ASA Grading and Preoperative Investigations

Question 1

Define the American Society of Anaesthesiologists (ASA) system of grading physical status

Answer 1

ASA 1
- Normal healthy patient without current or clinically significant past/present medical history

ASA2
- A patient with mild systemic disease

ASA 3
- A patient with severe systemic disease

ASA 4
- A patient with severe systemic disease that is a constant threat to life

ASA 5
- A moribund patient who is not expected to survive without the operation

ASA 6
- A declared brain dead patient whose organs are being removed for donor purposes

E - Suffix added for any emergency operation

Question 2

Give examples of ASA 1 patients

Answer 2

Normal, healthy, non-smoker, no or minimal alcohol use

Question 3

Give examples of ASA 2 patients

Answer 3

No substantive limitations:

Current smoker
Social alcohol drinker
Pregnancy
Obesity (30

Question 4

Give examples of ASA 3 patients

Answer 4

Substantive functional limitations:

Poorly controlled: HPT/DM/COPD/BMI≥40
Active hepatitis
Alcohol dependence or abuse
Implanted pacemaker
Moderate reduction in EF
ESRD (with regular scheduled dialysis)
Premature infant: Post conceptual age (PCA) < 60 weeks

> 3 months after previous MI/CVA/TIA/CAD/Stents

Question 5

Give examples of ASA 4 patients

Answer 5

< 3 months MI/CVA/TIA/CAD/Stents

Ongoing cardiac ischaemia
Ongoing severe valve dysfunction
Severe reduction in EF
Sepsis/DIC/ARDS/ESRD (no regular scheduled dialysis)

Question 6

Give examples of ASA 5 patients

Answer 6

Ruptured abdominal/thoracic aneurysm
Massive trauma
Intracranial bleed with mass effect
Ischaemic bowel with significant cardiac pathology or MODS

Question 7

Describe the NICE scale used to classify complexity of surgery

Answer 7

Four Point Scale

Grade 1 - Diagnostic endoscopy or laparoscopy; breast biopsy

Grade 2 - Inguinal hernia; varicose veins; adentotonsillectomy; knee arthroscopy

Grade 3 - Total abdominal hysterectomy; TURP; lumbar discectomy; thyroidectomy

Grade 4 - Total joint replacement; artery reconstruction; colonic resection; radical neck dissection

Question 8

Define sensitivity of a test

Answer 8

The proportion of diseased patients who have a positive test result

The ability of a test to identify abnormality

Question 9

Define specificity of a test

Answer 9

The proportion of healthy patients who have a normal test result

The ability of a test to identify normality

Question 10

Define prevalence of disease

Define incidence of disease

Answer 10

Prevalence: The proportion of the population with disease

Incidence: Rate of new cases and is expressed as number of cases per unit time

Question 11

Define positive predictive value

Answer 11

PPV is the likelihood of a patient with a positive result having the disease

Question 12

Define negative predictive value

Answer 12

NPV is the likelihood that a patient with a negative test does not have the disease

Question 13

What does sensitivity of 99% mean

Answer 13

Tests results are positive in 99 out of every 100 abnormal patients

Question 14

What does 99% specificity mean

Answer 14

Tests are negative in 99 our of every 100 normal patients.

Question 15

When is a preoperative CXR required

Answer 15

If a patient is scheduled for postoperative ICU or there is a clinical indication

Question 16

When is Sickle Cell testing appropriate

Answer 16

Family history of homozygous or heterozygous trait
African or Afro-Caribbean ancestry
Asian ancestry
Middle eastern ancestry
East-mediterranean ancestry

Question 17

When should advanced Cardiac Investigations be considered? What are the various advanced cardiac investigations

Answer 17

1. Severe cardiac symptoms
OR
2. Can't climb stairs 
OR
3. Mild cardiac symptoms + Grade 4 surgery

Cardiopulmonary exercise testing
Traditional treadmill ECG exercise testing
Dobutamine stress ECHO
Myocardial perfusion scanning

Question 18

What is the anaerobic threshold

Answer 18

The end point of cardiopulmonary exercise testing (CPX) and the point at which oxygen delivery is no longer adequate and anaerobic metabolism starts

Question 19

When can CPX not be done

Answer 19

When the patient is unable to exercise in the case of arthritis