to be a valuable prognostic tool and can be recommended to identify an increased risk of anesthetic mortality until 24–72 h after anesthesia, and a greater risk of development severe intraoperative hypothermia.

Interrater variability in ASA physical status assignment: an analysis in the pediatric cancer setting.

The American Society of Anesthesiologists (ASA) physical status is a universal classification system that helps clinicians to categorize their patients preoperatively. However, there is a lack of both inter-rater and intra-rater reliability among clinicians for the ASA physical status classification. Our study focuses on testing these reliabilities within pediatric anesthesia providers in the cancer setting. In our retrospective observational study, a total of 1177 anesthesia records were reviewed. The cohort included all pediatric patients (≤18years old) diagnosed with either retinoblastoma or neuroblastoma who had two or more anesthesia procedure within a 14-day time period. Overall, the ASA physical status score among two different anesthesia providers for the same patient treated at different times had very little inter-rater reliability, κ=-0.042 (95% CI -0.17; 0.09). Of the 1177-patient anesthesia records, only 25% had two or more ASA physical status score assigned by the same anesthesiologist within a 14-day time period. There was moderate intra-rater reliability κ=0.48 (95% CI 0.29; 0.68) for patients who were assigned an ASA physical status score by the identical anesthesia provider at different times points within a 14day period. In contrast to observations in earlier studies, findings indicate poor agreement in inter-rater reliability. Although there was moderate agreement in intra-rater reliability, one would expect to find stronger, even perfect, intra-rater reliability. These findings suggest the need to develop a specific physical status classification system directed toward patients with a systemic illness such as cancer in both young and adult patients.

The Assignment of American Society of Anesthesiologists Physical Status Classification for Adult Polytrauma Patients: Results From a Survey and Future Considerations.

The American Society of Anesthesiologists (ASA) physical status (PS) classification system assesses the preoperative health of patients. Previous studies demonstrated poor interrater reliability and variable ASA PS scores, especially in trauma scenarios. There are few studies that evaluated the assignment of ASA PS scores in trauma patients and no studies that evaluated ASA PS assignment in severely injured adult polytrauma patients. Our objective was to assess interrater reliability and identify sources of discrepancy among anesthesiologists and trauma surgeons in designating ASA PS scores to adult polytrauma patients. A link to an online survey containing questions assessing attitudes regarding ASA PS classification, demographic information, and 8 fictional trauma cases was e-mailed to anesthesiologists and trauma surgeons. The participants were asked to assign an ASA PS score to each scenario and explain their choice. Rater-versus-reference and interrater reliability, beyond that expected by chance, among respondents was analyzed using the Fleiss kappa analysis. A total of 349 participants completed the survey. All 8 cases had inconsistent ASA PS scores; several cases had scores ranging from I to VI and variable emergency (E) designations. Using weighted kappa (Kw) analysis for a subset of 201 respondents (101 trauma surgeons [S] and 100 anesthesiologists [A]), we found moderate (Kw = 0.63; SE = 0.024; 95% confidence interval, 0.594-0.666; P < .001) interrater-versus-reference reliability. The interrater reliability was fair (Kw = 0.43; SE = 0.037; 95% confidence interval, 0.360-0.491; P < .001). This study demonstrates fair interrater reliability beyond that expected by chance of the ASA PS scores among anesthesiologists and trauma surgeons when assessing adult polytrauma patients. Although the ASA PS is used in some trauma risk stratification models, discrepancies of ASA PS scores assigned to trauma cases exist. Future modifications of the ASA PS guidelines should aim to improve the interrater reliability of ASA PS scores in trauma patients. Further studies are warranted to determine the value of the ASA PS score as a trauma prognostic metric.

Prognostic factors for elderly patients with primary malignant bone and soft tissue tumors.

