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ASA (American Society of Anesthesiologists) physical status classification system

2020-07-07

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Class	Original
1	No organic pathology or patients in whom the pathological process is localized and does not cause any systemic disturbance or abnormality. Examples: This includes patients suffering with fractures unless shock, blood loss, emboli or systemic signs of injury are present in an individual who would otherwise fall in Class 1. It includes congenital deformities unless they are causing systemic disturbance. Infections that are localized and do not cause fever, many osseous deformities, and uncomplicated hernias are included. Any type of operation may fall in this class since only the patient's physical condition is considered.
2	A moderate but definite systemic disturbance, caused either by the condition that is to be treated or surgical intervention or which is caused by other existing pathological processes, forms this group. Examples: Mild diabetes. Functional capacity I or IIa. Psychotic patients unable to care for themselves. Mild acidosis. Anemia moderate. Septic or acute pharyngitis. Chronic sinusitis with postnasal discharge. Acute sinusitis. Minor or superficial infections that cause a systemic reaction. (If there is no systemic reaction, fever, malaise, leukocytosis, etc., aid in classifying.) Nontoxic adenoma of thyroid that causes partial respiratory obstruction. Mild thyrotoxicosis. Acute osteomyelitis (early). Chronic osteomyelitis. Pulmonary tuberculosis with involvement of pulmonary tissue insufficient to embarrass activity and without other symptoms.
3	Severe systemic disturbance from any cause or causes. It is not possible to state an absolute measure of severity, as this is a matter of clinical judgment. The following examples are given as suggestions to help demonstrate the difference between this class and Class 2. Examples: Complicated or severe diabetes. Functional capacity IIb. Combinations of heart disease and respiratory disease or others that impair normal functions severely. Complete intestinal obstruction that has existed long enough to cause serious physiological disturbance. Pulmonary tuberculosis that, because of the extent of the lesion or treatment, has induced vital capacity sufficiently to cause tachycardia or dyspnea. Patients debilitated by prolonged illness with weakness of all or several systems. Severe trauma from accident resulting in shock, which may be improved by treatment. Pulmonary abscess.
4	Extreme systemic disorders which have already become an eminent threat to life regardless of the type of treatment. Because of their duration or nature there has already been damage to the organism that is irreversible. This class is intended to include only patients that are in an extremely poor physical state. There may not be much occasion to use this classification, but it should serve a purpose in separating the patient in very poor condition from others. Examples: Functional capacity III -(Cardiac Decompensation). Severe trauma with irreparable damage. Complete intestinal obstruction of long duration in a patient who is already debilitated. A combination of cardiovascular-renal disease with marked renal impairment. Patients who must have anesthesia to arrest a secondary hemorrhage where the patient is in poor condition associated with marked loss of blood. Emergency Surgery: An emergency operation is arbitrarily defined as a surgical procedure which, in the surgeon's opinion, should be performed without delay.
5	Emergencies that would otherwise be graded in Class 1 or Class 2.
6	Emergencies that would otherwise be graded as Class 3 or Class 4.

Suppl. 3

CLASSIFICATION OF OPERATIONS DEPENDING ON THE RISK OF SEPTIC OF COMPLICATIONS

Class I/Clean This class describes an uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in this category if they meet the criteria. Example: abdominal incision from primary closure of exploratory surgery for repair of splenic laceration following blunt trauma.

Class II/Clean-Contaminated This class describes an operative wound in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in sterile technique is encountered. Example: tonsillectomy.

Class III/Contaminated This class contains open, fresh, accidental wounds, as well as operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category. Example: hemorrhoidectomy.

Class IV/Dirty-Infected
This class describes an incision created during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (e.g., emergency surgery for peritonitis from gross fecal contamination), as well as delayed presentation of traumatic wounds with existing contamination and devitalized tissue. This definition suggests that the organisms causing post-operative infection were present in the operative field before the operation. Example: chronic wound debridement.

INCIDENCE OF SEPTIC COMPLICATIONS AFTER DIFFERENT OPERATIONS

Операции	Risk of post-operation septic complications (%)	Necessity of prophylaxis
«Clean»	below 2-5	+/-
«Clean-contaminated»	7-10	+
«Contaminated»	12-20	+
«Dirty-contaminated»	30-40	Antibacterial therapy

Suppl. 4

ПЕРИОПЕРАЦИОННАЯ ПРОФИЛАКТИКА ТРОМБОЭМБОЛИЧЕСКИХ ОСЛОЖНЕНИЙ

ASSESSMENT OF RISK OF DVT AND PULMONARY EMBOLISM ID SURGERY (by C. Samama и M. Samama, 1999, modifie).

