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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK549785_"><span class="title" itemprop="name">American Society of Anesthesiologists Staging</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Lauren A. Hocevar</span><sup>1</sup>; <span itemprop="author">Brian M. Fitzgerald</span><sup>2</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> University of Pikeville - KCOM</div><div class="affiliation"><sup>2</sup> Brooke Army Medical Center</div><p class="small">Last Update: <span itemprop="dateModified">January 29, 2023</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-17454.s1"><h2 id="_article-17454_s1_">Definition/Introduction</h2><p>In 1963, the American Society of Anesthesiologists instituted a system to assess a patient's physical health status and clinical risk during anesthetic administration and surgical operation. Pre-operatively, the patient is subjectively assigned a score according to their physical status, which is determined by the anesthesiologist after considering the patient's presentation, history, and functional limitations. Assigning this score, ranked ASA I through ASA VI, would thereby attempt to categorize the patient's risk of perioperative complications based on their physical status and overall health. Patients assigned to higher numerical categories have an increased risk of perioperative adverse events. The goal of creating the ASA Physical Status Classification System (ASA-PS) was to improve patient outcomes and predict perioperative risk.<a class="bk_pop" href="#article-17454.r1">[1]</a> Despite its setbacks, it has since become a standard practice during perioperative encounters and plays a key role in preventative medicine associated with anesthesia.</p></div><div id="article-17454.s2"><h2 id="_article-17454_s2_">Issues of Concern</h2><p>A concern commonly encountered with assigning ASA scores is that there is often significant variation in how providers classify the same patient. Assessment and evaluation of patients can vary between providers in different specialties compared to the staff anesthesiologists, causing a significant increase in standard deviation even when participants had access to the same medical records. This situation proves to be a problem that is more prevalent outside the specific specialty, posing a potential threat to the success of healthcare teams composed of multiple providers from multiple specialties.<a class="bk_pop" href="#article-17454.r2">[2]</a> Studies have shown that adding examples for each respective score aided anesthesia and non-anesthesia providers in accurately classifying patients.<a class="bk_pop" href="#article-17454.r3">[3]</a> In 2014, the ASA provided access to a catalog of examples for simplification when assigning an ASA score, increasing accuracy and decreasing inter-observer variation.<a class="bk_pop" href="#article-17454.r4">[4]</a></p></div><div id="article-17454.s3"><h2 id="_article-17454_s3_">Clinical Significance</h2><p>Using the ASA Physical Status Classification System to evaluate and prepare for possible adverse events remains 1 of the most widely used pre-operative screening methods for all providers worldwide<a class="bk_pop" href="#article-17454.r5">[5]</a>. The ASA Physical Status Classification System has been shown to predict the frequency of perioperative morbidity and mortality. Research has shown that the implementation of the classification system correctly predicts the frequency and severity of adverse events, which improves patient outcomes<a class="bk_pop" href="#article-17454.r5">[5]</a>. The ASA score is assigned based on a patient's presence and severity of systemic disease. Examples of some disease processes commonly encountered are listed with their respective score assignment. The letter E may be added to any category (ie, ASA IIE) to denote an emergency.</p><ul><li class="half_rhythm"><div>ASA I: a healthy patient with no evidence of active or chronic disease processes, non-smoker, and BMI under 30.<a class="bk_pop" href="#article-17454.r6">[6]</a></div></li><li class="half_rhythm"><div>ASA II: a patient with mild systemic disease. Examples include a patient who has no functional limitations and well-controlled disease, BMI under 35, is a social drinker or smokes cigarettes, or has well-controlled hypertension.<a class="bk_pop" href="#article-17454.r6">[6]</a></div></li><li class="half_rhythm"><div>ASA III: a patient with severe systemic disease that is not life-threatening. Examples include patients with functional limitations as a result of systemic disease, poorly treated hypertension or diabetes, renal failure, BMI greater than 40, stable angina, or pacemaker.<a class="bk_pop" href="#article-17454.r6">[6]</a></div></li><li class="half_rhythm"><div>ASA IV: A patient with severe systemic disease that is a constant threat to life. Examples include patients with functional limitations as a result of severe systemic disease such as unstable angina, poorly controlled COPD, symptomatic CHF, recent MI, or stroke less than 3 months prior.<a class="bk_pop" href="#article-17454.r6">[6]</a></div></li><li class="half_rhythm"><div>ASA V: A moribund patient who is not expected to survive without surgical intervention. Examples include ruptured abdominal aortic aneurysm, massive trauma, or extensive intracranial bleeding with mass effect.<a class="bk_pop" href="#article-17454.r6">[6]</a></div></li><li class="half_rhythm"><div>ASA VI: A patient declared brain-dead who is a transplant donor. </div></li></ul></div><div id="article-17454.s4"><h2 id="_article-17454_s4_">Nursing, Allied Health, and Interprofessional Team Interventions</h2><p>During perioperative care, the actions of the nurse contribute not only to patient outcomes but also to preventing and monitoring adverse events. Nurses should not only understand what may place a patient in a specified category but also should be able to interpret any complications each patient may face as a result of their assigned score and/or illness. With the education and utilization of the ASA Physical Status Classification System, a nurse can intervene when necessary and collaborate with other providers to ensure the best possible clinical outcome. Interpretations of a patient's categorization are important to nursing staff as they use the complete clinical evaluation to guide their patient monitoring and communicate effectively with other anesthesia care team members.