The number of patients with primary malignant bone and soft tissue tumors in Japan is increasing in line with the increasing size of the elderly population. The aim of the present study was to determine the prognostic factors of primary malignant bone or soft tissue tumors in elderly patients. Clinical data was obtained from 90 patients, aged ≥65 years, with primary malignant bone or soft tissue tumors (bone, 20 cases; and soft tissue, 70 cases), treated at the Osaka City University Hospital between 1993 and 2013. Clinical information prior to treatment and tumor type, location, size, depth, grade and American Society of Anesthesiologists-Physical Status (ASA-PS) score were evaluated in order to identify prognostic factors using the Cox proportional hazards regression model. In addition, 5-year survival rates were evaluated using the Kaplan-Meier method. The average follow-up period was 44.8 months and the 5-year overall survival rate was 77.5%. In the multivariate analysis, ASA-PS score and high-grade sarcoma were found to be associated with a poorer overall survival. No significant differences were observed between the patient group aged 65-74 years and that aged ≥75 years. In general, aging is associated with physically reduced function and an increased prevalence of comorbidities. It was therefore expected that increasing age may be a predictive factor for poor prognosis. However, the results of the present study suggested that ASA-PS score and tumor grade were significant factors associated with poor prognosis, whereas increasing age was not. Therefore, the treatment of elderly patients with primary bone and soft tissue tumors should not be based on age.

Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Plastic and Reconstructive Surgery Patients

The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patient's likelihood of developing postoperative complications. In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations. The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means (t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios. For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%. ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non-venous thromboembolism complications, providing a broader measurement for postoperative complication risks. 4.

Effects of a rapid response system on quality of life: a prospective cohort study in surgical patients before and after implementing a rapid response system

BackgroundThe aim of a rapid response system (RRS) is to improve the timely recognition and treatment of ward patients with deteriorating vital signs The system is based on a set of clinical criteria that are used to assess patient’s vital signs on a general ward. Once a patient is evaluated as critical, a medical emergency team is activated to more thoroughly assess the patient’s physical condition and to initiate treatment. The medical emergency team included a critical care physician and a critical care nurse.AimTo assess the effect of an RRS on health-related quality of life (HRQOL).MethodsProspective cohort study in surgical patients before and after implementing an RRS. HRQOL was measured using the EuroQol-5 dimensions (EQ-5D) and the EQ visual analogue scale (VAS) at pre surgery and at 3 and 6 months following surgery.ResultsNo statistical significant effects of RRS implementation on the EQ-5D index and EQ-VAS were found. This was also true for the subpopulation of patients with an unplanned intensive care unit admission. Regarding the EQ-5D dimensions, deterioration in the ‘mobility’ and ‘usual activities’ dimensions in the post-implementation group was significantly less compared to the pre-implementation group with a respective mean difference of 0.08 (p = 0.03) and 0.09 (p = 0.04) on a three-point scale at 6 months. Lower pre-surgery EQ-5D index and higher American Society of Anesthesiologists physical status (ASA-PS) scores were significantly associated with lower EQ-5D index scores at 3 and 6 months following surgery.ConclusionsImplementation of an RRS did not convincingly affect HRQOL following major surgery. We question if HRQOL is an adequate measure to assess the influence of an RRS. Pre-surgery HRQOL- and ASA-PS scores were strongly associated with HRQOL outcomes and may have abated the influence of the RRS implementation.

Deterioration of Surgical Outcomes With Aging in Patients With Cervical Spondylotic Myelopathy