Risk	Surgery associated risk factors	Patient associated risk factors	Way of prophylaxis
Низкий IA	I. non-complicated interventions below 45 min § appendectomy § delivery § hernia repair § abortion § transurethral adenomectomy	A. absent	§ early activation § elastic compression of low extremities
Moderate IB, IC, IIA, IIB	II. Major interventions § cholecystectomy; § gastric/intestinal resection; § complicated appendectomy; § caesarian section; § uterus amputaion; § arterial reconstruction; § transvesical adenomectomy; § leg osteosynthesis	B. § age > 40; § varicose veins; § estrogens; § heart failure; § stay in bed >4 days; § infection; § obesity; § postpartum period (6 weeks)	§ elastic compression; § intermittent pneumocompression; § Heparim 5000 IU 2-3 times a day; § LMWH according to producer’s recommendations
High IIC, IIIA, IIIB, IIIC	III. Extended interventions. § gastrectomy; § pancreatectomy; § colectomy; § uterus extirpation; § femur osteosynthesis § thigh amputation; § joints prosthetics.	C. § tumors; § DVT and TE in the past; § Paralysis of extremities; § thrombophilia.	§ elastic compression; § intermittent pneumocompression; § Heparim 5000 IU 2-3 times a day; § LMWH according to producer’s recommendations

ПРИЛОЖЕНИЕ 5

CLINICAL SYNDROMES IN SURGERY

5.1. Syndrome of endogenous intoxication

Cause	Diseases accompanied with congestion of biological toxins in tissues and fluids (peritonitis, acute cholecystitis, acute pancreatitis, crush-syndrome, extended necroses, moist gangrene, Graves’ disease etc.)
Paramenters	Degree
Paramenters	I	II	III
Clinical signs
Disorder of CNS function	Mild euphoria/inhibition	Psychomotor excitation	Delusion
Color of skin	normal	pale	Earthy, acrocyanosis, hyperemia
Body temperature	Subfebrile	Febrile	Febrile
Respiratory rate	22	22 – 30	above 30
Auscultation of lungs	Vesucular	Hard	Moist rales
Pulse rate	below 110	110 – 130	above 130
BP (mm.m.с.)	normal	hypertension	hypotension
Intestinal motility	slow	slow	absent
Daily diuresis, ml	above 1000	1000 – 800	below 800
Lab data
LII	below 3	3 – 6	above 6
Middle-weight molecules concentration	Moderately increased	Significantly increased	Significantly increased
Clotting system	Trend to hypercoaglulation	Hypercoaglulation	Hypocoaglulation
Urea	Moderately increased	Increased	Significantly increased
Serum protein	Norm	Decreased	Decreased

5.2. Syndrome of gastric dyspepsia

Cause	Inflammatory diseases of organs in the upper floor of abdominal cavity: distal esophagitis; acute gastric and duodenal ulcers; chronic ulcers during exacerbation/ presence of surgical complications (perforation, penetration, stenosis); acute cholecystitis; acute pancreatitis, etc.
Questioning	Complaints of pain, feeling of heaviness in the abdomen, belching, nausea and vomiting, sometimes heartburn, decreased appetite, upset stool and weight loss. In the localization of pathology in stomach, pain and heaviness in the epigastrium immediately after eating, nausea and vomiting after eating, bringing relief, noticeable weight loss are characteristic. In the localization of pathology in duodenum, late and hunger pains are characteristic, pains can be seasonable, have an atypical localization (in the right hypochondrium, iliac region, in the area of the heart and behind the breastbone). Vomiting and weight loss are less common. In acute pathology of the gallbladder and pancreas, pain is provoked by fatty foods, localized in the upper abdomen, has a typical irradiation and is accompanied by vomiting without relief. In dehydration and acid-base disorders, complaints of weakness, decreased performance, dizziness, dry mouth, thirst, headache, cramps, decreased diuresis, etc. are possible. A history of gastrointestinal disease is often detected.
General inspection	Plaque on the tongue, dry tongue, halitosis. Pallor of the skin due to anemia (iron deficient, B12-deficient), jaundice with cholelithiasis, dry skin and mucous membranes, decreased turgor during dehydration. The patient has the forced body position to relieve pain - in pain in stomach, duodenum more often on the right side with bent knees, in pancreatitis - on the abdomen, legs stretched underneath. In biliary colic, the patient rushes about, not finding a place for himself. In severe cases, a decrease or increase in temperature, impaired consciousness, etc.
Systems	Physical signs: painful palpation of the appropriate part of abdomen, splash noise and significant lowering of gastric lower border in gastrostasis, enlarged liver, increased strained gall bladder in obstructive cholecystitis and pancreatic cancer, special symptoms in cholecystitis (Kera, Ortner), etc. In water-electrolyte and acid-base disorders due to vomiting, signs of hemodynamic disorders are detected: drop of BP, increase in heart rate, RR, arrhythmia, etc. In the localization of pathology in duodenum, bradycardia often occurs.
Instrumental study	X-ray contrast examination (ulcer sign - a niche with convergence of folds, change in the evacuation rate, a sign of tumor - defect of filling, etc.), endoscopy with biopsy, ultrasound, and motor research.
Lab data	Changes in the leukocyte blood count (leukocytosis with a shift to the left), in chronic diseases - decrease in the number of red blood cells and hemoglobin, in severe diseases - symptoms of water-electrolyte distorders (increased hematocrit, hypercoagulation, oliguria, etc.), alkalosis, hypokalemia, hyperbilirubinemia, etc.

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