<a class="bk_pop" href="#article-17454.r7">[7]</a> This categorization also applies to pharmacists and other health professionals who may be contributing to a patient's care plan. Studies have shown that interprofessional team communication failures continue to be a leading cause of adverse outcomes.<a class="bk_pop" href="#article-17454.r8">[8]</a> Therefore, an increased effort toward improving collaboration between nurses and physician anesthesia providers ultimately improves patient care.<a class="bk_pop" href="#article-17454.r9">[9]</a><a class="bk_pop" href="#article-17454.r10">[10]</a></p></div><div id="article-17454.s5"><h2 id="_article-17454_s5_">Nursing, Allied Health, and Interprofessional Team Monitoring</h2><p>Nurses provide pre- and postoperative care in addition to monitoring changes in the anesthetic plan. As stated, nurses must understand the ASA Physical Classification System and what conditions patients may have that might increase their chance of adverse outcomes during the perioperative period. Nurses play a vital role in perioperative care as they closely monitor patients in the PACU for possible adverse outcomes. Nurses should integrate the patient's ASA categorization into their perioperative care plan and monitor for any adverse outcomes that may be associated with their illness. </p></div><div id="article-17454.s6"><h2 id="_article-17454_s6_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div id="article-17454.s7"><h2 id="_article-17454_s7_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-17454.r1">Daabiss M. American Society of Anaesthesiologists physical status classification. <span><span class="ref-journal">Indian J Anaesth. </span>2011 Mar;<span class="ref-vol">55</span>(2):111-5.</span> [<a href="/pmc/articles/PMC3106380/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3106380</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21712864" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21712864</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-17454.r2">Knuf KM, Maani CV, Cummings AK. Clinical agreement in the American Society of Anesthesiologists physical status classification. <span><span class="ref-journal">Perioper Med (Lond). </span>2018;<span class="ref-vol">7</span>:14.</span> [<a href="/pmc/articles/PMC6008948/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6008948</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29946447" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29946447</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="article-17454.r3">Hurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, Abouleish AE. Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients. <span><span class="ref-journal">Anesthesiology. </span>2017 Apr;<span class="ref-vol">126</span>(4):614-622.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28212203" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28212203</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="article-17454.r4">Irlbeck T, Zwißler B, Bauer A. [ASA classification : Transition in the course of time and depiction in the literature]. <span><span class="ref-journal">Anaesthesist. </span>2017 Jan;<span class="ref-vol">66</span>(1):5-10.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/27995282" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27995282</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="article-17454.r5">Saubermann AJ, Lagasse RS. Prediction of rate and severity of adverse perioperative outcomes: "normal accidents" revisited. <span><span class="ref-journal">Mt Sinai J Med. </span>2012 Jan-Feb;<span class="ref-vol">79</span>(1):46-55.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22238038" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22238038</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="article-17454.r6">Doyle DJ, Hendrix JM, Garmon EH. <span class="ref-journal">StatPearls [Internet].</span> StatPearls Publishing; Treasure Island (FL): Aug 17, 2023. American Society of Anesthesiologists Classification. [<a href="/pmc/articles/PMC441940/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC441940</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28722969" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28722969</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="article-17454.r7">Lee CP, Bora V. <span class="ref-journal">StatPearls [Internet].</span> StatPearls Publishing; Treasure Island (FL): Mar 19, 2023. Anesthesia Monitoring of Mixed Venous Saturation. [<a href="/pmc/articles/PMC539835/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC539835</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30969657" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30969657</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="article-17454.r8">Wilbanks BA, Geisz-Everson M, Clayton BA, Boust RR. Transfer of Care in Perioperative Settings: A Descriptive Qualitative Study. <span><span class="ref-journal">AANA J. </span>2018 Oct;<span class="ref-vol">86</span>(5):401-407.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/31584410" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31584410</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="article-17454.r9">Torgersen KA, Chamings PA. Examining collaborative relationships between anesthesiologists and certified registered nurse anesthetists in nurse anesthesia educational programs. <span><span class="ref-journal">AANA J. </span>1994 Apr;<span class="ref-vol">62</span>(2):139-48.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/8085417" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8085417</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="article-17454.r10">Canales C, Strom S, Anderson CT, Fortier MA, Cannesson M, Rinehart JB, Kain ZN, Perret D. Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees. <span><span class="ref-journal">Br J Anaesth. </span>2019 Dec;<span class="ref-vol">123</span>(6):887-897.</span> [<a href="/pmc/articles/PMC6993108/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6993108</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31591019" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31591019</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Lauren Hocevar declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Brian Fitzgerald declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div></div></div>
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