: A retrospective investigation. : To clarify at which age and at what point in the postoperative period neurological deterioration occurs in patients with cervical spondylotic myelopathy. : Inferior surgical outcomes tend to be seen with increasing age, however, the age threshold and the postoperative period associated with deterioration have not been established. : Of 273 patients who underwent laminoplasty, 75 were enrolled in our study who met the criteria of having cervical spondylotic myelopathy, being monitored for a minimum of 2 years after surgery, and experiencing no morbidities within 2 years after surgery. Participants were classified into 4 age groups: group A, 54 years or below (n=12); group B, 55-64 years (n=22); group C, 65-74 years (n=24); and group D, 75 years or above (n=17). Preoperative physical status scores, using the American Society of Anesthesiologists (ASA) classification system, and neurological recovery, indicated by Japanese Orthopaedic Association (JOA) scores, were compared and surgical complications were reviewed. : The ASA physical status score was significantly lower in group A (1.4±0.5) than in group C (2.0±0.5) or group D (2.2±0.4) (P<0.0083). No difference was seen between the preoperative and 1-year postoperative JOA scores between the groups. However, the JOA score at ≥2 years after surgery was significantly lower in group D (12.9±2.0) than in group A (15.2±1.4; P<0.0083). Major complications of cardiopulmonary disorders were documented only in patients in groups C and D with A higher ASA scores. : Inferior surgical outcomes were seen in patients 75 years of age or above at 2 years after surgery compared with patients of 54 years or below of age. These clinical features could be reasonably explained by the patients' preexisting physical status related to age.

The Relationship Between the American Society of Anesthesiologists Physical Rating and Outcome Following Total Hip and Knee Arthroplasty

The purpose of this study was to review the results of the first four years of use of the American Society of Anesthesiologists (ASA) physical status rating system in the New Zealand Joint Registry. Our hypothesis was that patients with a higher ASA score would have an increased mortality rate, an increased early revision arthroplasty rate, and poorer clinical outcomes at six months after total hip or knee arthroplasty. We prospectively evaluated the preoperative ASA classes for all patients in the registry who underwent primary total hip or knee arthroplasty from 2005 to 2008 with regard to the six-month mortality rate and the Oxford Hip and Knee Scores at six months. Survival curves were constructed with use of revision joint replacement as the end point. Twenty-two thousand six hundred patients who underwent total hip arthroplasties and 18,434 patients who underwent total knee arthroplasties were recorded in the New Zealand Joint Registry. The six-month mortality rate was 0.77% following hip arthroplasty and 0.40% following knee arthroplasty. Significant differences were observed in the mortality rate between all ASA classes following hip arthroplasty (p &lt; 0.001). Similarly, significant differences were observed in the mortality rate between ASA classes after knee arthroplasty, except between ASA classes 1 and 2 and between ASA classes 3 and 4. The mortality rate was significantly higher (p &lt; 0.001) following hip arthroplasty compared with knee arthroplasty. A significant difference (p &lt; 0.001) in Oxford scores was observed when ASA class 1 and ASA class 2 were compared with ASA class 3 and ASA class 4, independent of age and sex, following both hip or knee arthroplasty. A significant difference was observed in the rate of early revision (revision less than two years after the index procedure) following total hip arthroplasty when ASA class 1 (hazard ratio, 1.39 [95% confidence interval (CI), 1.04 to 1.95]; p = 0.015) and ASA class 2 (hazard ratio, 1.24 [95% CI, 1.02 to 1.55]; p = 0.030) were compared with ASA class 3, which was independent of age and sex. No significant difference was observed in the rate of early revision after total knee arthroplasty. The ASA physical status score can be used as a predictor of postoperative mortality and functional status following both hip and knee arthroplasty and may predict early failure of total hip arthroplasty necessitating revision. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Classification of comorbidity in trauma: agreement and reliability of the pre-injury ASA-PS Scale

Background Pre-injury comorbidity influence outcome in severely injured patients. Pre-injury comorbidity graded according to the American Society of Anesthesiologists Physical Status (ASA-PS) classification system (Table 1) is an independent predictor of survival in trauma patients, and is suggested as a comorbidity score in the Utstein Trauma Template. Little is known about the levels of agreement and reliability of pre-injury ASA-PS scores. The objective of the study was to examine if pre-injury ASA-PS was a reliable scale for grading comorbidity of trauma patients among a representative group of trauma registry coders.